with HR-ALL, admitted for 3rd dose of HD-MTX with Leucovorin rescue.
Tolerated previous doses well.
Hydration/alkalinization/antiemetics, close monitoring of MTX level.
Tim Garrington, MD
Associate Professor, Pediatrics
Leader, Solid Tumor Team
Center for Cancer and Blood Disorders
Children's Hospital Colorado
(MR #
Printed by
[103311] at 10/11/13 10:21 AM
Page 12
Electronically signed by Smolik, Suzanne B. at 8/4/2013
5:55 PM
Electronically signed by Smolik, Suzanne B. at 7/23/2013
4:14 PM
Electronically signed by Garrington, Timothy P. at 7/23/2013 10:22 PM
IP Encounter Report
MRN:
DOB:
Sex: M
Adm:7/23/2013, D/C:7/25/2013
Procedures - All Notes
is a 16 year old male who had the following procedure(s) performed today:
Procedure(s):
Lumbar Puncture with Intrathecal Chemotherapy
Procedure Technique:
Lumbar Puncture with Intrathecal Chemotherapy:
The procedure site over the lumbar
spine was prepped and draped in sterile fashion.
Once adequate analgesia was achieved, a 3 1/2 inch 22
gauge spinal needle was inserted thru the skin and into the lumbar interspace.
Upon entering the dural sac,
the needle stylette was removed and samples of spinal fluid for the tests listed below were collected and
placed in sterile tubes.
The chemotherapy syringe then was attached to the needle and the medication was
slowly instilled into the intrathecal space.
The needle then was removed and a Band-Aid was applied to skin at
the entry site.
Volume of CSF removed:
4 mL
Medication(s) (Dose):
Methotrexate 15 mg
Performed by:
Lesley C. Arland, PA-C
Attending Physician Supervising Procedure:
N/A
Present for entire procedure:
N/A
Anesthesia/Sedation: Propofol
Complications: None
Tests Obtained: CSF cell count and CSF cytology
(MR #
Printed by
[103311] at 10/11/13 10:21 AM
Page 13
Procedure Orders:
1. Lumbar Puncture with Intrathecal Drug [39054186] ordered by Arland, Lesley C. at 07/23/13 1434
Author:
Arland, Lesley C.
Service:
Oncology
Author Type:
Procedures
1. LUMBAR PUNCTURE W INTRTHECAL DRUG [96450 (CPT®)]
Physician Assistant
Filed:
7/23/2013
2:34 PM
Electronically signed by Arland, Lesley C. at 7/23/2013
2:34 PM
Note Time:
7/23/2013
2:32 PM
Procedures signed by Arland, Lesley C. at 7/23/2013
2:34 PM
