Tag Archives: dictation

Central Venous Catheter (CVC, Central Line) Placement

Date: <____>
Time: <____>
Indication: Hemodynamic monitoring/Intravenous access
Resident: <____>
Attending: <____>

A time-out was completed verifying correct patient, procedure, site, positioning, and special equipment if applicable. The patient was placed in a dependent position appropriate for central line placement based on the vein to be cannulated. The patient’s <right/left> < neck/shoulder/groin> was prepped and draped in sterile fashion. 1% Lidocaine was used to anesthetize the surrounding skin area. A triple lumen <9-French> Cordis catheter was introduced into the the <subclavian/internal jugular/common femoral vein> using the Seldinger technique <and under ultrasound guidance>. The catheter was threaded smoothly over the guide wire and appropriate blood return was obtained. Each lumen of the catheter was evacuated of air and flushed with sterile saline. The catheter was then sutured in place to the skin and a sterile dressing applied. Perfusion to the extremity distal to the point of catheter insertion was checked and found to be adequate. <Attending/Resident> was present for the entire procedure.

Estimated Blood Loss: <____>
The patient tolerated the procedure well and there were no complications.

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Stroke Core Measures

1.  VTE prophylaxis

[YES] VTE prophylaxis was provided with TED stockings and sequential compression devices on the day of admission.  

[NO] Pharmacologic VTE prophylaxis was not initiated becuase patient had a hemorrhagic stroke.

2.  Antithrombotic Therapy

[YES] This patient presented with ischemic stroke, and is discharged on antithrombotic therapy with [aspirin, Plavix].

Antithrombotic Therapy by the end of Day 2

[YES] Antithrombotic therapy with [aspirin, Plavix] was administered by the end of hospital day 2.

3.  Anticoagulation Therapy

[YES] Etiology of stroke for this patient is most likely due to cardioembolic event [atrial fibrillation].  Anticoagulation therapy with [coumadin, Xarelto, Pradaxa, Eliquis] has been  prescribed at discharge to prevent recurrent ischemic stroke. [Coumadin reduces the relative risk of thromboembolic stroke by 68%.]

[NO] Anticoagulation therapy is not indicated in this patient.

 

Thrombolytic Therapy

[YES]  Intravenous TPA was administered to this patient with acute ischemic stroke within 3 hours of symptom onset based on the evidence provided by the NINDS Studies [part 1 and 2].

[NO] Intravenous TPA was not given to this patient because the patient presented to the emergency department greater than 2 hours from the time he was last known to be well, and will not fall within the 3-hour window period for TPA administration.

[NO]  Intravenous TPA was not given to this patient because of the following contraindication/s:  ___.

4.  Statin Medication

[YES]  Lipid profile was measured within 48 hours of admission. [Lipid profile was available from within th epast 30 days].  LDL in this patient measured more than 100 mg/dL [or is less than 100mg/dL while on statins] and he/she is prescribed statin medication [atorvastatin] at hospital discharge based on the SPARCL study which demonstrated that the use of statin was associated with dramatic reduction in the rate of recurrent ischemic stroke.

5.  Stroke Education

[YES] Patient and/or the caregivers were given educational materials during the hospital stay addressing activation of EMS, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke.

6.  Assessed for Rehabilitation

[YES]  Patient was assessed for rehabilitation services by the physical and occupational therapists to prevent complications, minimize impairments, and maximize his function.

Dictations

NORMAL SYSTEMIC PHYSICAL EXAMINATION
Vital signs as follows: BP HR RR Temp sats
General: awake, not in distress
Heart: normal S1 S2, no MRG, NRRR, peripheral pulses 2+ bilaterally, no edema
Lungs: clear to auscultation bilaterally, no wheezes, rales, rhonchi, no accessory muscle use
Abdomen: soft, nontender, nondistended, bowel sounds normal, no palpable masses
 
NORMAL NEURO DICTATION
Mental Status, patient is awake, alert, oriented to person place and time, normal affect;  Attention, can spell WORLD backwards, good attention span; speech is fluent without paraphasic errors, able to repeat, name objects, read and write; memory is good, calculation is good, no left-right confusion; Praxis: able to mimic blowing out match with either hand.
Cranial nerve exam:  II, III pupils equal and briskly reactive to light; visual acuity, visual fields full by confrontation, III IV VI EOM intact without nystagmus, no ptosis; V sensation intact to light touch, masseters strong symmetrically, VII face symmetric without weakness; VIII hearing grossly intact; IX X palate elevates symmetrically XI good shrug XII tongue protrudes midline, no atrophy or fasciculation.
DTRs: normoreflexive – bilateral biceps, brachioradialis, patellar and Achilles reflexes
MMT, strength is 5/5 on all 4s.  Sensory testing intact to light touch, pinprick, temperature, vibration and joint position intact.  No evidence of extinction.  Coordination: able to do rapid alt and point-to-point movements.  
Gait posture, stance, stride and arm swing normal.
 
CORE MEASURES:
NIHSS in ED
If no tPA given, why?
If Afib – on AC? If no AC, reason / plan
Meds listed out
Lipid panel, A1C Carotids (Doppler, CTA, angio), Echo
On statin, if not, why?
ASA & PLavix
PT/OT, if no PT/OT why?
Modified Rankin Scale

Lumbar Puncture Procedure Note

Before the procedure:

  1. Obtain consent.  Inform regarding complications (esp. headache 22%, back pain 25%, bleeding, infection, cerebral herniation)
  2. Note contraindications:  raised ICP, thrombocytopenia or other bleeding diathesis, anticoagulation, suspected spinal epidural abscess

Procedure Note

Procedure:  Lumbar puncture, bedside
Exam Date:  <today’s date>
Fellow: <Dr. _____>, Fellow in Neurocritical Care
Supervising Physician:  <Dr. _____>

Clinical Indication:
[Urgent] suspected CNS infection (not brain abscess or parameningeal process) – Patient presents with fever, AMS, headache, meningeal signs
[Urgent] suspected subarachnoid hemorrhage in patient with negative CT scan
[Nonurgent] Idiopathic intracranial HTN (pseudotumor cerebri)
[Nonurgent] Carcinomatous meningitis
[Nonurgent] tuberculous meningitis
[Nonurgent] normal pressure HCP
[Nonurgent] CNS syphilis
[Nonurgent]  CNS vasculitis
[Others] MS, GBS, paraneoplastic
[therapeutic or diagnostic] spinal anesthesia, intrathecal chemo, intrathecal Abx, myelography or cisternography

CONSENT:  Patient is alert and oriented to person, place and time and he/she appeared to understand the indications, risks and benefits of the procedure.  Patient is able to give both verbal and written consent.

PROCEDURE:  The patient was placed in a [right/left] sidelying osition.  The skin overlying the L3-L4 interveertebral space was identified using the iliac crests as landmarks.  This area was prepped and draped in sterile fashion.  Skin and soft tissue anesthesia was achieved with 1% lidocaine, 5 mL.  A [20/22]-gauge 3.5 inch spinal needle was introduced and advanced in a single puncture into the subarachnoid space.  The stylet was removed with appropriate return of [clear] fluid.  40 mL of clear CSF was obtained and placed in 4 vials.  These vials were identified with the patient’s name and medical record number.  Needle was removed after adequate fluid collected.  Blood loss was minimal.

The tubes were sent for the following tests:

  • Tube 1: Cell Count
  • Tube 2: Gram Stain, CSF Culture, Glucose, Protein, Other …
  • Tube 3: Pt ID placed and held if further CSF studies indicated
  • Tube 4: Cell Count

Opening Pressure:  obtained while patient in lateral decubitus position is ____ cm H2O

Fluid appearance:  clear / bloody

The patient tolerated the procedure well, without any complaints.  The procedure was completed without any complications.

Simplified LP Procedure Note

Procedure – Lumbar Puncture
Indication – [insert here]
Anesthesia – local 1% lidocaine w/ epi

Informed consent was obtained from the patient.  The area was prepped and draped in the usual sterile fashion. Using landmarks, a 22 guage spinal needle was inserted in the L4-L5 innerspace. The stylet was removed and the opening pressure was measured at 18 cm of water. 4cc of clear fluid was collected and sent for routine studies. CSF was also sent for [other studies].
The patient tolerated the procedure well. There was no blood loss or hematoma.