CAUSE OF DEATH REPORT DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE UNIVERSITY OF SUMATERA UTARA – H. ADAM MALIK GENERAL HOSPITAL MEDAN PERSONAL IDENTIFICAT ION Name : Kartini Medical Record No. : 64.14.29 Age : 66 years old Date of admission : June 14 t! 2"1# $e% : &emale 'ime of admission : 11.4# (m Nationality : )ndonesian Date of deat: June 2" t! 2"1# Address :Desa $u*adame Kec. 'a na'i me of deat: 1".+# (m ,inem Doctor in -arge : dr. -aisar Riana Marital status: Married $u(erisor : dr . -airil Amin /! $(.$ HISTORY TAKING Main -om(laint : Decreased leel of consciousness 0istory of ,resent ) llness : $e ad een suffered te declining leel of consciousness a((ro%imately 1 day (rior to admiss ion to Adam Mal i* eneral 0os(i tal ! 3i coccurre d sud denl y 3en se 3as resting. 0istory of eadace 3as not found. 0istory of seiure 3as not found. 0istory of(ro5ectile omit 3as not found. 0istory of ead trauma 3as not found. 0istory of feer 3as not found 0istory of y(ertension 3as found since tese last 1 year! ut uncontrolled. 0istory ofy(erc olest erolemia 3as found since tese last # year and te use of medicatio ns 3ere unclear. 0istory of diaetes mellitus 3ere denied. 0istory of eart disease 3ere denied. GENERAL PHYSICAL EXAMINATION Alertness : A(atis /lood (ressure : 22"11" mm0g Res(iratory rate : +" %minute 0eart rate : 1"" (m 'em(erature : +6!7 o - NEUROLOGIC EXAMINAT ION 8eel of consciousness : A(atis $igns of increased ) -, : 0eadace ;! ,ro5ectile < o miting ;! $eiures ; $i gns of meningeal irri ta ti on : Nuc al Rigidit y ;! Kernig $ig n ;! /rudin s*i ) ;! /rudins*i )); CRANIAL NERVES 1 st nere : Difficulty to e%amine 2 nd and + rd neres : ,u(illary ligt refle%es ==; ,u(il isocoria! >D ? + mm! >$ ? + mm • >(t a lmosc o( e e%amina ti on : >(tic disc Rigt @ye 8eft @ye -olor : yello3isyello3is/oundary : clear clear @%caation : cone% cone% A< : 2+ 2+ )m(ression : Normal (a(il + rd !4 tand 6 tneres : Dolls @ye ,enomenon =; B tnere : Droo(y moutto te rigt 7 tnere : Difficulty to e%amine 9 tand 1" tneres : ag refle% =; 11 tnere : Difficulty to e%amine 12 tnere : 'ongue at rest laid symmetrically
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7/25/2019 Cod Kartini
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CAUSE OF DEATH REPORT
DEPARTEMENT OF NEUROLOGY - SCHOOL OF MEDICINE
UNIVERSITY OF SUMATERA UTARA – H. ADAM MALIK GENERAL HOSPITAL
MEDAN
PERSONAL IDENTIFICATION
Name : Kartini Medical Record No. : 64.14.29
Age : 66 years old Date of admission : June 14t ! 2"1#$e% : &emale 'ime of admission : 11.4# (m
Nationality : )ndonesian Date of deat : June 2"t! 2"1#
,inem Doctor in -arge : dr. -aisar RianaMarital status: Married $u(erisor : dr. -airil Amin /! $(.$
HISTORY TAKING
Main -om(laint : Decreased leel of consciousness
0istory of ,resent )llness :
$e ad een suffered te declining leel of consciousness a((ro%imately 1 day (rior toadmission to Adam Mali* eneral 0os(ital! 3ic occurred suddenly 3en se 3as
resting. 0istory of eadace 3as not found. 0istory of seiure 3as not found. 0istory of
(ro5ectile omit 3as not found.
0istory of ead trauma 3as not found. 0istory of feer 3as not found0istory of y(ertension 3as found since tese last 1 year! ut uncontrolled. 0istory of
y(ercolesterolemia 3as found since tese last # year and te use of medications 3ereunclear. 0istory of diaetes mellitus 3ere denied. 0istory of eart disease 3ere denied.