10/04/1982 - 10/06/1982

Five months on US soil

Mylogram Consent 🚩

THE JOHNS HOPKINS HOSPITAL

Authorization (or consent) for Administration

Of Anesthesia and for Performance of Operations

Or other Procedures

PATIENT Deepa Long

DATE 10/4/82

TIME A.M. ☐ P.M. ☐

I hereby give my consent and authorize Doctor Zinreich Assoc.

Of The Johns Hopkins Hospital to perform the following operation or other procedure:

Myelogram - inject dye into spinal column through spinal needle and take xray to determine problem. Under general anesthesia

(Identify and explain in non-medical terms, use no abbreviations)

I acknowledge that:

1. The nature and purpose of the operation or other procedure and anesthesia, the risks involved, alternatives and the possibility of complications has been explained to me by Doctor _____________ and all my questions, if any, have been answered to my satisfac-

I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantee has been made as to the results that m 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, oth conditions are discovered which, in the best judgment of the medical staff of The Johns Hopkins Hospital, require an extension of the original contem operation or other procedure or a different operation or other procedure, I authorize and request that the said operation or other procedure be perform

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

4. Exceptions to surgery or anesthesia, if any, are: non (If "none", so state)

5. I consent to the disposal by authorities of The Johns Hopkins Hospital of any tissues or parts which it may be necessary to remove. I authorize Th 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 televisi the taking of photographs (including motion pictures), and the preparation of drawings and similar illustrative graphic material, and I also consent to th use of such photographs and other materials for scientific purposes, provided my identity is not revealed by the pictures or by the descriptive text accor panying them.

7. The undersigned acknowledges receipt of a copy of the foregoing consent and authorization to an operation or other procedure.

Witness' Signature Michele PAC

Patient’s Signature ____X _____________

Signature of Physician Securing Consent _____________

JHH ID NO. _____________

IF PATIENT IS UNABLE TO SIGN OR IS A MINOR, COMPLETE THE FOLLOWING:

Patient is a minor _____________ years of age (or) is unable to sign because: _____________

Witness' Signature [signed illegible]_____________

Closest Relative or Legal Guardian’s 🚩 [Signature] HR, Long [labeled] mother 🚩

Informed Consent Supplement 🚩

THE JOHNS HOPKINS HOSPITAL

INFORMED CONSENT SUPPLEMENT

I. INDICATIONS FOR THE OPERATION OR OTHER PROCEDURE ARE:

Diagnosis

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):

Discomfort

Headache

Nausea/vomiting

Allergic rx

Back/neck pain/weakness/numbness

III. Alternatives to the proposed operation or other procedure:

Not do procedure

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 the reason for this decision. (This space may also be used for explanatory diagrams.):

___________________

Witness’ Signature Michele PAC

Patient’s Signature X _____________

Signature of Physician Securing Consent _____________________ JHH ID NO. ______

The undersigned acknowledges receipt of a copy of the foregoing Informed Consent Supplement for an operation or other procedure this ____ day of ____________

Witness’ Signature X _____________

Patient, Closest Relative or Legal Guardian’s Signature X 🚩 [Signature] HR Long [labeled] mother 🚩

Photo Consent 🚩

CHILDREN’S CENTER

JOHNS HOPKINS HOSPITAL

PHOTOGRAPHY CONSENT

I do ☑ do not ☐ hereby give the Johns Hopkins Children’s Center permission to use identified photographs of:

Deepa

taken for the purpose of public relations releases.

These photographs will not be used for scientific or medical teaching purposes.

RESTRICTIONS: ____________________

SIGNATURE: HR Long 🚩

Relationship to Patient: mother 🚩

WITNESS: blank________________________

DATE: 10/4/82

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: 10/4/82

Responsible Physician: JAMES CAMPBELL

Service: Ped neurosurgery

Referring Physician: __________

Address: __________

Admitting Complaint, Major Findings (Include History and Hospital Course):

Injured in train accident about 18 mos ago

now has flex (R) short bowel amputation without hip

muscle movement + sensory loss +

Being assessed for possible nerve reconstruction

time is clear now she has no

foot/ankle probably now has dropped Vit + the grades.

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

Myelogram 10/5/82

Confirmed Diagnosis Causing Admission (No Abbreviations)

(R) Lumbosacral nerve root avulsion

Relevant Diagnoses and Complications Listed in Order of Importance (No Abbreviations):

(R) Abducted amputation

S/P long tract injury

Condition on Discharge: Stable

Discharged: X Home ☐ Nursing Home ☐ Deceased ☐ Other

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

No meds

Follow Up (When, Where, By Whom):

Dr. James Campbell

Date of Discharge: 10/6/82

Completed by: G. H. DAMSON (Signature)

Code Number: 161 81 9

JHH 15-29304 Revised 11/80

Order Sheet #1

CHC WG 9 202 91 94

LONG, DEEPA

09/09/80

ORDER SHEET

USE BALLPOINT PEN – PRESS FIRMLY

Date Time ORDER Noted By Order Completed

10/4/82 5:00 P See Anesthesia preop ________

NPO p MN

No premed

____________________ (signature)

10/4/82 6:00 PM Pre-myelogram CT orders:

1) Myelo asked for 12 NOON 10/5 under genl. anes.

2) Send pt in a stretcher to neurorad ground

3) NPO p MN Thank you

Mydulia PAC – NVR

10/5/82 12 N Orders to T. Wilkenson

10/5/82 4 PM Vd start RN

10/5/82 2:10 D/C IV fluids

Order Sheet #2

CHC WG 9 202 91 94

LONG, DEEPA

09/09/80

F

Page No. 7

ORDER SHEET

USE BALLPOINT PEN – PRESS FIRMLY

Date Time ORDER

10/4/82 1840
1) Admit 6W (Dr. Campbell)

2) Diagnosis: S/P amputation (R) leg lumbosacral injury

3) Condition stable

4) Vital signs q shift

5) Diet: nil by mouth after midnight tonight

6) Activity: free

7) Allergies: nil known

8) Meds: nil

9) Urine: collect clean catch

(1) in fridge for HO

(2) C+S to lab in am please

10) Blood sent, type + CBC

11) IV placement, fluids

D5 0.2 NaCl + 20 mEq KCl at 40 cc/hr

(Signatures at bottom)

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

JHH-15-193060

Order Sheet #3

CHC WG 9 202 91 94

LONG, DEEPA

09/09/80 F

Page No. 3

ORDER SHEET

USE BALLPOINT PEN – PRESS FIRMLY

Date Time ORDER

10/5 0845
1. Anesthesia Orders

a) NPO today

b) Please have CBC and type report on chart prior to going to Neuroradiology

c) No premeds ordered

(signature) J. McKennett, Chief To. Anes. MD

10/5/82

4. IV Fluids D5 / 0.2% Saline + 20 mEq KCl at 40 cc/hour until GA, then post GA 40 cc/hour

(signature)

10/5/82 POST METRIZAMIDE MYELOGRAM ORDERS

- Keep head of bed elevated 20° for 12 hours

- Encourage fluids orally

- No phenothiazines or other neuroleptic drugs for 48 hours!

- Other: (signature S. J. Fratantonio, M.D.)

Valium 2 mg IV, prn for spasm (neuroradiology)

(signature + initials 4:15 PM)

Order Sheet #4

CHC WG 9 202 91 94

LONG, DEEPA

09/09/80 F

Page No. 4

ORDER SHEET

Date Time ORDER

10/5/82 12 N
Orders to T. Wilkenson RN

v d start RN

10/6/82 210 D/C

(signature) James Campbell

(additional signatures/initials)

Doctors Notes

Doctors notes by page:

#1. NOTE PAPER

History of Present Illness:

This 2 year old female was referred by Dr. Katz for evaluation of possible nerve repair. She was apparently involved in a train accident in India at approximately 9 months of age. She was adopted by her present mother (Mrs. Long) and father. At the time of the accident she suffered an above knee amputation of the right lower extremity and was noted to have a flaccid right lower extremity as well. She has been evaluated in India and subsequently here by Dr. Katz. He has requested evaluation by Dr. Campbell to consider nerve repair.

Past Medical History:

She has had episodes of diarrhea. She has been treated for giardiasis. She has also been treated for a urinary tract infection.

Medications: None

Allergies: None

Social History:

The child now lives with her parents, Mr. and Mrs. Long, in Columbia, Maryland.

Family History: Noncontributory.

#2. NOTE PAPER

Physical Examination:

General: This is a happy, interactive 2 year old girl in no apparent distress.

HEENT: Pupils equal, round, reactive to light. Extraocular movements full. Oropharynx clear. No lymphadenopathy.

Chest: Lungs clear to auscultation bilaterally. Heart: regular rate and rhythm. No murmurs, rubs or gallops.

Abdomen: Soft, nontender, no hepatosplenomegaly.

Extremities: Right above-knee amputation stump, well-healed. Right lower extremity flaccid with no voluntary motor activity noted. No reflexes elicited in the right lower extremity. Left lower extremity normal with normal motor and reflexes. Upper extremities normal.

Skin: No rashes.

Neurologic: Sensory appears diminished in right lower extremity. Cranial nerves II-XII grossly intact. Tone normal in upper extremities and left lower extremity. Right lower extremity flaccid with no volitional motor activity.

#3. NOTE PAPER

Neurologic Examination:

Cranial nerves II-XII grossly intact. Upper extremities normal motor, sensory, and reflexes. Left lower extremity normal motor, sensory, and reflexes. Right lower extremity flaccid with no motor activity noted. No reflexes elicited in the right lower extremity. Sensory diminished in right lower extremity.

Impression:

2 year old female with history of above knee amputation and flaccid right lower extremity. Findings consistent with possible lumbosacral plexus/root injury.

Plan:

Admit to pediatric neurosurgery service.

Obtain CBC, type and crossmatch, urinalysis and culture.

Prepare for anesthesia and myelogram tomorrow.

Discussed risks and benefits of myelogram with mother. Mother understands and wishes to proceed.

#4. NOTE PAPER

Pre-Anesthesia Note:

This is a 2 year old female scheduled for myelogram.

Past Medical History:

History of diarrhea, treated for giardiasis.

History of urinary tract infection.

No known drug allergies.

No medications at present.

Review of Systems:

No recent fever, cough, or cold. No vomiting or diarrhea currently.

Physical Examination:

General: Well developed, well nourished child in no acute distress.

Chest: Lungs clear to auscultation bilaterally.

Heart: Regular rate and rhythm, no murmurs.

Abdomen: Soft, nontender.

Extremities: Right above-knee amputation, well healed. Right lower extremity flaccid.

Neurologic: Alert, interactive.

Assessment:

2 year old female for myelogram under general anesthesia. No contraindications noted.

#5. NOTE PAPER

Date: 10/5/82

Subjective:

Patient NPO since midnight, somewhat irritable this morning.

Objective:

IV started this morning.

Vital signs stable.

Lungs clear.

Heart regular rate and rhythm.

Abdomen soft, nontender.

Right lower extremity flaccid.

Left lower extremity normal.

Assessment:

2 year old female scheduled for myelogram today under general anesthesia.

Plan:

Proceed with myelogram as planned.

Maintain IV fluids.

Monitor closely post-procedure.

#6. NOTE PAPER

Progress Note

Date: 10/5/82

Subjective:

Patient returned from neuroradiology following myelogram.

Currently sleeping.

Objective:

Vital signs stable.

IV fluids running.

Head of bed elevated.

No nausea or vomiting noted.

Neurologic exam limited due to sedation.

Assessment:

2 year old female, s/p myelogram.

Findings consistent with right lumbosacral root avulsion.

Plan:

Continue IV fluids.

Encourage oral fluids when awake.

Maintain head of bed elevated.

Monitor neurologic status as sedation wears off.

#7. NOTE PAPER

Progress Note

Date: 10/6/82

Subjective:

Patient awake and alert this morning.

Tolerated regular diet.

Ambulating with some difficulty, slightly unsteady gait.

Objective:

Vital signs stable.

Chest clear.

Heart regular.

Abdomen soft, nontender.

Right lower extremity flaccid, no motor activity.

Left lower extremity normal.

Assessment:

2 year old female, s/p myelogram with findings of right lumbosacral root avulsion.

Plan:

Discussed case with Dr. Johnson and with mother.

Plan is for patient to return at a future date for surgical intervention.

Continue supportive care.

Anticipate discharge later today if stable.

#8. NOTES PAPER

Discharge Note

Date: 10/6/82

Subjective:

Patient doing well, no complaints.

Objective:

Vital signs stable.

Chest clear.

Heart regular.

Abdomen soft, nontender.

Neurologic exam unchanged.

Assessment:

2 year old female, s/p myelogram with right lumbosacral root avulsion.

Plan:

Discharged home this afternoon with parents and belongings.

Follow up in neurosurgery clinic for further evaluation and surgical planning.

Nurses Flow Sheet No Date 🚩

Pediatric Daily Flow Sheet, [10/4/82]

Top Section (Vitals/Weights):

- Weight: 8.3 kg

Parents/Visitors:

- Mom

Nurse’s Notes (Evening):

8pm Sitting and coloring, alert, bright

10pm In mom’s arm in room, offered no complaints. Relaxed, friendly

11pm Sleeping

Nurses Flow Sheet (mylogram dye caused Chemical Arachnoiditis Drooping Right Eyeball) 🚩

Pediatric Daily Flow Sheet, 10/5/82

Top Section (Vitals/Weights):

Temp: 96.8

Pulse: 70

Resp: 28

BP: 96/60

Weight: 9.1 kg

Parents/Visitors:

Mom

Activity/Diet:

Activity: Sleep

Diet: NPO (night/day), clear liquids (evening)

Nurse’s Notes:

12 am: Sleeping, mom's cot blocking crib at 8pm. VSS (vital signs stable) omit 12 midnight vital signs

3 am: Sleeping

5 am: Sleeping

8 am: Sleeping

9 am: IV started, D5 0.2 at 60 cc/hr

10 am: no fever (afebrile), VSS. patient stated she was hungry.

5 pm: Returned from neuroradiology post-myelogram and CT. Sleeping/sedated

6 pm: Asleep in bed 30° angle, pillow under mattress

8 pm: Awake, VSS, bowel sounds active, head of bed at 30°, IV intact and infusing well. tolerating PO (oral fluids) well, no nausea or vomiting. Voided large amount in diaper. right eye drooping.

9:45pm IV D/C'd taking food and drink by mouth.

Nurses Flow Sheet (drooping eyeball) 🚩

Pediatric Daily Flow Sheet

Top Section (Vitals/Weights):

Temp: 98.0

Pulse: 80

Resp: 20

BP: 80/40

Parents/Visitors:

Mom

Activity/Diet:

Activity: Ambulated, cooperative

Diet: Regular

Nurse’s Notes:

12:30 am: Sleeping, head of bed at 30°, no distress

3 am: Sleeping, no distress

6 am: Sleeping

Day

8 am: moving well, denies headache, taking regular diet well, urinating. Right eye appears to be drooping slightly. 🚩 voiding fluids and solids. ambulating exam room with difficulty.

11 am: Dr. Johnson into speak with mom regarding test results. Child and mom to be discharges today and to return at some future date for surgery

24 hr Pediatric I&O record not dated

24-HOUR PEDIATRIC INTAKE & OUTPUT RECORD

The Johns Hopkins Hospital

Patient’s Name: Long, Deepa

History No: 2029194

Date: 10/5/82 Weight: 9.1 kg Age: 2 yr

Diet: NPO → Clear Liquids

IV Fluids: D5 0.2 NS + 20 mEq KCl/L @ 40 cc/hr

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

HOURS I.V. P.O. N.G. Blood Other Total Urine Stools Emesis

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

7-8 40

8-9 40

9-10 40

10-11 40

11-12 40

12-1 40

1-2 40

2-3 40

3-4 40

4-5 40

5-6 40

6-7 40

7-8 40

8-9 40

9-10 40

10-11 40

11-12 40

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

TOTALS 801 180 — — 981 180 pH6

120 320

160 150

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

Nurse’s Notes: (Blank)

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

Form No. JHH-15-21802 (Rev. 1/80)

Pre Operative Checklist 🚩

THE JOHNS HOPKINS HOSPITAL

PRE-OPERATIVE CHECK LIST

Name: Long, Deepa

History Number: 9 202 91 94 A

Date: 10-5-82

Assemble Medical Record in the following order and fasten with clip:
Pre-Operative Check List
- Signed Operative Consent
- Temperature Chart (record height and weight)
- All Doctors’ Order Sheets (add new sheet stamped with patient’s plate)
- Remainder of Record (including Medication Administration Records)
Religion : Lutheran 🚩
If patient is Roman Catholic, has the Sacrament of the Sick been received?
Yes ___ No ___
Check for, or remove, and initial each item below:
Jewelry ☐ Artificial Limb ☐ Wig or hair piece ☐
Dentures ☐ Hearing Aid ☐ Hairpins ☐
Removable Bridge ☐ Perma-type Urinal ☐ Fingernail Polish ☐
Artificial Eyes ☐ Colostomy/Ileostomy Bag ☐ Face Makeup ☐
Contact Lenses ☐ False Eyelashes ☐ Other ☐
Wedding Band: Removed ___ Unable to Remove ___
Check Identification Band: ✓
Personal belongings stored at: 6 W Transferred to ______ By ______
Valuables stored at: 6 W Transferred to ______ By ______
Temperature (immediately prior to pre-operative medication): 36.9°C
Voided: ✓ Yes No ___
Time Voided: 11 a.m.
Pre-operative medication: ___________ Time: ___________

Nurse’s Signature: D. Gant, R.N.

Form ID: 15-211640 7/80

lab

DEPARTMENT OF LABORATORY MEDICINE

BACTERIOLOGY LAB

LAB NO. 41 - X-867

TS: CC

COLL-TIME: 4 OCT 82

PROC-TIME:

J.H.H. - 202 91 94

NAME - Long, Deepa

LOC: CMC-W6 N.D. - G.H. Johnson

GRAM STAIN REPORT

CELLS

( ) Squamous Epithelial Cells: NONE FEW MOD MANY

(x) Polymorphonuclear Cells: NONE FEW MOD MANY

( ) Other:

ORGANISMS

( ) No Organism Seen

( ) Normal Upper Respiratory Flora FEW MOD MANY

( ) Gram Positive Cocci in Chains: FEW MOD MANY

( ) Gram Positive Cocci in Pairs: FEW MOD MANY

( ) Gram Positive Cocci in Clumps: FEW MOD MANY

( ) Gram Positive Coccobacilli: FEW MOD MANY

( ) Gram Positive Bacilli: FEW MOD MANY

( ) Gram Negative Cocci: FEW MOD MANY

( ) Gram Negative Diplococci: FEW MOD MANY

( ) Gram Negative Coccobacilli: FEW MOD MANY

( ) Gram Negative Bacilli: FEW MOD MANY

( ) Yeast ( ) Hyphae: FEW MOD MANY

COMMENTS:

TECH: (signature) DD

DATE: 10/04/1982

lab

DEPARTMENT OF LABORATORY MEDICINE

BACTERIOLOGY LAB

LAB NO. 41 - X-868

TS: CC

COLL-TIME: 4 OCT 82

PROC-TIME:

J.H.H. - 202 91 94

NAME - Long, Deepa

LOC: CMC-W6 N.D. - G.H. Johnson

URINE CULTURE REPORT

Specimen: Urine, clean catch

Result:

Growth of Escherichia coli

Colony count: >100,000 organisms/ml

Sensitivity:

Ampicillin – Resistant

Carbenicillin – Sensitive

Cephalothin – Sensitive

Chloramphenicol – Sensitive

Gentamicin – Sensitive

Kanamycin – Sensitive

Nitrofurantoin – Sensitive

Streptomycin – Sensitive

Sulfonamides – Resistant

Tetracycline – Sensitive

Tobramycin – Sensitive

Comments:

TECH: (signature)

DATE: 10/6/82

Cumulative Lab Summary 01/06/1983

THE JOHNS HOPKINS HOSPITAL - DEPARTMENT OF LABORATORY MEDICINE

CUMULATIVE LABORATORY SUMMARY

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

CHEMISTRY 1 -- ELECTROLYTES

Na K Cl CO2 Anion SUN Creat SUN/Creat GLU CA Amylas TBILI

135 3.5 96 30.0 12.0 7.0 0.0 10.5 65 9.0 60 0.3

145 5.0 111 30.0 20.0 25.0 1.5 20.0 105 11.0 160 1.2

140 5.5^ 106 A 22^A 18 A 17 A 0.4 A 43 A 84 A 5594 B181

DATE TIME

10/04 0630P

MISCELLANEOUS CHEMISTRY TEST RESULTS

Test Name Result Units Normal Values

CSF Glucose EMERG 67 MG/DL (50-75)

CSF Protein EMERG 19 MG/DL (15-45)

DATE TIME

10/05 0100P

**** DIAGNOSTICIMMUNOLOGY**

VDRL,C IGGCSF TPC,CSF XIGGTP TP,U

15 1.0^H

Normal Low/High not filled

IgG IgA IgM

1641^ 291^ 373^

(MG/DL)

DATE TIME

10/05 0100P PEND

*********** HEMATOLOGY ************

BLOOD COUNTS

WBC RBC HGB HCT MCV MCH MCHC PLT RETIC ESR

6.0 3.50 11.6 36.0 73.0 22.0 28.5 150 0.5 0

17.0 5.50 13.6 40.0 82.0 30.0 35.5 350 1.5 15

14.0 5.57 13.7 38.8 84.9^ 29.9 35.2^ 410 — —

DATE TIME

10/04 0630P 1440

* A = Hemolyzed - results questionable

* ^ = Abnormal value

Values may be age, sex adjusted - see lab handbook

Cumulative Lab Summary 01/06/1983

THE JOHNS HOPKINS HOSPITAL – DEPARTMENT OF LABORATORY MEDICINE

CUMULATIVE LABORATORY SUMMARY

Date: 10/05

Time: 0100P

Appear: Clear

Color: No color

CSF: Cell Count and Differential

#/cu mm WBC: 1

#/cu mm RBC: 2

Other: 0

Polys: 0

Monos: 1

ACN: M742

MD: N999

Printed: Oct 06 82, 2:01 AM

Page: 2

Name: Long, Deepa

J.H.H. #: 202-91-94

Operating Room for Mylogram

THE JOHNS HOPKINS HOSPITAL

DEPARTMENT OF ANESTHESIOLOGY

OPERATING ROOM ANESTHESIA RECORD

Patient: Long, Deepa

Hospital No.: 2029194

Age: 2 yrs

Weight: 9.6 kg

Date: 10/5/82

Procedure: Myelogram

Surgeon: Johnson

Pre-op Diagnosis: Right leg paralysis, ? nerve root avulsion

Post-op Diagnosis: Same

Anesthetic: General anesthesia

Airway: Mask

IV Fluids: D5 1/4 NS with KCl

Blood Loss: Minimal

Specimens: CSF to lab

Medications:

Induction by mask

Maintenance: Halothane, Nitrous Oxide, Oxygen

Muscle relaxants: none

Narcotics: none

Other: none

Intraoperative Vitals:

10:45 HR 140 BP 92/60 RR 22

11:00 HR 138 BP 90/58 RR 20

11:15 HR 142 BP 94/60 RR 22

11:30 HR 136 BP 92/60 RR 20

11:45 HR 140 BP 90/58 RR 22

12:00 HR 138 BP 92/60 RR 22

Fluids in: 150 cc

Urine out: not recorded

Complications: none noted

ASA Classification: II

Signed: (illegible signature)

Remarks

@Pt arrived in OR, was sedated w/ ketamine. EKG, BP cuff & temp monitor in place. IV infusion atropine already going.

03:20 pm – Spinal tap done atraumatically.

1 × 10 cc metrizamide injected.

03:27 pm – Needle removed.

To RR:

BP 94/p P 136 R 24 T 36 (N)

Post Anesthesia Records

THE JOHNS HOPKINS HOSPITAL

DEPARTMENT OF ANESTHESIOLOGY

ANESTHESIA RECORD

Name: Long, Deepa

Hospital No: 2029194

Age: 2 yrs

Weight: 9.6 kg

Date: 10/5/82

Procedure: Myelogram

Surgeon: Johnson

Pre-operative Diagnosis: Right lower extremity paralysis, ? nerve root avulsion

Post-operative Diagnosis: Same

Anesthesia: General anesthesia

Induction: Inhalation

Airway: Mask

IV fluids: D5 1/4 NS

Blood loss: Minimal

Specimens: CSF sent to lab

Pre-op Condition: ASA Class II

Allergies: NKDA

Premedication: None

Intra-operative Vitals (approximate entries):

10:45 HR 140 BP 92/60 RR 22

11:00 HR 138 BP 90/58 RR 20

11:15 HR 142 BP 94/60 RR 22

11:30 HR 136 BP 92/60 RR 20

11:45 HR 140 BP 90/58 RR 22

12:00 HR 138 BP 92/60 RR 22

Fluids in: 150 cc

Urine out: not measured

Complications: None noted

Anesthesiologist: (signature) Toung

Anesthesia Notes

THE JOHNS HOPKINS HOSPITAL

HISTORY NO.:

LONG, DEEPA

PATIENT'S NAME:

(Space left blank for Service no history number recorded)

Anesthesia Note

2 y.o. Female with amputation R leg

Blood Pressure: 90 syst (palp)

Temperature: 36°

Pulse: 104

Respiration: 32

HEENT: mod

Lungs: clear

Heart: HS (heart sounds) clear, no added sounds

Hematocrit: 37

White Blood Count: 14,800

Urinalysis: pH 6.5, neg protein, glucose, ketones, hemolyzed

Chest Film: ---

Electrocardiogram: ---

Medications: nil

Medical Illnesses: ---

Transfusions: ---

Allergies: nil known

Operations: amputation

Cells and Serum: ---

Operative Permit: ✓

Last P.O. Intake: undetermined

Previous Anesthesias: ---

Intake/Outtake

INTAKE / OUTPUT

1335 IV fluid, peripheral line: D5.2NS + 20 KCL, 40 cc

1405 Amt up 40 cc → Amt in 40 cc

1425 Amt up 40 cc → Amt in 40 cc

Apple juice 45 cc

OUTPUT

1515 urine (check mark)

PROGRESS NOTES

01:35 pm Received in Peds RR semi-conscious. Heart rate regular & strong, breath sounds clear and equal. IV infusing well into right hand. Color pink, skin warm and dry. 40% O₂ to face.

2:00 pm Awake now in holding infant.

2:50pm RR note. Awake, alert, VS stable, airway patent. D/C for RR. [signature]

03:15 pm Signed out by anesthesia, sent to CAT scan.

DISCHARGE TO:

Printed/typed: CMSC 6W (scratched out)

Handwritten replacement: cat scan

Signed: Susan Martin, RN

Mylogram Results

THE JOHNS HOPKINS HOSPITAL

Department of Radiology

Name: Long, Deepa

Hospital No.: 2029194

Age: 2 yrs

Sex: Female

Date: 10/5/82

Referring Physician: Dr. Johnson

Procedure: Lumbar myelogram with metrizamide

Clinical history: 2 year old female with traumatic amputation of the right lower extremity,

persistent paralysis of the right lower extremity, possible nerve root avulsion.

Technique:

Under general anesthesia, a lumbar puncture was performed at the L4-5 interspace.

Approximately 5 cc of clear cerebrospinal fluid was obtained and sent to the laboratory.

10 cc of metrizamide 170 mg% was instilled intrathecally. The patient was placed in various

positions on the tilting table, and multiple spot films and overhead radiographs were obtained.

A CT scan was performed immediately following the myelogram.

Findings:

There is a complete block to the flow of contrast at the level of the L2 vertebral body on the

right. The right-sided nerve root sleeves at L2, L3, L4, and L5 fail to fill with contrast,

consistent with avulsion injury. The left-sided nerve root sleeves fill normally. No abnormal

filling defects are seen in the thecal sac. The spinal cord outline appears intact.

Impression:

Findings are consistent with right-sided lumbosacral nerve root avulsion, involving at least

the L2 through L5 roots.

Infectious Disease (A) Same Day Saying Two Different Things 🚩

THE JOHNS HOPKINS HOSPITAL

PEDIATRIC NURSING DATA BASE

Infectious Disease Screening – to be completed prior to admission to the unit whenever possible.

Has your child had the following:

Regular Measles, German Measles, Rubella ?

Chicken Pox ?

Mumps ?

Whooping Cough ?

In the past month, has your child been exposed to (been around anyone) with the following:

✓ Regular Measles, German Measles, Rubella

✓ Chicken Pox

✓ Mumps

✓ Whooping Cough

Does your child have a fever, stuffy nose, cough or a rash TODAY?

✓

Date: Oct. 4th 1982

Signature: C. Hegman

Infectious Disease (B) Same Day Saying Two Different Things 🚩

THE JOHNS HOPKINS HOSPITAL

PEDIATRIC NURSING DATA BASE

Infectious Disease Screening – to be completed prior to admission to the unit whenever possible.

Has your child had the following:

Regular Measles, German Measles, Rubella ?

Chicken Pox ?

Mumps ?

Whooping Cough ?

In the past month, has your child been exposed to (been around anyone) with the following:

[blank]

Does your child have a fever, stuffy nose, cough or a rash TODAY?

[blank]

Note: Has had 2 DPTs

Date: Oct. 4th 1982

Signature: Pasela J. Calom, R.N.

Handwritten note:

“All immunizations are questionable because information was not obtainable.”

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: —

Living in: —

Pertinent Parent Needs (medical or otherwise): —

When do parents plan to visit: Mom rooming in

Has child ever been away from home: NO

May the child call home: —

Number to call if different than contact person: —

Orientation to unit: YES

To visiting hours: YES

Given copy of parent book: —

Other: —

Patient/Parent advised to label items left at hospital: YES

Patient/Parent advised that hospital cannot assume responsibility for lost or stolen items/valuables: YES

Patient/Parent Expectation of Hospitalization: —

Patient/Parent’s Concerns and Questions: Avoid trauma of IV insertion

Additional Findings: —

Preliminary Problem List:

Avulsion of (R) hip

o/k on 1-20

Home description (stairs, plumbing, heat): —

Health Resources Used:

Social Worker (Name/Agency): —

PHN/VNA: —

Clinic: —

Other: —

Projected teaching/discharge needs: —

R.N. (blank lines)

Date (blank lines)

Nurses Database

THE JOHNS HOPKINS HOSPITAL

PEDIATRIC NURSING DATA BASE

Page 2 of 2

Past experience in hospitals (when, how did child react?):

Kernan Hospital – calm

Other medical/surgical problems/procedures:

Amputation of stump grafts

Are immunizations up-to-date?

Questionable

Eating patterns/restrictions:

Eats 3 meals/day

Restrictions: milk, nuts

Sleep pattern:

Goes to bed between 8 & 9 – takes nap – sleeps well

Elimination Bowel:

Pattern noted – stool daily

Word used: B.M.

Bladder:

Records recommended

Word used: B.M.

Habits (alcohol, smoking, drugs): N/A

IMP/menstrual patterns: N/A

Favorite Toy/activities:

Likes being in playroom – likes all kinds of toys

Grade: N/A

School: N/A

Teacher: —

Performance: N/A

Continuation of school activities during hospitalization: —

Peer relationships:

Has good relationships with other children

Developmental level according to informant (slow, fast, according to age):

Appears extremely fast

Primary caretaker: Mom

Family composition: Has 2 brothers, mom & dad

Significant others: Father

What problems will family have because of this hospitalization (financial, child care, etc.):

No problems

Form code: 15-041120 7/80

Nurses Database

Date: Oct 4, 1982

Time: 4 PM

Informant/reliability: Mom

Name patient responds to: Deepa

Age: 2

Sex: F

Baptism: N/A

Religion: N/A

Ambulatory / wheelchair / stretcher / carried (infant): in carriage

Level of consciousness / orientation:

- Alert (circled)

Temp: 36°C

Pulse: 104

Resp: 32

B/P: 90/?

Allergies (medicine, food, environmental): Milk

Usual Allergic Reaction: intermittent diarrhea

Current Medications (include date/time last dose): No

Reason for Admission (patient’s/parent’s statement/diagnosis): Myelogram

Contact Person (if other than informant): Dr. S. E. Long

Relation to patient: Father

Phone: 992-9141

Signature: Nina Colson, R.N.

Admission Note section: Crossed out (blank)

Physical Assessment (to be completed by R.N. within 24 hours of admission):

Behavior: very bright and intelligent

Physical Appearance: well hydrated, clean, neat

Skin Condition (describe): well hydrated

Mobility: normal (ROM good)

Communication Ability: speaks some English

Vision: good

Hearing: good

Final Cumulative Lab Summary 01/08/1983

THE JOHNS HOPKINS HOSPITAL - DEPARTMENT OF LABORATORY MEDICINE

CUMULATIVE DISCHARGE SUMMARY

* FINAL REPORT *

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

CHEMISTRY 1--ELECTROLYTES

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

NORMAL LOW 135 3.5 101 30 20 25/1.0 65 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 MEQ/L MG/DL MG/DL MG/DL U/L MG/DL

DATE TIME 10/04 0630P 140 A 5.5 A 106 A 22 A 18 A 17 A 0.4 A 43 A 84 A

ACN MD S594 B1819

---------------------- MISCELLANEOUS CHEMISTRY TEST RESULTS -----------

DATE TIME TEST NAME RESULT UNITS NORMAL VALUES

10/05 0100P CSF GLUCOSE EMERG 67 MG/DL (50-75) S944 M999

10/05 0100P CSF PROTEIN EMERG 19 MG/DL (15-45) S944 M999

*****DIAGNOSTIC IMMUNOLOGY*****

DIAGNOSTIC IMMUNOLOGY 3

VDRL,C IGG CSF TP,CSF XIGT,0.9% IGG IGA IGM TP,U

NORMAL LOW - - - 691 60 30 -

NORMAL HIGH 15 8.0 1.0% 1641 291 373 -

DATE TIME 10/05 0100P

NON REACTIVE 15 8.0 0.9% 1641 291 373

ACN MD W284 M999

Final Cumulative Lab Summary 01/08/1983

************ HEMATOLOGY***************

BLOOD COUNTS

WBC RBC HGB PCV MCV MCH MCHC PLT RETIC ESR

NORMAL LOW 6000 3.50 11.6 36.0 73.0 22.0 31.0 150 0.5 0

NORMAL HIGH 17000 5.00 13.6 40.0 82.0 28.5 35.0 350 1.5 10

#/CU MM M/CU MM G/DL % FL PG G/DL K/CU MM % MM/HR

DATE TIME 10/04 0630P

14000 4.57 13.7 38.8 84.9 A 29.9 A 35.2 A 410 A 0.5 0

ACN MD L885 B1819

---------- CSF: CELL COUNT AND DIFFERENTIAL ----------------------

DATE TIME 10/05 0100P

APPEAR COLOR WBC RBC OTHER POLYS MONOS

CLEAR NO COLOR 1 2 0 0 1

ACN MD M742 M999

Discharge Summary

THE JOHNS HOPKINS HOSPITAL

HISTORY NO.: 202 91 94

PATIENT'S NAME: LONG, Deepa

PEDIATRIC NEUROLOGY

Dr. Graham Johnson

DISCHARGE SUMMARY:

DATE OF ADMISSION: October 4, 1982

DATE OF DISCHARGE: October 6, 1982

ATTENDING PHYSICIAN: Dr. James Campbell

CHIEF RESIDENT: Dr. Shlomo Shinnar

ASSISTANT RESIDENT: Dr. Graham Johnson

PRESENT PROBLEM: Above knee amputation on the right with lack of hip movement.

PRESENT ILLNESS: Deepa is an Indian girl adopted by the Long family in America. The year before she came she was involved in a train accident, which killed her mother. She has had an above knee amputation and when the Long’s received her they also found that it was also associated with lack of hip movement. This is being investigated with the possibility of nerve reconstruction.

HOSPITAL COURSE: On examination Deepa is an active, chubby, well developed young female with right amputation. She has a sensory level which is absent on the right up to L1. Her left lower extremity is normal and rectal type appears normal.

In the hospital on this admission she had a myelogram on 10/5/82. This showed a right lumbar root avulsion. Planning will be on possible transplant or manipulation which may allow us some flexion of the hip. This will be done as an outpatient with Dr. Campbell.

DISCHARGE DIAGNOSES:

1. Right lumbar root avulsion.

2. Right above the knee amputation.

3. State is stable.

FOLLOWUP: By Dr. Campbell service.

cc: to all the above name physicians:

Graham Johnson, M.D.

med/transcribed: 10/13/82

dictated: 10/11/82

Medication Record Dicharge Summary

THE JOHNS HOPKINS HOSPITAL

MEDICATION RECORD DISCHARGE SUMMARY

NAME: LONG, Deepa

HISTORY NUMBER: 2029194

PAGE 1

FLOOR: CMCW6

PHYSICIAN MEDICAL UNASSIGNED

DATE ADMITTED: 10/04/82

DATE DISCHARGED: 10/06/82 0500P

039-A DIAZEPAM

Ordered as Valium

2 MG DOSE

(00.40ML – 5 MG/1ML IV INJ)

SDU

0001 DOSES GIVEN

0000 DOSES OMITTED

STAT DOSE: 10/05 03P

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