Transcribed Medical Transcription Sample Reports and Examples
Transcribed Medical Transcription Sample Reports and Examples
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Sample Type / Medical Specialty: Neurosurgery
Sample Name: Lumbar Puncture - 2

Description: Lumbar puncture. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained.
(Medical Transcription Sample Report)

PROCEDURE PERFORMED: Lumbar puncture.

The procedure, benefits, risks including possible risks of infection were explained to the patient and his father, who is signing the consent form. Alternatives were explained. They agreed to proceed with the lumbar puncture. Permit was signed and is on the chart. The indication was to rule out toxoplasmosis or any other CNS infection.

DESCRIPTION: The area was prepped and draped in a sterile fashion. Lidocaine 1% of 5 mL was applied to the L3-L4 spinal space after the area had been prepped with Betadine three times. A 20-gauge spinal needle was then inserted into the L3-L4 space. Attempt was successful on the first try and several mLs of clear, colorless CSF were obtained. The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.

COMPLICATIONS: None. The patient was resting comfortably and tolerated the procedure well.

ESTIMATED BLOOD LOSS: None.

DISPOSITION: The patient was resting comfortably with nonlabored breathing and the incision was clean, dry, and intact. Labs and cultures were sent for the usual in addition to some extra tests that had been ordered.

The opening pressure was 292, the closing pressure was 190.

Keywords: neurosurgery, spinal needle, lumbar puncture, lumbar, gauge, csf,
NOTE: These transcribed medical transcription sample reports and examples are provided by various users and are for reference purpose only. MTHelpLine does not certify accuracy and quality of sample reports. These transcribed medical transcription sample reports may include some uncommon or unusual formats; this would be due to the preference of the dictating physician. All names and dates have been changed (or removed) to keep confidentiality. Any resemblance of any type of name or date or place or anything else to real world is purely incidental.
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Transcribed Medical Transcription Sample Reports and Examples