External Post-mortem Examination Research Articles

External post-mortem examination in virtual reality-scalability of a monocentric application.

Conducting external post-mortem examinations is an essential skill required of physicians in various countries, regardless of their specialization. However, the quality of these examinations has been a subject of continuous debates, and notable errors were reviled. In response to these shortcomings, a virtual reality (VR) application was developed at Halle's medical department in Germany, focusing on the scene of discovery and the completion of death certificates. The initial trial of this VR application in 2020 involved 39 students and 15 early-career professionals. Based on the feedback, the application underwent improvements and was subsequently introduced to the medical department in Dresden, Germany, in 2022. Its primary objective was to showcase the VR training's adaptability and scalability across various educational structures and levels of medical expertise. Out of 73 students who participated, 63 completed the evaluation process. 93.1% (n = 58) of the evaluators reported increased confidence in conducting external post-mortem examinations, and 96.8% (n = 61) felt more assured in filling out death certificates, crediting this progress to the VR training. Additionally, 98.4% (n = 62) believed that repeating forensic medical aspects in their coursework was crucial, and 96.8% (n = 61) viewed the VR examination as a valuable addition to their academic program. Despite these positive responses, 91.6% (n = 55) of participants maintained that training with real corpses remains irreplaceable due to the insufficiency of haptic feedback in VR. Nevertheless, the potential for enhancing the VR content and expanding the training to additional locations or related disciplines warrants further exploration.

Corpse or not? Two peculiar cases of misidentification.

Irrespective of whether they are intended for collectors or for the fetish market, dolls are being produced to look more and more realistic with such a degree of life-like detail that they can be mistaken for a real person. This paper reports two cases of misidentification due to this increasing similarity: In the first case, a sex doll was mistaken for a corpse; in the second case, a corpse was mistaken for a doll. While in the latter case, only medical laypersons were at the discovery site, in the first case, an emergency doctor had issued a medical certificate of death for the purported corpse. The medicolegal examiner who was subsequently called to the scene could still rectify the misconception on-site. Mistakes of this nature are likely rare phenomena. It, however, remains to be seen if the increasingly life-like appearance of dolls on the one hand, and the increasingly doll-like appearance of some people, e.g., through cosmetic surgery, will lead to a rise in such cases. To avoid misidentification as in the first reported case, it is essential to prepare medical students well for the task of performing a primary external postmortem examination; it is equally important that fully-trained doctors regularly refresh their expertise in this respect.

A 15-year review of lightning deaths in Germany—with a focus on pathognomonic findings

Lethal accidents caused by lightning are divided into observed and unobserved events. Pathognomonic or characteristic findings are often overlooked during external postmortem examination. Classical mistakes may be made which may often lead to an incorrect diagnosis. An analysis of 270 fatalities was performed on a historical collection of the Committee for Lightning Conductor Construction for the United Economic Area e. V. (ABBW) on lethal accidents due to lightning that occurred in Germany for the period 1951–1965. Furthermore, a selective literature research was carried out. The aim of the study was to analyze the death scene, the clothing, and the victim. The authors focused on chief findings which were relevant to the correct diagnosis of “death by lightning.” Both Lichtenberg figures and singed body hair were considered pathognomonic for a lightning strike. The question arose as to whether Lichtenberg figures, for example, represented the finding that most often led to the correct diagnosis. Of the 270 lightning-struck victims from the case collection, 129 (47.8%) had singed body hair and 25 (9.3%) had Lichtenberg figures. A comparison of the frequency of the two reported findings, singed body hair versus Lichtenberg figures, has only been performed in the literature for case numbers below 40. This study is the first evaluation of a relatively large number of lethal accidents due to lightning. Singed body hair was reported more frequently in lightning-struck victims than Lichtenberg figures. This study showed that singed body hair is probably more diagnostically important than Lichtenberg figures.

Distinction between stillbirth and miscarriage—Implications for the external postmortem examination of the corpse

Zusammenfassung Hintergrund Nach dem Grundgesetz der Bundesrepublik Deutschland (GG) liegt die Gesetzgebungsbefugnis für Todesfeststellung und Leichenschau bei den Ländern, während das Personenstandswesen in die Bundesgesetzgebungsbefugnis fällt. Das Personenstandsrecht ist im Personenstandsgesetz (PStG) und der Personenstandsverordnung (PStV) geregelt. Ziel der Arbeit Untersucht werden sollten evtl. Auswirkungen der Änderung des § 31 PStV vom 01.11.2018 auf die ärztliche Leichenschau. Konkret ging es um die Abgrenzung der Tot- von der Fehlgeburt und damit der Pflicht zur ärztlichen Leichenschau unter Berücksichtigung der Bundes- und Landesgesetzgebung. Methodik Die „Bestattungsgesetze“ der 16 Bundesländer sowie dazugehörige Verordnungen und das PStG und die PStV wurden systematisch analysiert. Ergebnisse In 12 der 16 Ländergesetze wird das Totgeborene bzw. tot geborene Kind – in Abgrenzung zur Fehlgeburt (Fehlgeborenes) – über das Geburtsgewicht von mindestens 500 g definiert. In Hessen, Bremen und im Saarland wird zusätzlich als alternatives Kriterium die 24. Schwangerschaftswoche (SSW) genannt. Das Kriterium „Erreichen der 24. SSW“ kam im bremischen und saarländischen Bestattungsrecht nach der Änderung des § 31 PStV hinzu. Im hessischen Friedhofs- und Bestattungsgesetz ist alternativ „nach der 24. SSW geboren“ verwendet. Diskussion Unabhängig von der nicht abschließend geklärten Frage, ob es sich bei einer Totgeburt um einen personenstandsrechtlichen „Sterbefall“ handelt, lässt sich eine von den „Bestattungsgesetzen“ der Länder unabhängige Leichenschaupflicht ableiten: bei der Annahme eines Sterbefalls unmittelbar aus § 38 Nr. 4 PStV, bei Ablehnung mittelbar aus § 33 S. 3 PStV i. V. m. § 5 PStV. Für diese Leichenschaupflicht müssten bezüglich der Leichendefinition die Kriterien des Personenstandsrechts gelten. Demnach wäre in allen Bundesländern – unabhängig von den Kriterien in den jeweiligen „Bestattungsgesetzen“ – zur Differenzierung zwischen Totgeburt und Fehlgeburt das alternative Merkmal „Erreichen der 24. Schwangerschaftswoche“ zu überprüfen, falls die tote Leibesfrucht, die keine Zeichen des Gelebthabens außerhalb des Mutterleibs aufweist, unter 500 g wiegt.

Undergraduate Education in Forensic Medicine in Germany, Japan, and Korea

Germany, Japan, and Korea have a similar medicolegal death investigation system, the so-called European style, governed by prosecutors for crime investigation and brought into Korea through Japan from Germany. In this system, all physicians must be engaged in postmortem external examination and issue a death certificate for unnatural death. Therefore, education in forensic medicine should be provided to medical students to ensure the ability to determine the cause of death and the manner of death after graduation. However, the quality of undergraduate education in forensic medicine is known to be unsatisfactory in Korea because there is no well-organized nation-based education policy. This study aims to review significant features of the education system for forensic medicine in Germany, Japan, and Korea. Related laws and regulations, standard curriculum, and incorporation of forensic medicine in medical license examination are comparatively analyzed. In conclusion, the Korean education system in forensic medicine has a weak structure for achieving competency in postmortem external examination, while Germany and Japan have sustained relatively concrete frameworks. Practical approaches are proposed for improving education quality, including incorporating forensic medicine into compulsory assessment in the medical licensing examination.

Simulation in the elective subject forensic medicine in the third section of the medical examination

In der COVID-19-Pandemie konnte der Dritte Abschnitt der Ärztlichen Prüfung an Simulationspersonen und Simulatoren durchgeführt werden. Auch im Fach Rechtsmedizin ist deren Einsatz sinnvoll, da eine höhere Standardisierung und Vergleichbarkeit von Prüfungsleistungen erreicht wird und die Verwendung von echten Leichnamen aus medikolegalen Gründen oft nicht vertretbar ist. Der vorliegende Fall berichtet über die Vor- und Nachteile einer Simulation im Staatsexamen, in der anhand einer Leichenschau am Simulator und einer Fremdanamnese eine Todesbescheinigung vollständig ausgefüllt werden sollte.

New Death Investigation System in Japan

Since after World War II, the death investigation system in Japan has been a dual system; with or without medical examiners. In areas without medical examiners, death investigation focused on unnatural death suspiciously involved with crime and depended on external postmortem examination for noncriminal cases. As a result, the forensic autopsy rate has been low, and several cases of missed homicide have been discovered. The social impact of the missed homicide of a young sumo player has encouraged the reformation of the death investigation system in Japan. “The Act on the Investigating of Cause of Death and on Identification of Bodies Handled by the Police” and the “Basic Act on Promotion of Death Investigation” were launched in 2013 and 2020, respectively. For noncriminal cases, a new type of autopsy becomes available without the consent of the bereaved family. Moreover, the concept and purpose of death investigation are not only to detect crime involvement, but also to extend respect for life and maintain personal dignity. The responsibility of the central government on death investigation service is stressed, including the establishment of a headquarters in the Ministry of Health, Labour and Welfare. This review aims to understand the background and major changes of the reform of the death investigation system in Japan and discuss the issues affecting forensic pathologists.

Does peer consultation between forensic physicians reduce inter-doctor variation when issuing medical death certifications?

IntroductionBecause earlier research showed that inaccuracies were observed in the interpretation and handling of deaths by forensic physicians, peer consultation among forensic physicians was introduced before advice was given to treating physicians calling for advice. In addition, peer consultation was introduced as a means to improve the correctness of conclusions concerning the manner of death when performing external post-mortem examinations. MethodIn the period of November 2017 until April 2018 all reports of external postmortem examinations (n = 498) and all telephonic consultations between treating physicians with forensic physicians, concerning postmortem examinations (n = 167), were analyzed retrospectively. ResultsPeer consultation among forensic physicians took place in 70% of the 167 telephonic consultations initiated by treating physicians. In 92% of all cases of telephonic consultation, the accurateness of advice to treating physicians was deemed accurate. In 67% (n = 498) of all external postmortem examinations in the study period, peer consultation between forensic physicians took place. The conclusion regarding the manner of death after external postmortem examination was accurate in 99% of all cases (n = 491 out of 498). ConclusionThe advices given by forensic physicians to treating physicians have improved after the introduction of peer consultation among forensic physicians. Peer consultation therefore should be recommended as a means for quality assurance.

Consistent acting, legal knowledge and competence of external postmortem examination in Dutch hospital settings

A crucial role in the external postmortem examination system of the Netherlands is that of the attending physicians, who are either general practitioners or physicians in hospitals. They perform 85% of all external postmortem examinations and must immediately report to forensic physicians all unnatural deaths and deaths that they are not convinced to be natural. These attending physicians need therefore to be properly qualified and need to be competent, by acting consistently and by having knowledge of the appropriate laws surrounding external postmortem examination. The aim of this study is to analyse the competence of the attending physicians in hospital settings. This research studied whether they regard themselves as competent, whether they had knowledge of and acted according to the appropriate laws, and whether they acted consistently in following the procedures around external postmortem examinations. A survey was conducted among clinicians. After discarding 23 questionnaires for various reasons, 326 datasets remained on which the research was based. There was no significant difference between the medical specialists (79%) and the residents and fellows (86%) in their feeling of being competent in undertaking external postmortem examinations. The answers of the respondents showed at least one inconsistency in 54%. Of the respondents 34% were considered as to have knowledge of relevant laws. Of the respondents 21% felt competent, was consistent in all their answers and scored a 100% on legal knowledge. The study showed that though a physician might feel competent, this does not mean he actually is competent in performing an external postmortem examination. Furthermore, the extent of a respondents’ ignorance of the appropriate laws and the inconsistency in acts and thoughts is undermining the system of postmortem examination.

Using simulation mannequins and actors in training for external post-mortem examinations -experiences from use in medical students and police officers

In the daily practice of external post-mortem examinations and dealing with surviving dependents, striking failures can be observed regularly, pointing to an increased demand for training of the various professional groups involved. In this study, the experience gained from using simulation mannequins and actors for post-mortem examination training in medical students and police officers are presented.Since 2017, a training station has been offered at the Medical Faculty of the Technical University of Dresden (Germany) for practicing examinations in death scene and establishing communication with grieving relatives. It is conducted in small groups of up to 5 people, both for medical students and for police officers and police recruits. These courses are evaluated by means of questionnaires including 3 and 11 items respectively for the different groups. The questionnaires have been completed by 679 medical students and 67 police participants.Both groups of participants evaluated their previous experience as average. They assessed the course as having a high degree of practical and professional relevance. The didactic transfer of the teaching contents and its competent support were rated remarkably positive by the participants. Additionally, the police group reported high rates of approval for the use of feedback, the learning effect, and the appropriateness of the group size.The establishment and continuation of the simulation-based external post-mortem examination in the form of small-group teaching is associated with a considerable expenditure of equipment, material and personnel. In addition, its implementation requires sound cooperation structures. On the other hand, introduction and continuation of these types of additional teaching and learning methods, with a large practical component, can increase confidence in daily practice, and thus improve the quality of external post-mortem examination. Ultimately, this can also improve the cooperation between forensic medicine and the investigating authorities.

Divulging on Autopsy and the External Post-Mortem Examination of a Dead Body for Criminal Proceedings

For criminal proceedings, the post-mortem examination of a dead body is composed of two stages.PME encompasses the apparent condition of the dead body in reference to the surrounding of the crime scene and the effects of the environment. The autopsy consists of the examination of the body in the autopsy room for detailed examination. Apart from these two categories, PME can also be divided according to the purpose and approval of authority for conducting the examination including; for the training of the medical students,organ donation, and identification of an unknown dead body where no crime is involved, or where the crime occurred it determines the cause of death or traces any sign of the criminal. The purpose of both examinations is to find the cause of death and trace the perpetrator of the crime, if possible under the given circumstances of dead body, and to prosecute the offender and exonerate the innocents.

Autoerotic Deaths in Hamburg, Germany: Autoerotic accident or death from internal cause in an autoerotic setting? A retrospective study from 2004-2018

IntroductionAutoerotic deaths are rare events. The death scene is often bizarre and the death unexpected, thus often requiring forensic autopsies. Our analysis will provide an overview of the expected range of causes and manners of death in cases of autoerotic deaths. MethodsA retrospective analysis was carried out on all scientific and forensic autopsies and postmortem examinations performed at the Department of Legal Medicine in Hamburg, Germany, over the period of 2004–2018. Results25 cases of autoerotic fatalities were identified over this 15-year-period or one to two cases per year, respectively. Autopsies were carried out on 23 of these cases. 16 (64%) of the cases involved autoerotic accidents and 7 (28%) from internal causes of death during an autoerotic act. Two cases had not undergone an autopsy. On average, those who were involved in autoerotic accidents had been younger in age (average age: 37 years) than the individuals who died from internal disease (average age: 61 years). Only one woman was involved. The most common cause of death in autoerotic accidents was strangulation (hanging: 8 cases, ligature strangulation: 1 case), followed by smothering of the respiratory tract (4 cases). Fatal intoxication was diagnosed in three of the cases. Fatalities with natural cause of death solely involved cardiovascular causes of death. ConclusionsAutoerotic deaths involved a wide range of natural and non-natural causes of death. The reconstruction of such unusual cases and detection of non-natural fatalities requires thorough investigation of the scene of death as well as a postmortem external and internal examination including a chemical toxicological and blood alcohol analysis.

Death abroad: Medico-legal autopsy results of repatriated corpses: A retrospective analysis of cases at the Department of Legal Medicine in Frankfurt am Main

IntroductionRepatriated corpses may have been autopsied abroad. The aim of the study was to compare the findings from second medico-legal autopsies with those from primary autopsies abroad to spotlight possible implications for the management of repatriated corpses. Material and MethodsAll autopsies from a 20-year period at the Institute of Legal Medicine in Frankfurt am Main on repatriated corpses of German citizens were reviewed. The results were compared with the information from the body passports, the protocols of the autopsies in the country of death, and the police files. ResultsIn total, 151 corpses repatriated from 56 different countries were autopsied. The interval between death and autopsy in Germany was 2–603 days (median: 11 days). 91 of the repatriated corpses (59.5%) had previously been autopsied abroad. Three body cavities had been opened in 78.0% (71/91) of the original autopsies; among them, there were 11 cases (15.5%) with dissection of all organs, as opposed to 7 cases (9.9%) with all organs intact and in situ.Of the previously autopsied corpses, 62.6% were accompanied by a body passport that noted the cause of death. In nearly 75% of these cases, the stated cause of death was compatible with that established at second autopsy. In 5 cases (10.2%), the cause of death established in the second autopsy disagreed with that on the body passport. The most prominent disparity was a cranial gunshot wound rather than the stated fatal fall. DiscussionThis analysis of individual cases spotlights the problematics of an uncritical approval of the body passport. In light of the different procedural autopsy standards around the world, the validity of an autopsy abroad is discussed in the context of the second autopsy results. ConclusionA second external postmortem examination by qualified medical practitioners should be obligatory in all cases of repatriated corpses, with notification of the criminal police in all cases of non-natural or undetermined death. A timely second autopsy is recommended even in cases with previous autopsy abroad.

Cases of asphyxia in children and adolescents: a retrospective analysis of fatal accidents, suicides, and homicides from 1998 to 2017 in Hamburg, Germany

PurposeInjury-related asphyxia is one of the most common causes of death in children in Germany. However, only a few systematic studies have analyzed the causes and circumstances of asphyxia in children and adolescents.MethodsAll cases of asphyxia in children and adolescents (0–21 years of age) among the Hamburg Legal Medical Department’s autopsy cases from 1998 to 2017 were retrospectively analyzed with special focus on how often external findings were completely absent.ResultsAmong 249 cases of fatal asphyxia, 68% were accidents, 14% were suicides, and 13% were homicides. Most of the cases involved boys. Adolescents and young adults aged 15–21 years represented the main age group. Drowning was the leading mechanism of asphyxia. Younger age was associated with less frequent detection of external signs of asphyxia in the postmortem external examination. Petechial hemorrhages were the most common visible external indication of asphyxia. No external findings indicative of asphyxia were present in 14% of the cases.ConclusionAsphyxia in children and adolescents often involves accidents. However, postmortem external examination alone is insufficient to identify asphyxia and the manner of death.

The postmortem examination prior to cremation: Still a necessary safety measure?

The postmortem external examination has repeatedly been the subject of political and medicolegal disputes. This study was performed to examine whether the postmortem external examination at the crematory provides additional benefits and to determine whether any differences in the quality of medical death certificates exist between hospital and non-hospital postmortem external examinations. All cases of death that had been examined within the context of a second postmortem external examination at crematories performed by medicolegal specialists from the Hamburg Department of Legal Medicine were analyzed during a 6-month investigation period. A second postmortem external examination was carried out on 9981 decedents prior to cremation during the investigation period. In the interim, the second postmortem medical examiner did not release 474 bodies (4.7%) for cremation. Suspicion of death caused by trauma was the most frequent cause for delaying the release of the body. The quality of information stated on the medical death certificate was good in 112 certificates issued by clinicians (48.9%, n=229) and in 51 issued by general practitioners (31.3%, n=163). This study verified deficiencies in the initial postmortem external examination. A postmortem external examination prior to cremation by a medical professional specialized in this field is currently an indispensable component for quality assurance.

Postmortem examination at crematories: experiences and forensic medical evaluations

Cremation is the most common type of burial in Germany. Evidence is lost when cremating the body. Asecond postmortem external examination (postmortem external examination at the crematory) is required by law in almost all German federal states prior to cremation. This duty is often performed by alegal medical specialist.This article provides an overview of different, mostly legal, medical assessments of the postmortem examination at the crematory and reports on personal experience in postmortem external examinations at crematories.The second postmortem medical examiner detects formal, content-related, and in some cases serious errors on medical death certificates on aregular basis. In cases with indications for anon-natural death or uncertain identity of the body, the cremation is stopped and some cases are reported to the investigative authority. Indications of death caused by physical trauma or malpractice are the most common reasons for delaying acremation during the postmortem medical examination at the crematory. The percentage of delayed cremations is minimal (up to 5%). The second postmortem examiner reports approximately 0.5-2% of cases to the investigating authorities. The number of court-ordered autopsies of decedents that had been reported as being conspicuous has always been low (approximately 1%).Currently, the postmortem external examination by aspecialist postmortem medical examiner at the crematory remains avital prerequisite for identifying non-natural cases of death. Only ahigh number of autopsy orders can significantly improve the cause-of-death statistics of the postmortem external examinations at the crematory.

External post-mortem examination according to S1 guideline 2017 of the German Society of Legal Medicine

In Germany, the system of external post-mortem examinations is regulated by state law. In order to standardize the performance of external post-mortem examinations as far as possible throughout Germany, the German Society of Legal Medicine developed the S1 guideline "Rules for the performance of external post-mortem examination." The current version of this guideline was published on the Association of the Scientific Medical Societies in Germany (AWMF) homepage in November 2017. The guideline explains in detail the reliable determination of death, the diagnosis of the cause of death, the classification of the manner of death, the estimation of the time of death, and the reporting obligations of the post-mortem examination physician. Detailed information is provided on the examination of the corpse. Acareful performance of the external post-mortem examination avoids false death determinations, lies in the presumed will of the deceased, and serves to protect the interests of the bereaved. In addition, it is of importance to society as awhole in that communicable diseases and legally relevant deaths are identified. Finally, the validity of cause-of-death statistics is improved, which can have far-reaching consequences for health-related policy decisions. In this article the main rules of the guideline are described.

Qualified post-mortem examination-experiences from Bremen

On 1 August 2017, the qualified post-mortem examination was introduced in Bremen by changing the relevant law. A substantial change is the separation of the pure death determination, which can be done by any physician, and the subsequent execution of the post-mortem examination by asuitably qualified physician. For the city of Bremen, the Institute for Legal Medicine (IRM) was charged with this task (in Bremerhaven, the health department).In this article, practical implementation, problems, and advantages and disadvantages of the new law are presented. For the year 2018 we did astatistical evaluation of the qualified post-mortem examination.After notification of acase of death to the IRM, the post-mortem examination will be carried out on the same or the following working day by an IRMdoctor. In 2018, 7585 post-mortem examinations took place. In nearly 300 cases (4%) the type of death had to be changed (natural/not natural).Problems arise if external undertakers are involved. Further challenges arise in the collection of the anamnesis and implementation after extended weekends as well as due to the lack of knowledge about the death scene and generally the difficulty to conclude on the cause of death within the scope of an external post-mortem examination. One advantage to mention is that every deceased person is relatively promptly subjected to apost-mortem examination by aqualified doctor and overall the quality of the examination has improved. Adisadvantage is the increased cost.

Death certificates-an underestimated source of information for statistics, judicature, public health, and science

The thorough external examination of acorpse and the correct completion of the death certificate are medical duties with far-reaching consequences. Data obtained from the death certificates are the basis for mortality statistics and for scientific research. They can be helpful in uncovering criminal offences or for the surveillance of medical facilities. For many years the deficiencies of external post-mortem examinations and death certificates have been discussed in professional journals.The important task of analysing all death certificates is performed by the local health authorities. This is the only opportunity for quality control and, if necessary, the doctors who issued the death certificate must be asked for corrections. This also improves the quality of the mortality statistics and contributes to the administration of justice.Additionally, important information for routine duties of the public health authorities can be obtained from the death certificates concerning the monitoring of narcotics, the supervision of medical facilities and the adherence to notification requirements for infectious diseases. Furthermore, death certificates contain relevant data for selected medical research projects.The high information content of death certificates is widely unknown and should be used by the health authorities comprehensively and systematically. Enough qualified staff needs to be allocated to further secure the important task of quality control of death certificates.

Reliability of police reports when assessing health information at the forensic post-mortem examination-using schizophrenia as a model.

Autopsies continue to be the most reliable source of mortality statistics; however, more and more death certificates are based on the post-mortem external examination (PME) alone. Forensic PMEs differ from clinical PMEs, because the forensic pathologist usually has no preceding knowledge of the health of the decedent and must rely on information from authorities in the form of the police report. It is useful at the forensic PME to know whether the decedent suffered from a mental illness; however, it is unknown how valid such a diagnosis is, when based upon information in the police report alone. This study compared tentative diagnoses of schizophrenia from 500 forensic PMEs with a reference database based on the Danish National Patient Registry. We found that 19.3% of schizophrenia cases were missed, and 9.1% of identified cases were false positives. Overall, 11.4% of all assessments were incorrect. Subgroup analysis showed that marital status as 'single' and the finding of illegal substances at the scene were predictors for both correctly identified and overlookedschizophrenia cases. The most reliable source of information was the decedent's general practitioner, whereas friends and neighbors were the most unreliable. Future studies should be aware of the risk of assigning a wrong diagnosis and use as many sources of information as possible. Taking the decedent's social history and observations about the scene into account may add to the diagnostic accuracy.