Learning Internal Medicine

Procedure: Lumbar Puncture

Indication: <Diagnostic/Therapeutic>

Attending physician:

Performing staff:

Consent for the procedure was obtained from the <patient/next of kin/DPOA>. All risks and benefits were discussed prior to obtaining consent and initiating the procedure. 

A time out was performed prior to the procedure demonstrating the appropriate patient, appropriate procedure site, and identifying patient allergies prior to any drug administration. 

The patient was placed in a <right/left> lateral decubitus position with their knees pulled up towards their chest. Anatomic landmarks were used to locate the appropriate vertebral interspace. The area was cleansed in a sterile fashion. I gowned and gloved in a sterile manner. The patient was draped in a sterile manner. The area was anesthetized locally with 1% lidocaine. A <20/22> guage, <___> inch needle was advanced into the <L3-L4/L4-L5> interspace. <Clear/Cloudly/Purulent/Pigmented/Blood tinged> CSF was obtained. The opening pressure was <__> cmH2O. Approximately <___> ml of CSF was removed. The fluid was placed in sterile containers and sent to lab for further study. The needle was removed and the area was cleaned and dressed. There was negligible blood loss and the patient tolerated the procedure well. Post procedure complications were again explained and the patient was advised to lay flat for 1-2 hours.

Opening Pressure:

Fluid Color:

Amount removed:

Procedure: Central venous line placement

Indication: Central venous access for medical therapy

Attending physician:

Performing staff:

Consent for the procedure was obtained from the <patient/next of kin/DPOA>. All risks and benefits were discussed prior to obtaining consent and initiating the procedure. 

A time out was performed prior to the procedure demonstrating the appropriate patient, appropriate procedure site, and identifying patient allergies prior to any drug administration. 

An ultrasound was used to identify the <right/left> <internal jugular vein/femoral vein> and the associated structures.

The patient was then placed in a <trandellenberg/supine> position and the puncture site was sterilized. I gowned and gloved in a sterile manner. The patient was draped in a sterile manner. The area was anesthetized locally with 1% lidocaine. A needle was used to puncture the vein under ultrasound guidance. A guidewire was introduced into the vein and threaded an appropriate distance into the vena cava. A dilator was used to dilate the skin and subcutaneous tissue. A central line was then advanced over the guidewire using the Seldinger technique. Each port of the catheter was flushed with saline. Good blood flow was noted from each port. The line was sutured into place and a sterile dressing was placed. A post procedure x-ray was performed to assess placement. The patient experienced minimal blood loss. The procedure was tolerated well without complication.

Type of Line: __ French, ___ Lumen, ___ Length

Procedure: Paracentesis

Indication: <diagnostic/therapeutic>

Attending physician:

Performing staff:

Consent for the procedure was obtained from the <patient/next of kin/DPOA>. All risks and benefits were discussed prior to obtaining consent and initiating the procedure. 

A time out was performed prior to the procedure demonstrating the appropriate patient, appropriate procedure site, and identifying patient allergies prior to any drug administration. 

An ultrasound was used to identify an appropriate pocket of abdominal fluid.

The patient was then placed in a supine position and the puncture site was sterilized. I gowned and gloved in a sterile manner. The patient was draped in a sterile manner. The area was anesthetized locally with 1% lidocaine. A sterile blade was used to puncture the skin. An introducer needle and catheter were advanced through the skin into the peritoneal cavity. <Yellow/Clear/Cloudy/Thick/Purulent> fluid was withdrawn. Several samples were taken for further laboratory study. A total of <__> fluid was removed. The catheter was removed and the area was cleaned and bandaged. The patient experienced minimal blood loss. The procedure was tolerated well without complication. <Supplemental albumin was given at a ratio of 5g per liter of fluid over 5 liters>

Fluid description:

Amount removed: __ L