Attending Staff: I MD Resident/Fellow: PA-C Indications: is a 60 y.o. female patient needing central line for Hemodynamic monitoring. The identity of the patient was confirmed and a bedside time out was performed. Description of Procedure: Patient's right internal jugular vein was prepped and draped in usual sterile fashion. 2% Lidocaine was not used to anesthetize the area. The wire was place without difficulty into the existing catheter. The catheter was removed easily and a new (?Fr. triple lumen) catheter was inserted using the seldinger technique. Good blood flow was noted from all 3 ports and each was flushed with saline and capped. The catheter was sutured into place and secured. Follow- up chest x-ray is pending to assess placement and rule out pneumothorax. Complications: none Specimens: not applicable Estimated Blood Loss:zero 3:50 PM I was presentfor procedure Revision History ... Date/Time 5:48 PM 5:48 PM 3:51 PM View Details Report about:blank User MD,MD PA-C Addend Cosign Sign Action
Page 1 of 4 MRN Sex Female DOB Age 60 Resident Signed Vascular Surgery Related encounter: Admission (Discharged\ from in UF 55MS H&P Service date: 5:09 PM Department of Surgery Division of Vascular Surgery Admission Date and Time: 10:14 AM Subjective: Chief Complaint: aorto-iliac occlusive disease History of Present Illness: is a 60 y.o. female who is being admitted for aortobifemoral bypass. Pt originally admitted on for claudication symptoms. Pt found to have 60% right CIA stenosis and a patent left CIA that occludes. She underwent ABis on that demonstrated 0.56/0.30. Pt presented today for ABF but OR case had to be delayed. Pt admitted preoperatively for ABF. Pt denies any recent CP/SOB/abd pain/f/c/n/v/d. Past Medical History Diagnosis • CAD (coronary artery disease) • HLD (hyperlipidemia) • S/P CABG x 4 • PVD (peripheral vascular disease) • DM (diabetes mellitus) Past Surgical History Procedure • Coronary artery bypass graft Date Laterality Date History reviewed. No pertinent family history. History Social History • Marital Status: Spouse Name: Number of Children: • Years of Education: Occupational History • Not on file. Social History Main Topics • Smoking status: Quit date: • Smokeless tobacco: • Alcohol Use: • Drug Use: • Sexually Active: about:blank Married NIA N/A N/A Former Smoker --1.50 packs/day for 20 years Not on file Not on file Not on file Not on file
Othe1· Topics Concern • Not on file Social History Narrative • No narrative onfile I have reviewed the past medical, surgical, family and social history. Home Medications: Prescriptions prior to admission Medication Sig Dispense Refill • aspirin (ASPIRIN) 81 MG EC tablet • insulin detemir (LEVEMIR) injection • pentoxifylline (TRENTAL) 400 MG ER tablet • rosuvastatin (CRESTOR) 40 MG tablet Take by mouth daily.