01/19/1983 - 01/26/1983

About 9 months after arrival on US soil.

Consent for Operation, Anesthesia, and Tissue 🚩

THE JOHNS HOPKINS HOSPITAL

AUTHORIZATION (OR CONSENT) FOR ADMINISTRATION OF ANESTHESIA

AND/OR PERFORMANCE OF OPERATIONS OR OTHER PROCEDURES

Patient’s Name (Last, First, M.I.): Long, Deepa

Hospital No.: 202 91 94

Date: 1/19/83

I hereby give my consent and authorize Doctor Winfield J. Campbell

of The Johns Hopkins Hospital to perform the following [circled: operation] or other procedure:

[handwritten: Intercostal to gluteal muscle transposition conditional leg graft]

1. The nature and purpose of the operation or other procedure and [circled: anesthesia], the risks involved, alternatives, and the possibility of complications have been explained to me by my doctor. I acknowledge that no guarantee has been made as to the results that may be obtained.

2. I consent to the performance of the above-named operation or other procedure and if, during the contemplated operation or other procedure, other conditions are discovered which, in the best judgment of the medical staff of The Johns Hopkins Hospital, require an extension of the original contemplated operation or other procedure or a different operation or other procedure, I authorize and request that the said operation or other procedure be performed.

3. I further consent to the administration of such anesthetics as may be considered necessary or advisable in the judgment of the medical staff of The Johns Hopkins Hospital.

4. Exceptions to surgery or anesthesia, if any, are: None

5. I consent to the disposal by authorities of The Johns Hopkins Hospital of any [circled: tissue] or parts which it may be necessary to remove. I authorize The Johns Hopkins Hospital to retain, preserve, and use for scientific or teaching purposes any tissues or specimens taken from my body.

6. I consent to the admittance of observers, in accordance with ordinary practices of The Johns Hopkins Hospital, to the use of closed-circuit television, the taking of photographs (including motion pictures), and the preparation of drawings and similar illustrative graphic material, and I also consent to the use of such photographs and other materials for scientific purposes, provided my identity is not revealed by the pictures or by the descriptive text accompanying them.

Witness’s Signature:

J.H. Wompler [?]

Signature of Physician Securing Consent:

Winfield J. Campbell

Patient’s Signature:

[handwritten: C 3243] 🚩

Witness’s Signature:

Deborah Knoll, R.N.

Patient, Closest Relative or Legal Guardian’s Signature:

HR Long [signed] 🚩

Informed Consent Suppliment 🚩

THE JOHNS HOPKINS HOSPITAL

INFORMED CONSENT SUPPLEMENT

I. INDICATIONS FOR THE OPERATION OR OTHER PROCEDURE ARE:

Flaccid lower extremity

II. MAJOR RISKS OF THE OPERATION OR OTHER PROCEDURE AND ANESTHESIA (including such items as failure to obtain the desired result, discomfort,

injury, additional therapy and death):

Bleeding

Infection

Anesthesia

50% failure of grafts

III. Alternatives to the proposed operation or other procedure:

Ø

IV. In instances where a discussion of the above is deemed unwise medical practice, there should be documented a statement to this effect below, stating

Ø

Signature of Physician Securing Consent

J S Winfield MD PHD [signed]

____________________

The undersigned acknowledges receipt of a copy of the foregoing consent supplement for an operation or other procedure this ____

day of ________ 19___. [date blank]

Deborah Knoll R.N. HR Long [signed] 🚩

Wmitness’s Signature Patient, Closest Relative or Legal Guardian’s Signature

Photo Contest Consent 🚩

CHILDREN'S CENTER

THE JOHNS HOPKINS HOSPITAL

PHOTOGRAPHY CONSENT

I do _X_ do not ____ hereby give the Johns Hopkins Children's

Center permission to use identified photographs of:

above

____________________

taken for the purpose of public relations releases.

These photographs will not be used for scientific or

medical teaching purposes.

RESTRICTIONS: ____________________

SIGNATURE: HR Long [signed] 🚩

Relationship to Patient: mother [signed] 🚩

WITNESS: Chepier [signed]

DATE: 1-19-83

CPR Sheet

The Johns Hopkins Hospital

CPR Sheet

Patient: LONG, DEEPA
DOB: 09/09/80
History No.: 202 91 94
Weight: 9.6 kg

Drugs and Doses (Final Dose):

Epinephrine 1:10,000 → 1 ml EPI
NaHCO₃ (Sodium Bicarbonate) 1 mEq/ml → 10 ml NaHCO₃
Atropine 0.1 mg/ml → 1 ml ATRO
CaCl₃ (Calcium Chloride) 10% 100 mg/ml → 1 ml CaCl₃
CaGluconate 10% 100 mg/ml → 3 ml CaGLU
Lidocaine 20 mg/ml → 0.5 ml LIDO
Narcan 0.4 mg/ml → 0.2 ml NARC

Intubation Drugs:

Atropine 1 mg/ml → 0.1 mg ATRO
Succinylcholine 20 mg/ml → 10 mg SUCC
Pavulon 1 mg/ml → 0.1 mg PAV
Paralytic Pavulon 1 mg/ml → 1 mg PAV

Defibrillations: 20 (2 watt-sec/kg, may double and repeat)

Signed by: R.N. and M.D. (signatures present)

Front Sheet Summary

THE JOHNS HOPKINS HOSPITAL

FRONT SHEET SUMMARY

Patient’s Name: Long, Deepa

History Number: 202 91 94

Service: Ped. Neuro

Responsible Physician: Campbell

Date of Admission: 1/19

Referring Physician: [blank]

Admitting Complaint, Major Findings (include history) and Hospital Course:

2 y/o Indian child, history involved in train accident at 1 y/o.

Sustained avulsion injury to lumbosacral plexus and above knee amputation (RT).

Admitted for exploration of right leg with grafting of intercostal nerves to superior gluteal nerve.

Remainder of history, exam otherwise negative except for fever and post-op complications.

List Operations and/or Procedures in Order of Importance, Include Date and Surgeon (no abbreviations):

Grafting intercostal nerves to superior gluteal nerve

Confirmed Diagnosis Causing Admission (no abbreviations):

Grafting intercostal nerves to superior gluteal nerve

Relevant Diagnoses and Complications Listed in Order of Importance (no abbreviations):

Avulsion lumbosacral plexus

Condition on Discharge: Good

Discharged: ☑ Home ☐ Nursing Home ☐ Deceased ☐ Other

Discharge Instructions Including Medications and Dosages, Diet and Activity Restrictions:

Remove spica cast in 4 wks in ortho clinic
Appt same day with Dr. Campbell

Follow-up (When, Where, By Whom):

Dr. Campbell in 4 wks

Date of Discharge: 1/26

Completed by: Kaplan

Signature: [signed, illegible]

Code Number: D4874

Admission Screening Data

THE JOHNS HOPKINS HOSPITAL

ADMISSION SCREENING DATA

Patient: Long, Deepa

Address/Telephone: [Columbia, MD – 9972641 / 730-4531]

History Number: 2029194

Date of Last Admission: [blank]

Age: 2

Sex: F

Service: Peds Neuro

Admitting Physician: Campbell, J. — Code C3605

Admission Diagnosis:

Avulsion Lumbo-sacral Plexus

Scheduled for Surgery? ☐ No ☑ Yes Procedure: [blank]

Admission Screening:

EKG: ☐ No ☑ Yes
Chest X-ray: ☐ No ☑ Yes
Laboratory: ☑ None ☐ Group A ☐ Group B ☐ Group C
Other (List): [blank]

Procedures to be scheduled by admitting office: [blank]

Consultations requested: [blank]

Admission Medications: ☐ None ☑ To be ordered ☐ Ordered on pre-admission history

Admission Diet: ☐ Regular ☑ To be ordered ☐ Ordered on pre-admission history

Special Instructions: [blank]

Information received from: [blank]

Form completed by: [blank]

Date: [blank]

Order Sheet #1

ORDER SHEET

Patient: Long, Deepa

History No.: 202 91 94

Date: 1/19/83

Weight: 10.1 kg

Page no. 1

Orders:

Admit to 6W
Diagnosis – Nerve graft
Condition – good
Unit – 6W
Diet – regular
Allergies – NKA (No Known Allergies)
Medications – as selected
Activity – as selected
Old cast to floor

Signed: Kaplan

Later Orders (same day 1/19/83):

12:00 PM: Volume (fluid order) — [signed: Russ, RN]
Compressed humidified air at bedside — T.O. (telephone order) Dr. Kaplan / C. Fitzpatrick, RPh
V/D 75 mL [unclear, likely IV fluid] — Christ Fitzpatrick

Evening (1/19/83, 8:30 PM):

On call to OR: Keflin 250 mg
Tomorrow at 7:30 AM: IV D5 ¼ NS + 20 mEq KCl at 40 cc/hr
NPO (nothing by mouth) after 2 AM

Signed: Kaplan / Ellenberg, MD

Order Sheet #2

ORDER SHEET

Patient: Long, Deepa

History No.: 202 91 94

Date: 1/19/83

Page no. 2

Orders:

Pre-op 83 Cast
NPO (nothing by mouth) after midnight
Morphine 1.0 mg IM (intramuscular injection)
Demerol 40 mg IM
Atropine 0.4 mg IM at 0645 (6:45 AM)

Noted by: multiple initials and signatures (including “C. Fitzpatrick”)

Later entries:

1/21 at 9:30 PM – by Kynes locality, RN
1/23 – “stop surround” [unclear, handwriting partly illegible]

Order Sheet #3

ORDER SHEET

Patient: Long, Deepa

History No.: 202 91 94

Date: 1/20/83

Page no. 3

Orders:

Admit to OR → Consent
Procedure: Endoneurotomy gluteal nerve w/ autograft from L sural polygraph
U.S. Preanesthesia
Activity: Bed – rest, elevate L leg
Allergies: NKA (none known)
Medications:
- Keflin 300 mg IV q6h × 4 doses then D/C
- Tylenol 30 mg PO q6h PRN for pain
- Phenergan 25 mg PO BID (non-formulary)
- 0.5% NS + 20 mEq KCl @ 45 cc/hr × 24 hrs then D/C

Foley → straight cath when able, D/C Foley
Bedpan
Warm dressing
If fever, call H.S. 24 hr
CXR now

Additional note (1/20/83, 7:00 PM):

“Please give q. 4–6 hr Morphine Sulfate IV – given D/C 1/20”

Signed: J. Winfield Campbell MD, witnessed/signed by house staff.

Order Sheet #4

1/24/83

0 120 mg Tylenol PO q4h PRN for pain/fever Mainwaring

1 5% glucose Tylenol order Mainwaring

J. Daugherty D. M. Anderson RN

1/20 1:20

D/C Pericolace

Tylenol 120 mg PR or PO PRN q6 temp > 99 or pain C. Page-Thibault

1/20 1:30

Demerol 10 mg IV q6 PRN pain P. Pypers

1/21 4:30 A

ed P. Pypers RN

1/21 5 A

5 mg Demerol IV x1 (extra) P. Pypers

1/21/83 11 A

Laura Russell RN

1/22/83

Please D/C IV J. Daugherty

Sent for C & S Sunday a.m.

Order Sheet #5

1/21 5 P

0 D/C Demerol

1 Tylenol + codeine elixir

(120mg Tylenol + 12mg codeine / 5cc)

4cc q4h PRN pain

[crossed out text:]

“4cc q4h PRN pain PO”

[end crossed out]

or 120mg Tylenol PRN pain q4h PO Kapla

1/21 5:30 P

2 D/C Demerol

3 Tylenol 120mg PO q4h PRN pain

4 Codeine 10mg q6 & 20 PRN D. Daugherty

5 if pain of Tylenol doesn’t work D. Daugherty

6 Chest PT q4h Kapla

7 Void at 10:10 P by Lynne Korelitz, PN

1/22/83 3:30 PM

8 ed P. Pypers RN

1/22 1 P

9 IV to 20cc/hr

D/C if infiltrate Kapla

1/22/83 3:30 P

√ Mary Beth Raven RN

Order Sheet #6

1/22 7 P

0 D/C IV

1 D/C Pericolace Kapla / Howell R.N.

Void at 9:30 P by Lynne Korelitz, P.N.

1/23 2 P

2 Void D. Mae R.N.

Void at 10:15 P by Lynne Korelitz, P.N.

1/24 5 A

3 Void at St. Conroy R.N.

1/24/83

4 Void D. Anderson R.N.

1/24/83 9 P

5 Chas Fitzpatrick

Void at 10:15 P by Lynne Korelitz, P.N.

1/25/83 12:30 P

6 Void at 12:30 P by Lynne Korelitz, P.N.

1/25/83 7 P

7 Void M. Kelley R.N.

1/26 2:30 A

8 Void St. Conroy R.N.

1/26 3 P

9 Discharge

a) Return to ortho clinic for cast removal in 4 wks. Same day

appointment with Dr. Campbell.

M. Morton 8645

Kaplan

Doctors Notes #1

Doctors Notes #2

Doctors Notes #3

Doctors Notes #4

Doctors Notes #5

Doctors Notes #6

Doctors Notes #7

Doctors Notes #8

Doctors Notes #9

Doctors Notes #10

Doctors Notes #11

Doctors Notes #12

Doctors Notes #13

Doctors Notes #14

Doctors Notes #15

Doctors Notes #16

Doctors notes by page

coming soon

Nurses Flow Sheet Notes 01/19/1983

THE JOHNS HOPKINS HOSPITAL

Pediatric Daily Flow Sheet

Date: 1/19/83

Day: J Chris Stagatuck RN

Eve: KG Latain LPN Tho TR

VITAL SIGNS

Temp 98.8 97.5

Pulse 128 134

Resp 28

Blood Pressure 141/90

Weight -

COMMENTS

Night:

(blank)

Day:

Parents/Visitors: Mom coming in

Activity: ambulating with assistance

Diet: Reg.

10:30 AM Admitted to 650, for OR. 💚 Walks well w/prosthesis & assistance

11:30 AM Dr. Kaplan up.

2 PM Dr. Campbell up

3 PM Anesthesia in to evaluate patient

Evening:

Parents/Visitors: mom

Activity: Up + around

Diet: ate fair

4 PM Awake. Alert. Pleasant + cooperative

4:30 PM Large regular brown stool HO aware

5 PM Ate dinner poorly. Taking fluids well

5:45 PM Blood drawn for OR

Evening

7:45 PM H.O. in to see patient. blood obtained for H.O.

8pm resting with mom and to sleep

9:30 pm repeat blood draw

Nurses Flow Sheet Notes 01/20/1983

PEDIATRIC NURSING FLOW SHEET

Date: 1-20-83

Nurse’s Initials – Signature – Title:

Night: VH / Virginia Halstead

Day: Q / Chris Fitzpatrick

Eve: VS / Lateran Sue Thiel

Vital Signs

Temperature (R O A): 98.0

Pulse: 120

Respiration: 28

Blood Pressure: 108/74

Weight: (blank)

Treatments & Medications

Warm moist O₂

Moisturize points

Albuterol Q 6 hrly

Linen change: (blank)

Bath: Self Assist Comp: (blank)

Position changes: abd back R L: (blank)

COMMENTS

Night

Parents/Visitors: Mom

Activity: Crib

Diet: O

12 Am Sleeping calm. good color. Respiration is regular and easy

2 Am Sleeping

4 Am Sleeping

6 Am Sleeping NPO @ 6 AM

Day

Parents/Visitors: Mom

Activity: Out/held

Diet: NPO

7:45 AM Pre-ops medication given

🚩 (missing time 13 hours) 🚩

Evening

Parents/Visitors: Mom, Dad

Activity: Crib

Diet: NPO – Adrm

8:45 PM Back to floor from RR. Sleeping. Will opens eyes to verbal stimuli. Spika cast in tact. Toes warm & blanch well. Stump warm. Skin warm & dry. Dressing intact. IV infusing well.

10:15 PM Asleep; Awakens & cries during VS. left toes cool, poor blaching 🚩 Right stump cool 🚩 Cast dry. Foley dressing and intact.

Nurses Flow Sheet Notes 01/21/1983

The Johns Hopkins Hospital

Pediatric Daily Flow Sheet

Date: 1-21-83

Nurse’s Initials – Signature – Title:

Night: SC – Sandra Chalett RN

Day: Ph – Patricia Z. Ryon RN

Eve: MA – Mary Andruszewski

Vitals (from chart):

Temperature: 39°, 37.6, 38.6, 38.2, 39.4, 39.6

Pulse: 120, 146, 146, 140, 148, 144

Respiration: 32, 40, 40, 40, 44

Blood Pressure: 120/60, 106/64, 118/60, 110/64

Treatments & Medications:

Keflin 300 mg IV
Demerol 8 mg IV
Tylenol (rectal suppository) 120 mg

Comments

Night:

1 AM: Sleeping fitfully. When awake crying and flailing arms. Demerol given.

2 AM: More peaceful, sleeping easier. IV intact and draining. Light colored urine. Cast damp & cool. Dressing on chest, dry in place.

2:45 AM: Sleeping quietly.

3:20 AM: Awake, crying for short periods. IV shows no evidence of infiltration.

5 AM: Additional 5 mg Demerol given per order. H.O. Irrtable by any contact except mother.

Comments

Day:

8 AM Very irritable. Crying, C/O pain in low back. Dressing - dry and intact. Cast Slightly Damo and cool. IV infusing well. Tylenol given then sleep.

10 AM: Sleeping.

12 N: no pain. Slightly febrile. IV infusing good. well. Tylenol given - doing ok taking fluids well

Comments

Evening:

4 PM: Sleeping.

5 PM: Awake – had large liquid stool, some previously went down in cast. Cast is dry. H.O. notified of temp and bloody-greenish stool.

6 PM had large liquid stool. Chest xray done

8 PM: Cast physiotherapy (CPT) Very irritable. Chest sounds clear.

9 PM: Had large liquid greenish brown stool.

Nurses Flow Sheet Notes 01/22/1983

The Johns Hopkins Hospital – Pediatric Daily Flow Sheet

Date: 1/22/83

Patient: Long, Deepa

Nurse’s Initials / Signature – Title:

Night: PLR – Patricia L. Ryan, RN

Day: MBH – [Mary Ellen Brown?] RN

Eve: GJ – Gio Fitzgerald

Vital Signs

Temp: 38.5, 37.7, 38.8, 39.0

Pulse: 148, 132, 146, 148, 140

Respiration: 28, 32, 34, 36

BP: 124/84, 110/70, 104/62, 106/62

Weight: 16.2 kg → 16.4 kg

Treatments/Medications:

Keflin 300 mg IV

Demerol 10 mg IV

Tylenol 120 mg PO

IV Fluids

Comments

Night

12 MN: Febrile 39.4 (102.9°)Patient alert, responsive to mom. Patient had diarrhea stool x2. Patient took fluids well. Mom sponging and cool rags to chest and Axillae. IV intact

4:30 AM: Temp 38.4. Patient stool frequent. Patient chest Physiotherapy. stool light yellow. breath sounds clear most all quads.

6 AM temp down 38.4. Patient asleep. Awakens to touch. very restless and pale. Restraints used - velcro wrist to reach IV and catheter.

Comments

Day

9 AM: Awake, painful. Cast remains. Slightly damp. Dressing to chest is dry and intact. Continues to have slight diarrhea-type stooling. Afebrile. Foley draining clear yellow urine. IV infusing well. Tolerates PO well.

12 N: Sleeping. Temp stable.

2 PM: IV rate ↓ to 20 cc/h to be D/C'd IV slowed ro 20ml/hr

Comments – Evening

5 PM: Awake + alert. IV infusing well left hand, Good circulation and VSS. Continues loose stools. Foley intact to straight drain. Taking diet well. IV to be D/C'd if leacking into tissue or failed,

6:30 PM: IV discontinued. Awake, alert.

8:30 PM: Awake, alert. Circulation/VSS good. Breathing sounds clear. Taking diet well. Taking fluids well.

9:20 PM: Sleeping.
11 PM: Sleeping.

Nurses Flow Sheet Notes 01/23/1983

The Johns Hopkins Hospital

Pediatric Daily Flow Sheet

Date: 1/23/83

Nurse’s Initials – Signature – Title:

Night: PJR – Patricia J. Rygard, RN

Day: DL – [illegible], RN

Eve: J. Chris Fitzpatrick, RN

Vital Signs:

Pulse: 138, 134, 126, 120, 120, 126

Respiration: [not clearly marked]

Blood Pressure: 116/76, 131/87, 104/68

Weight: [not recorded]

Treatments & Medications:

Tylenol 650 mg PO

Comments

Parents/Visitors

Night: Mom

Day: Mom/Family

Eve: Mom

Activity

Night: Bed Rest

Day: Bed Rest

Eve: Bed rest / 100% full body spica cast

in cast

Diet

Night: Clear liquid

Day: Clear liquid

Eve: Reg

Night Notes

12 MN: Febrile 38.5. Medicine Tylenol. Circulation and VSS. stable. cheerful. no problem with dressing.

2:30 AM: Afebrile 37.2. Patient tolerating cast well.

4:30 AM: VSS. Patient tolerating PO well. Afebrile. one diahrrea stool. moved ti 658 (room)

6 AM: Asleep. Circulation and VSS good. Toes warm. Cheerful while awake.

Day Notes

8 AM: Afebrile alert, VSS, circulation is good. Foley draining well.

10 AM: Foley discontinued. Patient seems irritable when approached. 🚩

12 N: Patient still hasn’t voided. Afebrile, VSS. Lying in bed playing with toys. Sira ans stays still at rest.

2 PM: Sleeping, appears to be in no apparent distress. Doctor notified regarding no void yet recorded.

Evening Notes

4 PM: Awake + alert. Cooperative. Dressing dry + intact. Circ V’s good. Toes warm + blanch well. Right leg slightly cool to the touch. Talking P.O. well. Voided small amount

5 PM: out of bed in cast. Tolerated well. Breathing sounds clear.

6 PM: Voided large amount.

8 PM: Circ V’s good. Breathing sounds clear. Taking PO well. Voided good.

10:30 PM: Sleeping.

Nurses Flow Sheet Notes 01/24/1983

The Johns Hopkins Hospital

Pediatric Daily Flow Sheet

Date: 1-24-83

Nurse’s Initials – Signature – Title:

Night: BSC

Day: DL

Eve: G (illegible) Stoupakis

Patient: Long, Deepa

CMCWG 9 202 91 94 A

DOB: 09/09/80 F

VITAL SIGNS

Temperature (R O A): 37.6, 37.0, 36.8, 37.2, 37.4

Pulse: 126, 120, 126, 120

Respiration: 28, 26, 24, 28

Blood Pressure: 116/64

Weight: (not filled)

TREATMENTS & MEDICATIONS

(blank except for “CIRC VS” and “SC” written several times)

COMMENTS

Parents/Visitors: Mom

Activity: BR

Diet: Reg

Night:

12:30 Irritable, crying, waving arms. Calmed by mom. Toes warm, moves on own, blanch well. Cast pressing on outer edge of right stump. large void. Foley dressing dry and intact

3 AM Sleeping

5:00 AM Sleeping

Day:

8 AM – Afebrile, VSS, appears to be irritable. Circ V’s good, appetite fair.

10 AM – Down in playroom, appears to be less irritable.

12 N – Return to room, cast wet in back, blow dried, turned to side. 🚩

2 PM – Ambulating in hall via stretcher. Off PT & mom, returned down to playroom.

Evening:

4 PM Cast damp on posterior side — on abdomen to let cast dry. Circ and VSS good. Cast patted dry per mom. In playroom. Active + alert. Dressings dry & intact.

6 PM out of bed in cart. Breathing sounds clear.

9:30 PM Awake + alert in crib.

Nurses Flow Sheet Notes 01/25/1983

The Johns Hopkins Hospital

Pediatric Daily Flow Sheet

Date: Jan. 25, 1983

Nurse’s Initials / Signature / Title:

Night: SC — Sandra Chabot RN

Day: SA — Alfred Stelly LPN

Eve: OJ — Olive Jozefcik RN

Patient Name: Long, Deepa

Vital Signs:

Temp: 35.2 → 36 → 37

Pulse: 82 → 130 → 94

Respiration: 20 → 20 → 31

Blood Pressure: 77/7 → 106/6

Weight: 6.25

Comments

Night:

Parents/Visitors: Mom

Activity: Crib

Diet:

12 MN: Easily aroused by touch + movement.

2 A: Sleeping quietly. Breathing normal. Skin warm + dry.

4 A: Sleeping.

7 A: Sleeping.

Day:

Parents/Visitors: Mom

Activity: Bedrest

Diet: Reg diet

8 AM: Awake + fussy. Voided mod. amount.

10 AM: in play room. toes warm – good circulation. In spirits. Voiding well.

12 noon: Good appetite. Alert + playful. Toes warm. Blanch well.

2 PM: out of bed ate well

3 PM: Asleep.

Evening:

Parents/Visitors: Mom

Activity: BR.

Diet: Reg diet

4 PM: in cart with mom. active and alert

5 PM: ate dinner well

7 PM: awake and alert playing. breathing sounds clear. Cooperative. Toes warm and blanch well. dressing changed, strips dry and intact.

9 PM: out of bed in cart

11 PM asleep

Restraints: blank

Checked: 11-7 / 7-3 / 3-11

Nurses Flow Sheet Notes 01/26/1983

The Johns Hopkins Hospital

Pediatric Daily Flow Sheet

Date: 1-23-83

Nurse’s Initials – Signature – Title: JSC (James S. Conway)

Day: Dr. C. Lebovitz

Eve: ______________________

VITAL SIGNS

Temperature: R O A ______

Pulse: ______

Respiration: ______

Blood Pressure: ______

Weight: ______

COMMENTS

Parents/Visitors: Mom

Activity: BR

Diet: ____________________

Night

12 M Sleeping

2 A Sleeping

4 A Sleeping

6 A Sleeping

Day

Parents/Visitors: Mother

Activity: Bed Rest

Diet: ____________________

Evening

Parents/Visitors: Mom

Activity: Bed Rest

Diet: Reg

24hr Pediatric I&O Record 01/20/1983

THE JOHNS HOPKINS HOSPITAL

24 Hour Pediatric I & O Record

Date: 1-20-83

IV tubing change at: _______

by: _______

Description (bottle no., rate):

D5 .45 NS + 20 mEq KCL @ 45 cc/hr

Line No. / TIME

2400 | 0100 | 0200 | 0300 | 0400 | 0500 | 0600 | 0700 | 0800 | 0900 | 1000 | 1100 | 1200 | 1300 | 1400 | 1500 | 1600 | 1700 | 1800 | 1900 | 2000 | 2100 | 2200 | 2300

site/type of line

1: ___________ (continuous)

Hourly IV Intake row is shaded throughout the 24 hrs

Hourly IV Intake: 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45 | 45

Total IV Intake: 1080

P.O. Intake: —

Total P.O. Intake: —

Total Fluid Intake: 1080

Blood & Deriv.: —

Drainage: —

Stool: —

Vomitus or N.G.: —

Urine: ✔

Specific Gravity: —

Total Urine Out: 100 cc

YESTERDAY’S SUMMARY:

Total Intake: New Adm

Total Output: _______

24hr Pediatric I&O Record 01/21/1983

The Johns Hopkins Hospital

24 Hour Pediatric I&O Record

Date: Jan 21, 1983

Description (bottle no., rate):

D5 ½ NS + 20 mEq KCl @ 45 cc

IV tubing change at: [blank]

Grid (Hour-by-Hour Intake/Output):

Hourly IV Intake (cc):
2400: 45 | 0100: 45 | 0200: 45 | 0300: 45 | 0400: 45 | 0500: 45 |
0600: 45 | 0700: 45 | 0800: 45 | 0900: 45 | 1000: 45 | 1100: 45 |
1200: 45 | 1300: 45 | 1400: 45 | 1500: 45 | 1600: 45 | 1700: 45 |
1800: 45 | 1900: 45 | 2000: 45 | 2100: 45 | 2200: 45 | 2300: 45
Total IV Intake (cc):
2400: 90 | 0100: 135 | 0200: 180 | 0300: 225 | 0400: 270 | 0500: 315 |
0600: 360 | 0700: 405 | 0800: 450 | 0900: 493 | 1000: 530 | 1100: 575 |
1200: 620 | 1300: 665 | 1400: 710 | 1500: 755 | 1600: 800 | 1700: 845 |
1800: 890 | 1900: 935 | 2000: 980 | 2100: 1025 | 2200: 1070 | 2300: 1110
P.O. Intake (cc):
0900: 70 cc | 1300: 120 cc | 1700: 120 cc | 2100: 120 cc
Total P.O. Intake (cc):
0900: 70 | 1300: 190 | 1700: 310 | 2100: 430
Total Fluid Intake (IV + P.O.):
0900: 493 + 70 = 563
1300: 665 + 120 = 785
1700: 845 + 120 = 965
2100: 1025 + 120 = 1145

Urine: “foley”

Specific Gravity: 1019

Urine Output: 1000 cc

Yesterday’s Summary:

Total Intake: 1040 / 1125 cc (two values written)
Total Output: 1040 cc

24hr Pediatric I&O Record 01/22/1983

The Johns Hopkins Hospital

24 Hour Pediatric I&O Record

Date: 1-22-83

Time Line No. Description (bottle no., rate)

12MN D5 .45 E20KCL @ 40 cc/hr

1970

I.V.F.

1/2 TPN

IV tubing change at ___________ by ___________

Line No. TIME 2400 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300

site/type of line A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58 A58

1

2

3

Hourly IV Intake 45 45 45 45 45 45 45 45 45 45 45 45 45 45 20 20 20 20 20 20 20 20 20 20

Total IV Intake 45 90 135 180 225 270 315 360 405

P.O. Intake 140 120 180 120

Total P.O. Intake 140 260 440 560

Total Fluid Intake 45 230 315 620 685 820 875 1020 1125 1010 1255 1275 1275 1315 1335 1335 1375 1375 1375 1375 1375 1375 1375 1675

Blood/B Deriv.

Drainage

Stool

Vomitous or N.G. 420

N.G. drainage

Urine: Foley

10:15

phos.

phos. cath

420?

Specific Gravity 100 1016 1014 1008

Total Urine Out. 500 1000

YESTERDAY’S SUMMARY:

Total Intake: __________________

Total Output: _________________

24hr Pediatric I&O Record No Date

The Johns Hopkins Hospital

24 Hour Pediatric I&O Record

Date: ___________

IV tubing change at __________ by __________

Line No. TIME 2400 0100 0200 0300 0400 0500 0600 0700 0800 0900 1000 1100 1200 1300 1400 1500 1600 1700 1800 1900 2000 2100 2200 2300

Site/type of line

1

2

3

Hourly IV Intake

Total IV Intake

P.O. Intake 136 120 180 240 180 180

Total P.O. Intake 136 256 436 626 856 1036

Total Fluid Intake 136 256 436 626 856 1036

Blood/B Deriv.

Drainage

Stool

Vomitus or N.G.

Urine Foley 320 60

Specific Gravity

Total Urine Out: 1009

Yesterday’s Summary:

Total Intake: __________

Total Output: __________

JHH X04-7007

24hr Pediatric I&O Record No Date

The Johns Hopkins Hospital

24 Hour Pediatric I&O Record

Date: __________

IV tubing change at: __________ by __________

| Line No. | TIME | 2400 | 0100 | 0200 | 0300 | 0400 | 0500 | 0600 | 0700 | 0800 | 0900 | 1000 | 1100 | 1200 | 1300 | 1400 | 1500 | 1600 | 1700 | 1800 | 1900 | 2000 | 2100 | 2200 | 2300

Hourly IV Intake: ———

Total IV Intake: ———

P.O. Intake: ———

Total P.O. Intake: ———

Total Fluid Intake: ———

Blood & Deriv.

Drainage: ———
Drainage: ———

Stool: 6pm large

Vomitus or N.G.: ———

Urine:

2x entries marked [illegible]“BRG”

Specific Gravity: ———

Total Urine Out:

x1
x2

Notes written in stool section:

“large”
“loose”
“stool”
“mucus”

Yesterday’s Summary:

Total Intake: __________
Total Output: __________

24hr Pediatric I&O Record No Date

The Johns Hopkins Hospital

24 Hour Pediatric I&O Record

Hourly IV Intake

(blank rows)

Total IV Intake

(blank)

P.O. Intake

120 | 60 | 120

Total P.O. Intake

120 | 60 | 120

Total Fluid Intake

120 | 60 | 120

Blood/B Deriv.

(blank rows for drainage)

Stool

(blank)

Vomitous or N.G.

(blank)

Urine

1 cc | 1 cc | cath

Specific Gravity

(blank)

Total Urine Out

✔ | ✔

Yesterday’s Summary:

Total Intake: _______

Total Output: _______

Pre Operative Checklist 01/20/1983 🚩

THE JOHNS HOPKINS HOSPITAL

ANESTHESIA RECORD

Patient: Long, Deepa

DOB: 09/09/80

History No: 9 202 91 94 A

Surgeon: Campbell

Anesthesiologist: [not fully legible, looks like “Weland” or “Wheland” + “Woodhead”]

Operation Proposed: C to Gluteal Nerve Transposition

Operation Performed: [blank]

Religion: [blank] 🚩

Pre-op Diagnosis: R Plexus

Post-op Diagnosis: [blank]

01/20/1983 🚩

Intraoperative Anesthesia Record

McPherson
Rhung
Campbell
Date: 01/20/83
Name: Long, Deepa
ID: 202 91 94
DOB: 09/09/80
Physical status: 4
Operation proposed: Intercostal to gluteal nerve transplant
Pre-op diagnosis: ? L plexus avulsion
Post-op diagnosis: same

Case times:

Case sched: 0900
Pat OR: 0830
Anes start: 0850
Surg start: 0850
Surg finish: 1825
Anes finish: 1835

Side/handwritten notes (left margin and around):

“5:10 BP 90/60”
“4:55 O₂ sat 95%”
“4:45 temp 36.6”
“5:30 100 cc urine”
“Blood 90 cc”
“10 cc/kg”
“EBL 90 cc”
“Fluid 450 cc”
“Urine 200 cc”
“10 cc/kg”

Vitals grid (central section):

Multiple recordings of BP, pulse, respirations, temp, etc.
BP ranges around 80–100 systolic.
Pulse in 140–160s.
Resp around 20–30.
Temps ~36–37°C.
Continuous ECG + doppler + stim tracings marked.

Remarks section (bottom):

pt from floor, mask induction after
EKG, spiral stethoscope
Miller 2, 4.5 ET + long leak
5.0 ET 5 leak 4.5 ET replaced + stylette
eyes lubed + taped, esoph. stethoscope
bair hugger blanket, humidifier, heating, lips
(1) tranex. 0.25 g IV ventral
(2) Keflin 0.25 g IV ventral
1003 incision (3) long trendelenberg
1020 Intercostal incision

remarks:🚩 Pt then given mask induction after EKG applied. Stethoscope applied.

Miller 2, 4.5 cuffed ETT, 5.0 OT, 5 lead, stylette used.

4.5 cuffed ETT inserted c stylette. Tube taped, equal breath sounds, equal chest rise, positive pressure ventilation instituted. 🚩

01/20/1983

Intraoperative Anesthesia Record

Name: LONG, DEEPA
History Number: 202 91 94
Date: 01/20/83
Location Room No.: OR
Surgeon: [not clearly filled]
Physical Status: 3, 4 circled
Emergency: Yes [checked]
Operation Proposed: “py 2 yz” (handwritten, unclear)
Operation Performed: [blank]
Pre-Op Diagnosis: [blank]
Post-Op Diagnosis: [blank]

Times

Case Scheduled: 9:00
Patient OR: 8:30
Anes Start: 8:30
Surg Start: 8:50
Surg Finish: 16:15
Anes Finish: 16:30

Monitoring & CPT

CVP: 36480
Swan G: 93503
A-Line: 36620
ECG: 93000
General: X
Other categories blank

Grid Entries (time-based vitals, abbreviated, as written)

BP: 120/70, 125/80, 110/70, 100/60, etc. (values vary across grid)
Pulse: 130, 128, 120, 110, etc.
Temp: ~36–37°C recorded across times
Resp: values recorded 20–28/min
Multiple IV fluid amounts listed, blood products tracked, urine output charted

Remarks .

“Hct 35, 10 kg”
“Keflin 250 mg IV via rental” (likely meant “renal” or “IV route”)
“16:30 Woodhead cross relieving”

No date 🚩🚩

Intraoperative Anesthesia Record

Header Information

Surgeons: Campbell
Operation Proposed: “? (R) Gluteal Nerve Transplantation”
Pre-Op Diagnosis: “? (R) BKA”
Post-Op Diagnosis: (blank)
Patient: Long, Deepa – DOB: 09/09/80
Case Scheduled: 0900
Patient to OR: 0820
Anesthesia Start: 0830
Surgery Start: 0850
Surgery Finish: 1825
Anesthesia Finish: 1835

Agents/Medications (handwritten entries):

Pentothal
Valium
Morphine
Pavulon
Succinylcholine

IVs:

Listed fluids (hard to fully read but looks like D5½ NS + KCl)
Continuous infusion lines noted

Estimated Blood Loss:

“90 cc”

Urine Output:

“1278”

Vitals (BP, Resp, Pulse, Temp):

Graphed throughout the sheet in small boxes, showing values recorded every 15–30 minutes
Examples:
- BP ~ 80/50 at one point
- Pulse ~ 152
- Resp ~ 20

Remarks (bottom):

🚩“18:25 extubated, 1 ET 3 difficulty”🚩

Post Anesthesia Records

JOHNS HOPKINS HOSPITAL

POST ANESTHESIA RECORD

History No.: 20291 94
Name: Long, Deepa
Date: 1/20/83
Age: 2F
Bed No.: 6

Operation: Intercostal → Gluteal Nerve Transfer

Time: 1535

Surgeon: Campbell

Anesthesia Technique: General

Anesthetist: Woodford

Agents: Halothane, N₂O (nitrous oxide), O₂ (oxygen)

Par Nurse: K. Woodin

Fent [likely Fentanyl]

Pre Med: Ø

Pre Op Hx: LBXA + Trauma, 10 kg

Allergies: Ø

On Arrival:

Consciousness: □ Conscious □ Semiconscious ☑ Unconscious
Intubated: ☑ Yes
Airway: □ None

INTRA OP INFORMATION:

EBL (Estimated Blood Loss): 90 cc
IVF (IV Fluids): 965 cc
Blood In: 0
Blood Products: 0
Problems: “Airway”

Vitals (graph section):

Temperature, pulse, respirations, and blood pressure tracked in 15-minute intervals.
Resp: 25/min written at bottom.
Temps range: ~37.4°C recorded.

Meds Section:

Morphine Sulfate – 15 mg, IV push, given at 1900, by A. Casella (RN).
Keflin – 300 mg, IV, given at 2000, by D. Colaimo (RN)

Miscellaneous Laboratory Sheet

Patient: Long, Deepa

ID: 2029194

CHEMISTRY

Date: 1/19 (6P, 10P), 1/20

Chloride (Cl): 106 | 107 | 108

CO₂: 16 | 14 | 20

Potassium (K): 3.8 | 4.3 | 4.1

Sodium (Na): 143 | 139 | 137

SUN (likely BUN): 16 | 9 | 6

Glucose (Glu): 77 | — | —

Calcium (Ca): —

Phosphorus (P): —

U.A.: —

Cholesterol (Chol): —

Total Protein (T.P.): —

Albumin (Alb): —

Total Bilirubin (T. Bil): —

Direct Bilirubin (D. Bil): —

Alkaline Phosphatase (Alk O): —

LDH: —

SGOT: —

SGPT: —

CPK: —

Creatinine (Creat): 0.4 | 0.4 | 0.2

Amylase (Amyl): —

Acid O: —

Magnesium (Mg): —

Blood Gas Results:

pH: 7.36

pO₂: 25

pCO₂: 40

HCO₃: 22

Room air (RA)

Miscellaneous Laboratory Sheet

HEMATOLOGY

Date: 1-19 (6P, 10P), 1-20 (6P)

Hgb: 12.5

Hct: 35.4

MCV: 83.4

MCH: 28.2

Retics: —

ESR: —

Plate.: 461

WBC: 13.9

Blast: —

Myelo: —

Juv: 4

Poly: 32

Eos: 2

Baso: 3

Lymph: 50

Mono: 7

At. ly: 2

Smear: —

Prothrombin: —

PTT: 27 / 27 / 27

11.5 / 11.5 / 11.5

URINALYSIS

Date: 1-19

Source: —

Sp. Gr.: 1.005

pH: 7.0

Prot.: –

Gluc.: –

Acet.: –

RBC: –

WBC: –

Bact.: –

Sed.: –

Intake / Output 🚩

INTAKE

TIME LINE I.V. FLUID AMT UP TIME AMT IN

9 W CPL D5 1/2 + 20KCL [illegible]

OUTPUT

TIME OUTPUT CC

200 [illegible] 1.012 foley

TIME LAB RESULTS X-RAY INTERPRETATION EKG INTERPRETATION

1940 Chest x-ray normal Cooley

533 Admitted from 6W (under my report). Resp easy, even

& O2 adequately. TL dressing dry. VSS. Febrile to 99°. Hip

abducted.

1907 Awake & crying. Medicated c 1/8 mg Vistaril.

IV patent per D. Estillen.

2000 Resting c analgesia. Mother in.

1030 Resting comfortably. VSS. Good resp excursion. Ready for transfer.

Cooley MD.

Distally cool but not cyanotic. Could

wiggle all toes.

All discharge criteria have been met.

discharges to: [illegible] at 20:45 by D. Clalveni RN 🚩

9:35 — Return from OR. Head elevated. Crying. Eyes closed.

9:45 — Awake – crying. Left thoracotomy dressing dry, clean.

10:15 — Coughing up secretions. Sats 95% on O₂ by mask.

10:30 — Resting comfortably. VSS. Good movement.

Dr. [illegible] at bedside — not to extubate until fully awake. Lungs clear to auscultation.

Analgesic given. Antibiotic given.

[Illegible] ready for transfer.

Chart up to date.

Card to Anes. [Anesthesiology]

Radiology 01/20/1983 🚩

X-RAY CONSULTATION REPORT

THE JOHNS HOPKINS HOSPITAL

DEPARTMENT OF RADIOLOGY AND RADIOLOGICAL SCIENCE

DATE OF EXAM: 1-20-83

BILLING NO: 202 91 94

PATIENT'S NAME: DEEPA LONG

PATIENT'S HISTORY NUMBER:

X-RAY SECTION: PEDS

REFERRING WARD OR CLINIC: CMSC 6

CHEST

No previous films for comparison.

At 1740 hours, a small irregular infiltrate is visible in the left lower

lobe, perhaps related to partial atelectasis or consolidation.

Gaseous distension of the stomach.

No evidence of pneumothorax.

The remainder of the chest is unremarkable.

#162 cb 1-27-83

SANDRA SUE KRAMER MD

RAD

CONCISE POSITIVE FINDINGS AND RELEVANT MEASUREMENTS REPORTED.

STRUCTURES NOT MENTIONED ARE JUDGED NORMAL FOR AGE.

Radilology 01/21/1983

THE JOHNS HOPKINS HOSPITAL

DEPARTMENT OF RADIOLOGY AND RADIOLOGICAL SCIENCE

DATE OF EXAM: 01 21 83

BILLING NO: 2029194

PATIENT'S HISTORY NUMBER: P581

PATIENT'S NAME: LONG, DEEPA

PATIENT'S PHYSICIAN: CAMPBELL, JAMES N

REFERRING WARD OR CLINIC: CISG-6 WEST NEUROLOGY

CHEST A.P.

PORTABLE EXAM 1830 HOURS

NO COMPARISON FILMS

NORMAL

INITIAL HYPOINFLATION LUNGS

01 24 83

MARK J KRANSDORF M.D.

JOHN P DORST M.D.

RAD

CONCISE POSITIVE FINDINGS AND RELEVANT MEASUREMENTS REPORTED.

STRUCTURES NOT MENTIONED ARE JUDGED NORMAL FOR AGE.

Cumulative Lab summary 01/22/1983

GOR Operative Data Sheet

THE JOHNS HOPKINS HOSPITAL

GOR OPERATIVE DATA SHEET

LOG: C16W

O.R. #: —

DATE: 1-20-83

AGE: 2 yrs

SEX: Female

SURGEON: Campbell

ATTENDING SURGEON: Dr. J. McKhann

M.D. DICTATING: Dr. Campbell

ASSISTANTS: Dexter

RECORD ROOM CORRECT READS:

□ HEALTH ASST. □ MED. STUD. □ O.R. ASST.

ANESTHETIST: S. Rusk, R.N. + R.M. Pullen

CIRC. NURSE/TECH: W. House, H. Taylor

CIRC. RELIEF: B. Ammie (“P.”)

SCRUB NURSES: W. House, H. Taylor

ANESTHESIOLOGIST: Williams (4:50 PM)

PRE-OP DIAGNOSIS:

Avulsion lumbosacral plexus (A)

OPERATION PERFORMED:

Intercostal → gluteal nerve grafting (B)

POST-OP DIAGNOSIS / MAJOR COMPLICATIONS:

Same

POSTED CASE: —

EMERG. DAY: □ GENERAL □ LITHOTOMY

EMERG. NITE: □ LOCAL □ PRONE

IN-OUT. ROOM: □ REGIONAL ☑ SUPINE

ARM BOARD: LT.

CAUTERY: PAD PLATE

PACEMAKER SERIAL #: —

VALVE SERIAL #: —

CHEST TUBE: □ YES ☑ NO

SPECIMENS TO: □ BACT. ☑ CHEMISTRY □ PATHOLOGY

FROZ. SEC: □

PACKING: □ PODRHOPH □ MYCOLOGY

DIRTY / CLEAN / CONTAMINATE: □ CLEAN □ CLEAN CONTAMINATE □ CONTAMINATE

NO. OF SPECIMEN: —

INSTRUMENT COUNT:

CORRECT □ INCORRECT □ Williams + Taylor

NEEDLE COUNT:

CORRECT □ INCORRECT □ Williams + Taylor (X)

SPONGE COUNT:

CORRECT □ INCORRECT □ Williams + Taylor

CROSS CLAMP TIME: — HR. — MIN.

ONTO PUMP: — HR. — MIN.

OFF PUMP: — HR. — MIN.

RT / LT ARTERIAL LINE: — ULNAR □ RADIAL □

RT / LT PERIPH. LINE: ARM □ LEG □

RT / LT CVP INT. JUG. □ EXT. JUG. □ SUBCLAVIAN □

RT / LT SWAN INT. JUG. □ SUBCLAVIAN □

CORRECT □ INCORRECT □

TIMES INTO O.R.: —

TIME OUT: 6:30 PM

REV. CODE: 422

PROC. CODE: —

GOR Nurses Operative Notes

THE JOHNS HOPKINS HOSPITAL

OFFICIAL RECORDS NOTE PAPER

GENERAL OPERATING ROOMS NURSING NOTES

DATE: 1-20-83 ARRIVAL TIME: 8:15 A

Via: stretcher (crib) bed, other: crib

Position: supine

Patient greeted, identified and record reviewed by: Dr. Regan

Emotional Status: pleasant when approached, tearful otherwise

Level of Consciousness: awake, alert

Physical Assessment: dry, skin cool to touch. NVD, BKA on (R)

Q: Yes □ No ☑ Safety Strap location: across thighs

Area shaved: — By: —

Positioning devices used or actions taken: bilateral T-chest,

rolled under R cast.

Induction: nasal, (oral)

Difficulties: nasal narrow

Comments:

To O.R. on crib. Induced to GA. Foley inserted.

Child secured on lumbar board. Positioned for surgical prep and drape.

Pre-scubbed, prepped and draped for gluteal to intercostal

nerve incision and graft.

Postoperative assessment:

Dry dressing applied to incision site. Special cast fitted into place.

Departure time: 6:30 PM

To: ERR

Signature: Dr. Regan (M.D.)

(Relief) Signature: H. Ammie R.N.

OR Operative Data Sheet

THE JOHNS HOPKINS HOSPITAL

OR OPERATIVE DATA SHEET

Name: Long, Deepa

History No.: 202 91 94

Date: 1-20-83

Surgeon: Dr. James Campbell

Assistants: Dr. Whitfield, Dr. Mackinnon

Anesthesia: General

Anesthesiologist: Dr. Williams

Diagnosis: Avulsion injury to superior gluteal nerves, right hip

Procedure: Interfascicular nerve grafting, right superior gluteal nerves with sural nerve graft

Room: 9

Service: Neurosurgery

Scrub Nurse: R. House

Circulating Nurse: R. House

Anesthesia Nurse: (illegible initials)

Orderlies: (initials illegible)

Blood Loss: 90 cc

Transfusion: None

Specimens: None

Cultures: None

Implants: None

Drains: None

Sponge Count: Correct

Needle Count: Correct

Instrument Count: Correct

Complications: None

Condition: Stable

CPT Proc. Code: 22

Rev Code: (blank)

Time Out: 6:30 p.m.

Signature: (initials, not fully legible)

Neurosurgery Operative Note

THE JOHNS HOPKINS HOSPITAL

HISTORY NO. 202 91 94

PATIENT’S NAME: LONG, DEEPA

DATE: 1-20-83

SERVICE: NEUROSURGERY

OPERATION: Interfascicular nerve-grafting of the superior gluteal nerves on the right side using sural nerve grafts.

SURGEONS: Dr. James Campbell, Dr. Jeffrey Whitfield, Dr. Susan Mackinnon

ANESTHESIA: General.

PROCEDURE: This 2-1/2-year-old Indian child had a laceration injury to the superior gluteal nerves on the right side and a previous exploration had been performed which had identified avulsion of the right superior gluteal nerves as described in the chart. The patient was induced under general anesthesia and salvaged sural nerve grafts were harvested from the right lower extremity by standard technique. The gluteal incision was made over the right iliac crest and the gluteal muscles were identified. The nerves were sought out and the superior gluteal nerves were identified and freshened. The nerve ends were dissected free under the operating microscope and the ends trimmed until fascicular bundles were seen. The nerve grafts were then inserted into the defect and sutured into place with 10-0 nylon sutures under high-power magnification. The grafts were secured in place using fibrin glue. The wound was then irrigated and closed in layers with Vicryl sutures. The skin was closed in routine fashion. The patient tolerated the procedure well.

James Campbell, M.D.

Dict: 1/20/83

D.S.: Mayer 7113.

cc: Mayer

SIGNATURE OF SURGEON: [blank – no signature present]

Cumulative Lab Report 01/20/1983

THE JOHNS HOPKINS HOSPITAL – DEPARTMENT OF LABORATORY MEDICINE

CUMULATIVE LABORATORY SUMMARY

*********** CHEMISTRY ***************

CHEMISTRY IN ELECTROLYTES

NA K CL CO2 ANION SUN/CR GLU CA AMYLAS TBILI

NORMAL LOW 135 3.5 99 20 25 10/0.5 70 9.0 60 0.3

NORMAL HIGH 145 5.0 111 30 20 25/1.5 105 11.0 160 1.2

MEQ/L MEQ/L MEQ/L MEQ/L MG/DL MG/DL U/DL MG/DL

DATE TIME

1/19 0600P 143 3.8 106 16* 25+ 19.0+ 24 25 77 T046 D4874

1/19 1000P 139 4.4 105 20+ 14 8.8 30 155* T046 D4874

1/20 1145P 138 4.1 103 20+ 14 8.8 30 155* W249 B3583

**************************************************************

CHEMISTRY – BLOOD GASES

NORMAL LOW PH 7.45 PCO2 35 PO2 75

NORMAL HIGH 7.45 45 100

DATE TIME PH PCO2 C-HCO3

1/19 1000P 7.36 40 C 22 N932 D4874

**************************************************************

HEMATOLOGY

BLOOD COUNTS

WBC RBC HGB HCT PCV MCV MCH MCHC PLT RETIC ESR

NORMAL LOW 6000 3.50 11.6 36.0 73.0 27.0 30.0 38.5 150 0.5 0

NORMAL HIGH 17000 5.50 13.5 50.0 82.0 30.0 31.0 35.0 350 1.5 10

DATE TIME

1/19 0600P 13900 4.28 12.5 35.4 82.2 29.2 35.2 40.0 461* 1.2

1/20 1145P CAN D CAN D CAN D CAN D CAN D CAN D CAN D CAN D D521 D4874

E521 B3583

* = AMENDED RESULT

# = CREAT MAY SHOW INTERFER FROM 5FC (UP TO 6.0/DL)

! = RESULT: 25

@ = CLUTTED

Δ = ABNORMAL VALUE

CMCV6 PRINTED: JAN 21 83 4:52 PM PAGE 1 LONG, DEEPA

J.H.H. 202-91-94

Cumulative Lab Report 01/20/1983

THE JOHNS HOPKINS HOSPITAL – DEPARTMENT OF LABORATORY MEDICINE

CUMULATIVE LABORATORY SUMMARY

*******************************************

WBC DIFFERENTIALS PERCENTS

MYELOS METAS BANDS POLYS LYMPHS MONOS ATYPS EOS OTHERS NRBC

NORMAL LOW x x 6.0 41.0 17.0 4.0 x x x

NORMAL HIGH x x 8.0 75.0 41.0 10.0 x x x

DATE TIME

1/19 0600P 4.0 32.0 50.0 7.0 2.0 2.0 3.0 D521 D4874

1/19 0600P WBC MORPHOLOGY: OCCAS. SMUDGE CELLS

1/20 1145P CAN A CAN A CAN A CAN A CAN A CAN A CAN A CAN A E521 B3583

1/20 1145P WBC MORPHOLOGY: CAN A

**************************************************************

WBC DIFFERENTIALS – ABSOLUTE COUNTS

NORMAL LOW BANDS 240 POLYS 1500 LYMPHS 1500 MONOS 300 EOS 140

NORMAL HIGH 800 7500 3500 850 440

DATE TIME

1/19 0600P 560 4400 7000 970* 280 D521 D4874

1/20 1145P CAN A CAN A CAN A CAN A E521 B3583

**************************************************************

COAGULATION

PT RATIO PT-FIB APTT PTT-FB FIB-GT TT

NORMAL LOW 9.9 0.9 9.1 18.6 20.6 150

NORMAL HIGH 11.9 1.1 13.1 28.5 30.4 400

DATE TIME

1/19 1000P 11.8 1.8 27.0 1:2 0800 D4874

1/20 1145P 0820 D4874

**************************************************************

BLOOD BANK

BLOOD BANK 1 – ROUTINE SCREENING

DATE TIME

1/19 ????? ABO/RH: A NEGATIVE BLOOD BANK DCT: NEGATIVE

ACN MD A597 D4874

**************************************************************

CMCV6 PRINTED: JAN 21 83 4:52 PM PAGE 2 LONG, DEEPA

J.H.H. 202-91-94

Microbiology Report

THE JOHNS HOPKINS HOSPITAL

DEPARTMENT OF LABORATORY MEDICINE

CLINICAL MICROBIOLOGY REPORT

Name: LONG, DEEPA

History No.: 202-91-94

Age: 2 Sex: F

Loc.: CM6WG

Physician: KAPLAN, RICHARD

Date Printed: JAN 22 83

LAB NO.: 541 D-9-83

TESTS: ANA CULT - BLOOD

COLL. TIME: 1/19/83 11:00 AM

REC’D TIME: 1/19/83 11:45 AM

BACTERIOLOGY

CULTURE NEGATIVE FOR:

AEROBIC BACTERIA _____ ANAEROBIC BACTERIA _____

DAYS _____ WEEKS _____

NEGATIVE FOR GROUP A STREPTOCOCCI

NEGATIVE FOR N. GONORRHOEA

NO ENTERIC PATHOGENS FOUND

NEGATIVE SURVEILLANCE STOOL CULTURE

FLORA: NORMAL __ MIXED BACTERIAL FLORA __

SKIN __ FECAL FLORA __

LIGHT __ MODERATE __ HEAVY __

URINE: LESS THAN 10,000 COLONIES PER ML __

GREATER THAN 100,000 COLONIES PER ML __

LESS THAN 100,000 COLONIES PER ML __

-------------------------------------------------------------

ANTIBIOTIC SUSCEPTIBILITY MICROGRAMS PER ML

ORGANISM: ___________________________________________

Drug MIC MIC MIC MIC MIC MIC MIC MIC

0.25 0.5 1 2 4 8 16 32+

Ampicillin 2

Carbenicillin 2

Cephalothin 2

Cefoxitin 2

Cefamandole 2

Cefotaxime 2

Gentamicin 0.5

Tobramycin 0.5

Amikacin 2

Chloramphenicol 2

Tetracycline 2

Erythromycin 2

Clindamycin 0.5

Vancomycin 2

Trimethoprim 0.5

Rifampin 0.5

-------------------------------------------------------------

* = MIC values in mcg/ml

R = Resistant

S = Sensitive

I = Intermediate

* ORGANISM IS STAPHYLOCOCCUS (RESISTANT) STAPHYLOCOCCUS

Other: ___________________________________

Terminal Tech: ____________________

Microbiology Report

THE JOHNS HOPKINS HOSPITAL

DEPARTMENT OF LABORATORY MEDICINE

CLINICAL MICROBIOLOGY REPORT

Name: LONG, DEEPA

History No.: 202-91-94

Age: 2 Sex: F

Loc.: CM6WG

Physician: APLIN, RICHARD

Date Printed: JAN 21 83

LAB NO.: 541 D-9-83

TESTS: ANA CULT - BLOOD

COLL. TIME: 1/19/83 11:00 AM

REC'D TIME: 1/19/83 11:45 AM

BACTERIOLOGY

CULTURE NEGATIVE FOR:

AEROBIC BACTERIA _____ ANAEROBIC BACTERIA _____

DAYS _____ WEEKS _____

NEGATIVE FOR GROUP A STREPTOCOCCI

NEGATIVE FOR N. GONORRHOEA

NO ENTERIC PATHOGENS FOUND

NEGATIVE SURVEILLANCE STOOL CULTURE

FLORA: NORMAL __ MIXED BACTERIAL FLORA __

SKIN __ FECAL FLORA __

LIGHT __ MODERATE __ HEAVY __

URINE: LESS THAN 10,000 COLONIES PER ML __

GREATER THAN 100,000 COLONIES PER ML __

LESS THAN 100,000 COLONIES PER ML __

-----------------------------------------------------------------------------

ANTIBIOTIC SUSCEPTIBILITY MICROGRAMS PER ML

ORGANISM: ________________________________________________________

Drug MIC MIC MIC MIC MIC MIC MIC MIC

0.25 0.5 1 2 4 8 16 32+

Ampicillin 2

Carbenicillin 2

Cephalothin 2

Cefoxitin 2

Cefamandole 2

Cefotaxime 2

Gentamicin 0.5

Tobramycin 0.5

Amikacin 2

Chloramphenicol 2

Tetracycline 2

Erythromycin 2

Clindamycin 0.5

Vancomycin 2

Trimethoprim 0.5

Rifampin 0.5

-----------------------------------------------------------------------------

* = MIC values in mcg/ml

R = Resistant

S = Sensitive

I = Intermediate

* ORGANISM IS STAPHYLOCOCCUS (RESISTANT) STAPHYLOCOCCUS

Other: ___________________________________

Terminal Tech: __________________________

Microbiology Report

THE JOHNS HOPKINS HOSPITAL

DEPARTMENT OF LABORATORY MEDICINE

CLINICAL MICROBIOLOGY REPORT

Name: LONG, DEEPA

History No.: 202-91-94

Age: 2 Sex: F

Loc.: CM6WG

Physician: MYHAND, SUSAN

Date Printed: JAN 26 83

LAB NO.: 541 D-9-83

TESTS: BACT CULT/UNSP: URINE

COLL. TIME: 2:00PM 23 JAN 83

REC’D TIME: 4:10PM 23 JAN 83

BACTERIOLOGY

CULTURE NEGATIVE FOR:

AEROBIC BACTERIA _____ ANAEROBIC BACTERIA _____

DAYS _____ WEEKS _____

NEGATIVE FOR GROUP A STREPTOCOCCI

NEGATIVE FOR N. GONORRHOEA

NO ENTERIC PATHOGENS FOUND

NEGATIVE SURVEILLANCE STOOL CULTURE

FLORA: NORMAL __ MIXED BACTERIAL FLORA __

SKIN __ FECAL FLORA __

LIGHT __ MODERATE __ HEAVY __

URINE: LESS THAN 10,000 COLONIES PER ML __

GREATER THAN 100,000 COLONIES PER ML X

LESS THAN 100,000 COLONIES PER ML __

-------------------------------------------------------------

ANTIBIOTIC SUSCEPTIBILITY MICROGRAMS PER ML

ORGANISM:

(1) E. coli

(2) E. coli (different morphology)

Drug MIC MIC MIC MIC MIC MIC MIC MIC

0.25 0.5 1 2 4 8 16 32+

Ampicillin 8

Carbenicillin 16

Cephalothin 8

Cefoxitin 4

Cefamandole 2

Cefotaxime 0.5

Gentamicin 0.5

Tobramycin 0.5

Amikacin 2

Chloramphenicol 4

Tetracycline 8

Erythromycin 32+

Clindamycin 32+

Vancomycin 32+

Trimethoprim 0.5

Rifampin 16

-------------------------------------------------------------

* = MIC values in mcg/ml

R = Resistant

S = Sensitive

I = Intermediate

* ORGANISM IS: (1) E. COLI

(2) E. COLI (DIFFERENT MORPHOLOGY)

Other: ___________________________________________

Terminal Tech: _________________________

Final Cumulative Lab Report

THE JOHNS HOPKINS HOSPITAL - DEPARTMENT OF LABORATORY MEDICINE

CUMULATIVE DISCHARGE SUMMARY

* FINAL REPORT *

******************************* C H E M I S T R Y *******************************

CHEMISTRY - ELECTROLYTES

NORMAL LOW NA K CL CO2 ANION SUN CREAT SUN/CR GLU CA AMYLAS TBILI

NORMAL HIGH 135 3.5 99 24 4 12 0.6 25 70 9.0 0.0 0.3

145 5.0 107 30 20 25 1.2 50 110 10.5 150 1.2

MEQ/L MEQ/L MEQ/L MEQ/L MEQ/L MG/DL MG/DL MG/DL MG/DL U/L MG/DL

E TIME

1/19 10:00P 143 3.3 106 16*A 25*A 19* 0.4* 25 77 T046 D4874

1/20 11:45P 139 4.1 107 26 19* 20 0.5 40 88 T082 D4874

1/21 10:00P 133* 4.3 105 19* 13 7* 0.8 18 166* W249 B3583

1/21 11:45P 138 4.1 108 18 18 7* 0.5 18 164* T811 D4874

=ACN MD

CHEMISTRY—BLOOD GASSES

NORMAL LOW pH PCO2 PO2 C-HCO3

NORMAL HIGH 7.35 35 75 20

7.45 45 100 26

MM HG MM HG MMOL/L

E TIME

1/19 10:00P 7.36 40 C 22 N932 D4874

=ACN MD

******************************* H E M A T O L O G Y *******************************

BLOOD COUNTS

NORMAL LOW WBC RBC HGB PCV MCV MCH MCHC PLT RETIC ESR

NORMAL HIGH 6000 3.50 11.6 35.0 73.0 24.0 28.5 150 0.5 0

17000 5.00 15.0 45.0 82.0 30.0 31.0 350 1.5 10

/CU MM M/CUMM G/DL % % CU MIC G/DL % /CU MM % MM/HR

E TIME

1/19 06:00P 13900 4.28 12.5 35.4* 82.7* 29.2 35.2* 461* 1.2 D521 D4874

=ACN MD

******************************* FOOTNOTES *****************************************

* = AMENDED RESULT

# = CREAT MAY SHOW INTERFER FROM 5FC (UP TO 6.0/DL)

= RESULT: 25

= ABNORMAL VALUE

MCW6 PRINTED: JAN 28 83 2:27 AM PAGE 1 LONG, DEEPA J.H.H. 202-91-94

Final Cumulative Lab Report

***************** H E M A T O L O G Y *******************************

BLOOD COUNTS

NORMAL LOW WBC RBC HGB PCV MCV MCH MCHC PLT RETIC ESR

NORMAL HIGH 6000 3.50 11.6 35.0 73.0 24.0 28.5 150 0.5 0

17000 5.00 15.0 45.0 82.0 30.0 31.0 350 1.5 10

/CU MM M/CUMM G/DL % % CU MIC G/DL % /CU MM % MM/HR

E TIME

1/21 11:45P CAN A CAN A CAN A CAN A CAN A CAN A CAN A CAN A CAN A E521 B3583

1/21 06:00P 6800 3.58 10.4* 28.9* 83.0* 29.0 34.3 290 0.8 E831 D4874

=ACN MD

WBC DIFFERENTIALS: PERCENTS

NORMAL LOW MYELOS METAS BANDS POLYS LYMPHS MONOS ATYPS EOS OTHERS NRBC

NORMAL HIGH x x 0 40 45.0 2.0 0.0 4.0 x x

6.0 60 75.0 8.0 4.0 x /100WBC

E TIME

1/19 06:00P x 4.0 32.0 50.0 7.0 2.0 2.0 3.0

OTHER CELLS DETECTED: BASOS 3.0% D521 D4874

WBC MORPHOLOGY: OCCAS. SMUDGE CELLS D521 D4874

1/21 06:00P x 2.0 47.0* 23.0* 11.0* 2.0 2.0 3.0 E831 D4874

OTHER CELLS DETECTED: CAN A CAN A CAN A CAN A CAN A CAN A

WBC MORPHOLOGY: CAN A CAN A CAN A CAN A CAN A E831 B3583

WBC DIFFERENTIALS: ABSOLUTE COUNTS

NORMAL LOW BANDS POLYS LYMPHS MONOS EOS

NORMAL HIGH 240 1500 3500 300 160

650 4300 10000 800 440

/CU MM /CU MM /CU MM /CU MM /CU MM

E TIME

1/19 06:00P 560 4400* 7000 970* 280 D521 D4874

1/21 06:00P 150 3200 1600 750 200 E831 D4874

=ACN MD

******************************* FOOTNOTES *****************************************

= CLOTTED

* = ABNORMAL VALUE

1 = SEE SPECIAL NOTE 1

2 = SEE SPECIAL NOTE 2

SPECIAL NOTE 1 = RESULTS DIFFER SIGNIFICANTLY FROM PREVIOUS VALUES;

RESULTS HAVE BEEN DOUBLE CHECKED

MCW6 PRINTED: JAN 28 83 2:27 AM PAGE 2 LONG, DEEPA J.H.H. 202-91-94

Final Cumulative Lab Report

************** H E M A T O L O G Y *******************************

WBC DIFFERENTIALS: ABSOLUTE COUNTS

NORMAL LOW BANDS POLYS LYMPHS MONOS EOS

NORMAL HIGH 240 1500 3500 300 160

650 4300 10000 800 440

/CU MM /CU MM /CU MM /CU MM /CU MM

E TIME

1/20 11:45P CAN A CAN A CAN A CAN A CAN A E521 B3583

1/21 06:00P 150 3200 1600 750 200 E831 D4874

=ACN MD

******************************* C O A G U L A T I O N ******************************

NORMAL LOW PT RATIO PT-FIB APTT RATIO PTT-FB FIB-9T TT

NORMAL HIGH 11.0 1.0 3.1 18.5 1.2 30.0 150

13.0 1.3 6.5 28.5 40.0 200

SECONDS PAT/NORM SECONDS SECONDS PAT/NORM SECONDS MG/DL SECONDS

E TIME

1/19 06:00P 11.3 1.0 27.0 1.2 0800 D4874

1/19 10:00P 0820 D4874

=ACN ************* B L O O D B A N K****************

E TIME

1/19 ????? ABO/RH A Negative

BLOOD BANK 1 - ROUTINE SCREENING

A/SSAL Negative DCI A597 D4874

=ACN MD

*********** FOOTNOTES **********************

= CLOTTED

* = ABNORMAL VALUE

MCW6 PRINTED: JAN 28 83 2:27 AM PAGE 3 LONG, DEEPA J.H.H. 202-91-94

Neaurological Discharge Summary

01/24/1983

THE JOHNS HOPKINS HOSPITAL

INTEROFFICE MEMORANDUM SERVICE

HISTORY NO.: 202-91-94

PATIENT’S NAME: Long, Deepa

DOCTOR: James S. Campbell, M.D.

DATE: [White-out applied here; handwritten correction reads: "1-20-83 → 1-24-83"]

DISCHARGED: [Typed: "1-24-83"; handwritten correction notes: "Discharged 2 days later, 1-26-83"]

This is a 2-1/2 year old child who was involved in a train accident in India in April of 1982. She sustained a severe crushing injury to the right leg resulting in a below knee amputation, and a traction injury to the right brachial plexus. She was adopted by a family in the United States and admitted to the Johns Hopkins Hospital for evaluation of her brachial plexus injury.

On January 20, 1983, she underwent an exploration of the brachial plexus and a nerve grafting procedure. She tolerated the procedure well and was discharged on [Typed: "January 24, 1983"; handwritten correction: "actually discharged on January 26, 1983"].

She will be followed in the neurosurgery outpatient clinic.

James S. Campbell, M.D.

JSC:bb

white out top right of page, written in dates, discharge date inccorect.

Pediatric Neurology 01/26/1983

THE JOHNS HOPKINS HOSPITAL

DISCHARGE SUMMARY

DIVISION OF PEDIATRIC NEUROSURGERY

HISTORY NO.: 202-91-94

PATIENT’S NAME: Long, Deepa

DISCHARGE DATE: January 26, 1983

DIAGNOSIS:

Avulsion of tenth, eleventh, and twelfth thoracic roots; superior and inferior gluteal nerves.

HISTORY AND HOSPITAL COURSE:

This patient is a 2-1/2-year-old Indian child who was involved in a train accident in India in April of 1982. She sustained a severe crushing injury to the right lower extremity, which resulted in a below-knee amputation, and also a traction injury to the right brachial plexus. On January 20, 1983, she underwent exploration of the right brachial plexus with excision of neuromas and nerve grafting to the posterior cord, and to the upper and lower trunks of the brachial plexus with sural nerve autografts. She tolerated the procedure well and was returned to the floor in satisfactory condition. Her postoperative course was uneventful and she was discharged on January 26, 1983, with follow-up to be continued in the neurosurgery clinic. Her discharge medications included only Tylenol for discomfort.

Dictated by: Richard Kaplan, M.D.

D: 1-26-83

T: 1-27-83

RJK:bb

Medicine Record Discharge Summary

THE JOHNS HOPKINS HOSPITAL

MEDICATION RECORD DISCHARGE SUMMARY

PATIENT: LONG, DEEPA

HISTORY NUMBER: 2029194

DATE ADMITTED: 01/19/83 0600P

DATE DISCHARGED: 01/26/83 0400P

STAT DOSE: 01/20 08A

018-A CEPHALOSPORIN KEFLIN

ORDERED AS: KEFLIN

300.0ML = 100MG/6ML IV INJ

FOR 4 DOSE(S) GIVEN

0000 DOSES OMITTED

0640-1

021-A MORPHINE

MAX DOSE: 10 MG/ML IM INJ

FOR 1 DOSE(S) GIVEN

0000 DOSES OMITTED

0640-1

021-B PENTOBARBITAL ANESTHETIC

ORDERED AS: PENTOBARBITAL

100MG/2ML = 50 MG/ML INJ

FOR 1 DOSE(S) GIVEN

0000 DOSES OMITTED

0640-1

021-C ATROPINE

ORDERED AS: ATROPINE

10.0ML = 1 MG/ML IM INJ

FOR 1 DOSE(S) GIVEN

0000 DOSES OMITTED

0640-1

034-A CEPHALOSPORIN KEFLIN

ORDERED AS: KEFLIN

300.0ML = 100MG/6ML IV INJ

FOR 4 DOSE(S) GIVEN

0000 DOSES OMITTED

0641-1

Medicine Record Discharge Summary

ORDERS CONTINUED FOR: LONG, DEEPA

2029194 01/26/83 PAGE 2

095-A MORPHINE INJ SOLN – 15 MG/ML

ORDERED AS: MORPHINE

10.0ML = 15 MG/ML IV INJ

FOR 1 DOSE(S) GIVEN

0000 DOSES OMITTED

0940-1

040-A ACETAMINOPHEN

ORDERED AS: TYLENOL

120.0ML = 80MG/2.5ML ORAL LIQ

FOR 1 DOSE(S) GIVEN

0000 DOSES OMITTED

0941-1

043-A ACETAMINOPHEN

ORDERED AS: TYLENOL

120.0MG = 120MG RECT SUPP

FOR 1 DOSE(S) GIVEN

0000 DOSES OMITTED

0942-1

043-C ACETAMINOPHEN

ORDERED AS: TYLENOL

120.0MG = 120MG RECT SUPP

FOR 1 DOSE(S) GIVEN

0000 DOSES OMITTED

0942-1

045-A MEPERIDINE INJ SOLN

ORDERED AS: DEMEROL

10.0ML = 50 MG/ML IM INJ

FOR 3 DOSE(S) GIVEN

0000 DOSES OMITTED

0943-1

Medicine Record Discharge Summary

ORDERS CONTINUED FOR: LONG, DEEPA

2029194 01/26/83 PAGE 3

054-A CODEINE ORAL SYRUP

10MG DOSE

(01.67ML = 30 MG/5ML ORAL LIQ)

Q6H

PRN PAIN

FOR 2 DAY(S) GIVE IF TYLENOL DOESN’T WORK

0000 DOSES GIVEN

0000 DOSES OMITTED

********** LAST PAGE **********

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