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 The spinal needle was then withdrawn and the area cleaned and dried and a Band-Aid applied to the clean, dry area.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.
The opening pressure was 292, the closing pressure was 190.
Keywords: neurosurgery, spinal needle, lumbar puncture, lumbar, gauge, csf,