Broward County Medical Examiner 5301 SW 31* Avenue Fort Lauderdale, FL 33312 NAME: Fitzsimmons, Jason ME CASE NO.: 18-1016 SEX: Male DATE OF AUTOPSY: April 2, 2018 RACE: White TIME OF AUTOPS' 0900 Hours AGE: 42 Years EXAMINER: Wendolyn Sneed, MD DOD: April 1, 2018 Associate Medical Examiner Circumstances of Death: This man with history of an injury, upper respiratory tract infection, anxiety and sleep apnea was found deceased at his place of residence. Authorization for Autopsy: Florida Statute 406 Identification: By Police/Driver’s License Cause of Death: Combined toxic effects of hydrocodone, alprazolam, dextromethorphan and doxylamine Manner of Death: AccidentFitzsimmons, Jason April 2,2018 0900 Hours 18-1016 EXTERNAL EXAMINATION The body is that of a white male that measures 76 inches in length, weighs 224 pounds, and appears consistent with the reported age of 42 years. The body is well-preserved and cool to touch. Rigor mortis is fully developed in the extremities and jaw. Pink fixed lividity is on the posterior surfaces of the body, except for areas exposed to pressure. Pink, fixed lividity is also on the anterior surfaces of the body. An appropriate toe tag is bound to the left great toe. The head is without deformities. ‘The scalp has a full crop of short, brown-gray hair. ‘The irides are blue, The pupils are equal and intermediate in size. The sclerae and palpebral conjunctivae are devoid of hemorrhages. The nasal bridge is midline. The nasal bones are devoid of palpable fractures. The nasal septum is without perforation or deviation. The ears are free of deformities. ‘The extemal auditory canals are without blood or fluid collections. Two piercings are on the left carlobe. The lips and frenula are symmetric. The oral mucosa is atraumatic. ‘The teeth are native and in fair repair. ‘The neck is grossly straight and without palpable masses. The chest and back are symmetric. Patches of hypopigmented skin are on the chest. The abdomen is flat. ‘The penis is circumcised and devoid of trauma, neoplasm or lesions. ‘The testicles are descended into the scrotal sac. Acne ison the back. The anus is devoid of trauma or neoplasm. Tattoos of the torso are photographically documented. The upper and lower extremities are symmetric, normally developed and without track marks, palpable fractures or edema. Round sears are on the right deltoid region. Linear scars are on the dorsal aspect of the left forearm and the right knee. There is no absence of fingers or toes. The nails are short and kempt, Tattoos of the extremities are photographically documented, CLOTHING & PERSONAL EFFECTS ‘The body is received clad in blue shorts and white and blue underwear, EVIDENCE OF INJURY A 0.3-centimeter abrasion is on the posterior surface of the right helix. ‘The inferior aspects of the bilateral sternocleidomastoid muscles, and the subcutaneous tissues overlying the head of the sternum are hemorrhagic. ‘The right third toe is contused. EVIDENCE OF THERAPY A total of four electrocardiograph pads are on the chest and thighs. RADIOGRAPHS Full body radiographic images are taken to reveal no osseous trauma.Fitzsimmons, Jason April 2, 2018 0900 Hours 18-1016 INTERNAL EXAMINATION BODY CAVITIES and MUSCULOSKELETAL SYSTE] ‘The body is opened by a Y-shaped incision and the chest plate is removed. Injuries of the torso have been previously described; otherwise the chest wall and abdominal walls are unremarkable, The muscles are well developed and glistening. There are no fractures of the clavicles, stemum, vertebrae, or pelvic bones. The stemum has a mild concave shape. The pericardial sac is intact and contains a physiologic amount of clear, serous fluid. The pleural and peritoneal cavities are lined by glistening, smooth membranes and are devoid of adhesions, plaques, fluid or neoplasm, The diaphragm is symmetric and intact. The mesentery and omentum are devoid of injury or neoplasm. ‘The intemal organs are within their usual positions HEAD: (Central Nervous System) The reflected scalp is devoid of injury; petechial hemorrhages are on the occipital scalp. The calvarium and skull base are intact, devoid of deformities, and discolored yellow. ‘The dura mater and falx cerebri are intact and devoid of neomembranes or discoloration. ‘There are no epidural, subdural, or subarachnoid hemorthages. ‘The leptomeninges are thin and translucent. ‘The brain is 1,760 grams and has symmetric cerebral and cerebellar hemispheres. The gyri are flattened and the sulei are narrowed. ‘The brain has no scar, hemorrhage, or neoplasm. The ventricles contain clear cerebrospinal fluid. The gray matter-white matter junction is well demarcated. The midbrain, brain stem, and proximal spinal cord have no abnormalities. The pituitary gland sits normally on the sella tureiea. The atlanto-occipital joint is stable. NECK: ‘The subcutaneous tissues and muscles of the anterior neck are well hydrated and devoid of injury, other than as previously described. The thyroid cartilage and hyoid bone are intact. ‘The thyroid gland has a homogenous brown parenchyma and is without neoplasm or hemorrhage. The larynx is devoid of injury or neoplasm. The cervical spine is without trauma. The cervical vessels are ‘not unusual. CARDIOVAS LAR SYSTEM: The heart is 480 grams. The epicardial surface is smooth, glistening and invested by normal adipose tissue. The coronary arteries arise from patent and normally situated ostia and follow a right dominant distribution; they are devoid of atherosclerosis. The myocardium is without scar, hemorrhage, or necrosis. The right and left ventricular free walls are 0.4-centimeter, and 2.1- centimeters in thickness, respectively. The interventricular septum is 2.0-centimeters in thickness. ‘The endocardium is without thrombus or neoplasm. The superior and inferior vena cavae are engorged by liquid blood and devoid of thrombi or neoplasm. The aorta branches in the usual fashion and has a smooth intimal surface.Fitzsimmons, Jason April 2,2018 0900 Hours 18-1016 RESPIRATORY SYSTEM: The right and left lungs are 1,150 grams and 960 grams, respectively. ‘The pleural surfaces are smooth and glistening. The pulmonary parenchyma is diffusely congested, edematous, and without cysts, hemorrhage, necrosis, neoplasm or suppuration. The branches of the pulmonary artery are devoid of thromboemboli. The tracheobronchial tree is patent, devoid of foreign objects and contains frothy fluid. HEPATOBILIARY SYSTEM: ‘The liver is 2,030 grams. ‘The capsule is smooth, and the parenchyma is pale brown, congested and without hemorrhage, neoplasm, or scar. The gallbladder contains 15 milliliters of brown bile and is, devoid of calculi. ‘The mucosal surface is brown and velvety. ‘The porta hepatis is intact. GASTROINTESTINAL SYSTEM: The tongue has no bite mark, neoplasm, or scar. The esophageal mucosa is congested and without neoplasm or varices; superficial ulcers are throughout the esophagus. The gastric serosa is smooth, and the mucosa has normal rugal folds. The stomach contains an estimated 700 milliliters of fluid and is devoid of intact pills. The intestines have glistening serosal surfaces and are devoid of constrictions, dilatations, palpable masses, volvuli, diverticula, or intussusceptions. The appendix is ‘grossly normal in the usual position. The rectal mucosa is intact, ‘The intestines contain well-formed, brown fecal matter. GENITOURINARY SYSTEM: ‘The right and left kidneys are 250 grams and 230 grams, respectively. The surfaces are smooth and retract with ease from their respective capsules. ‘The parenchyma is congested and without neoplasm, hemorrhage, or scar. A large, smooth walled cyst ison the lower pole of the right kidney. The calyces, elves, and ureters are without dilatations, calculi, or neoplasm. The ureters course normally into the urinary bladder. The urinary bladder is distended by a measured 110 milliliters of clear, yellow urine; the bladder mucosa is tan and smooth. The prostate gland is tan and without nodules, hemorthage, corneoplasm. The testicular parenchyma is tan and unremarkable. RETICULOENDOTHELIAL SYSTEM: ‘The spleen is 250 grams. The splenic capsule is smooth, and the parenchyma is maroon and without neoplasm, hemorthage, or sear. The regional lymph nodes are inconspicuous. ENDOCRINE SYSTEM: ‘The pancreas is tan-pink and has a normal lobular architecture; it is congested and without hemorrhage, saponification, or neoplasm. The adrenal glands are soft, and have yellow cortices, brown medullae and are without hemorthage, neoplasm, or scar.Fitzsimmons, Jason April 2, 2018 0900 Hours 18-1016 MICROSCOPIC EXAMINATION: Selected portions of each organ are retained in formalin without preparation of histologic slides. ADDITIONAL PROCEDURES: 1. Documentary photographs are taken by: Ms. Megan McPherson 2. Additional personnel preser . Specimens retained for toxicology testing and/or DNA identification are: Vitreous fluid, bile, peripheral blood, brain, gastric contents, liver, serum, urine and a DNA blood card. Forensic Technician: Mr. Glen Yerich The dissected organs are released with the body. Additional specimens retained as evidence by OMETS: None Evidence retained by OMETS: Fingerprint card Evidence submitted directly to law enforcement: None Personal effects are released with the body. Sen as AUTOPSY FINDINGS: 1 Cerebral edema. I. Pulmonary congestion and edema. UL. Left ventricular hypertrophy, heart. IV. Yellow discoloration of the calvarium. V. Superficial esophageal ulcers. VI. Blunt trauma: a. Abrasion of right helix. b. Focal hemorrhage of subcutaneous tissues of upper chest and lower aspects of the sternocleidomastoid muscles. ©. Contusion of right third toe. VIL. Toxicolo, Blood (peripheral) GC/MS Alprazolam Positive Blood (peripheral) GC/MS Cyclobenzaprine/TCA None detected Blood (peripheral) GC/MS Dextromethorphan Positive 0.81 mg/L Blood (peripheral) GC/MS Doxylamine Positive 0.22 mg/L Blood (peripheral) GC/MS Cocaine/Metabolites None detected Blood (peripheral) GC/MS Hydrocodone Positive 0.14 mg/L Blood (peripheral) LC/MS/MS Alprazolam Positive 19 ng/mL. Blood (peripheral) HSGC/FID Ethanol None detected Urine GC/MS Cocaine/Metabolites None detected Urine GC/MS Hydrocodone P Urine A Benzodiazepines PositiveFitzsimmons, Jason April 2,2018 0900 Hours 18-1016 Urine LA Opiates Positive Urine LA Cyclobenzaprine/TCA Unconfirmed positive Vitreous HSGC/FID Ethanol None detected OPINION Per investigation Mr. Fitzsimmons was found unresponsive on his sofa by his gielftiend. EMS ‘was summoned and he was pronounced dead at the scene. Multiple prescribed medications, as well as supplements, growth hormone, and anabolic steroids were present at the scene. Reportedly he was also prescribed antibiotics and cough syrup for an upper respiratory tract infection. ‘The hydrocodone/homa medication was found on a table next to the sofa. It was prescribed one day prior to his death and appeared to have been consumed at an accelerated pace. Medical records from four treating physicians were requested on multiple occasions and not provided for clinicopathologie correlation. However, one of the prescribing physicians was contacted via phone and he indicated to the investigator that based on the insurance documents, Mr. Fitzsimmons appeared to be “doctor shopping.” The autopsy fails o reveal a catastrophic natural event, gross evidence of pneumonia, or significant ‘trauma to account for his death. The autopsy also shows a heart weight on the upper border of normal with concentric thickening of the left ventricle; the latter finding can be seen in hypertension. ‘The autopsy also reveals edematous brain and lungs; these findings are consistent with central nervous system depression. Toxicology reveals presence of alprazolam (anxiolytic) and doxylamine (sedative) in therapeutic concentrations, and presence of hydrocodone (narcotic analgesic) and dextromethorphan (antitussive) in toxic concentrations; the combined effects of these medications can account for the cerebral and pulmonary changes. Given the data set, this 42-year-old white male, Jason Fitzsimmons, died as a result of the combined toxic effects of hydrocodone, alprazolam, dextromethorphan and doxylamine, ‘The manner of death is determined to be: Accident. This opinion as to the cause and manner of death is based on the information available atthe date ofthis report. If additional objective, probative information becomes available, this office reserves the right to consider such ‘information, andif appropriate, amend the report, including the eause and manner of death. Physical Evidence, Body Parts, and Specimens will be retained and disposed of in accordance with Florida Administrative Code Rule 11G. 5/2} y Wendolyiy Sheed, MD Date Associate Medical Examiner