Embedded Files
5 Months on US Soil.
Front Sheet Summary
Front Sheet Summary
THE JOHNS HOPKINS HOSPITAL
FRONT SHEET SUMMARY
REPORTABLE DISEASE: X No □ Yes
PHONE REPORTED: X No □ Yes
BY: (Physician Name) ___________
DATE CARD SENT: ___________
DATE OF ADMISSION: 9/21/82
REFERRING PHYSICIAN: Dr. James Campbell
ADDRESS: JHH Neurosurgery
RESPONSIBLE PHYSICIAN: Dr. James Campbell
SERVICE: Ped neurosurgery
ADMITTING COMPLAINT, MAJOR FINDINGS (include history) AND HOSPITAL COURSE:
Age 2 yrs.
Traumatic amputation of (R) leg about 1 yr
adopted in May. Found to be
paralyzed (R) leg. Flaccid since knee amputation
with sensory changes.
EMG evidence of longstanding L-2, 3 muscle
denervation + sensory probable of L-4.
LIST OPERATIONS AND/OR PROCEDURES IN ORDER OF IMPORTANCE, INCLUDE DATE AND SURGEON: (NO ABBREVIATIONS)
EMG.
CONFIRMED DIAGNOSIS CAUSING ADMISSION (NO ABBREVIATIONS)
Probable lumbar nerve root avulsion
RELEVANT DIAGNOSES AND COMPLICATIONS LISTED IN ORDER OF IMPORTANCE (NO ABBREVIATIONS)
Above knee amputation
Urinary Tract Infection
Possible Giardia
CONDITION ON DISCHARGE: Stable
DISCHARGED: X Home □ Nursing Home □ Deceased □ Other
DISCHARGE INSTRUCTIONS INCLUDING MEDICATIONS AND DOSAGES, DIET AND ACTIVITY RESTRICTIONS:
Bactrim for UTI 5-7 bid
Flagyl for Giardia 125 mg qid
FOLLOW UP (WHEN, WHERE, BY WHOM):
Readmission 10/4 for myelogram
DATE OF DISCHARGE: 9/23/82
COMPLETED BY: G.H. Johnson
SIGNATURE: [signed]
CODE NUMBER: B 1 8 1 9
Admissions Screening Data
Admissions Screening Data
THE JOHNS HOPKINS HOSPITAL
ADMISSION SCREENING DATA
PATIENT
LAST NAME: Long
FIRST: Deepa
INITIAL: __
STREET ADDRESS: __
CITY: __ STATE: __ ZIP: __
TELEPHONE: __
HISTORY NO IF KNOWN: 2029194
HOPKINS PATIENT BEFORE? NO [ ] NOT KNOWN [ ] YES [X]
DATE OF LAST ADMISSION: Prev
AGE: 2
SEX: F
ADMISSION DATE: 9/21/82
SERVICE: PPN
M.D. CODE: 3605
Campbell
ADMISSION DIAGNOSIS: __
SCHEDULED FOR SURGERY? NO [X] YES [ ] PROCEDURE: __
DATE: __ UNIT: __
ADMISSION SCREENING
EKG NO [ ] YES [X]
CHEST X-RAY NO [ ] YES [X]
LABORATORY: NONE [ ] GROUP A [X] B [ ] C [ ] D [ ] E [ ]
SEE LIST FOR TESTS IN EACH GROUP
OTHER (LIST): __
DOCTOR WILL MAIL REQUISITION
REQ. BY ADMITTING OFFICE
PROCEDURES TO BE SCHEDULED BY ADMITTING OFFICE
Procedure: __
Date: __
Time: __
Scheduled by: __
CONSULTATIONS REQUESTED -
Service: __
Physician: __
Date: __
Time: __
Scheduled by: __
ADMISSION MEDICATIONS
NONE [ ]
TO BE ORDERED [ ]
ORDERED ON PRE-ADMISSION HISTORY [ ]
ADMISSION DIET
REGULAR [ ]
TO BE ORDERED [ ]
ORDERED ON PRE-ADMISSION HISTORY [ ]
SPECIAL INSTRUCTIONS: __
INFORMATION RECEIVED FROM: __
FORM COMPLETED BY: __
DATE: __
AUDIT COPY
Order Sheet #1
Order Sheet #1
THE JOHNS HOPKINS HOSPITAL
ORDER SHEET
CMCWG 9 202 91 94 A
LONG, DEEPA
09/09/80 F
Page No. 1
Date: 9/21/82
Admit to GW
Investigation of flail (L) leg 🚩 (wrong leg)
Condition stable good
Diet free regular / chopped.
Activity free – may use walker.
Vital signs q shift ✓
Allergies not known ✓
Med: Metronidazole 125 mg po (6 hourly) q 7, 9, 59
Tests:
a. Feces ×2 daily to lab – parasites (done 9/22)
b. urine → ? q shiftReferral:
a. neuromuscular neu
b. orthopedics
c. myelogram if possible
[Signature: D. Johnson]
Order Sheet #2
Order Sheet #2
ORDER SHEET
CMCWG 9 202 91 94 A
LONG, DEEPA
09/09/80 F
9/21/82 4:10 p
Pleax [=Please] collect CCU and send for C+S (sent 9/21)
resp / urine
[signed] Johnson
9/21/82 10 p vid Beaman
9/21/82
Please Amed times to 9-1-5-9 prev. [illegible/faint text keenman RN or Keeman RN]
9/21/82
Vital signs q shift / strict observation.
[signed] Johnson
9/22/82 6 am
Vd Brown
9/22/82 10 p
Vd Russo RN
6.9/23/82 9 p D/C IV Fluids
Vd J. Howarth RN
9/23/82 11 p
Vd J. Howarth RN
9/23/82
Dischge [=Discharge] home with parent.
1) Metronidazole 125 mg qid 8 days
2) Return for myelogram admit 10/4
3) Urinary infection
[signed] Johnson
Order Sheet #[blank] OVERDOSE EVENT 🚩
Order Sheet #[blank] OVERDOSE EVENT 🚩
ORDER SHEET
Page No. ___blank___
Patient’s Name and History No.
LONG, DEEPA
202 91 94
Weight: 9.6 Kgs
Ordered
Date: 9/23/82
Time: 9:30 AM
Order: 🚩
Premed: Chloral hydrate 750 mg orally now
Noted by: [signature: Johnson]
Order Completed 🚩
Date: 9/23/82
Time: [noted as “9:30 AM” again, initials beside it]
[Signature again: Johnson]
Doctos 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
Dcotrs notes #10
Doctors notes #11
Doctors Notes #12
Doctors Notes #13
Doctors Notes #13
Doctors Notes #14
Doctors Notes #14
Doctors notes by page
#1. 9/21
Med Stud Admission Note
Attending: Dr Campbell x 6405 [ Mayer 7-113 ]
Chief Res: Dr Shinnar
Res: Dr Graham Johnson
Med Stud: Victoria L Schneider MST
CC
2-yr Indian girl admitted for R/O peripheral avulsion secondary to traumatic Right BKA.
HPI
Approx 1–1½ yrs ago Deepa was involved in a train accident → traumatic Right BKA and her mother was killed. Her parents adopted her 5/7/82 (19 mos old). She had never had any use of her remaining Right leg prior to adoption. Parents noted that the leg was a “flail leg.” They took her to an amputee clinic at Kernan Hosp (Dr Decker / orthopedics). Arthrogram was done at Kernan (read by Dr Garfinkel) showing dysplastic Right acetabulum probably secondary to repeated subluxations of Right femoral head.
An EMG was also performed; no official report is available, but in a correspondence it was said that EMG showed no visible muscle action potentials in the anterior or posterior aspects of the Right thigh. The parents contacted Dr Campbell in....
#2. ...hope of the possibility of restoration, at least in part, of function of the muscle groups of the Right thigh in order to facilitate the use of a prosthesis. She is admitted for closer evaluation of the neural and neuromuscular function of Right thigh and hip, including myelogram with the possibility of grafting other motor nerves into the sciatic nerve.
history:
Birth / Dev – unknown.
Immunizations – 2 so far (2 DPTs).
Infectious – relat on 5/82; giardia since 5/82.
Meds: Furazone 3.75 cc QID (50 mg/15 ml) – giardia.
Allergies – diarrhea ↑ milk drinking.
Hosp: Kernan Hosp ~6/82 for arthrogram Right hip.
History: unknown.
History:
Lives with 2 adopted brothers, mother + father.
Father – psychiatrist in Columbia, MD.
Insurance – BS/BS.
Address: 5626 Oakland Mills Rd, Columbia 21045 Tel 730-4531.
#3. ROS
Gen’l — healthy, well-adjusted, walks + smiles
Skin — recent rashes
HEENT — HA, eye or ear infections, rhinorrhea, epistaxis, sore throat, cough, lymphadenopathy.
Lungs — cough, hemoptysis
C-V — heart, palpitations
GI — ↓ appetite, recent blood in stools
occasional cramps → giardiasis; bowels have been consistently loose, ~1x/day, become watery + mucoid; she has fairly good continence, can tell Mom when she has to defecate but then must do so immediately (↓ sense of urgency).
GU — c/o soreness in wetted area; mom using A+D oint.
No hematuria, polyuria.
Neuro — alert, oriented.
Good m. strength asymmetrically, no m. strength in R stump, ⌀ sensory to touch, lower ⅓ @ stump.
R = 36, P = 120
Length = 83 cm (25th %tile)
HC = 46½ cm (70th %tile).
PE reveals an alert, chatty Indian girl in NAP.
#4. HEENT: NC/AT, PERRLA, FROM, no nystagmus, fundi not seen.
TMs mobile, slightly hyperemic. Nose clear. Pharynx without exudate.
Neck: No adenopathy or masses.
Lungs: Clear to A.
C-V: R S1, S2. No murmurs. No S4.
Abd: Soft, nontender, bowel sounds present. Liver 1½ fb below costal margin, smooth.
Ext/Genit: + erythema perianal area. No discharge, no bleeding.
Rectal: Sphincter tone appears intact.
Neuro: Alert, oriented.
23.5 cm 22.5 cm (see drawing)
Motor: Right stump flaccid, no muscle tone or strength. Normal muscle tone and strength otherwise.
Sensory: Right stump – loss of peripheral sensation L1 distribution. Vibration sensation appears intact. Normal pinprick and vibration elsewhere.
Cerebellar: Good finger-to-nose bilaterally.
Cranial nerves II–XII grossly intact.
#5. done at Kernans. The aim is to document evulsion of spinal nerve in hopes that it may be possible to graft other motor nerves into the sciatic nerve.
Plan
N-M consult – probable EMG to pinpoint damage more exactly (?Future N cord study)
Myelogram – to be scheduled ASAP
Anesthesiology 5606 (Nita)
Anesthesiologist (Dr Malla) 5606
Neuroradiology – Marsha Updike scheduling 211Giardia – stool for O&P Metronidazole 125 mg q6h
Perianal erythema – prob 2° to irritation An-D ointment urine for C+S to R/O UTI
V. Schneider MSIV
#6. reflexes
[diagram present with “2+” marks]
U/A pH=5 SG 1.025 Ø heme, prot, glu, ket, bili micro 0–2 wbc 0 casts 4 BACT
TESTS
Arthrogram (done at Kernans; read by Dr Garfinkel)
Dysplasia of R acetabulum prob 2° to repeated subluxation of R femoral head
L femoral head normal in appearance
L hip nl
#EMG (done at Kernans) — no official report, but a correspondence by Dr Ira Wexler 6/2/82 reports that no visible motor action potentials could be seen from ant or post portions of R thigh despite movement of the child
A/P
R hip dysplasia
Plan consult ? pediatric orthopedics re strategy to restore nl R acetabular architectureNeural / Neuromuscular ? Sciatic N Damage
We have no good report of the EMG of the pt
#7. (R) lower extremity
no hip flexor extension
loss of body of gluteii, no fasciculations
(L) good lower tone
reflexes normal toes ↑
Sensation:
(L) MAD
(R) no touch nor pinprick up to L1 level
No obvious nystagmus or dysmetria
Rectal sphincter tone appears normal with anal wink on cheelom (L) ?(R)
Impression: (1) (R) above knee amputation without sensation or muscle tone below L1 on (R)
needs to understand anatomy of damage; peripheral nerve root avulsion
#8. Alert reactive girl of small stature
weight 9.6 kilograms length 25½ in HC 46½ cm
Normocephalic
nasal physiognomy ear structure
teeth satis.
Chest clear good air entry
HS dual no murmurs
Abd soft no masses liver edge palpable
genitalia slightly irritated
R (leg) scars except skin graft donor recipient sites on the R above knee stump of amputation soft + flabby
Alert oriented
Cranial nerves full eye movts
Fundi not seen
Facial movts symmetrical
hearing grossly normal
R + (L) upper extremities tone good, tone and reflexes brisk symmetrical
#9. perhaps graft to poorer motor nerve from intercostal motor — many possibilities. Restoration of some function would represent a significant gain.
James Campbell
(leg with flaccid thigh muscles)
Clinical findings of flaccid thigh muscles seem already clear.
Neurodiagnosis after findings at Kernan anticipated to lead findings or hypothesis of findings at Hopkins with further investigation.
(R) BKA without sensation or muscle tone below (L) or (R)
Needs to understand anatomy of damage, peripheral nerve root avulsion.
#10. (2) Chronic diarrhoea past proven
giardia — need to check
treat with metronidazole [illegible initials/signature]
Referrals as above Thank you Dr Schneider
9/22/82 1 pm: Orthopaedics have seen Deepa — comment awaiting.
• Neuromuscular are coming; EMG etc.
At present we have a GA [illegible] myelogram + CT arranged for
12 noon Tues 10/5
but probably will not need it.
• Dr Campbell will be seeing.
9/22/82 Pt appears to have no
motor function in RLE c? L2
sensory level. Myelogram will
be needed to determine if avulsion
is present. No avulsion — explore
plexus / sciatic. If avulsion then
#11. Ped AR note:
Attending: Dr. Singh
Senior Resident: Dr. Shinnar
Resident: Dr. Johnson
History — from adoptive mother and previous medical notes.
2 year old Indian female brought to Johns Hopkins by her adoptive parents for investigation of flail limb.
Sometime ago in India Deepa & her mother are believed to have been involved in a train accident. Apparently this killed her mother and left Deepa with an above knee amputation which is reported as being present as normal.
She has come to the USA in May & has been adopted by Dr. & Mrs. Long. Since her arrival the residual nature of the stump has been appreciated and investigated. Dr. Wexler has shown no EMG activity in the muscles of the stump and Kernan Hospital are making a prosthesis. This admission has been planned to evaluate the neurological status of the stump and consider any actual therapy.
#12. has been planned to evaluate the neurological status of the stump and consider any actual therapy.
PMH: As above.
Chronic diarrhoea since immigration.
Had one course of furazolidine for giardia but this has recurred.
Currently on 2nd course.
No allergies.
FH: nil known.
SH: Adopted by Dr. & Mrs. Long.
Dr. Long is a psychiatrist.
2 sibs – 7, 10 boys. well.
ROS / Development:
💚 May 82 she had vocab of 50 two-word phrases.
By 3 weeks she had 50 + English words, now using sentences.
Mobility – by crawling or just now able to 1-foot hop with support. 💚
#13. to lead. Possible old injury of the Right lower nerves L2 and of cord.
Was possibly injured at the L1 level (note: interjection “Avulsed roots proximal to dorsal ganglion” appears to be in Dr. Rechtshaffen’s handwriting and pen)
accounting for the sensory failing.
Very unusual case — if she’d [illegible] awake a more definitive diagnosis.
C.F. Batzle, Ph.D.
E. Rechtshaffen, M.D.
Addendum: The most definite statement I can make is that she has long-standing denervation of muscles innervated by L2–S2 on the right. The L1 pin level suggests associated sensory denervation L2–S4. By hx there is intact sympathetic function in the (R) leg. She may have had 2 events. If this is all due to the accident then the most probable cause is avulsion of roots on the Right from L2–S4.
Suggest: Thermography of Right leg
Myelogram
[signed] Rechthand
Thank you. Plan for myelogram 10/5/82, 12 noon.
Home meanwhile on Metronidazole × 10, 100 mg Q8H.
Lactose function on cath urine suggest E. coli.
2-hr stool investigation showed heavy VUCG infection.
After Rx → re-admit for myelogram.
[Signed: Johnson]
#14. 9-21-82 3 PM
Admitted to 6W for work-up of Nerve Avulsion in Rt. Leg which is a BKA.
2 yr. old Indian female. VSS, alert. Scar noted on Rt. leg, appears to be from skin graft. 💚 Ambulates w/ walker. Appears to be in no apparent distress. – D. Ament
9-22-82 5 PM
VSS, alert, perls, appetite good, ambulating well & walker, stool specimen obtained and sent, ortho consult done. Down to playroom. – D. Ament
9-23-82 12:30 PM
Problem: Peripheral Nerve Avulsion
S – “I going home soon.” Deepa says 💚
O – VSS, alert, perls, appetite good, 💚 ambulating well w/ walker. Little muscular control and sensation in Rt. stump.
Mom has done necessary preparation for discharge.
A – Stable and ready for discharge.
P – Plan to assist in discharge. Plan to readmit on 10/4 for myelogram.
D. Ament GVS
9-23-82
Deepa discharged to mother’s care.
Mom has Metronidazole & instructions and supply for 8 days.
More conclusive tests (myelogram) will be performed when Deepa returns on 10/4.
D. Ament GVS
Consultation Request
Consultation Request
THE JOHNS HOPKINS HOSPITAL
CONSULTATION REQUEST AND REPORT FORM
LONG, DEEPA
CMCWG 9 202 91 94 A
LONG, DEEPA
09/09/80 F
Referral Date: __________
Dr. (Consultant): Neuromuscular (Specialty or Clinic)
When Needed? ( ) <24 hrs ( ) 24-72 hrs (x) >72 hrs.
To be completed by REFERRING PHYSICIAN:
1. Primary Problem: Traumatic amputation of (R) leg.
2. Other Relevant Problems: no flexor of stump + sensation at L level
Question To Be Answered: ? EMG & Future neuromuscular studies useful
(Referring Physician’s Signature) J Johnson
(Referring Clinic or Nursing Unit) CMC SOM.
CONSULTANT’S FINDINGS ________________________
CONSULTATION DATE: ________________________
Lab Results
Lab Results
THE JOHNS HOPKINS HOSPITAL
DEPARTMENT OF LABORATORY MEDICINE — LABORATORY REPORT
Lab No.: 43 - V-322
J.H.H. History No.: 202-91-94
Patient Name: Long, Deepa
Doctor: Johnson, Graeme
Processed: 09/22 01:09 PM
Printed: Sep 23 ’82
TESTS: Parasite/Stool
Parasitology Lab
(✓) No blood or tissue parasites found.
(✓) No protozoan cysts or trophozoites found.
(✓) No helminth ova, larvae, or adult forms found.
( ) Parasitologic examination positive for: ——
Occult blood: ( ) Negative ( ) Positive
Specimen unacceptable for the following reason(s): ——
Comments: Brown, formed
Labs 09/22/82
Labs 09/22/82
THE JOHNS HOPKINS HOSPITAL
DEPARTMENT OF LABORATORY MEDICINE
LABORATORY REPORT
Lab No. 41 - 8 - 013
History No. J.H.H. 202-91-94
Date Printed: Sep 22 82
Patient: Long, Deepa
Location: CMCW6
Doctor: Pride-Boone, Janice D.
TESTS — BACT CULT/CC URINE
Coll. Time — 01:30 PM 21 SEP 82
Proc. Time — 06:45 PM 21 SEP 82
Culture Negative for: [ ] Aerobic Bacteria [ ] Anaerobic Bacteria
at ____ Days ____ Weeks
[ ] Negative for Group A Streptococci
[ ] Negative for N. Gonorrhoea
[ ] No Enteric Pathogens Found
[ ] Negative Surveillance Stool Culture
[ ] Normal Flora
[ ] Light [ ] Moderate [x] Heavy
[ ] Urine-Mixed Bacterial [ ] Skin [ ] Fecal Flora
[x] Urine - Greater than 100,000 colonies per ml.
[ ] Urine - Greater than 10,000 colonies per ml.
[ ] Urine - Less than 10,000 colonies per ml.
[ ] Urine - Less than 1,000 colonies per ml.
Organism: 1. E. coli
ANTIBIOTIC SUSCEPTIBILITY
Number circled represents minimal inhibitory concentration in micrograms per ml.
YEAST - like organism sent to mycology for identification
* Penicillinase producing (resistant) if staphylococcus
METH PEN ERY CLIN TET CHL CEP AMP GEN KAN TOB AMIK TIC CAR SUL PUR
Row 1:
2 0.1 0.5 0.5 1 2 0.25 2 (2) (2) (2) (8) 32 32 32 32
Row 2:
16 16* 8 8 16 32 (16) 8 4 16 8 8 (128) (256) (R 128) 32+
Row 3:
2 0.1 0.5 0.5 1 2 0.25 2 2 2 2 8 32 32 32 32
Row 4:
16 16* 8 8 16 32 16 8 4 16 8 8 128 256 R 128 32+
Prelim. Tech: [initials unclear]
Date/Time: [blank]
Labs 09/23/1982
Labs 09/23/1982
THE JOHNS HOPKINS HOSPITAL
CLINICAL MICROBIOLOGY LABORATORIES
Name: LONG, DEEPA
History No.: 2029194
Location: CMCW6
Age: 2
Sex: F
Date Collected: 9/22/82
Time Collected: 1400
Date Received: 9/22/82
Date Reported: 9/23/82
STOOL CULTURE
Specimen: Stool
Results:
No enteric pathogens isolated.
Comments:
Normal enteric flora present.
[Signature/initials not clear]
---------------------------------------------
Name: LONG, DEEPA
History No.: 2029194
Location: CMCW6
Age: 2
Sex: F
Date Collected: 9/22/82
Time Collected: 1400
Date Received: 9/22/82
Date Reported: 9/23/82
STOOL OVA & PARASITE EXAM
Specimen: Stool
Results:
No ova or parasites seen.
[Signature/initials not clear]
Nurses Flow Sheet NO DATE
Nurses Flow Sheet NO DATE
THE JOHNS HOPKINS HOSPITAL
Pediatric Daily Flow Sheet
Patient: LONG, DEEPA
History No.: 202 91 94
DOB: 09/09/80
Location: CMCW6
Night: [blank]
Day: D. Dele
Evening: Dina Beeman
VITAL SIGNS
Temperature R O A: [blank]
Pulse: 97, 114, 116
Respiration: 24
Blood Pressure: 96/47
Weight: [blank]
TREATMENTS & MEDICATIONS
Metronidazole 125 mg po
Comments:
Night: [blank]
Day:
Parents/Visitors: Mom
Activity: [blank]
Diet: regular
11:00 am — VSS, alert, right lower leg amputated. Scar noted
on left leg appear to be from skin graft, Alert Apprehensive
about being touched.
12 noon — appetite good
2 pm — sleeping in mom's arms. Dr. Johnson talking to mom.
2:30p— Dr. Johnson examined
pt.
Evening
Parents/Visitors: Mom
Activity: amb
Diet: reg
4:00 pm — Out of bed in playroom.
6:00 pm — out of bed in hall & Mom. CCU sent this afternoon.
9:00 pm — Took med. Getting ready for bed.
Nurses Flow Sheet 09/22/1982
Nurses Flow Sheet 09/22/1982
The Johns Hopkins Hospital
Pediatric Daily Flow Sheet
Date: 9-22-82
Nurse’s Initials – Signature – Title
Night: V.H. (Virginia Haller, RN)
Day: D.D. (Dublin Deale, ? signature not fully clear)
Eve: J.T. (Jean Tanner, Student Nurse) / H.L.R. (H.L. Rhoads, RN)
LONG, DEEPA
202 91 94
DOB: 09/09/80
Location: CMCW6
Sex: F
VITAL SIGNS
Temperature R O A: [blank]
Pulse: 104, 120
Respiration: 24
Blood Pressure: 118/104
Weight: [blank]
TREATMENTS & MEDICATIONS
Metronidazole 125 mg
Comments:
Night
Parents/Visitors: Mom
Activity: Sleeping
Diet: Reg
12 M.N — Sleeping. Easily aroused. Color is good.
2a — Sleeping.
4a — Sleeping.
Day
Parents/Visitors: Mom
Activity: ab lib
Diet: NO milk products
8a — VSS, sleeping.
8:30a — Appetite good.
10a — Down to playroom.
11:30a — Stool specimen obtained and sent off. Appetite good.
1p — Sleeping.
2p — Orthopedic consultation done.
3p — Down to playroom.
Evening
Parents/Visitors: Mom
Activity: ad lib
Diet: reg & milk
N/P — Awake & alert. Active in playroom. Color pink.
6:15p — Feeds self well. Good appetite.
7p — Ambulating in stroller no diarrhea
9:30p, 10p — Sleeping.
Nurses Flow Sheet 09/23/1982 OVERDOSE AND DISCHARGED 🚩
Nurses Flow Sheet 09/23/1982 OVERDOSE AND DISCHARGED 🚩
THE JOHNS HOPKINS HOSPITAL
Pediatric Daily Flow Sheet
Date: 9/23/82
Nurse’s initials – signature – title: O.H. / Virginia Hall, RN
Nurse’s initials– signature – title: [daytime blank]
CMCW6 9 202 91 94 A
LONG, DEEPA F
VITAL SIGNS
Temperature R O A: 36
Pulse: 160
Respiration: 24
Blood Pressure: 108/64
Weight:
TREATMENTS & MEDICATIONS
Metronidazole 125 mg
Linen change:
Bath: Self Assist Comp
Position changes: abd back R L
COMMENTS
Night
Parents/Visitors: Mom
Activity: crib/sleeping
Diet: 0
MN sleeping
2A sleeping
4A sleeping
6A slept thru the nite
Day
Parents/Visitors: Mom
Activity: walking
Diet: Reg.
8A – VSS, up eating breakfast and ambulating in hall
11am – returned from EMG – alert and active
Evening
[all fields blank]
24 hr Pediatric I&O Record 09/22/1982
24 hr Pediatric I&O Record 09/22/1982
The Johns Hopkins Hospital
24 Hour Pediatric I&O Record
Date: 9/22/82
IV tubing change at: ___
By: ___
Line No. / TIME
Columns labeled 2400 through 2300 (hourly).
All entries: blank
1. site/type of line: blank
2. blank
3. blank
Hourly IV Intake: blank
Total IV Intake: blank
P.O. Intake: blank
Total P.O. Intake: blank
Total Fluid Intake: blank
Blood/B. Deriv.: blank
Drainage: blank
Stool: blank
Vomit or N.G.: blank
Urine: blank
Specific Gravity: blank
Total Urine Out.: blank
Yesterday’s Summary:
Total Intake: new adm.
Total Output: new adm.
24 hr Pediatric I&O Record 09/23/1982
24 hr Pediatric I&O Record 09/23/1982
The Johns Hopkins Hospital
24 Hour Pediatric I&O Record
Date: 9/23/82
IV tubing change at: _______
by: _______
Line No.
1: [blank]
2: [blank]
3: [blank]
Hourly IV Intake: [all blank]
Total IV Intake: [blank]
P.O. Intake: [blank]
Total P.O. Intake: [blank]
Total Fluid Intake: [blank]
Blood/B. Deriv.: [blank]
Drainage: [blank]
Drainage: [blank]
Stool: [blank]
Vomitous or N.G.: [blank]
Urine: [blank]
Specific Gravity: [blank]
Total Urine Out: [blank]
Yesterday’s Summary:
Total Intake: ad lib
Total Output: [blank]
Infectious Disease 09/21/1982
Infectious Disease 09/21/1982
The Johns Hopkins Hospital
Pediatric Nursing Data Base
LONG, DEEPA
page 1 of 2
9 202 91 94 A
LONG, DEEPA
09/09/80 F
Infectious Disease Screening - to be completed prior to admission to the unit whenever possible.
Has your child had the following:
In the past month, has your child been exposed to (been around anyone) with the following:
If yes, give details:
DISEASE
Regular Measles, German Measles, Rubella
YES [ ] NO [ ] YES [ ] NO [✓]
Chicken Pox
YES [ ] NO [ ] YES [ ] NO [✓]
Mumps
YES [ ] NO [ ] YES [ ] NO [✓]
Whooping Cough
YES [ ] NO [ ] YES [ ] NO [✓]
Does your child have a fever, stuffy nose, cough or a rash TODAY?
YES [ ] NO [✓]
Date: 9/21/82
Signature: [Signed] CM Cook
Nurses Database
Nurses Database
The Johns Hopkins Hospital
Pediatric Nursing Data Base
LONG, DEEPA
9 202 91 94 A
09/09/80 F
Date: 9/21/82
Time: 11:00 AM
Informant/Reliability: Mother
Name patient responds to: Deepa
Age: 2 yrs
Sex: F
Religion: None
Ambulatory / wheelchair / stretcher / carried (infant): Ambulatory
Level of consciousness / orientation: Alert
Drowsy [ ]
Lethargic [ ]
Unresponsive [ ]
Oriented [ ]
Disoriented [ ]
Temp: 37.4°C
Pulse: 114
Resp: 24
B/P: 110/P
Height: [blank]
Weight: 9.6 kg
Allergies (medicine, food, environmental): Milk products
Usual allergic reaction: Diarrhea
Current Medications (include date/time last dose):
Furoxone 9/13/82, 8:30 AM morning
Reason for admission (patient’s/parent’s statement/diagnosis):
Exploring where nerve in sick leg are stopping.
Contact person (if other than informant): [blank]
Relation to patient: Mother
Phone: 730-7531
Signature: D. Kent
Title: H.S.
Admission Note (to be written on admission when data base cannot be completed on admission shift): [blank]
Physical Assessment (to be completed by RN within 24 hrs of admission):
Behavior: Calm
Physical appearance: R. leg amputated. L. leg has scars from possible skin graft. Appears to be in good physical condition.
Skin condition: L. leg has scar from possible skin graft.
Mobility: Walks and walks with ROM
Communication ability: Speaks English well
Vision: [blank]
Hearing: [blank]
Nurses Database
Nurses Database
Have parents or others who may visit been exposed to any infectious diseases listed on the front of the data base: NO
Do they have a respiratory infection: NO
If yes, what action taken: (blank)
Living In: motel
Pertinent Parent Needs (medical or otherwise): NO
When do parents plan to visit: mother will live in hospital
Has child ever been away from home: (blank)
May the child call home: (blank)
Number to call if different than contact person: (blank)
Orientation to unit: to visiting hours
Given copy of parent book: (blank)
Other: (blank)
Patient/Parent advised to label items left at hospital
Patient/Parent advised that hospital cannot assume responsibility for lost or stolen items/valuables
Patient/Parent Expectation of Hospitalization:
clarify condition of nerves in leg to aid in decision of possible reconstruction
Patient/Parent’s Concerns and Questions:
will she get many shots
Additional Findings: (blank)
Preliminary Problem List:
worms
nerve lacerations in R. leg
diarrhea
Home description (stairs, plumbing, heat): (blank)
Health Resources Used: (blank)
Social Worker (Name/Agency): (blank)
PHN/VNA: (blank)
Clinic: (blank)
Other: (blank)
Projected teaching/discharge needs: (blank)
Signature: D. Glas, R.N.
Date: 9-21-82
Nurses Database
Nurses Database
THE JOHNS HOPKINS HOSPITAL
PEDIATRIC NURSING DATA BASE
page 2 of 2
HEALTH HISTORY
Past experience in hospitals (when, how did child react?):
In hospital when had train accident.
Other medical/surgical problems/procedures:
Rt. leg amputated. No other, W/O except arthrogram in Kenya to see shape of hip.
Are immunizations up-to-date?
No, only 2 series of DPT.
PATTERNS OF DAILY LIVING
Eating patterns/restrictions:
3 meals per day, restricted to milk products.
Sleep pattern: __________
Elimination Bowel: diarrhea word used _______
Bladder: might be infection word used O.K.
Habits (alcohol, smoking, drugs): __________
LMP/menstrual patterns: __________
Favorite Toy/activities: doll baby
SCHOOL/DEVELOPMENT
Grade: __________
School: __________
Teacher: __________
Performance: __________
Continuation of school activities during hospitalization: N/A
Peer relationships: __________
Developmental level according to informant (slow, fast, according to age):
According to age.
FAMILY
Primary caretaker: Mother
Family composition: 5
2 bros, mother, father
Significant others: __________
What problems will family have because of this hospitalization (financial, child care, etc.):
None expected.
Medication Record Dicharge Summary 🚩
Medication Record Dicharge Summary 🚩
The Johns Hopkins Hospital
Medication Record Discharge Summary 🚩
Name: LONG, DEEPA
History Number: 2029194
Admitted: 09/21/82
Discharged: 09/23/82 at 0400P
Floor: CMCW6
Physician: Medical Unassigned
Medications:
Metronidazole Oral Suspension 125 mg (100 mg/5 ml oral liquid, 6.25 ml dose)
09/21 09P to 09/22 12A
Q6H (every 6 hours)
0001 doses given, 0000 omitted
Metronidazole Oral Suspension 125 mg (100 mg/5 ml oral liquid, 6.25 ml dose)
09/22 09A to 09/23 05P
QID (four times daily)
0006 doses given, 0000 omitted
Chloral Hydrate (Noctec) 750 mg/5 ml (500 mg/5 ml oral liquid, 7.50 ml dose) 🚩
Stat dose: 09/23 09A
0001 doses given, 0000 omitted
Note: Last page marked
“******** LAST PAGE ********”
Discharge Summary
Discharge Summary
THE JOHNS HOPKINS HOSPITAL
HISTORY NO. 202 91 94
PATIENT'S NAME: LONG, Deepa
PEDIATRIC NEUROLOGY
Dr. G. Johnson
Birthdate: 9/9/80
Admitted: 9/21/82
Discharged: 9/23/82
DISCHARGE SUMMARY:
REFERRING PHYSICIAN: Dr. James Campbell, JHH Neurosurgery
ATTENDING PHYSICIAN: Dr. James Campbell
SAR: Dr. Shlomo Shinnar
RESIDENT: Dr. G. Johnson
ADMITTING PROBLEM: Investigation of flail above knee amputation of the right leg.
HISTORY OF PRESENTING COMPLAINT: Deepa is a child 🚩who has been adopted from India recently in May by Dr. and Mrs. Long. She was involved in a train accident in India about a year ago and her mother died and she had amputation of her right leg 🚩above the knee (below knee). Since then she has been in a nursery and 🚩has been adopted as mentioned above in May this year.
When the Long's had Deepa arrive they found that she had a flail leg without hip muscular movement and have been investigating this since then. To the current admission for myelography and for a need of possible surgery follow up.
On admission examination 💚 Deepa is a active lass who is well proportioned and is quite mobile hopping on her left foot. She has this currently in good physical condition. Weight on admission is 3rd percentile, length for 25th percentile and head in the 10th percentile. Head was normocephalic and teeth were satisfactory. Chest was clear. Abdomen had no masses. Liver edge was palpable and genitalia showed a slight irritation in vulva. Left leg is satisfactory except she has some scarring consistent with skin grafts being taken and also placed outside of her left thigh. The right leg has an above knee amputation. The stump which is soft and flabby. She in this area has reduced muscle mass and power. She is unable to flex or extend her hip and has considerable wasting of the glutel. Sensation is normal left but on the right she has only pin prick above the level of L-1. Rectal sphincter tone appeared to be normal.
HOSPITAL COURSE: She had an EMG which confirmed longstanding denervation of muscles up to L-1 on the right. The L-1 level was shown associated with sensory denervation of L-2 to S-1 and it is probably by history clinically evident. Myelogram unfortunately was not able to be organized. She will be admitted again on 10/4/82 for this.
Other problems. On transfer U.S. Deepa was found to have Giardia and has been treated Furmazoliodine and apparently still got this giardia is actively on a course at present. During her hospital stay we introduced Metronidazole and this appeared to have immediate affect in reducing her diarrhea and she will continue to use this at home. On treating her vulva irritation, it was found that she had a urinary tract infection and she was given Bactrim on discharge for this. The results of a infection work up of the E. Coli is the organism which is resistant Trimethoprim and Sulfamethoxazole and sensitive to the glycosides and Furadantin but insufficient differential for us to change to this medication and for us to consider using a CMG to check on the neurogenic data problem if myelography shows a change in problem.
Discharge Summary
Discharge Summary
THE JOHNS HOPKINS HOSPITAL
HISTORY NO. 202 91 94
PATIENT'S NAME: LONG, Deepa
PEDIATRIC NEUROLOGY
DISCHARGE SUMMARY
DISCHARGE DIAGNOSES: Probable lumber nerve root avulsion with above knee amputation from past injury and proven urinary tract infection, possible Giardia.
CONDITION ON DISCHARGE: Stable. She is on Bactrim 🚩, Flagyl and will be readmitted 10/4/82.
DICTATED: 9/27/82, Dr. Johnson
TRANSCRIBED: 9/27/82, ra
cc: Dr. Campbell, Neurosurgery
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