Demographic Data:

Patient Name: Mr. Elvis Young MRN 80808080 DOB: 7/27/1985

Date: 11/20/20 Time: 5:45

Location: ER bay #12

Procedure: Lumbar Puncture

Indication: CSF sample to test for CNS infection

Provider: Mirsha Warren, PA-C

Allergies: None Reaction: N/A

Consent:

Discussed with patient the need to perform a lumbar puncture to test for infection. Discussed with
patient the complication that could arise from not performing this procedure which includes not being
able to examine the CSF to provide important diagnostic information. Discussed with the patient the
complications that could arise from not performing this procedure including, but not limited to post-LP
headache, infection, bleeding, cerebral herniation and minor neurologic symptoms. Written consent
was obtained by the patient and witnessed by RN before the procedure was performed.

Pertinent Diagnostic Data: none

Anesthesia: Topical 1% lidocaine was used

Relevant exam: Patient presented with a fever, neck stiffness and severe nausea. A physical exam was
performed which revealed a positive Brudzinski sign and a positive kernig sign, both of which are
indicative of a CNS infection. The physical exam also revealed bradycardia and slight hypertension.

Description of the procedure: Patient was prepped and placed in the lateral recumbent position. The
intercristal line was located and confirmed by palpation of bony landmarks. The area was marked and
using sterile technique, the puncture sight was prepped with povidine-iodine solution in circular
movements. The lumbar puncture tray was opened using sterile technique. The needle was positioned
in the midline, and inserted bevel up. It was advanced and a pop was heard as the needle penetrated
the dura. The stylet was removed and CSF return was noted. A manometer was attached and he
opening pressure was measured. CSF was collected for analysis and the needle was removed after safely
replacing the stylet. The iodine was cleaned up and an adhesive dressing was placed over the puncture
site.

Findings: Elevated opening pressure was noted. The CSF also appeared cloudy.

Complications: No complications during the procedure.

Instructions and patient follow up: Patient was instructed to get adequate rest post procedure.
Discussed with the patient the possibility of getting a post spinal headache. The patient was started on
ibuprofen for pain control.
Disposition: Patient admitted to the floor for monitoring until lab results return.

Time completed 12:00

CPT Procedural Code 62270 Lumbar Puncture

Signature: Lacey Mikaal PA-C 11/20/20 Time: 12:00