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4QUNM | neattisciencrs | OFFICE of the MEDICAL INVESTIGATOR CENTER Report of Findings Case Number: 2017-00704 AZ County Pronounced: Beso aw Enforcement Agent: Date of Birth: Pronounced Date: 2472017 {2:10.00 aM Central Ofc Investigator Cot Kaien Deputy Field Investigator: Coit Kaicich CO! CAUSE OF DEATH Pulmonary thromboembolism Duete Pregnancy MANNER OF DEATH ‘Natural Rebecca Asch-Kendrick, MD. Lauren E Dvorscak, MD Forensic Pathology Flow ecial investigator, Asistant Professor of Pathology ‘lsignatures authenticated eectonicaly Date: 57252017 1:31:28 PM inte 528201713128 PM Report Name Death Ivesiaton Repti Too! Case Number: 2017-00704 ‘Summary Opinion — Medical Investigator Medical Investigator Trainee Lauren E Dvorscak, MD Rebecca Asch Kendrick, MD ‘SUMMARY AND OPINION PATHOLOGIC DIAGNOSES: 1. Pulmonary thromboembolism A. Extensive organizing thromboemboli, bilateral pulmonary arterial vasculature B Pulmonary edema C. Clinical echocardiogram demonstrated reduced ventricular funtion I. Clinical evidence of septic abortion, per medical records ~ A. Status post fetal abortion by dilatation and evacuation 1. Catheter placement, uterus 2. Complete products of conception and intact placenta with trivascular umbilical cord B. Antemortem blood culture positive for Aerococcus species (per medicel records) C. Postmortem uterine swabsitissue cultures grew rare to few colony growth of Aerococcus species Uterine endometritis 1. Microscopic neutrophilic exudates, uterine endometrium and maternal surface of placenta MI Pleural effusions 1 Left chest cavity, 600 mL serous fluid 2. Right chest cavity, 600 mL serous fluid IV, Clinical evidence of acute coagulopathy, per medical records A. Bloody fluid, 100 mL, peritoneal cavity B Fibrin microthrombi, glomerclar C. Parenchymal hemorrhage, eft adrenal gland /D. Status post multiple blood product transfusions '. Status post extensive resuscitation attempts, A. Contusions, chest B. Rib fractures, anterolateral VI Probe patent foramen ovale VIL. Contusions, minor, extremities SUMMARY AND OPINION: ‘This 23 year old woman, KINI ANIM, died of pulmonary thromboembolism due to pregnancy. 7 According to reports, Ms, AMINE vas at a clinic preparing forthe final portion ofa termination of pregnancy. She presented tothe clinic with complaints of cramping pain as expected and was resting preparing for labor. While at the clinic, she noted that she was feeling short of breath, and her oxygen saturation dropped below her baseline. She was placed on oxygen with some improvement of her symptoms, Due to the conceming symptoms, she transferred to University of New Mexico Hospitals, where she continued to have cramping abdominal pain, elevated heart rate and difficulty maintaining normal blood oxygen levels despite supplemental oxygen therapy. ‘At the hospital, inital testing revealed fluid buildup in the lungs (pulmonary edema), without evidence of significant bload clots, and evaluation of er heart revealed reduced ventricular (pumping chamber) function. Due to rapid decompensation inher clinical status (requiring the placement of a breathing tube) and the concer for a significant infection, she was taken emergently tothe operating room to complete the abortion procedure. During the operatios sustained a cardiac arrest. Extensive resuscitation efforts were ultimately unsuccessful she Bacterial cultures taken during her hospital admission ultimately grew Aerococcus species in the blood and mixed organisms (including Aerococcus species) inthe placental tissue Autopsy examination revealed a well-developed, well-nourished young woman with extensive medical intervention. Internal and mieroscopic examination revealed large, organizing, bilateral pulmonary thromloemboli (large blood clots inthe arteries ofthe lungs). Additional autopsy findings included pulmonary edema with large pleural effusions (Aid in ‘and around the lungs), and a boggy, intact uterus, consistent with recent pregnancy. The lining of the uterus, as well as coe OF Dest: Paget Printed S017 13129 7M case Number: 2047-00704 ‘Summary Opinion —, the maternal surface of the placenta showed acute inflammation, consistent with the clinical picture ofa septic abortion The placenta and products of conception were otherwise unremarkable. Incidental findings included a patent foramen ovale (opening between two chambers in the heat). Injuries including bruising on the chest and ri fractures were most consistent with resuscitation attempts. The only other injuries detected were minor scattered bruises on the arms and. legs. Toxicology analysis of the antemortem blood revealed a therapeutic level of oxycodone and its breakdown product, oxymorphone, Postmortem microbiological cultures ofthe uterus were positive for rare to few colony growth of Aerovoccus species. Postmortem bacterial cultures ofthe heart blood and lungs grew many types of organisms, most consistent with postmortem bacterial overgrowth and/or contamination Pulmonary thromboembolism, or blood clots that occlude the arteries of the lungs, may be rapidly fatal, causing death by blocking normal blood flow to the lungs and preventing the normal oxygenation of tissues. Clinically, Ms. AIIINE's evaluation (by CT angiography) for pulmonary thromboembolism (blood clot in the lungs) was negative at her presentation to the hospital. A review of the literature reveal that falsely negative results for this test are typically rare, but such rates have been reported tobe as high as 10.7% in one study (1). Essentially, even though the clinical test for a blood clot was negative, Ms, AIIM did have a significant blood clot in her lungs atthe time of autopsy that caused her sudden and unexpected death ‘When the arteries in the lungs are significantly oochuded (blocked) by thromboemboli (blood clots) symptoms and signs such as shortness of breath, increased heart rate, decreased oxygenation of the blood, and chest pain may occur. Ms. AMINE experienced many of these symptoms, along with a rapid deterioration in her respiratory function, reduced heart ‘function, and fluid buildup in her lungs. These clinical findings are all consistent with the postmortem findings of large blood clots in her lungs. Most often, a blood clot in the lungs actually originates from another source such as the deep leg veins. Risk factors for the development of blood clots include hypercoagulable states, such as pregnancy, among other factors such as high blood pressure, smoking, obesity, and immobility. Ms. AlMNNI's pregnancy ultimately placed her at increased probability of developing blood clots, which occur at approximately #4 fold higher rate in pregnant women when compared tothe general poptlation (2-4), Pulmonary embolism is the th leading cause of maternal mortality in the United States (2-4) ‘To further complicate her clinical picture, Ms. ANH also had a high white blood cell count and other clinical features concerning for sepsis (or widespread inflammation and infection) upon her hospital admission. At autopsy, Ms. A {id have some evidence of acute inflammation aad a positive postmortem bacterial culture for Aerococeus species. However, her overall condition in the hospital was remarkable for significant respiratory distress that decompensated rapidly. While she likely did have an infection from the abortion process, the blockage of her pulmonary arteries by blood clots would have caused the rapid clinical symptoms leading to death, even without infectious or inflammatory complications. The cause of death, therefore, is best certified as pulmonary thromboembolism due to pregnancy. The ‘manner of death is natural REFERENCES: 1, Hogg K, Brown G, Dunning J, Wright H, Carley S, Foex B, and Mackway-Jones K. Diagnosis of pulmonary ‘embolism with CT pulmonary angiography’ a systematic review. Emerg Med J. 2006,23:172-178, 2, Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008;359(19):2025. 3, Creanga AA, Berg Cl, Syverson C, Seed K, Bruce C, Callaghan WM. Pregnancy-Related Mortality in the United States, 2006-2010, Obstetries & Gynecology. 2015;125(1):5-12. 4, Schwartz DR, Malhotra A, Weinberger SE. Pulmonary embolism in pregnancy: Epidemiology, pathogenesis, and diagnosis In: UpToDate, Leung LLK, Mandel J, Lockwood CI (SEds); Finlay G (Ed), UpToDate, Waltham, MA (accessed April 2017) Caste OfDeam: Page 2 ito 57252017 131:28 PI \UNM HEALTH SciENCrS | OFFICE of the MEDICAL INVESTIGATOR CENTER DEATH INVESTIGATION SUMMARY Case Number: 2017-00704 —, {i County Pronounced: Benalla law Enforcement: ‘Agent Date of Ei: Pronounced DateTime: 24/2017 121000 AM Central Ofc Investigator: Ct Kalcch Deputy Feld Investigator: Cot Kakicn CO! CAUSE OF DEATH Pulmonary thromboembolism Deb Pregnancy ‘MANNER OF DEATH ‘Natural Rebecca Asch-Kendrick, MD Lauren E Dvorscak, MD Forensic Pathology Fellow Mica investigator, Assstnt Professor of Pathology ‘sites auencates cetoricaly Dae: 5252017 13128 Pa Pir 2097 131:204 apo hae De estan Repay Ts Death Investigation Report page 1 of 26 DECLARATION The death of AMIN, KEEN was investigated by the Office of the Medical Investigator under the statutory authority of the Office of the Medical Investigator. |, Lauren E Dvorscak, MD, a board certified anatomic, clinical, and forensic pathologist licensed to practice pathology in the State of New Mexico, do declare that | personally performed or supervised the tasks described within this Death Investigation Summary document. Itis only after careful Consideration of all data available to me atthe time that this report was finalized that | attest tothe diagnoses and opinions stated herein Numerous photographs were obtained along the course of the examination. | have personally reviewed those photographs and attest that they are representative of findings reported in this document. This document is divided into 8 sections with a final Procedural Notes section: Summary and Opinion External Examination Medical Intervention Postmortem Changes Evidence of Injuries Internal Examination Microscopy Ancillary Lab Studies Should you have questions after review of this material, please feel free to contact me at the Office of the Medical Investigator (Albuquerque, New Mexico) - 505-272-3063. Pn Sasz017 19.20 7 Repost Nave Dea Inesigaon Summary Death investigation Repert page 2 of 26 Case Number: 2017-00704 ‘Summary Opinion —, Medical Investigator Medical Investigator Trainee Lauren E Dvorscak, MD Rebecca Asch- Kendrick, MD ‘SUMMARY AND OPINION PATHOLOGIC DIAGNOSES: |. Pulmonary thromboembolism A. Extensive organizing thromboemboli bilateral pulmonary arterial vasculature B. Pulmonary edema C. Clinical echocardiogram demonstrated reduced ventricular function IL Clinical evidence of septic abortion, per medical records ‘A. Status post fetal sbortion by dilatation and evacuation 1. Catheter placement, uterus 2. Complete products of conception and intact placenta with trivascular umbilical cord 'B. Antemortem blood culture positive for Aerococcus species (per medical records) . Postmortem uterine swabsitssue cultures grew rare to few colony growth of Aerocoecus species D. Uterine endometritis I, Microscopic neutrophilic exudates, uterine endometrium and maternal surface of placenta TIL, Pleural effusions 1. Left chest cavity, 600 mL serous fluid 2. Right chest cavity, 600 mL serous fluid IV. Clinical evidence of acute coagulopathy, per medical records ‘A. Bloody fuid, 100 mL, peritoneal cavity BB. Fibrin microthrombi, glomerular . Parenchymal hemorthage, let adrenal gland DD, Status post multiple blood product transfusions YV. Status post extensive resuscitation attempts ‘A. Contusions, chest B. Rib fractures, anterolateral VIL. Probe patent foramen ovale Vil, Contusions, minor, extremities ‘SUMMARY AND OPINION: ‘This 23 year old woman, KEN AMINIL, died of pulmonary thromboembolism due to pregnancy. According to reports, Ms. ANNIE was ata clinic preparing for the final portion ofa termination of pregnancy. She presented to the clinic with complaints of cramping pain as expected and was resting preparing for labor. While atthe clinic, she noted that she was feeling short of breath, and her oxy'gen saturation dropped below her baseline. She was placed on oxygen with some improvement of her symptoms, Due to the concerning symptoms, she transferred to University of New Mexico Hospitals, where she continued to have cramping abdominal pain elevated heart rate and difficulty maintaining normal blood oxygen levels despite supplemental oxygen therapy. {At the hospital, initial testing revealed fluid buildup in the lungs (pulmonary edema), without evidence of significant ‘blood clots, and evaluation of her heart revealed reduced ventricular (pumping chamber) function, Due to rapid ‘decompensation in her clinial status (requiring the placement of a breathing tube) and the concem fora significant infection, she was taken emergently to the operating room to complete the abortion procedure. During the operation, she sustained a cardiac arrest. Extensive resuscitation efforts were ultimately unsuccessful Bacterial cultures taken during her hospital admission ultimately grew Aerococcus species in the blood and mixed organisms (including Aerococcus species) in the placental tissue. Autopsy examination revealed a well-developed, well-nourished young woman with extensive medical intervention, Internal and microscopic examination revealed large, organizing, bilateral pulmonary thromoemboli (large blood clots in the arteries ofthe lungs), Additional autopsy findings included pulmonary edema with large pleural effusions (fluid in ‘and around the lungs), and a boggy, intact uterus, consistent with recent pregnancy. The lining of the uterus, as well as caso 01 Det Page 1 Pied: $2017 13131 PAL Death investigation Report page 3of 26 Case Number: 2017-00704 ‘Summary Opinion —— the maternal surface of the placenta showed acute inflammation, consistent with the clinical picture ofa septic abortion. ‘The placenta and products of conception were otherwise unremarkable. Incidental findings included a patent foramen ‘ovale (opening between two chambers in the heart). Injuries including bruising on the chest and rib fractures were most Consistent with resuscitation attempts. The only other injuries detected were minor scattered bruises on the arms and legs. Toxicology analysis of the antemortem blood revealed a therapeutic level of oxycodone and its breakdown product, oxymorphone. Postmortem microbiological cultures ofthe uterus were positive for rare to few colony growth of Acrococeus species Postmortem bacterial cultures ofthe heart blood and lungs grew many types of organisms, most consistent with postmortem bacterial overgrowth and/or contamination, Pulmonary thromboembolism, or blood clots that occlude the arteries of the lungs, may be rapidly fatal, causing death by blocking normal blood flow to the lungs and preventing the normal oxygenation of tissues Clinically, Ms. AIINIF's evaluation (by CT angiography) for pulmonary thromboembolism (blood clot inthe lungs) was negative at her presentation to the hospital. A review of the literature reveals that falsely negative results for this test are typically rare, but such rates have been reported to be as high as 10.7% in one study (1). Essentially, even though the clinical test fora blood clot was negative, Ms. Atkins did have a significant blood clot in her lungs atthe time of autopsy that caused her sudden and unexpected death ‘When the arteries in the lungs are significantly occluded (blocked) by thromboembol (blood clots), symptoms and signs such as shortness of breath, increased heart rate, decreased oxygenation of the blood, and chest pain may occur. Ms experienced many of these symptoms, along with a rapid deterioration in her respiratory function, reduced heart function, and luid buildup in her lungs. These clinical findings are all consistent with the postmortem findings of large blood clots in her lungs. Most often, a blood clot in the lungs actually originates from another source such asthe deep leg veins. Risk factors for the development of blood clots include hypercoagulable states, such as pregnancy, among other factors such as high blood pressure, smoking, obesity, and immobility. Ms pregnancy ultimately placed her at increased probability, of developing blood clots, which occur at approximately a4 fold higher rate in pregnant women when compared to the general population (2-4), Pulmonary embolism is the 6th leading cause of maternal mortality in the United States (2-4). To further complicate her clinical picture, Ms. Alllilalso had a high white blood cell count and other clinical features concerning for sepsis (or widespread inflammation and infection) upon her hospital admission. At autopsy, Ms. A id have some evidence of acute inflammation and a positive postmortem bacterial culture for Aerococcus species. However, her overall condition in the hospital was remarkable for significant respiratory distress that decompensated rapidly. While she likely did have an infection from the abortion process, the blockage of her pulmonary arteries by blood clots would have caused the rapid clinical symptoms leading to death, even without infectious or inflammatory complications, The cause of death, therefore, is best certified as pulmonary thromboembolism due to pregnancy. The manner of death is natural REFERENCES: 1. Hoge K, Brown G, Dunning J, Wright H, Carley 8, Foex B, and Mackway-Jones K, Diagnosis of pulmonary embolism with CT pulmonary angiography: a systematic review. Emerg Med J. 2006;23:172-178 2. Matik PE, Plante LA. Venous thromboembolic discase and pregnancy. N Engl J Med. 2008;359(19):2025. 43, Creanga AA, Berg CJ, Syverson C, Seed K, Bruce C, Callaghan WM, Pregnancy-Related Mortality inthe United States, 2006-2010. Opstetries & Gynecology. 2015;125(1}:5-12. 4, Schwartz DR, Mathotra A, Weinberger SE. Pulmonary embolism in pregnancy: Epidemiology, pathogenesis, and diagnosis In: UpToDate, Leung LLK, Mandel J, Lockwood CJ (SEds); Finlay G (Ed), UpToDate, Waltham, MA (aceessed April 2017) CatseofDeate Page 2 Piss 257201713131 PL Death Investigation Report page 4 of 26 Cave Number: 2017-00704 External Examination Medical Investigator [Lauren E Dvorscak, MD Exteral exam dat time: ‘Authority for examination: 1D confirmed at time of exam: Means used to confm identity: fication means: Name on orange bracelet: Other name on orange bracelet: Location of green bracelet: Name on green bracelet: Cte name on green bracelet Hospital 10 tags or bracelets? yes specty stated name and location: Boy length (rm Body weight (has): BM: Development: Development comments: Statue: Age: Anasarca Edema localized Dehydration: ‘Scalp hair color: ‘Scalp hair color comments: Medical Investigator Trainee Rebecea Asch-Kendrick, MD 2/4/2017 9:13:00 AM oMr Yes Visual Left wrist Decedent name Left wrist, Decedent name Yes Right ankle decedent name 162.00 67.40 25.68 Well-developed Well-nourished Appears to be stated age No No No Brown ‘The roots are dark with blonde ends, ‘Scalp hair length: Eyes: rides: Eyes corneas: Eyes sclerae: Eyes conjunctvae: Eyes petechiae: Palpebral petechiz: ‘Bulbar ptechise: Facial petechiae Estamal Exinaton Long Both eyes present Brown ‘Translucent White ‘Translucent No No No No Paget Death investigation Report page 5 of 26 Pied 5282087 13:1 PM Case Number: 2017-00704 External Examination (ral mucosal peteciae: Nose: Ears Ups: Facial hair: Facial har color Maxllary dentition: Mandibular detion Condition of dentition: Neck Trachea midline: (Chest development: ‘Chest symmetrical: (Chest diameter ‘Abdomen: Ars: Back: Spine External genitalia Breast development Breast masses: Right hand digits complete: Lett hand cits complete: Right fot agit complete: Let fot digits complet: Extromiies: ‘Muscle group atrophy: Senile purpr Piting edema: Muscle other: Tattoos preset: Tattoo anterior chest: Tattoo back: Tattoo right forearm: Tattoo left shoulder: Tatoo left arm: Tatoo lef forearm: Tattoo right lower leg: Tatoo lef thigh Tattoo let lower leg: tem Eatin No Normally formed Normally formed Normally formed None Does not apply Natural Natural Adequate ‘Unremarkable Yes Normal Yes “Appropriate Protuberant Unremarkable ‘Unremarkable Normal Female ‘Symmetric None Yes ‘Well-developed and symmetrical No No No No Tattojs) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Page 2 Death Investigation Report page 6 of 25 Pena S25 2087 13131 PAL Case Number: 2017-00704 Cosmetic piercing present ‘Cosmetic piercing right ear: (Cosmetic piercing let er: Cosmetic piercing lower ip: Cosmetic piercing umbilicus: Scarfs) present: Scar right knee: Scar left knee: Reported by: Verified by: Reviewed and approved by: ama! Examiaton External Examination Cosmetic Piercings) Yes Yes Yes Yes Yes Searls) Yes Yes Yes Reporting Tracking Rebecca Asch-Kendrick, MD Lauren E Dvorscak, MD on 5/25/2017 9:58:26 AM Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM Page 3 DDoath investigation Report page 7 of 26 Pina $252017 13131 PU Case Number: 2017-00704 Medical Intervention A Moscal Investigator ‘Lauren E Dvorscak, MD Evidence of meical intervention: nasogastric tube present, specify course and posit endotracheal tube present, speci course and poston: Endotrachesl tube: Endotrachel tube comment: Tracheostomy steube: Mediastial tube(): Chest tube(s) If Foley catheter present, specify course and poston Foley catheter: Foley catheter commont: Medical Investigator T Rebecca Asch-Kendtick, MD Yes Indweling Tubes Yes Passes through the mouth and oropharynx, between the vocal folds and terminates in the trachea proximal tothe carina Other A catheter passes through the cervix and terminates inthe uterus. Medical intervention other: Injuries associated with cardiopulmonary resuscitation attempts include multiple, bilateral, anterolateral rib fractures and scattered contusions on the central chest. A pulse oximeter monitor is on left hand ECG Monitoring Pads Present?: ECG Chest Pade: ECG abdomen pads: Other pads comments: Defirilator pads present: Left Lower outer chest: Back: Vascular eatheters): Right internal jugular von Right femoral vein Posterior aspect fright hand: Let antecubitl fossa: Posterior aspect of left hand: Mest nterventon Electrocatdiogram (ECG) Monitoring Pads Yes Yes Defibrtator Pads Yes Yes Vascular Catheter(s) Paget Pinot Sz017 13131 PA Death investigation Report page 8 of 26, Case Number: 2017-00704 Medical Intervention Vascular catheters) comments ‘An additional vascular eatheter is in the right arm. Recent Surgical Intervention Evidence of recent surgical No Intervention Roport Tracking Reported by: Rebecea Asch-Kendrick, MD Veriied by: Lauren E Dvorscak, MD on 5/25/2017 9:49:21 AM Reviewed and approved by: Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM ec nevenion Page 2 Death investigation Report page 9 of 26 rine 8252017 13132 Case Number: 2017-00704 Medical Investigator Lauren E Dvorscak, MD External exam date: Body temperature: Lvor ments = atlon (applicable Liver mots (applicable) Livor ments blanching and patterns (i applicable): Postmortem Changes Medical Investigator Trainee Rebecca Asch Kendrick, MD 2/4/2017 9:13:00 AM Cool subsequent to reftigeration Fully fixed Purple Fully Fixed. Both anterior and posterior ‘The head, neck, and upper chest are congested State of preservation: Reported by: Verified by: Reviewed and approved by: Postma Change No decomposition Report Tracking Rebecea Asch-Kendrick, MD Lauren E Dvorscak, MD on 25/2017 9:59:24 AM Lauren E Dvorak, MD on 5/28/2017 1:31:28 PM Page 1 Death Investigation Report page 10 of 28 Pinte 862017 12432 PM Case Number: 2017-00704 Evidence of Inury ——. Maia ovessgtr Medical investor Tee Lawen€Dvowcak MD Rebeca Asch Kendik, MD Avatar ay jt Yes iden nig Atopy cate: 24/2017 9:13:00 AM uy Lecaon inury Description 1 Blunt injury Eaeaiies Scattered 0.1 -0.4 em, purple contusions ae on the upper and lower extremities. Report Tracking Reported by: Rebecca Asch-Kendrick, MD Verified by: Lauren E Dvorscak, MD on 5/25/2017 9:59:56 AM Reviowed and approved by: Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM idee jury Page1 Pinas 5250047 13132 Death Investigation Report page 11 of 26 Case Number: 2017-00704 Internal Examination — Medical Investigator Medical investigator Trainee Lauren E Dvorscak, MD Rebecea Asch-Kendrick, MD. Date of Autopsy: 2182017 9:13:00 AM Date of ternal Exam: 2/4/2017 9:13:00 AM ‘BODY CAVITIES Chest cavities examined: Yes ‘See evidence of injury section No (Organs in normal anatomic Yes postion Other organ position comments Diaphragm: Intact Serosal surfaces: ‘Smooth and glistening Body cavity adhesions present No Fiuld accumulation present: Yes Fluid accumulation ight chest Yes avi: Fluid accumulation left chesteavity Yes Fluid accumulation pericardial sac: No Fluid accumulation abdominal Yes caviy: Fluid accumulation pelvis: Yes Fluid accumulation comments: Left chest - 600 mL. serous uid Right chest - 600 mL serous fluid ‘Abdomen and pelvis - 100 mL bloody fluid HEAD Brain examined: Yes ‘See separate forensic No neuropathology consultation report See evidence of injury section: No See evidence of medial No Intervention section: See postmortem changes section: No Brain fresh (gh: 11ss Brain xed (g): Facial skeleton: No palpable fractures Calvatum: No fractures ‘Skul base: No fractures ‘Skull comments Dura mater: Unremarkable and without masses Dural venous singuses: Patent Leptomeninges: ‘Thin and transparent nema Examination Paget ‘Death investigation Report page 12 of 26 PM case Number: 2047-00704 Internal Examination Epidural hemorrhages hematomas: ‘Subdural hemorrhages hematomas: Subarachnoid hemorrhag Cereal hemispheres: (Gyral and sucal pattems: {yal convolutions and sul: Uncal process: ‘cerebellar tosis: Cranial nerves: Basilar arterial vasculature: (cerebral cortex: White matter: (Corpus callosum: Deep gray matter structures: Brainstem: ‘cerebellum: ‘Spinal cord examined: Mile ears examined: Neck examined: ‘See Evidence of Inury section: ‘See Evidence of Medical Intervention section ‘See Postmortem Changes section: ‘Subcutaneous soft tissues: ‘Strap muscles: Jugular vein: ‘Carotid artres: Tongue: Epiglottis: Hyoid bone: Lary Platine tonsils: Heart examined: See separate Cardiovascular Pathology report: See Evidence of Injury section: See Evidence of Medical Interveation section: Ina Exsmiston Absent Absent Absent Symmetrical Unremarkable No widening or flattening of gyri and no narrowing of sulci Unremarkable ‘Unremarkable Unremarkable Unremarkable ‘Unremarkable ‘Unremarkable Unremarkable ‘Unremarkable ‘Unremarkable ‘Unremarkable Spinal Cord No Middle Ears No Yes No No No Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Unremarkable Not examined ‘CARDIOVASCULAR SYSTEM Yes No Pag Death Investigation Roport page 19 of 26 ina 9252017 13133 4 Case Number: 2017-00704 Internal Examination — See Postmortem Changes section: No Hoar Rightcoronaryoatum postion: Normal Ltt coronary otum position: Normal Supply ofthe posteioe Right coronary artery myocardium: Heart rsh (g 2900 Heart ed (gh Coronary ater stenosis by atherosclerosis (perce) Right coronary ostium: 0 Proximal thd ight coronary 0 rey: Wide thid ight coronary atey: 0 Distal thd ght coronary atary: 0 Left coronary ostium: ° Lat main coronary ater: ° Proximal third et anterior ° descending coronary artery ide thied et anterior ° descending coronary artery: Distal third left anterior descending — 0 coronary artary: Proximal third ot lecuflex o coronary artery Middle tid left circumflex o coronary artery: Distal third leftcrcumflex coronary 0 artery: ‘Cardiac Chambers and Valves: cardiac chambers: Unremarkable ‘Tricuspid valve: Unremarkable Pulmonie valve: ‘Unremarkable Mitral valve: Unremarkable Aortic valve: Unremarkable Other valve comments: Circumferential valvular measurements ere as follows: Tricuspid valve = 11 em Pulmonic valve = 5 em. Mitral valve = 8.5 em Aone valve = 6m Right ventricular myocardium: No fibrosis, erythema, pathologic infiltration of adipose tissue or areas of accentuated softening oF induration Left ventricular myocardium: No fibrosis, erythema, or areas of accentuated softening or induration Ail sptum: Other - See comments Ventricular septum: Unremarkable ‘ther septal comments Inara Examination ges Pinta S017 #389 FAL Death investigation Report page 14 of 26, Case Number, 2017-00704 Internal Examination — ‘The foramen ovale is probe-patent. Right ventricular fre wall 0.2m thickness: Left ventricular free wallthickness: 0.8m Intervetricuar septum thickness: 0,8 cm ota ‘ora examined: Yes Orices ofthe major vascular Patent branches: Coaretation No ‘Vascular dissection: No ‘Aneurysm formation: No Complex atherosclerosis: No Other aortic pathology: No Vena Cava Great vessels examined Yes Vena cava and major tbutar Patent [RESPIRATORY SYSTEM Lungs examinee: Yes ‘See separate Cardiovascular No Pathology report ‘ee Evidence of Inury section: No ‘See Evidence of Medical No Intervention section: ‘See Postmortem Changes section: No Lung Fight): ns Lung tet 950 Upper and lower airways: Unobstructed, and the mucosal surfaces are smooth and yellow-tan Pulmonary parenchyma color: Dark red-purple Pulmonary parenchyma congestion Slight amounts of blood and frothy fuid and edema Pulmonary trunk: Other - See comments Pulmonary atary thrombi: Other - See comments Pulmonary artery atherosclerosis: None Other siway and lung comments: Bilateral organizing blood clots occlude the pulnonary artery vasculature. A true saddle embolism is not detected, however the the blood clots extend from the hilum of both the right and left lungs, into the peripheral vasculature and are partially adherent tothe arterial walls. HEPATOBILIARY SYSTEM Liver examined: Yes ‘See Evidence of Injury section: No See Evidence of Medical No Intervention section: ‘See Postmortem Changes section: No ba xaninaton Page 4 Pied 782017 131.39 FH Death Investigation Report page 15 of 25 ese Number: 2047-00704 Liver (a Bile vol (mt: Gallstones autopsy: Gallstones autopsy dese: Hepatic parenchyma (color Hepatic parenchyma (texture): Hepatic vasculature: Gallbladder: Galetones: Intrahepatic ilar tre: Extrahepatic ily tree: ‘Alimentary tact examined ‘See Evidence of Injury section: See Evidence of Medical Intervention section: See Postmortem Changes section Stomach contents vol (i) ‘Stomach contents description: brown liquid ‘Appendix found: Cours: Mucosa: Pylon: Lurminaleont Mucosa: Caller and continuity: Lumina contents: Mucosa: Caliber and continuity: For: Genitourinary system examined: See Evidence of Injury section See Evidence of Medical Intervention section: ‘See Postmortem Changes section: rat Eatin Internal Examination a 1675 No Reé-brown ‘Unremarkable Unremarkable and free of thrombus ‘Unremarkable None ‘Unremarkable Unremarkable ‘GASTROINTESTINAL SYSTEM Yes No No No 10 Yes Esophagus Normal course without fistulae Gray-white, smooth and without lesions Stomach ‘Usual rugal folds Patent and without muscular hypertrophy ‘Sal lntestne Partially digested food Unremarkable Appropriate caliber without interruption of luminal continuity Colon Formed stool Unremarkable Appropriate caliber without interruption of luminal continuity Pancreas "Normal tan, lobulated appearance ‘GENITOURINARY SYSTEM Yes No Yes No Page 5 Pinte 9252017 19138 MR Death invesigaton Roport page 16 of 26, se Number: 2017-00704 Internal Examination a Kidneys Kidneys capsules: ‘Thin, semitransparent Conical surfaces: ‘Smooth Contices: ‘Normal thickness and well-delineated from the medullary pyramids Calyces, pelves and ureters: [Non-dilated and free of stones and masses Kidney right (: 170 Kidney ie (g: 190 Urine volume (mt): 0 sine deserption: Urinary Blader Urinary bladder mucosa: Gray-tan and smooth Female Female: Yes Breasts Broast tissue: Usual fibrous and adipose mixture Breast tise comments: Female Gontal Tract Uterus: ‘Other - See comments Uterine cervix: Unremarkable Folloplan tubes: Unremarkable Ovaries: Unremarkable Vagina Unremarkable Other female genital tract, comments “The intact uterus is bogey and enlarged. The endometrial surfaces are red-tan and irregular. Medical intervention isin place. RETICULOENOOTHELIAL SYSTEM Reticulendthalal system Yes examined ‘See Evidence of Injury section: No ‘See Evidence of Medical No Intervetion section ‘See Postmortem Changes section: No Spleen Spleen (a: no ‘Spleen parenchyma: Moderately firm ‘Spleen capsule: Intact ‘Spleen whit pul Prominent Bone Marrow Color: Red-brown, homogeneous and ample Lymph Nodes Regional adenopathy No adenopathy Thymus tora Examination Pages Pred: 9201713138 Pl Death investigation Report page 17 of 26, Case Number: 2017-00704 Internal Examination a ‘Tyr Parenchyma Endocrine system examine: ‘See Evidence of Injury section: See Evidence of Medical Intervention section: ‘See Postmortem Changes section: Position Size: Parenchyma: ‘Adrenal ight): ‘Arona lef (9 Size: Paronehyma Other adronal gland comments: Absent (involution by adipose tissue) ENDOCRINE SYSTEM Yes No No No Pituitary Gland Normal “Thyroid Gand Normal Normal Homogeneous ‘Adrenal Glands 10 1s Normal Other - See comments ‘The right adrenal is unremarkable. The left adrenal gland demonstrates hemorthagic parenchyma ‘Musculoskeletal systom examined: ‘See Evidence of Injury ect See Evidence of Medical Intervention section ‘ee Postmortem Changes section: Bony framework: Musculature: Subcutaneous sof tissues: MUSCULOSKELETAL SYSTEM Yes No Unremarkable ‘Unremarkable Unremarkable ‘ADDITIONAL COMMENTS Received separately is placenta and produets of conception ‘The products of conception includes disrupted, variably identifiable fetal parts. ‘The placenta consists ofan overall, unremarkable, intact dise with <10! ‘maternal surface infarction, There is no evidence of purulence on either the maternal or fetal surface. No evidence of placental abruption ison the maternal surface, ‘The umbilical cord is trivascular Reported by: Verified by Reviewed and approved by: nama Exeminaton Repot Tracking Rebecca Asch-Kendrick, MD Lauren E Dvorscak, MD on 52572017 9:61:14 AM Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM Page7 Pitot 252017 13153 Death investigation Report page 18 af 26 case Number: 2047-00704 Internal Examination —— Prat S017 1339 PM neal Extn Pag Death Investigation Report page 19 of 26 (Case Number 2017-00704 Microscopy Medical Investigator ‘Lauren E Dvorseak, MD Medical Investigator Trainee Rebecca Asch-Kendrick, MD Microscopic description: Hear: no significant histopathologic diagnosis Lungs: Organizing thrombi in large and smal vessels bilaterally histologically composed of layered fibrin admixed with erytnocytes and leukocytes into characteristic "nes of Zahn"; no definitive evidence of fetal squamous cells or mucin (AEV/AE3 stain), acellular proteinaceous debris and fluid within alveoli; abundant alveolar macrophages Kidney: fibrin thrombi within glomerular vasculature ‘Adrenal: predominately conical extnvasation of erythrocytes Liver: no significant histopathologic diagnosis Uterus: exuberant neutrophilic exudate on endometrial surface; arias-stella reaction Cervix: dilated vascular spaces within cervical stroma associated with interstitial erythrocytes and neutrophils Placenta: abundant acute inflammation associated with maternal surface Products of conception: Fetal pats identified “Unless otherwise indicated sections are stained only with hematoxylin and eosin (H&E). Block Tissue Location Description Stain AL Uterus A2 Uterus and cervix A3 Heart, liver and left adrenal Ad Right lung AS Leftlung A6 Kidneys, left and right AT Brain, hippocampus AS POC A9 Placenta Report Tracking Reported by Rebecca Asch-Kendsick, MD Vetfied by: [Lauren E Dvorseak, MD on 5/25/2017 1:07:46 PM Reviewed and approved by: [Lauren E Dvorseak, MD on 5/25/2017 1:31:28 PM Marecone Paget Price: 7801713130 Po Death investigation Report page 20 of 26 Caso Number: 2017-00704 Ancillary Lab as Medica Investigator Lauren E Dvorscak, MD ‘Autopey date ‘Study type(s Resuits of ancilary studies: Microbiology cultures: Medical Investigator Trainee Rebecca Aseh-Kendrck, MD 2/4/2017 9:13:00 AM Microbiology cultures Uterine swab (A): few Aerococcus species Uterine tissue (A): no growth on aerobic culture rare Dialister micraerophilus isolated on anaerobic culutre Uterine swab (B): rare Aerococcus species Uterine tissue (B): no growth on aerobic culture, rare growth of Aerococcus species on anaerobic culture Heart blood: Klebsiella oxytoca, Citrobacter species, Streptococeus anginosus, Streptococcus salivarius group, Streptococcus, alpha, not entero- or pneumo-coccus Lung, right: moderate growth Streptococcus, alpha, not entero- or pneumo-coccus, few Streptococcus salivarius group, rare Streptococcus anginosus Lung, left: moderate growth Streptococcus salivarius group, moderate growth Streptococcus alpha, not entero- or peumo-corcus Reported by: Verified by Reviewed and approved by: Posty Lb Stes Repot Tracking Rebecea Asch-Kendrick, MD Lauren E Dvorseak, MD on 5/25/2017 10:08:45 AM Lauren E Dvorscak, MD on 5/25/2017 1:31:28 PM Page 1 Prot 8282017131347 oath investigation Roport page 21 of 26 Case Number: 2017-00704 Procedural Notes ae ‘case Number 2017-00704 Decedent Name: — Pathologist: Lauren E Dvorseak, MD FollowResident: Rebecca Asch-Kendick, MD Date of Examination: 2/4/2017 9:13:00 AM Morphology tecnican(s) present Yellow Sheet ‘Morphology Techni ‘Angeles Macstas ‘Attendees " Angelea Maestas Identification ‘Angeles Macstas ‘Autopsy Angelea Maestas Evidence Angelea Maestas Evidence Angelea Maestas Radiology Angelea Maestas Retention ‘Angelea Maestas Morphology tecnicansupervisor(s) present Yellow Sheet Morphology Technician Lead Identification Brandon Phinney Autopsy Kimberly Marquez Evidence Brandon’ Phinney Radiology Brandon Phinney Retention Brandon Phinney Labother (Cassandra Toledo Attendees Brandon Phinney Prout Notes Rept Page t Ponat S52017 13:25PM Death investigation Report page 22 of 26, Case Number: 2017-00704 Procedural Notes —— ‘Autopsy attondees ‘Other morphology technicians present: Daria Koehlert-Student Tech Prowl Nets Ropar Page2 Pine 8252047 13128 Death Investigation Roport page 23 of 26 Case Number: 2017-00704 Procedural Notes ae ‘Specimens obtained fr laboratory testing HIV serology: No HIV spin and store: Yes HCVIHBV serology No Influenza serology: No Other serology: No Freezer protoco! No DNA card Yes Metaboicsereen: No cytogenetics: No MedX protocol: No Urine dipstick: No Blood cultures (bacterial) Yes Lng cultures (bacterial No (SF culture (bacteria) No ‘Spleen culture (bacteria No ‘Stool culture (bacterial): No ther bacterial culture (spect) x2 Uterine tissue(A,B) x2 Uterine swabs(A,B) Mycobacterial culture (ung) No Mycobacterial culture (ther No Viral Cutures: No ‘Approach to autopsy dissection Rokitanshyevisceration: Yes Virchow evisceration: No Mosifed evscertion: No Proce Netes Repat Page 3 Pons S252017 13138 PM ‘Death investigation Report page 2 of 25, Case Number: 2017-00704 HIV serology: Pereranial membrane removal: Neck anterior dissect Neck posterior dissection: Facial dissection: Vertebral artery dissection in st) Cereal spine removal: Layered anterior trunk dssection Anterolatra bare dissection: Back dissection: Posterior rib are dissection: Extremity soft tissue dissection: Eye enucleation: Inner middle ear evaluation: Maxila or mandible resection: ‘Spinal cord removal (antrot ‘Spinal cord removal (posterior) Other dissections): ‘Stock ar with standard issue retentior Rib sogment Pituitary gland Breast tissue (women on Brain retention: Spina cord retention: Cervical spine retention: Heart retention: HeartJung block retention: Rib cage retention Long bone retention: Other retenton.specty: ‘Specimen outcome: Prowl Nate Report Procedural Notes — i Special autopsy techniques No No No No No No No No No No No No No No No ‘Tiesues retention Disposition of tissues retained for extended examination Not applicable; no tissues were retained for extended examination. Pages Pn S282017 13135 Death Investigation Report page 25 of 26 cave Number: 2017-00704 Scene Photo: ‘Autopsy Photos: FBI blood tube: Blood spot card ‘APD blood cad Thumbprint: Fingerprints: Palmorints: Print hol Oral swab: ‘Vaginal sv: ‘Anal eva: Other swab: Fingerais: Scalp hair Pubic hair: Puble hair combi Projectiles) Retain clothing Retain valuable Retain trace evidence: Retain body bag Retain hand bags: Ligature: Other evidence retain: Property Type Valuables Valuables Property Type Clothing Clothing CClthing Clothing Prossiai Noles Rep, Procedural Notes — Number of scene photos produced by the OMI Number of autopsy photes produced by the OMI 26 Evidence collected Personal effects Property Description Property Detail Hair te nla Misc Body Jewelry la Clothing Property Description Property Detai Hat la Shir ia Gloves nla Blanket or Shoot ola ge 5 Printed Sano 13135 PM Death investigation Report page 26 of 25 NMS Labs ‘3701 Welsh Road, PO Box 439A, Wilow Grove, PA 19090-0437 Phone: (218) 657-4900 Fax: (215) 657-2972 [=scAnseen ‘ema: nms@nmsabs. com Robert A Middleberg, PRD, F-ABFT, DABCC-TO, CONFIDENTIAL aboratory Director Toxicology Report Patient Name AS Patient ID 2017-00704 Reportlssued 04/10/2017 15:01 Ration zara Age23Y 10 zn Gender Female To: 20164 New Mexico Office of Medical Investigators Workorder 27099868 ‘Attn; Yvonne A, Villalobos cD 1101 Camino de Salud NE- Ste B Albuquerque, NM 87105 Positive Findings: |Compound Result Units Matrix Source Oxycodone - Free 28 ngiml ‘001 -Antemortem Blood Oxymorphone - Free 40 ngimL ‘004 -Antemortem Blood ‘See Detaled Findings section for additonal information Testing Requested: ‘Analysis Code Description Do Postmortem, Basis, Blood (Forensic) Specimens Received: 1D TubelContainer Volume! Collection Matrix Source Miscollaneous Mass Date/Time Information O07 Cavender Vii Zink. Oa]0SOVT W70S —Ariemoriam Blood 002 Bue Vial 25ml 021032017 17-08 _Antemortem Blood 003 Fol Top Vial 325ml 021032017 17:08 Antemortem Blood ‘All sample volumes/weights are approximations Specimens received on 03/31/2017, NMS v.16.0 NMS woe Page 20f3 Detailed Findings: Rpt. Analysis and Comments Result Units Limit. Specimen Source Analysis By (Oxycodone - Free’ 38 ‘agit. 50 (001-Antemortem Blood LC-MS/MS Oxymorphone - Free 10 glmL. 10 (001 -Antemortem Blood LC-MS/MS Other than the above findings, examination of the specimen(s) submitted did not reveal any positive findings of ‘toxicological significance by procedures outlined in the accompanying Analysis Summary. Reference Comments: 1. Oxycodone - Free (OxyContin; Roxicodone®) - Antemortem Blood: Oxycodone is a DEA Schedule Il controlled semi-synthetic narcotic analgesic. Its used to control pain associated with such ailments es bursts, injuries, simple fractures and neuralgia. The addiction liability of ‘oxycodone Is about the same as for morphine. This compound should be administered inthe smallest effective ‘dose and as infrequently 28 poselbie, The usual adult dose of the hydrochlorie salts § mg every 6 hr. Following the oral administration of oxycodone as both sustained-rolease (Oxycontin®) and regular formulations, peak plasma concentrations of the compound are generally less than 100 ngimL; however, the sustained-reiease preparation may also result in peak concentrations of oxycodone less than 10 ng/mL serum. ‘Oxymorphone is @ pharmacologically active metabolite of oxycodone that may be seen in blood in very low concentrations. In overdose, oxycodone can produce stupor, coma, muscle flaccdity, severe respiratory depression, hypotension and cardiac arrest, In twelve oxycodone-related deaths, blood concentrations averaged 1600 !ngiml. (range 240 to 8400 nglmL), However, sustained-release preparations appear to produce adverse reactions, up to and including death, at concentrations of oxycodone well below 1000 ngimiL, especially in ‘combination with other central nervous system depressants, depending on use pattern and route of ‘administration. 2. Oxymorphone - Free (Numorphan®; Opana®; Oxycodone Metabolite) - Antemortem Blood ‘Oxymorphone is @ Schedule II semisynthetic opioid analgesic. It's indicated for use inthe relief of moderate to severe pain and as a preanesthetic medication. The compound may be administered by injection or by mouth (Oral preparations are available as immediate-release tablets (5 of 10 mg) and as extended-release tablets (5 to 40 mg), Oxymorphone is also a pharmacologicaly active metabolite of oxycodone. ‘The mean oral bioavailabilty of oxymorphone is approximately 10%. The compound is extensively metabolized by reduction to 6-axymorphal and conjugaton to oxymorphane glucuronide and oxymorphone sulfate Approximately 50% of an oral dase of axymorphone is eliminated in the urine over § days primarily as, ‘conjugated oxymorphone and smaller amounts of free oxymorphane and free and conjugated &-oxymorphl. ‘The mean elimination hal-life of oxymorphone is approximately 7.6 to 95 hours. ‘Thity minutes folowing a single 5, 10, or 20 mg immediste-elease tablet, mean peak plasma concentrations were 1.1, 1.9 and 4.4 nglml, respectively. Twenty mg extended-release tablets given every 12 hours for 3 days. resulted in a mean peak plasma concentration of 2§ ngimL within 3.5 hours folowing the last dose, Doubling the dose to 40 mg increased the mean peak plasma concentration to 4.6 ng/mL, ‘Adverse effects of exymorphone ae typical of the opioid group of compounds. Peripheral blood concentrations in 20 oxymorphone related fatalities ranged from 30 to 120 ng/ml. ‘Sample Comment 001 _PhysicianvPathologist Name: Rebecca Asch-Kendrick MD/Lauren E Dvorscak MD ‘Chain of custody documentation has been maintained forthe analyses performed by NMS Labs. Uniess alternate arrangements are made by you, the remainder of the submitted specimens will be discarded six (6) weeks ffom the date ofthis report, and generated data will be discarded five (5) years from the date the analyses were performed, NMS v.16.0 CONFIDENTIAL Workorder_—_+7099868 NMS Chain 74405 Patent 2017-00704 Page 3 of 3 Workorder 17089888 was electronically signed on 04/10/2017 14:15 by: Wither th Ambuon William H. Anderson, Ph.D, F-ABFT Forensic Toxicologist Analysis Summary and Reporting Limits: All ofthe following tests were performed for this case. For each test, the compounds listed were included in the scope. The Reporting Limit listed for each compound represents the lowest concentration of the compound that will be reported as being positive. Ifthe compound is listed as None Detected, its not present above the Reporting Limit. Please refer tothe Positive Findings section ofthe repor for those compounds thet were identified as being present, ‘Acode 500168 - Opiates - Free (Unconjugated) Confirmation, Blood (Forensic) -Antemartem Blood Analysis by High Performance Liquid Chromatography! TandemMass Spectrometry (LC-MS/MS) for: Compound ot Limit ‘Compound ‘Bot Limit @-Monoacetyimorphine - Free 4.0 ngimt Hydromorphone - Free 1.0 ngimt. Codeine - Free SO ngimt. Morphine - Free 5.0 ngimt Dinydrocodeine / Hydrocadol-Free 5.0 ngimt Oxycodone - Free 5.0 ngimt Hydrocodone - Free 50 ngimL ‘Oxymorphone - Free 1.0 ngimt ‘Acode 621988 - Cannabinoids Confirmation, Bioad (Forensic) -Antemortem Blood Analysis by High Performance Liquid Chromatography! ‘TandemMass Spectrometry (LC-MSIMS) for: Compound Rot Limit Compound Bot Limit ‘1-Hydroxy Delte-9 THC 4.0 ngimt Detta-9 THE 0.50 agit. Delta-2 Carboxy THC 5OngimL, ‘Acode 60518 - Postmortem, Basic, Blood (Forensic) -Antemortem Blood Analysis by Enzyme-Linked Immunasorbent Assay (ELISA) fer ‘Compound ‘Bot. Limit Compound Rot Limit ‘Amphetamines 20 agit. Fentanyl / Acetyl Fentanyl 0.50 ngimt. Barbiturates 0.040 megimt. Methadone / Metabolite 25 ngimL. Benzodiazepines 100 ngimi. Methamphetamine / MDMA 20 ngimL. Buprenorphine / Metabolite 0.50 ng/mL, Opiates 20 ngim Cannabinoids 10 ngim. ‘Oxycodone / Oxymarphone tongimt. Cocsine / Metabolites 20 ngimt. Phencycidine 10rgimL Analysis by Headspace Gas Chromatography (GC) for ‘Compound Bot Limit ‘Sompound Rot Limit ‘Acetone 5.0 mgldL |sopropano! SOmgiat Ethanol tomolct, Methanol 5.0 mglal NMS v.16.0