DATE OF SERVICE: MM/DD/YYYY
REASON FOR VISIT: Lumbar puncture for central diagnosis of multiple sclerosis.
SUBJECTIVE: The patient is a (XX)-year-old who we saw last week for multiple enhancing lesions throughout the brain, cervical, thoracic spine with left greater than right-sided weakness and sensory impairment suspicious for multiple sclerosis. He is here today for diagnostic lumbar puncture.
Informed consent was obtained. Specifically, we discussed potential complications of post LP headache, infection, back pain, and bleeding. The patient had a CBC that showed normal platelet count, and PT and INR were within normal limits with an INR 1.0 and a PTT of 34.
PROCEDURE IN DETAIL: The L3-L4 interspace was identified and marked. The patient identification was performed. The patient was prepped and draped in the usual sterile manner in the left lateral decubitus position, and 1% lidocaine was used to infiltrate the L3-L4 interspace. A 3-1/2 inch Whitacre spinal needle was used to penetrate the space and approximately 12 mL of clear, colorless spinal fluid was obtained and sent for CSF profile, myelin basic protein, cytology, Gram stain and culture, Lyme titer, and CSF-ACE. The patient tolerated the procedure well.
ASSESSMENT AND PLAN: The patient’s questions were answered. We advised the patient to drink plenty of fluids and advised that he may consume some caffeine to obviate headache; although, we do not anticipate headache, having used a Whitacre needle for the procedure. We told him we would give him a call later today assuming that we are going to have some results of the cell count and Gram stain. We told him that the rest of the studies may not be returned until later this week or early next week.
The patient is going to come in tomorrow for possible steroid infusion. We would probably treat him for five days. The patient briefly discussed getting a second opinion, which we certainly have no objection to. The patient, however, agreed to go ahead with the steroids while awaiting another appointment.
