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Death Note
HISTORY:
Found apparently dead by
nurse
family
at
Death was
expected
unexpected
,
patient was
Do Not Resuscitate
EXAM:
Unresponsive to pain
Pupils are fixed, dilated and unreactive to light
No corneal reflexes
No chest expansion or respiratory effort
No audible breath sounds
after 1 min
No audible heart sounds
after 1 min
No palpable pulse after
after 1 min
No palpable cardiac pacemaker
Rigor mortis
External exam is
unremarkable
significant for
Death confirmed at
on
from natural cause
ASSESSMENT:
Death
likely
suspected
possible
Cause of death:
likely
suspected
possible
PLAN:
- Family notified, questions answered
- Attending physician notified
- Coroner notified
- Death certificate filled
- Autopsy requested by family