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
present
for procedure
Revision History
...
Date/Time
5:48
PM
5:48
PM
3:51
PM
View Details Report
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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
on
file
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.
