Lumbar Puncture Note:
The patient was counseled
on the risks, benefits, and alternatives to the procedure, and provided
consent. A timeout procedure was
performed prior to initiating the procedure.
The performing physician and support staff donned appropriate sterile
garments, including surgical masks, sterile gloves, and caps. The patient was placed in the [left/right
lateral recumbent/seated and flexed] position with help from the supporting staff. The area was cleansed and draped
in usual sterile fashion using [betadine/chlorhexidine] scrub. Anesthesia was achieved with [##] mL of
lidocaine injected subcutaneously.
A
[##] gauge [##] inch spinal needle was placed in the [L2-L3/L3-L4/L4-L5]
interspace. On the [first/second/etc.]
attempt, [clear/bloody/straw-colored] cerebral spinal fluid was obtained. The opening pressure was [##] cm of H2O.
CSF was collected into 4
tubes. These were sent for the usual
tests with 1 tube to be held for further analysis if needed. A sterile bandage was placed over the
puncture site.
The patient had no
immediate complications and tolerated the procedure well.
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