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HomeMy WebLinkAbout07-0846ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. (37 - a 'Y CIVIL ACTION - LAW JURY TRIAL DEMANDED NOTICE TO DEFEND You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. oR\G1NN%- 343650 IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 S. Bedford St., Carlisle, PA 17013 TELEPHONE 717-249-3166 AVISO USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse. de las demandas que se persentan mas adelante en las siguientes paginas, debe tomar acci6n dentro de los pr6ximos veinte (20) dias despues de la notificaci6n de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a , las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar acci6n como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamaci6n o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Used puede perder dinero o propiedad u otros derechos importantes para used. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 S. Bedford Street, Carlisle, PA 17013 TELEFONO 717-249-3166 343650 ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attomey ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 07 -- PY4 a' / CIVIL ACTION - LAW JURY TRIAL DEMANDED COMPLAINT 1. Plaintiffs April and John Peter Rudick are citizens of the Commonwealth of Pennsylvania and adult individuals who reside in Mechanicsburg, Cumberland County, Pennsylvania. 2. Defendant Lisa Buenaventura is an adult individual and citizen of the Commonwealth of Pennsylvania who resides at 201 Shirley Lane, Boiling Springs, Cumberland County, Pennsylvania 17007. 3. The facts and occurrences hereinafter related took place on or about October 16, 2006, on the Route 15 South ramp at the Shiremanstown exit, Cumberland County, Pennsylvania. 4. Mrs. Rudick was operating her motor vehicle, a 2005 Hyundai Elantra, and had come to a stop at the end of the Route 15 South Shiremanstown exit. 5. At the same time, Defendant Lisa Buenaventura was operating a Subaru Impreza behind Mrs. Rudick's Hyundai Elantra. 6. As Mrs. Rudick was looking to her left to merge, the front of the Defendant's vehicle collided into the rear of Mrs. Rudick's vehicle. 343650 7. The foregoing accident and all of the injuries and damages set forth herein sustained by Plaintiff April Rudick are the direct and proximate result of the negligent, careless, wanton, and reckless manner in which Defendant Lisa Buenaventura operated her motor vehicle as follows: a. failure to have her vehicle under such control as to be able to stop within the assured clear distance ahead; b. failure to keep alert and maintain a proper watch for the presence of motor vehicles in front of her; C. failure to apply her brakes in sufficient time to avoid striking the rear of the Mrs. Rudick's vehicle; and d. driving her vehicle upon the highway in a manner endangering persons and property and in a reckless manner with careless disregard to the rights and safety of others and in violation of the Motor Vehicle Code of the Commonwealth of Pennsylvania. CLAIM I April Rudick v. Lisa Buenaventura 8. Paragraphs 1 through 7 of the Complaint are incorporated herein by reference. 9. Plaintiff April Rudick sustained painful and severe injuries, which include but are not limited to right shoulder pain, back pain, blurred vision, and muscle spasms of her neck. 10. By reason of the aforesaid injuries sustained by Plaintiff April Rudick, she was forced to incur liability for medical treatment and physical therapy and may continue to incur medical expenses in an effort to restore herself to health, and claim is made therefor. 343650 2 11. Because of the nature of her injuries, Plaintiff April Rudick has been advised and therefore avers that she may be forced to incur similar expenses in the future, and claim is made therefor. 12. As a result of the aforementioned injuries, Plaintiff April Rudick has undergone and in the future may undergo physical and mental suffering, inconvenience in carrying out her daily activities, loss of life's pleasures and enjoyment, and claim is made therefor. 13. As a result of the aforementioned injuries, Plaintiff April Rudick has been and in the future may be subject to humiliation and embarrassment, and claim is made therefor. 14. Plaintiff April Rudick continues to be plagued by persistent pain and limitation and, therefore, avers that her injuries may be of a permanent nature, causing residual problems for the remainder of her lifetime, and claim is made therefor. CLAIM II John Peter Rudick v. Lisa Buenaventura 15. Paragraphs 1 through 14 of the Complaint are incorporated herein by reference. 16. As a result of the aforementioned injuries sustained by his wife, Plaintiff John Peter Rudick has been and may in the future be deprived of the care, companionship, consortium, and society of his wife, all of which will be to his great detriment, and claim is made therefor. 343650 3 WHEREFORE, Plaintiffs April and John Peter Rudick demand judgment against Defendant Lisa Buenaventura in an amount in excess of Fifty Thousand Dollars ($50,000.00), exclusive of interest and costs and in excess of any jurisdictional amount requiring compulsory arbitration. ANGINO & ROVNER, P.C. Date: Davi L. Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791- phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Plaintiffs 343650 4 VERIFICATION We, April and John Rudick, Plaintiffs, have read the foregoing COMPLAINT and do hereby swear or affirm that the facts set forth in the foregoing are true and correct to the best of our knowledge, information and belief. We understand that this Verification is made subject to the penalties of 18 Pa. Cons. Stat. Ann. §4904, relating to unsworn falsification to authorities. WITNESS: s ApriY-Rutlick .- r John Rudick 343650 Dated: -,Q 9 Q vl N 1 c L V -t STEPHEN L. BANKO, JR., ESQUIRE Pa. Supreme Court I. D. No. 41727 MARGOLIS EDELSTEIN 3510 Trindle Road Camp Hill, PA 17011 Telephone: (717) 760-7501 Attorney for Defendant, FAX: (717) 975-8124 Lisa Buenaventura E-mail: sbanko(&margolisedelstein.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA APRIL AND JOHN PETER RUDICK, NO. 07-846 Plaintiffs CIVIL ACTION - LAW V. LISA BUENAVENTURA, JURY TRIAL DEMANDED Defendant --------------------------------------------------------------------------------------------------------------------- PRAECIPE TO ENTER APPEARANCE TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Please enter my appearance on behalf of Defendant, Lisa Buenaventura, in the above-captioned action. MARGOLIS EDELSTEIN Date: February /7, 2007 By Counsel for Defendant, Lisa Buenaventura e -.- CERTIFICATE OF SERVICE I hereby certify that I served a true and correct copy of the foregoing on all counsel of record by placing the same in the United States mail at Camp Hill, Pennsylvania, first- class postage prepaid, on the day of February, 2007 and addressed as follows: David L. Lutz, Esquire 4503 North Front Street Harrisburg, PA 17110-1708 (Counsel for Plaintiff) i - ta?alm t?-) Angela M. Gayman, cretary c? r-3 o _a E ,• m r CD Aw ... ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 07-846 CIVIL TERM CIVIL ACTION - LAW JURY TRIAL DEMANDED PLAINTIFFS' REQUEST FOR ADMISSIONS ADDRESSED TO DEFENDANT PURSUANT TO Pa.RC.P. 4014 TO: Lisa Buenaventura c/o Stephen L. Banko Jr., Esquire Margolis Edelstein P.O. Box 932 Harrisburg, PA 17108-0932 Please take notice that you are hereby required, pursuant to Rule 4014 of the Pennsylvania Rules of Civil Procedure to serve upon the undersigned within thirty (30) days from service, your response to the admission(s) requested herein: 349237 REQUEST FOR ADMISSIONS #1: Do you admit that on October 16, 2006 you were operating a Subaru Impreza on the Route 15 South ramp at the Shiremanstown Exit? Admit Deny REQUEST FOR ADMISSIONS #2: Do you admit that there was a 2005 Hyundai Elantra that was in front of your vehicle, and the vehicle came to a stop at the end of Route 15 South Shiremanstown Exit? Admit Deny REQUEST FOR ADMISSIONS #3: Do you admit that the front of your Subaru Impreza collided into the rear of the stationary Hyundai Elantra? Admit Date: Deny ANGINO & ROVNER, P.C. Wv)jJ L. Lutz I.D. No.35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791 -phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Plaintiff 349237 CERTIFICATE OF SERVICE I, Michelle M. Milojevich, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of the PLAINTIFFS' REQUEST FOR ADMISSIONS ADDRESSED TO DEFENDANT PURSUANT TO Pa.R.C.P. 4014 upon all counsel of record via postage prepaid first class United States mail addressed as follows: Stephen L. Banko Jr., Esquire Margolis Edelstein P.O. Box 932 Harrisburg, PA 17108-0932 Attorney for Defendant Michelle M. Milojevich Dated: 013 349237 -T! IOD C)o >. i .. i Y? s .? ?.?? 1 ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attomey ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 07-846 CIVIL TERM CIVIL ACTION - LAW JURY TRIAL DEMANDED PRAECIPE TO REINSTATE COMPLAINT To the Prothonotary of Cumberland County: Please reinstate the attached Complaint and forward same to the Sheriff for service on Defendant Lisa Buenaventura. ANGINO & ROVNER, P.C. Date: ? '? David L. Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791- phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Plaintiffs 350320 CERTIFICATE OF SERVICE I, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of the PRAECIPE TO REINSTATE COMPLAINT upon all counsel of record via postage prepaid first class United States mail addressed as follows: Stephen L. Banko Jr., Esquire Margolis Edelstein P.O. Box 932 Harrisburg, PA 17108-0932 Attorney for Defendant t ary T. eraets Dated: ? - ? .- 0 ? 350320 %? v s°;?s r- '? ..CSC N L-' .`:._ -; } F _ .• ...- :<. STEPHEN L. BANKO, JR., ESQUIRE Pa. Supreme Court I. D. No. 41727 MARGOLIS EDELSTEIN 3510 Trindle Road Camp Hill, PA 17011 Telephone: (717) 760-7501 Attorney for Defendant, FAX: (717) 975-8124 Lisa Buenaventura E-mail: sbanko[cb-margolisedelstein.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA APRIL AND JOHN PETER RUDICK, Plaintiffs V. NO. 07-846 CIVIL ACTION - LAW JURY TRIAL DEMANDED LISA BUENAVENTURA, Defendant --------------------------------------------------------------------------------------------------------------------- NOTICE TO PLEAD TO: April and John Peter Rudick, Plaintiffs c/o David L. Lutz, Esquire 4503 North Front Street Harrisburg, PA 17110-1708 Attomey for Plaintiffs You are hereby notified to file a written response to the enclosed New Matter within twenty (20) days from service hereof or a default judgment may be entered against you. Date: March 13, 2007 MARGOLIS EDELSTEIN By: / Step L. anko, Jr. Attorn No. 41727 Counsel for Defendant, Lisa Buenaventura STEPHEN L. BANKO, JR., ESQUIRE Pa. Supreme Court i. D. No. 41727 MARGOLIS EDELSTEIN 3510 Trindle Road Camp Hill, PA 17011 Telephone: (717) 760-7501 Attorney for Defendant, FAX: (717) 975-8124 Lisa Buenaventura E-mail: sbankot&-maraolisedelstein.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA APRIL AND JOHN PETER RUDICK, NO. 07-846 Plaintiffs CIVIL ACTION - LAW V. JURY TRIAL DEMANDED LISA BUENAVENTURA, Defendant --------------------------------------------------------------------------------------------------------------------- ANSWER AND NEW MATTER OF DEFENDANT. LISA BUENAVENTURA, TO PLAINTIFFS' COMPLAINT 1. Admitted in part and denied in part. With respect to the current whereabouts or resident address of Plaintiffs, after a reasonable investigation, Defendant is without knowledge or information sufficient to form a belief as to the truth of said averments and, therefore, they are denied. 2. Admitted. 3. Admitted. 4. Admitted. 5. Admitted. 6. Admitted. 7a-d. Denied. The allegations contained in this paragraph state a legal conclusion to which no response is necessary. To the extent an answer to this paragraph is required, Defendant denies that any conduct on her part caused any injury or damages. By way of further answer, with regard to any allegations that Plaintiff sustained an injury or damages as a result of any conduct on the part of Defendant, after a reasonable investigation, Defendant is without knowledge or information sufficient to form a belief as to the truth of said averments and, therefore, they are denied. CLAIM I. April Rudick v. Lisa Buenaventura 8. The answers contained in paragraphs 1 through 7 hereof are incorporated herein by reference as if set forth in their entirety. 9. Denied. After a reasonable investigation, Defendant is without knowledge or information sufficient to form a belief as to the truth of said averments contained in this paragraph and, therefore, they are denied. 10. Denied. The answer contained in paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 11. Denied. The answer contained in paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 12. Denied. The answer contained in paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 13. Denied. The answer contained in paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 14. Denied. The answer contained in paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. CLAIM II. John Peter Rudick v. Lisa Buenaventura 15. The answers contained in paragraphs 1 through 14 hereof are incorporated herein by reference as if set forth in their entirety. 16. Denied. After a reasonable investigation, Defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph and, therefore, they are denied. WHEREFORE, Defendant, Lisa Buenaventura, demands judgment in her favor and against Plaintiffs. NEW MATTER 17. The answers contained in paragraphs 1 through 16 hereof are incorporated herein by reference as if set forth in their entirety. 18. Plaintiffs' claims, if any, for non-economic damages are governed by their tort selection pursuant to 75 Pa.C.S.A. § 1705. WHEREFORE, Defendant, Lisa Buenaventura, demands judgment in her favor and against Plaintiffs. Date: March 12, 2007 MARGOLIS EDELSTEIN By: ? St n . Banko, Jr. Attorney No. 41727 Counsel for Defendant, Lisa Buenaventura VERIFICATION I, Lisa Buenaventura, have read the foregoing document which has been drafted by my counsel. The factual statements contained therein are known by me and are true and correct to the best of my knowledge, information and belief. This statement and verification is made subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unsworn falsifications to authorities, which provides that, if I knowingly make false averments, I may be subject to criminal penalties. Date: o? -A (J LISA B NAVENTURA CERTIFICATE OF SERVICE I hereby certify that I served a true and correct copy of the foregoing on all counsel of record by placing the same in the United States mail at Camp Hill, Pennsylvania, first- class postage prepaid, on the day of March, 2007 and addressed as follows: David L. Lutz, Esquire 4503 North Front Street Harrisburg, PA 17110-1708 (Counsel for Plaintifii ?O - (]Wa /M. Angela M. ayman, Secreta tJ - cs? CERTIFICATE PREREQUISITE TO S13 ICE OF A SUBPOENA PURSUANT TO RULE 4009.22 IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- ORIGI%;1 COURT OF COMMON PLEAS TERM, CUMBERLAND CASE NO: 07-846 LISA BUENAVENTURA As a prerequisite to service of a subpoena for documents and things pursuant to Rule 4009.22 !.III MCS on behalf of STEPHIN L. BANKO JR. ESQ. certifies that (1 A notice of intent to serve th? subpoena with a copy of the subpoena attached thereto was mailed orildelivered to each party at least twenty days prior to the date On which the subpoena is sought to be served, IIII? (2) A copy of the notice of intenti including the proposed subpoena, is attached to this certificate, No objection (3) to the subpoena has been received, and I' (4) The subpoena which will be seed is identical to the subpoena which is attached to the notice of i. tent to serve the subpoena. DATE: 05/16/2007 o beha of? / P LKO ,A, E + 1 Attorney for DEFENDANT R1.33 133-H DE11-0687929 60911-LO1 COMMONWEALTH OF PENNSYLVANIA COUNTY OF IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- LISA BUENAVENTURA PINNACLE HLTH/HARRISBURG HOSP. MEDICAL MECHANICSBURG FAMILY MEDICAL STUART DRUG-MAN, D.C. MEDICAL DRAYER PHYO'ICAL THERAPY MEDICAL PA DEPT. OF PUBLIC WELFARE EMPLOYM THE OLIVE GARDEN EMPLOYM DAUPHIN COUNTY SOCIAL SERVICES EMPLOYM COURT OF COMMON PLEAS TERM, CASE NO: 07-846 TO: DAVID L. LUTZ, ESQ., PLAINTIFF COUNS L S MCS on behalf of STEPHEN L. BANKO, JR., Q. intends.to serve a subpoena identical to the one that is attached to this notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoena. If the twenty day notice period is waived or if no objection is made, then he subpoena may be served. Complete copies of any reproduced records may be rdered at your expense by completing the attached counsel card and returning ame to MCS or by contacting our local MCS office. DATE: 04/26/2007 MCS on behalf of STEPHEN L. BANKO, JR., ESQ. Attorney for DEFENDANT CC: STEPHEN L. BANKO, JR., ESQ. - 63000.4-00046 Any questions regarding this matter, cont ct THE MCS GROUP INC. 1601 MARKET STREET #800 PHILADELPHIA, PA 19103 (215) 246-0900 R1.31S 133-H DE02-0361584 60911-COl COMMONWEALTH F PENNSYLVANIA COUNTY OF C MBERLAND APRIL & JOHN PETER RUDICK File No. 07-846 VS. II LISA BUENAVENTURA TO: Custodian of P Within twenty (20) days after service of this subpoena, documents or things: ****SEE ATTACHED RIDE i are ordered by the court to produce the following *** at The CS Cyr= Inc.- 1601 Market Street Suite 800 ihiladelphia. PA 19103 I? You may deliver or mail legible copies of the documents ? or produce things requested by this subpoena, together with the certificate of compliance, to the party making thi$ request at the address listed above. You have thesight to seek, in advance, the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order compelling you to comply with it. II THIS SUBPOENA WAS ISSUED AT THE REQUEST 0F THE FOLLOWING PERSON: NAME: STEPHEN L. BANKO. JR.. ESQ. ADDRESS: 3510 TRISIDLE. ROAD CAMP HILL PA 17011 TELEPHONE: (215) 246-0900 SUPREME COURT ID #: ATTORNEY FOR: Defendant BY TH COURT: Prot onotary! vil ivision MAY 16 2007 Date: Deputy Seal of the Court 60911-01 EXPLANATION 01 REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: PINNACLE HLTH/HARRISBURG HOSP. 111 SOUTH FRONT STREET MEDICAL RECORDS HARRISBURG. PA 17101 RE: 60911 APRIL RUDICK VIII Prior approval is required for fees Illln excess of $150.00 for hospitals, $100.00 for all other providers. IIII ?I Entire hospital medical file, including but not limited to any and all records, correspondence to and from the consulting and/or treating physidian, files, memoranda, handwritten notes, history and physical reports, medication/ prescription records, nurse's notes, doctor's comments, dietary restrictions, and all patient consent or refusal o treatment, procedures, test, and/or medication, lab and diagnostic test results, including any and all such items as may be stored in a computer datab se or otherwise in electronic form, relating to any examination, consult tion, diagnosis, care, treatment, admission, discharge, or emergency c ire pertaining to: Dates Requested: up to and includin4 the present. Subject : APRIL RUDICR Social Security #: 185-60-3146 Date of Birth: 02-18-1980 R1.31S 133-H SU10-0682564 60911-LO1 PREREQUISITE TO PURSUANT TO F IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- OF A SUBPOENA ORIGIN& 4009.22 COURT OF COMMON PLEAS TERM, CUMBERLAND CASE NO: 07-846 LISA BUENAVENTURA As a prerequisite to service of a to Rule 4009.22 for documents and things pursuant MCS on behalf of STEPHE L. BANKO, JR., ESQ. certifies that (1) A notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or delivered to each party at least twenty days prior to the date o which the subpoena is sought to be served, (2) A copy of the notice of intent, attached to this certificate, including the proposed subpoena, is (3) No objection to the subpoena has been received, and (4) The subpoena which will be ser is attached to the notice of is DATE: 05/16/2007 is identical to the subpoena which t to serve the subpoena. o beh f f ? SQ. Attorney for DEFENDANT R1.33 133-H ~? DE11-0687930 60911-L02 COMMONWEALTH PENNSYLVANIA COUNTY OF C MBERLAND APRIL & JOHN PETER RUDICK VS. LISA BUENAVENTURA TO: Custodian of Records for (Name Within twenty (20) days after service of this subpoena, documents or things: **** SF.F. ATTACHED RTDF File No. 07-846 or Entity) i are ordered by the court to produce the following *** at You may deliver or mail legible copies of the documei with the certificate of compliance, to the party making t to seek, in advance, the reasonable cost of preparing the If you fail to produce the documents or things required the party serving this subpoena may seek a court order THIS SUBPOENA WAS ISSUED AT THE REQUEST or produce things requested by this subpoena, together request at the address listed above. You have the right pies or producing the things sought. this subpoena within twenty (20) days after its service, spelling you to comply with it. THE FOLLOWING PERSON: NAME: STEPHEN L. BANKO. JR.. ESQ. ADDRESS: 3510 TRM1,F ROAD CAMP LUL. PA 17011 TELEPHONE: -(215) 246-0900 SUPREME COURT ID #: ATTORNEY FOR: Defendant BY OURT917V Pro onotary/Cl ision MAY 16 2007 Date: 62? - ( ((? Seal of the Court Deputy 60911-02 EXPLANATION O? REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: MECHANICSBURG FAMILY PRACTICE CENTER 122 S. FILBERT ST. MECHANICSBURG. PA 17055 RE: 60911 APRIL RUDICK Prior approval is required for fees hospitals, $100.00 for all other pr Entire medical file, including but n correspondence to and from the consu. memoranda, handwritten notes, histor prescription records, including any computer database or otherwise in el diagnosis or treatment pertaining to Dates Requested: up to and incl Subject : APRIL RUDICK Social Security #: XXX-XX-3146 Date of Birth: 02-18-1980 excess of $150.00 for ders. t limited to any and all records, ting and treating physicians, files, and physical reports, medication/ nd all such items as may be stored in a ctronic form, relating to any examination, the present. R1.31S 133-H SU10-0682566 60911-LO2 CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- LISA BUENAVENTURA As a prerequisite to service of a to Rule 4009.22 MCS on behalf of ORIGINAL COURT OF COMMON PLEAS TERM, CUMBERLAND CASE NO: 07-846 for documents and things pursuant STEPHE L. BANKO, JR certifies that (1) A notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or elivered to. each party at least twenty days prior to the date o which the subpoena is sought to be served, (2) A copy of the notice of intent, attached to this certificate, (3) No objection to the subpoena (4) The subpoena which will be serv is attached to the notice of in DATE: 05/16/2007 including the proposed subpoena, is been received, and is identical to the subpoena which t to serve the subpoena. o beha o?j A1fK0((, 1YJ.?R1p?n, ` Q .? Attorney for DEFENDANT R1.33 133-H DE11-0687931 60911-L03 COMMONWEALTH OF PENNS COUNTY OF IN THE MATTER OF : APRIL & JOHN PETER RUDICK -VS- LISA BUENAVENTURA PINNACLE HLTH/HARRISBURG HOSP. MEDICAL REi MECHANICSBURG FAMILY MEDICAL RE, STUART DRUCKMAN, D.C. MEDICAL RE, BRAYER PHYSICAL THERAPY MEDICAL RE PA DEPT. OF PUBLIC WELFARE EMPLOYMENT THE OLIVE GARDEN EMPLOYMENT DAUPHIN COUNTY SOCIAL SERVICES EMPLOYMENT TO: DAVID L. LUTZ, ESQ., PLAINTIFF COUNSEL MCS on behalf of STEPHEN L. BANKO, JR., ES identical to the one that is attached to t: days from the date listed below in which t undersigned an objection to the subpoena.' waived or if no objection is made, then th copies of any reproduced records may be or the attached counsel card and returning sa MCS office. DATE: 04/26/2007 COURT OF COMMON PLEAS TERM, CASE NO: 07-846 intends to serve a subpoena. s notice. You have twenty (20) file of record and serve upon the the twenty day notice period is subpoena may be served. Complete red at your expense by completing to MCS or by contacting our local MCS on behalf of STEPHEN L. BANKO, JR., ESQ. Attorney for DEFENDANT CC: STEPHEN L. BANKO, JR., ESQ. Any questions regarding this matter, con = 63000.{-00046 R1.31S 133-H THE MCS GROUP INC. 1601 MARKET STREET #800 PHILADELPHIA, PA 19103 (215) 246-0900 DE02-0361584 60911-CO1 APRIL & JOHN PETE] File No. 07-846 vs. LISA BUENAVENTURA Y TO: Custodian of Records for (Name of Within twenty (20) days after service of this subpoena, documents or things: **** S ATTACHED or Entity) are ordered by the court to produce the following ** at You may deliver or mail legible copies of the documei with the certificate of compliance, to the party making t to seek, in advance, the reasonable cost of preparing the or produce things requested by this subpoena, together request at the address listed above. You have the right pies or producing the things sought. If you fail to produce the documents or things required the party serving this subpoena may seek a court order THIS SUBPOENA WAS ISSUED AT THE REQUEST NAME: STEPHEN L. BANKO. JR.. ESQ. ADDRESS: 3510 TRINDL.E ROAD CAMP HILL PA 17011 TELEPHONE: (215) 246-0900 SUPREME COURT ID #: ATTORNEY FOR: Defendant this subpoena within twenty (20) days after its service, pelling you to comply with it. THE FOLLOWING PERSON: BY THE URT: Proth4no-tary/Qle ivil sion MAY 18 2007 na L4 Date: V -, 1q, Zw2 Seal of the Court Deputy 60911-03 EXPLANATION OF REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: STUART DRUCKMAN. D.C. C/O MECHANICBURG CHIRO. 1010 WESLEY DRIVE MECHANICSBURG, PA 17055 RE: 60911 APRIL RUDICK II'? Prior approval is required for feel in excess of $150.00 for hospitals, $100.00 for all other p oviders. Entire medical file, including but not limited to any and all records, correspondence to and from the consulting and treating physicians, files, memoranda, handwritten notes, history and physical reports, medication/ prescription records, including an and all such items as may be stored in a computer database or otherwise in electronic form, relating to any examination, diagnosis or treatment pertaining o: Dates Requested: up to and including the present. Subject APRIL RUDICK ' II Social security #: XXX-XX-3146 Date of Birth: 02-18-1980 R1.31S 133-H SU10-0682568 60911-LO3 CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA 021GAV441 PURSUANT TOI RULE 4009.22 IN THE MATTER OF: APRIL & JOHN PETER RUDICK COURT OF COMMON PLEAS TERM, CUMBERLAND -VS- CASE NO: 07-846 LISA BUENAVENTURA As a prerequisite to service of a to Rule 4009.22 for documents and things pursuant MCS on behalf of STEP EN L. BANKO, JR., ES certifies that (1) A notice of intent to serve t e subpoena with a copy.of the subpoena attached thereto was mailed o delivered to each party at least twenty days prior to the date on which the subpoena is sought to be served, (2) A copy of the notice of intent, including the proposed subpoena, is attached to this certificate,] (3) No objection to the subpoena has been received, and (4) The subpoena which will be seed is identical to the subpoena which is attached to the notice of ntent to serve the subpoena. DATE: 05/16/2007 o behaIO-, of &6J It K JR. ES 4. Attorney for DEFENDANT R1.33 133-H DE11-0687932 60911-L04 COMMONWEALTH OF COUNTY OF IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- LISA BUENAVENTURA PINNACLE HLTH/HARRISBURG HOSP. MECHANICSBURG FAMILY STUART DRUCKMAN, D.C. DRAYER PHYSICAL THERAPY PA DEPT. OF PUBLIC WELFARE THE OLIVE GARDEN DAUPHIN COUNTY SOCIAL SERVICES ICI PENNS LVANIA CUMBERLAND MEDICAL MEDICAL MEDICAL MEDICAL COURT OF COMMON PLEAS TERM, CASE NO: 07-846 TO: DAVID L. LUTZ, ESQ.:, PLAINTIFF COUNSEL MCS on behalf..of STEPHEN L. BANKO, JR., ESQ. intends to serve a subpoena identical to the one that is attached to this notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoena,. If the twenty day notice period is waived or if no objection is made, then ?he subpoena may be served. Complete copies of any reproduced records may be {ordered at your expense by completing the attached counsel card and returning same to MCS or by contacting our local MCS office. DATE: 04/26/2007 CC: STEPHEN L. BANKO, JR., ESQ. - 63000.4-00046 Any questions regarding this matter, contact R1.31S 133-H MCS on behalf of STEPHEN L. BANKO, JR., ESQ. Attorney for DEFENDANT THE MCS GROUP INC. 1601 MARKET STREET #800 PHILADELPHIA, PA 19103 (215) 246-0900 DE02-0361584 60911-CO1 COMMONWEALTH OF PENNSYLVANIA COUNTY OF UMBERLAND APRIL & JOHN PETER RUDICK File No. 07-846 VS. LISA BUENAVENTURA TO: Custodian of Records for (Name of Within twenty (20) days after service of this subpoena, documents or things: **** SEE ATTACHED RIDE or Entity) iu are ordered by the court to produce the following **** at The MCS Groun_ Inc._ 1601 Market Street_ Suite 900 _ Philadelnhia_ PA 19103 You may deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the certificate of compliance, to the party making this request at the address listed above. You have the right to seek, in advance, the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things "required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order compelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: STEPHEN L. BANKO. JR.. ESQ. ADDRESS: 3510 TRINDLE ROAD TELEPHONE: _ (215) 246-0900 SUPREME COURT ID #: ATTORNEY FOR: Defendant BY THE COURT. Pro onota ,YA,,tl Division MAY 18 2DD7 Date: Seal of the Court Deputy 60911-04 EXPLANATION Off' REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: DRAYER PHYSICAL THERAPY 5275 E. TRINDLE ROAD MECHANICSBURG, PA 17050 RE: 60911 APRIL RUDICK Prior approval is required for fees hospitals, $100.00 for all other pr Entire medical file, including but no correspondence to and from the consul memoranda, handwritten notes, history prescription records, including any a computer database or otherwise in ele diagnosis or treatment pertaining to: Dates Requested: up to and inc Subject : APRIL RUDICR Social Security #: XXX-XX-3146 Date of Birth: 02-18-1980 excess of $150.00 for ,ers. limited to any and all records, :ing and treating physicians, files, and physical reports, medication/ ad all such items as may be stored in a :!tronic form, relating to any examination, the present. R1.31S 133-H SU10-0682570 60911-L04 CERTIFICATE PREREQIIISITE TO SER ICE OF A SUBPOENA ORKINN PURSUANT TO ULE 4009.22 IN THE MATTER OF: COURT OF COMMON PLEAS APRIL & JOHN PETER RUDICK TERM, CUMBERLAND -VS- CASE NO: 07-846 LISA BUENAVENTURA As a prerequisite to service of a subpoea for documents and things pursuant to Rule 4009.22 MCS on behalf of STEPHEN L. BANKO, JR., ESQ. certif es that (1) A notice of intent to serve thelsubpoena with a copy of the subpoena attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena is sought to be served, (2) A copy of the notice of intent,Nlincluding the proposed subpoena, is attached to this certificate, (3) No objection to the subpoena has been received, and (4) The subpoena which will be se is attached to the notice of DATE: 05/16/2007 is identical to the subpoena which t to serve the subpoena. V L S H AN L. B KO, JR., ES? Attorney for DEFENDANT R1.33 133-H DE11-0687933 60911-L05 COMMONWEALTH OF COUNTY OF IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- LISA BUENAVENTURA PINNACLE HLTH/HARRISBURG HOSP. MEDICAL MECHANICSBURG FAMILY MEDICAL STUART DRUCKMAN, D.C. MEDICAL DRAYER PHYSICAL THERAPY MEDICAL PA DEPT. OF PUBLIC WELFARE EMPLOYM THE OLIVE GARDEN EMPLOYM DAUPHIN COUNTY SOCIAL SERVICES EMPLOYM TERM, CASE NO: 07-846 TO: DAVID L. LUTZ, ESQ., PLAINTIFF COUNSE MCS on behalf of STEPHEN L. BANKO, JR., E'Q, intends to serve a subpoena identical to the one that is attached to his notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoena. If the twenty day notice period is waived or if no objection is made, then t e subpoena may be served. Complete copies of any reproduced records may be o dered at your expense by completing the attached counsel card and returning s me to MCS or by contacting our local MCS office. i DATE: 04/26/2007 MCS on behalf of STEPHEN L. BANKO, JR., ESQ. Attorney for DEFENDANT CC: STEPHEN L. BANKO, JR., ESQ. - 63000 Any questions regarding this matter, contact .4-00046 R1.31S 133-H NIA COURT OF COMMON PLEAS THE MCS GROUP INC. 1601 MARKET STREET #800 PHILADELPHIA, PA 19103 (215) 246-0900 D902-0361584 60911-COl APRIL & JOHN PETER RUDICK VS. LISA BUENAVENTURA TO: Custodian of Records for (Name of File No. 07-846 or Entity) Within twenty (20) days after service of this subpoena, documents or things: **** SEE ATTACHED RIDI? are ordered by the court to produce the following ** at You may deliver or mail legible copies of the documer with the certificate of compliance, to the party making t to seek, in advance, the reasonable cost of preparing the or produce things requested by this subpoena, together request at the address listed above. You have the right pies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order compelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: STEPHEN L. BANKO. JR.. ESO. ADDRESS: 3510 TRINDLE ROAD CAMP HILL- PA 17011 TELEPHONE: (215) 246-0900 SUPREME COURT ID #: ATTORNEY FOR: Defendant BY COURT: Pro ono i ivision MAY 18 2007 Deputy Date: Seal of the Court 60911-05 EXPLANATION OF REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: PA DEPT. OF PUBLIC WELFARE 7TH & FOSTER STS. 3RD FL-WEST HARRISBURG. PA 171052675 RE: 60911 APRIL RUDICK Prior approval is required for fees hospitals, $100.00 for all other pr Any and all employment records, appli time and attendance records, personne all medical records as an employee, i stored in a computer database or othe Dates Requested: from: 11-03-2005 to subject : APRIL RUDICR Social Security #: XXX-XX-3146 Date of Birth: 02-18-1980 excess of $150.00 for ers. tions, files, memoranda, compensation, records, payroll and salary reports and luding any and all such items as may be ise in electronic form, pertaining to: the present. I R1.31S 133-H SU10-0682572 60911-LO5 CERTI PREREQUISITE TO SE PURSUANT TC IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- .VICE OF A SUBPOENA RULE 4009.22 ORIGINAL COURT OF COMMON PLEAS TERM, CUMBERLAND CASE NO: 07-846 LISA BUENAVENTURA As a prerequisite to service of a to Rule 4009.22 for documents and things pursuant MCS on behalf of STEPH N L. BANKO, JR., ESQ. certifies that (1) A notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or elivered to each party at least twenty days prior to the date o which the subpoena is sought to be served, . (2) A copy of the notice of intent, attached to this certificate, including the proposed subpoena, is (3) No objection to the subpoena has been received, and (4) The subpoena which will be s is attached to the notice of DATE: 05/16/2007 d is identical to the subpoena which ent to serve the subpoena. o behal L. o AK' JR., ESQ. Attorney for DEFENDANT R1.33 133-H DE11-0687934 60911-L06 COMMONWEALTH OF P COUNTY OF IN THE MATTER OF : APRIL & JOHN PETER RUDICK -VS- LISA BUENAVENTURA PINNACLE HLTH/HARRISBURG HOSP. MEDICAL MECHANICSBURG FAMILY MEDICAL STUART DRUCKMAN, D.C. MEDICAL DRAYER PHYSICAL THERAPY MEDICAL PA DEPT. OF PUBLIC WELFARE EMPLOYM THE OLIVE GARDEN EMPLOYM DAUPHIN COUNTY SOCIAL SERVICES EMPLOYM: COURT OF COMMON PLEAS TERM, CASE NO: 07-846 TO: DAVID L. LUTZ, ESQ., PLAINTIFF COUNSE MCS on behalf of STEPHEN L. BANKO, JR., E Q. intends to servea subpoena identical to the one that is attached to his notice. You have twenty (20) days from the date listed below in which o file of record and serve upon the undersigned an objection to the subpoena. If the twenty day notice period is waived or if no objection is made, then t e subpoena may be served. Complete copies of any reproduced records may be o dered at your expense by completing the attached counsel card and returning s me to MCS or by contacting our local MCS office. DATE: 04/26/2007 MCS on behalf of STEPHEN L. BANKO, JR., ESQ. Attorney for DEFENDANT CC: STEPHEN L. BANKO, JR., ESQ. Any questions regarding this matter, 63000.4-00046 :1.31S 133-H VANIA THE MCS GROUP INC. 1601 MARKET STREET #800 PHILADELPHIA, PA 19103 (215) 246-0900 D902-0361584 60911-CO1 COMMONWEALTH F PENNSYLVANIA COUNTY OF MBERLAND APRIL & JOHN PETER RUDICK VS. LISA BUENAVENTURA File No. 07-846 TO: Custodian of Records for, (Name of Within twenty (20) days after service of this subpoena, E documents or things: **** SEE ATTACHED RID at You may deliver or mail legible copies of the documer with the certificate of compliance, to the party making t to seek, in advance, the reasonable cost of preparing the If you fail to produce the documents or things required the party serving this subpoena may seek a court order THIS SUBPOENA WAS ISSUED AT THE REQUEST NAME: STEPHEN L. BANKO. JR.. ESQ. ADDRESS: 3510 TEMLE ROAD CAMP HILL , PA 17011 TELEPHONE: (215) 246-0900 SUPREME COURT ID #: ATTORNEY FOR: Defendant or produce things requested by this subpoena, together request at the address listed above. You have the right pies or producing the things sought. this subpoena within twenty (20) days after its service, spelling you to comply with it. THE FOLLOWING PERSON: BY THE COURT: Proth notary1C ivi ivision MAY 18207 Date: Seal of the Court or Entity) are ordered by the court to produce the following Deputy 60911-06 EXPLANATION Of REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: THE OLIVE GARDEN 6520 CARLISLE PIKE MECHANICSBURG, PA 17050 RE: 60911 APRIL RUDICK Prior approval is required for fees hospitals, $100.00 for all other prc in excess of $150.00 for viders. Any and all employment records, applications, files, memoranda, compensation, time and attendance records, personnel records.; payroll and salary reports and all medical records as an employee, including any and all such items as may be stored in a computer database or otherwise in electronic form, pertaining to: Dates Requested: from: 05-01-2001 Subject : APRIL RUDICR the present. Social Security #: XXX-XX-3146 Date of Birth: 02-18-1980 R1.31S 133-H SU10-0682574 60911-LO6 CERTI PREREQUISITE TO SE PURSUANT TO IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- CE OF A SUBPOENA LE 4009.22 ORGINW, COURT OF COMMON PLEAS TERM, CUMBERLAND CASE NO: 07-846 LISA BUENAVENTURA As a prerequisite to service of a to Rule 4009.22 for documents and things pursuant MCS on behalf of STEPHE L. BANKO, JR., ESQ. certifies that (1) A notice of intent to serve th attached thereto was mailed-or twenty days prior to the date served, subpoena with a copy of the subpoena elivered to each party at least which the subpoena is sought to be (2) A copy of the notice of intent, attached to this certificate, (3) No objection to the subpoena (4) The subpoena which will be sere is attached to the notice of ii DATE: 05/16/2007 including the proposed subpoena, is been received, and is identical to the subpoena which t to serve the subpoena. behal o INE k Attorney for DEFENDANT R1.33 133-H DE11-0687935 60911-L07 COMMONWEALTH OF COUNTY OF IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- LISA BUENAVENTURA PINNACLE HLTH/HARRISBURG HOSP. MECHANICSBURG FAMILY STUART DRUCFMAN, D.C. DRAYER PHYSICAL THERAPY PA DEPT. OF PUBLIC WELFARE THE OLIVE GARDEN DAUPHik COUNTY SOCIAL SERVICES MEDICAL RECORDS MEDICAL RECORDS MEDICAL RECORDS MEDICAL RECORDS TO: DAVID L. LUTZ, ESQ., PLAINTIFF COUN.' MCS on behalf of STEPHEN L. BANKO, JR., identical to the one that is attached to days from the date listed below in whicl undersigned an objection to the subpoen waived or if no objection is made, then copies of any reproduced records may be the attached counsel card and returning MCS office. DATE: 04/26/2007 YLVANIA COURT OF COMMON PLEAS TERM, CASE NO: 07-846 ESQ. intends to serve a subpoena > this notice. You have twenty (20) i to file of record and serve upon the t. If the twenty day notice period is the subpoena may be served. Complete ordered at your expense by completing same to MCS or by contacting our local MCS on behalf of STEPHEN L. BANKO, JR., ESQ. Attorney for DEFENDANT CC: STEPHEN L. BANKO, JR., ESQ. = 63000.4-00046 Any questions regarding this matter, R1.31S 133-H THE MCS GROUP INC. 1601 MARKET STREET #800 PHILADELPHIA, PA 19103 (215) 246-0900 D902-0361584 60911-CO1 OF APRIL & JOHN PETER RUDICK vs. LISA BUENAVENTURA SUBPOENA TO PRODUCE TO: Custodian of Records for (Name of File No. 07-846 or Entity) Within twenty (20) days after service of this subpoena, documents or things: **** SEE ATTACHED RID F u are ordered by the court to produce the following at You may deliver or mail legible copies of the document or produce things requested by this subpoena, together with the certificate of compliance, to the party making this request at the address listed above. You have the right to seek, in advance, the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required b this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order compelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: STEPHEN L. BANKO. JR.. ESQ. ADDRESS: 3510 TRMLE ROAD CAMP HILL, PA 17011 TELEPHONE: (215) 246-0900 SUPREME COURT ID #: ATTORNEY FOR: Defendant OURT: BY T7 Prot notary/C Ci Division MAY 16 2007 Date: , & 2,5n2 Seal of the Court Deputy 60911-07 EXPLANATION Off' REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: DAUPHIN COUNTY SOCIAL SERVICES FOR CHILDREN & YOUTH 25 S. FRONT ST. #700 HARRISBURG, PA 17101 RE: 60911 APRIL RUDICK Prior approval is required for fees hospitals, $100.00 for all other pr excess of $150.00 for ers. Any and all employment records, appl'cations, files, memoranda, compensation, time and attendance records, personn 1 records, payroll and salary reports and all medical records as an employee, Including any and all such items as may be stored in a computer database or oth rwise in electronic form, pertaining to: Dates Requested: from: JUNE, 2003 Subject : APRIL RUDICK Social Security #: XXX-XX-3146 Date of Birth: 02-18-1980 SEPTEMBER, 2005. R1.31S 133-H SU10-0682576 60911-LO7 ? ?i ? ? ? ? ..# ? .? ' ? ?,,?, x , , -.-_• ??? _,. ,. , . ?, 7 , }"i° ? ? .' i..? SHERIFF'S RETURN - REGULAR CASE NO: 2007-00846 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND RUDICK APRIL ET AL VS BUENAVENTURA LISA MICHAEL BARRICK , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon BUENAVENTURA LISA the DEFENDANT , at 1828:00 HOURS, on the 9th day of March , 2007 at 201 SHIRLEY LANE BOILING SPRINGS, PA 17007 by handing to HANK CURLEY, HUSBAND a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 13.44 Postage .63 Surcharge 10.00 .00 3/3e. JO 7 4 2. 0 7 Sworn and Subscibed to before me this day of , So Answers: R. Thomas Kline 03/12/2007 ANGINO & ROVNER By. 4 Deputy h riff A.D. ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attomey 1D# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 PHONE: (717) 238-6791 FAX: (717) 238-5610 Attorney for Plaintiff: E-mail: dlutzQ_wglno-rovner corn APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-846 CIVIL TERM JURY TRIAL DEMANDED PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: David L. Lutz, Esquire, counsel for the Plaintiffs in the above action, respectfully represents that: 1. The above-captioned action is at issue. 2. The claim of the Plaintiffs in the action is $50,000. The counterclaim of the Defendant in the action is $0. The following attorneys are interested in the case(s) as counsel or otherwise disqualified to sit as arbitrators: David L. Lutz, Esquire, 4503 N. Front Street, Harrisburg, PA 17110; Stephen Banko, Jr., Esquire, P.O. Box 932, Harrisburg, PA 17108-0932. 359017 .bI WHEREFORE, your Petitioners pray Your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. ANGINO & ROVNER, P.C. VG) Date: David L. Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791 -phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Plaintiffs 359017 CERTIFICATE OF SERVICE I, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of the PETITION FOR APPOINTMENT OF ARBITRATORS upon all counsel of record via postage prepaid first class United States mail addressed as follows: Stephen L. Banko Jr., Esquire Margolis Edelstein P.O. Box 932 Harrisburg, PA 17108-0932 Attorney for Defendant Dated. 359017 0 o 0 -4 -t? (? ?? ' . r?_ C1 ur `-?rn co c-n ? ^5 lY w JUL 0 6 2007 PY APRIL and JOHN RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. 07-846 CIVIL TERM JURY TRIAL DEMANDED ORDER OF COURT AND NOW, this day of , 200 in consideration of the foregoing petition, WAIXY&W , Esq. 1XA4-e,,) U2. Esq. and captioned action as prayed for. Esq. are appointed arbitrators in the above- BY COUR . .. ? Gvl? P.J. 359017 f 1 rAi 7-sorb W'r?lv .,07 F7 'S APRIL RUDICK, ET AL., COURT OF COMMON PLEAS OF PLAINTIFFS CUMBERLAND COUNTY, PENNSYLVANIA V. LISA BUENAVENTURA, DEFENDANT 07-0846 CIVIL TERM ORDER OF COURT AND NOW, this 2Z 4 day of July, 2007, the appointment of David Baric, Esquire, to the Board of Arbitrators in the above-captioned case, IS VACATED. Michael Scherer, Esquire, is appointed in his place. By the Court, Edga . Bay ey, J. ? Gregory B. Abeln, Esquire Chairman Michael Scherer, Esquire Court Administrator :sal ?OpoMa o? ?,-• Gr; .r r red L,f? ." _ r??i? ??7 ? f { ? f"°- `. l.l._ ? ?::,? __ F--- - i?t_, ? r-- `? ._ ?= } . t ,.P ?w `'br? CrRIGM, ! CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- COURT OF COMMON PLEAS TERM, CUMBERLAND CASE NO: 2007-846 LISA BUENAVENTURA As a prerequisite to service of a subpoena for documents and things pursuant to Rule 4009.22 MCS on behalf of STEPHEN L. BANKO, JR., E certifies that (1) A notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena is sought to be served, (2) A copy of the notice of intent, including the proposed subpoena, is attached to this certificate, (3) No objection to the subpoena has been received, and (4) The subpoena which will be served is identical to the subpoena which is attached to the notice of intent to serve the subpoena. DATE: 07/31/2007 14 o beha fL. , JS Attorney for DEFENDAIM R1.35 133-H DE11-0701773 60911-L08 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND IN THE MATTER OF: APRIL & JOHN PETER RUDICK -VS- LISA BUENAVENTURA COURT OF COMMON PLEAS TERM, CASE NO: 2007-846 NOTICE OF INTENT TO SERVE A SUBPOENA TO PRODUCE DOCUMENTS AND THINGS FOR DISCOVERY PURSUANT TO RULE 4009.21 STATE AUTO INSURANCE COMPANIES INSURANCE TO: DAVID L. LUTZ, ESQ., PLAINTIFF COUNSEL MCS on behalf of STEPHEN L. BANKO, JR., ESQ. intends to serve a subpoena identical to the one that is attached to this notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoena. If the twenty day notice period is waived or if no objection is made, then the subpoena may be served. Complete copies of any reproduced records may be ordered at your expense by completing the attached counsel card and returning same to MCS or by contacting our local MCS office. DATE: 07/11/2007 CC: STEPHEN L. BANKO, JR., ESQ. - 63000.4-00046 Any questions regarding this matter, contact MCS on behalf of STEPHEN L. BANKO, JR., ESQ. Attorney for DEFENDANT THE MCS GROUP INC. 1601 MARKET STREET #800 PHILADELPHIA, PA 19103 (215) 246-0900 1.35S 133-H . DE02-0368063 60911-CO1 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND APRIL & JOHN PETER RUDICK vs. LISA BUENAVENTURA File No. 2007-846 SUBPOENA TO PRODUCE DOCUMENTS OR THINGS FOR DISCOVERY PURSUANT TO RULE 4009.22 TO: Custodian of Records for STATE AUTO INSURANCE COMPANIES (Name of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following documents or things:- ****SEE ATTACHED RIDER**** at The MC Loup,, Inc., 1601 Market Street, Suite 800 Philadelphia, PA 19103 You may deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the certificate of compliance, to the party making this request at the address listed above. You have the right to seek, in advance, the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoena within twenty (20) days after its service, the party serving this subpoena may seek a court order compelling you to comply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLOWING PERSON: NAME: STEPHEN L. BANKO. JR ESO_ ADDRESS: 3510 TRINDLE ROAD CAMP HILL. PA 17011 TELEPHONE: (215) 246-0900 SUPREME COURT ID #: ATTORNEY FOR: Defendant Date: 7 G ?0'1 Seal of the Court BY THE COURT: 6PoLthonotary/Clerk, Civil ivision k1. 44 n'. ?- Deputy 60911-08 EXPLANATION OF REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: STATE AUTO INSURANCE COMPANIES 518 EAST BROAD STREET COLUMBUS, OH 43215 RE: 60911 APRIL RUDICK Prior approval is required for fees in excess of $150.00 for hospitals, $100.00 for all other providers. POLICY# APA-0014635; POLICY PERIOD 8/9/06-2/9/07; AGENT:R.T. DUNN INSURANCE INC., 200 WEST MAIN STREET, MECHANICSBURG, PA 17055, PH# (717)766-0770 Any and all insurance records and PIP files, including but not limited to medical reports and/or records, claims, any and all correspondence, documentation supporting plaintiff's claim, payments including dates of payments, payee and reasons for payments, including any and all such items as may be stored in a computer database or otherwise in electronic form, pertaining to: Dates Requested: up to and including the present. Subject : APRIL RUDICK 14 SO.WASHINTON ST, MECHANICSBURG, PA 17055 Social Security #: XXX-XX-3146 Date of Birth: 02-18-1980 Date of Loss: 10/16/2006 R1.35S 133-H SU10-0694484 60911-L08 C? G ` .? t;r- -o ? ? rr ? ? ...rrr???...??? APRIL RUDICK, ET AL., PLAINTIFFS V. LISA BUENAVENTURA, DEFENDANT COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 07-0846 CIVIL TERM ORDER OF COURT AND NOW, this n4day of August, 2007, the appointment of Michael Scherer, Esquire, to the Board of Arbitrators in the above-captioned case, IS VACATED. Robert J. Dailey, Esquire, is appointed in his place. By the Cart, Edgar B. Bayley, J. Gregory B. Abeln, Esquir Chairman Robert J. Dailey, Esquire Court Administrator sal r C:) N ' cn i ? z APRIL RUDICK, ET AL., PLAINTIFFS V. LISA BUENAVENTURA, DEFENDANT IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 07-0846 CIVIL TERM ORDER OF COURT AND NOW, this day of September, 2007, the appointment of a Board of Arbitrators in the above-captioned case, IS VACATED. Gregory B. Abeln, Esquire, Chairman, shall be paid the sum of $50.00. By the Cou /Gregory B. Abeln, Esquire Court Administrator :sal Edgar B. Bayley, J. CoPN µ I? C`4 C) ck- Cf, t Ce) CL- - r?- Plaintiff Defendant County, Pennsylvania No. -?.T> Ct In The Court of Common Pleas of Cumberland Civil Action - Law. Oath We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United States and the Constitution of this Commonwealth and that we will discharge the duties of our office with fidelity. t Signature Name (Chairman) Law Firm Address VI U,7 City, Zip Signature Name Law Firm Address city, zip Signature Name Law Firm Address city, zip Award We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awarded, they shall be separately stated.) . Arbitrator, dissents. (Insert name if applicable.) Date of Hearing: (Chairman) Date of Award: Notice of Entry of Award r° Now, the day of , 20 , at .M., the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Arbitrators' conlTer_sation to be paid upon appeal: By: - Deputy ' -- Pro, onotary ABELN LAW OFFICES 37 East Pomfret Street Carlisle, PA 17013 Telephone: 717/245-2851 Facsimile: 717/245-9622 E-Mail: abelniaw@pa.net September 11, 2007 David L. Lutz, Esquire Angino & Rovner, P.C. 4503 N. Front St. Harrisburg, PA 17110-1708 Stephen L. Banko, Jr., Esquire Margolis Edelstein PO Box 932 Harrisburg, PA 17108-0932 RE: APRIL and JOHN RUDICK, v. LISA BUENAVENTURA ARBITRATION No. 07-846 Civil Term Dear Counselors: I have been informed that the parties are requesting a general continuance of this matter and a re-listing of the case with a new panel appointment. I believe this is appropriate, as I have now determined that the other two panel members appear to be conflicted. I will therefore return the file to the Prothonotary office with that notation. Again, I am sorry for the inconvenience. Ve 1 urs Gregory Barton Abeln, Esquire ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney 1D# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 07-846 CIVIL TERM CIVIL ACTION - LAW JURY TRIAL DEMANDED PLAINTIFFS' SECOND PETITION FOR APPOINTMENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: David L. Lutz, Esquire, counsel for the Plaintiffs in the above action, respectfully represents that: 1. The above-captioned action is at issue. 2. The claim of the Plaintiffs in the action is $50,000. The counterclaim of the Defendant in the action is $0. The following attorneys are interested in the case(s) as counsel or otherwise disqualified to sit as arbitrators: David L. Lutz, Esquire, 4503 N. Front Street, Harrisburg, PA 17110; Stephen Banko, Jr., Esquire, P.O. Box 932, Harrisburg, PA 17108-0932. Judge Bayley had previously appointed Gregory B. Abeln, Esquire; Andrew W. Barbin, Esquire; and David A. Baric, Esquire, as arbitrators to hear the above-captioned case, which was scheduled for September 5, 2007. However, not all of the arbitrators appeared and, therefore, the arbitration hearing had to be rescheduled. Counsel respectfully requests that a new arbitration panel be rescheduled. WHEREFORE, your Petitioners pray Your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Date: I ANGINO & ROVNER, P.C. David L. Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791- phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Plaintiffs CERTIFICATE OF SERVICE I, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of PLAINTIFFS' SECOND PETITION FOR APPOINTMENT OF ARBITRATORS upon all counsel of record via postage prepaid first class United States mail addressed as follows: Stephen L. Banko Jr., Esquire Margolis Edelstein P.O. Box 932 Harrisburg, PA 17108-0932 Attorney for Defendant Dated: ?,- ? 1 --0 364489 z7D A D I ' tai APRIL and JOHN RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant THE COURT OF COMMON PLEAS COUNTY, PENNSYLVANIA IVIL ACTION - LAW 0.07-846 CIVIL TERM JRY TRIAL DEMANDED ORDER OF COURT AND NOW, this oho Nay of ? 2006, in consideration of the foregoing petition, Esq. &X? G • Esq. and Esq. are appointed arbitrators in the above- captioned action as prayed for. BY T: Tv P.J. 364489 `101 CT t wY M?'?d 61. Cot* Dom, i,-. 9?d? •f ? ?Y, ?C J ??H. ??K1?.1 -? Plaintiff L-. C (? t.J n ?i ? e k 4 (c J & Defendant In The Court of Common Pleas of Cumberland County, Pennsylvania No. O ?-- Er ?4L Civil Action - Law. Oath We do solemnly swear (or affirm) that we will support, obey and defend the Constitution of the United Signature tution of this Commonwealth and that we will discharge the duties of our office States and the 7- with fidelity. C_ -Signature Name (Chairman) pipature (" PC cj? Law Firm R;??v? ?. rays, Name ,dle-r, A6 Law F It o t &in v-? Ave. Sie ,103 3331 Marka+ Sf. Address Address 64 9?l: N 17" C., 14 1l, OA 17011 City, Zip City, zip Award Name ??? Law Firm 71 Ae) Address City, Zip We, the undersigned arbitrators, having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awarded, they shall be separately stated.) qq `4 T/c. 4. ?1. ? I K J ! G. , - ?. (. t v i '^ 'rll ?C l ,rt R 1 }r G/ *L / Q 7 I r 0.` . Arbitrator dissents. (Insert name if applicable Date of Hearing: I 42 0 F- ?-' (Chairman) Date of Award: Y Z6 S 'Oe Notice of S:ry of Award Now, the A5*k_ day of JdnLftr'v , 200 , at 9:34 , A .M., the above award was entered upon the docket and notice thereof given by mail to the parties or their attorneys. Arbitrators' compensation to be paid upon appeal: $ 350.00 By: J rothonotary Deputy 0ay'd L. S?,Pjw^ L - , jps/oS old j4A Prof,eJ t _ )x _ l -zl ~ ' 3 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA April and John Rudick Plaintiffs Vs Lisa Buenaventura Defendant File No. 07-846 Civil Term NOTICE OF APPEAL FROM AWARD OF BOARD OF ARBITRATORS TO THE PROTHONOTARY: Notice is given that Defendant appeals from the award of the board of arbitrators entered in this case on 1/24/08 A jury trial is demanded X . (Check the line if a jury trial is demanded. Otherwise jury trial is waived.) I hereby certify that (1) the compensation of the arbitrators has been paid, or E Appell t o Attey of Appellant Note: The demand for jury trial on appeal from compulsory arbitration is governed by Rule 1007.1(b). (b) No affidavit or verification is required. Adopted March 16, 1981, effective May 15; 1981. -r c . 0 co 00 ?..V. 77 ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 07-846 CIVIL TERM CIVIL ACTION - LAW JURY TRIAL DEMANDED STIPULATION LIMITATION OF MONETARY RECOVERY PURSUANT TO RULE 1311.1 To: Defendant Lisa Buenaventura, by and through her counsel Stephen Banko, Esquire Plaintiffs, by and through counsel, Angino & Rovner, P.C., stipulate to $25,000.00 as the maximum amount of damages recoverable upon the trial of the appeal from the award of arbitrators in the above-captioned action. ORIGINAL 376753 Auril and John Rudick Name of Plaintiffs Date:` ' 376753 ANGINO & ROVNER, P.C. I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791- phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Plaintiffs CERTIFICATE OF SERVICE 1, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of the STIPULATION LIMITATION OF MONETARY RECOVERY PURSUANT TO RULE 1311.1 upon all counsel of record via postage prepaid first class United States mail addressed as follows: Stephen L. Banko Jr., Esquire Margolis Edelstein P.O. Box 932 Harrisburg, PA 17108-0932 Attorney for Defendant Dated: ?" w ?3 376753 rrl Cn -77 r , Ln L I' 4 ANGINO & ROVNER, P.C. David L. Lutz, Esquire Attorney ID# : 35956 4503 North Front Street Harrisburg, PA 17110-1708 (717) 238-6791 FAX (717) 238-5610 Attorneys for Plaintiff(s) E-mail: dlutz@angino-rovner.com APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA NO. 07-846 CIVIL TERM CIVIL ACTION - LAW JURY TRIAL DEMANDED NOTICE OF INTENT TO OFFER DOCUMENTARY EVIDENCE PURSUANT TO RULE 1311.1 To: Defendant Lisa Buenaventura, by and through her counsel Stephen Banko, Esquire Plaintiffs, by and through counsel, Angino & Rovner, P.C., intends to offer the documents attached hereto at the trial of the appeal from the award of arbitrators, in the manner provided by Rule of Civil Procedure 1311.1. The following documents are attached: I . Pinnacle Health Hospital records (Exhibit A). 2. Harrisburg Hospital records (Exhibit B). 3. Report and records from Dr. Thompson (Exhibit Q. 4. Report and records from Drayer Physical Therapy (Exhibit D). 376752 Ii 5. Employer report (Exhibit E). Date:, )4- A 376752 ANGINO & ROVNER, P.C. 4? - avid L. Lutz I.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791- phone (717) 238-5610 - fax dlutz@angino-rovner.com Attorney for Plaintiffs CERTIFICATE OF SERVICE I, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of the NOTICE OF INTENT TO OFFER DOCUMENTARY EVIDENCE PURSUANT TO RULE 1311.1 upon all counsel of record via postage prepaid first class United States mail addressed as follows: Stephen L. Banko Jr., Esquire Margolis Edelstein P.O. Box 932 Harrisburg, PA 17108-0932 Attorney for Defendant M T. eraets Dated: ? , 114 - DW 376752 RUDICK, APRIL R M#: ?i MKN: 185-60-3146 11?''t CASE: 00270096439 ..DM D2L1_W-1.s13a ADM' I '! 672U PinnacieHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 EMERGENCY DEPARTMENT CHIEF COMPLAINT: The patient is a 26-year-old female who comes to Seidle Hospital FirstPlace complaining of neck pain, back pain and vomiting. HISTORY OF PRESENT ILLNESS: She was the restrained driver of a car that was hit in the rear-ended, about a 1 hour ago. She -an -y-fting 2111 1.1 ie cai as fa, as sl ie ki Pows. She 1 idd immediate pain in the low back Then she developed pain in the neck and upper back Developed blurred vision and vomited x2 in the last 45 minutes. REVIEW OF SYSTEMS: She has migraine headaches. PAST HISTORY: NO ALLERGIES. Medications: She takes birth control pills and Relpax on a prn basis for migraines. She has had no surgeries. Family history of migraines. SOCIAL HISTORY: She smokes a pack of cigarettes a day. She drinks alcohol socially. PHYSICAL EXAM: Well-nourished, well-developed, 26-year-old female who does not appear to be in distress. She is alert and oriented. Aff ect and judgment are appropriate. Vital signs: Blood pressure 118170. Pulse 76 and regular. Respirations 18 and not labored. Temperature 98.7. She complains of her vision seeming rather fuzzy but nothing is demonstrable. Pupils react equally. Extraocular movements are intact. Peripheral vision is normal. Cranial nerves are grossly intact. Neurological exam is completely normal. She is tender in the right posterior cervical and right trapezius muscle areas. She has limitation of motion of the neck due to pain. EMERGENCY DEPARTMENT COURSE: In lieu of the fact that she has vomited twice since the accident, she needs to have a. CT scan of the head. That is scheduled to be done at Harrisburg Hospital as soon as she can get over there. DISPOSITION: She should go immediately to Harrisburg Hospital for a CT scan and a family member will take her. If it is positive she will go to the emergency department. If it is negative she should use heat on her neck and upper back 4 times a day. She should take ibuprofen 800 mg 3 times a day with food. She ER REPORT ER REPORT ER REPORT CHART COPY i Date: l%? /l •? ?? TRIAGE TIM CATEGORY T- P- R- B/P 70 ALLERGIES I& r7- CCURRENT EDS PMH L.M.P. ---- TETANUS HX -.. VISUALACUITY O.S. O.D. WEIGHT INITIAL ASSESSMENT Cpl \a- L Z6 Zc-le Q? 644Q4?t 6i? ZZ?t?? a) 9z 3 I TIME T P R BP NOTE progress, Complications, Consultations, Instructions, Condition Discharge. 1-21 fu- U2 s1-- ?l C ?- '164 ?/ ?CSJ D ?2 9L- ???I U ? PINNACLEHEALTH Hospitals FIRSTPLACE NURSE ASSESSMENT Form 0666-60 (04/01) Formerty 1W 2858 SEIDLE HOSPITAL 120 S. Filbert Street Mechanicsburg, PA 17055-6591 i,?t???are?u MR: 185603146 CASE:270096439 RUDICK,APRIL F DATE: 10/16/06 DOB: 02/18/1980 Ph#: 717 691-1867 AGE: 26 DR: SSN:185603146 id L ;4 1 i PI.NNACL.EHEALTH. Sys>r_en Radiai _,t lma*n-g _Repgrt MRM 185603146 NAME: RUDICK, APRIL SSN: 165603146 14 S WASHINGTON ST ADM: 000270096439 MECHANICSBURG, PA 17055 MP-1m: LJVp nnrtnrt nmr, w.. ir+. ^.r??J 'JG/ IUJ 1.7VV !'l VC. GC11 -M- M__ C, Lim. Iy?- SlAGG, RICHARD D BED: - ORD#: 90001 PTCLAS S: O RAID ATT DR: STAGG, RICHARD D REASON: MVA FUZZY VISION & VOMITING COMMENTS: CALL BACK RESULTS ***Final Report*** HARRISBURG CT DEPARTMENT PROCEDURE: CTS - 0450 - CT BRAIN W/O CONTRAST PROCEDURE DATE: Oct 16 2006 9:00PM ACCESSION#: 5489224 Exam: CT scan of brain, unenhanced History: MVA, fuzzy vision and vomiting Result: Computed tomography of the brain was done without IV contrast enhancement. There no prior exams for The ventricles and extra-axial spaces are normal for age. The midline is not shifted. There are no regions of abnormally increased or decreased attenuation. There is no intracranial hemorrhage, mass, or mass effect The bony structures are appropriate for age. The visualized paranasal sinuses and mastoid air cells are clear. Impression: Normal unenhanced CT scan of the brain. DICTATED: (10!1612006 21:13) TRANS: (PSC/PS) ON: 10116/2006 21:16 INTERPRETED AND REVIEWED BY: DOUGLAS J MARTIN,MD ELECTRONICALLY SIGNED: 10/16/2006 21:16 To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a -Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-6030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful interpretations. Accordingly, if the clinical team is in search of answers to speck questions, please include your questions(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. t tJ Study interpretation provided by Quantum Imaging & Therapeutic Assoc/ales. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at 1-717-782-3240. Printed: October 26, 2006 3:02 PM J i?c?w?eesn? MR: 185603146 CASE:270096439 RUD/CK,APR/L F DATE: 10/16/06 DOB: 02/18/1980 Ph#: 717 691-1867 AGE: 26 DR: SSN:185603146 t 4?:PINNACLEIHEALTH ]:irstPlace Health Care (717) 795-6656 FirstPlace # INSTRUCTION TO THE PATIENT J in the FirstPlace Center has been rendered on an urgent basis only, and are not intended lete medical care. IF YOU DEVELOP NEW PROBLEMS OR COMPLICATIONS, _ LACE HEALTH CARE. LACERATION, ABRASIONS OR BURNS 1. Keep wound dean and dry 24-48 hours. 2. After 24-48 hours wash with soap and water or peroxide. 3. Watch for signs of swelling, tenderness, redness, heat or drainage - return to FirstPlace if any of these signs occur. 4. Return to FirsTlace to have your sutures. removed. 5. Tetanus Toxiodlfitanus diphtheria given _yes SPRAINS, BRUISES, AND FRACTURES 6. Elevate on 2 pillows and rest 7. Use ice for minutes times a day-for days. 8. Ace wrap 9. Use splint for 10. Use crutches for 11. Begin to.bear weight 12. Start .warm' soak on for minutes times a day until recheck or no symptoms present 13. Wear cervical collar 14. No heavy li ing for 15. Use sling for MEDICAL INSTRUCTIONS 16. Bed rest for 17. Take . Tylenol every hours. 18. If a child has fever. A. dress lightly - don't cover with blankets; B. place in tub of lukewarm water and sponge for 30 minutes. If temperature is higher than and won't come down with Tylenol® C. give plenty of fluids - offer small amounts frequently, D. give Tylenole 9 temperature higher than E. DO NOT use ice packs, cold water enemas or alcohol bath. 19. Clear liquid diet - advance as tolerated. 20. Drink plenty of liquids. A4Z HEAD INJURIES 26. Avoid strenuous physical activity for at least 24 hours. 27. Use for headache every 4 hours as needed. 28. Light diet for 24 hours. CALL DOCTOR IMMEDIATELY IF: A. Unable to arouse patient, confused, or irritable B. Patient continues to be nauseated andlor vomits C. Patient has trouble with balance D. Patient complains of any visual difficulty E. Headache persists longer then 24 hours or if it becomes more intense after 12 hours F. Convulsions. 21. Wear eye patch for hours. 22. Do not drive or operate machinery until 23. Return to FirstPlace Health Care or family physician . - bring sunglasses. 24.Avoid bright lights, T.V. and prolonged reading for hours. 25. Eye medication NOSEBLEEDS 29. Do not blow your nose. 30. If bleeding occurs through nasal packing or in throat call First Place or family physician. FOLLOW UP CARE ,J,Retum to FustRlace 32-Fbllow-up with family physician 33. See Dr. on at AM/PM EMPLOYMENT 34. Return to normal duty on 35. Limited duty from until Limitation 36. See Occupational Instructional Sheet 37.OTHE 7 - 4 fT`?? L ?L i /l? 6 /1= ! "?. y J k r 5 «? tS?S ?`? J l %ro J /,"C+cG?? o 27-0 Lr_' --y c t=?--vrfl,/?'? (2!?'_ /I C <<c./ ?y :/ S iCA? ?J X-RAY INSTRUCTIONS: Your x-rays have been read by the FirstPlace Health Care Physician. For your added protection, your x-ray will be reread by our Radiology Departrrlent. If any abnormalities are found that have not been called to your attention, you and your doctor will be called immediately. Sometimes fractures or abnormalities may not show up on x-rays for several days. If symptoms persist or get worse, call your Physician or return to this Firs PPaace Health Care Centel. More x-rays may have to be taken. LABORATORY INSTRUCTIONS: Call FirstPlace for result of your pending lab tests. SIGNATURES I HERBY ACKNOWLEDGE RECEIPT OF THESE INSTRUCTIONS AND R.N. UNDERSTAND THEM. I UNDERSTAND THAT I HAVE HAD URGENT TREATMENT ONLY AND THAT I MAY BE RELEASED BEFORE ALL i M.D. MY MEDICAL PROBLEMS ARE KNOWN OR TREATED. I WILL ARRAPGEFOLLmW--UP CARE AS I HAVE BEEN INSTRUCTED. Form 066" 1 (09/05) s„e,ty trav 21571 n,o X T'/{=4 t -(_ ?- C J r <G r z; Signature: Patient or responsible person Date 4'>-PINNACLEHEALTH Hospi[als PHYSICIAN LEVEL. OF CARE C I ? IV MED. EMEIR. ? 'Y e•t1 ? v Bl?l ? III ? Critical Care ? A TIME CUT EJ FIRST PLACE Non-ED Physician: ? After Hours ? Private Attending MEDICAL RECORDS REQUESTED ? YES ? No s a ? DEMED ? AUTHORIZATION # IF ACCIDENT, WHERE OCCURRED DATE &:TIME OF.AGCIDENT c MEANS,OF ARRIVAL ATTI NDJNG RHY=IAN C.G. PER PTJSIGNIRCANT OTHER FAMILY PHYSICIAN ?'•i i=_!"_"' >-,t.'%t; I01 T T E .4,= Tc-1C. M112`?0 I.4 T Ii - JAMES 6c- TIME IN DE`T TIM DR. IN CONDITION ~N ARRIVAL POLICE NOTIFIED LL BY., GOOD ? FAIR ? POOA ? CRMCAL ? DOA ? YES ? NO ] VITAL SIGNS AT TRIAGE ] VITAL SIGNS IN DEPT. BP P R T. ALLERGIES: NKDA, SEE NURSES N PHYSICIAN'S REPORT IHIPI, IMPRESSION + T TETANUS: >5 YEARS, e5 YEARS, OT fir! n? ?: l's3 r -c 14? R -1 . 7/off Cam( alet ,,vL'C CONSULT ? NAME 0 X c [ 4 i TIME DICTATED TIME ROOM # DIAGNOSTIC IMPRESSION DSl-its Lt: /l C 7Yit c.{C Ate '- % ?Ci ??? Z c C nCL C_C - S ! / L /?l/I!S CSC l./EC? YI?' L ^ -J SERVICE / MD BED TYPE DISCH.' Tt, , OW-UP CONDITION ON DISCHARGE ? ADMITS ? TRANSFER 1 EX ? :•'-- I OTHER PHYSICIAN'S ASSISTANT/MEDICAL STUDENT .D. PHYS OTHER LAST DIS. DATE 3ESIDENT PRIVA IAN NURSE LAST ER REG. S V? GUARANTOR NAME GUARANTOR EMPLOYER INFORMATION r;I_ID ?:CK . ;?P77,11- C Of-0.101• -JEAL.TF1 OF PA HOME- ' 7 _ <- r T - ? SG -; WORK NOTIFICATION NAME PATIENT EMPLOYER INFORMATION P 1 L NR :HE L -A $ . HOME")i. T_-J='=-'--J'.r-._L-!:WORK j1 -Y t.11- N1,ICjN1 Ei!:! FH OF f?i= HOSP SERV AREAS TO VISIT DIAG. CODE RELIGION m' " r? C '1 lpr-, I-'f PATIENT # DATE TIME AGE DATE OF BIRTH S M R SOCIAL SECURITY # P/T F/C MEDICAL RECORD # DOC -7 7117114 • 1. '- =I 1, C ' 'r F, -- I v -' : r r r t?} r' =S ._.:.?1 + 1; '• d A=; : 1 i . i- '? r ! i PATIENT NAME AND A DDRESS INSURANCE CO. NAME GROUP NO. POLICY NUMBER SUBSCRIBER NAME icy - r, T S' X;=?:5 /A { I i s _. LF ? I•. tai`: `'1 3 {•4 Ci !.: t`F'_L: :'tP ::`t :. 1. .t?t-+C r ADME WORK - (Rev. 2/03) hhh, av o c cam. Rudick, April Sex:F BD:02/18/1980 BRAIN W/O CNTRST DET View PACS Image VIEw ***Final Report*** HARRISBURG CT DEPARTMENT PROCEDURE: CTS - 0450 - CT BRAIN W/O CONTRAST PROCEDURE DATE: Oct 16 2006 9:OOPM ACCESSION#: 5489224 !Print this Page MR#:185603146 Oct 16, 2006 21:00 . Exam: CT scan of brain, unenhanced History: MVA, fuzzy vision and vomiting Result: Computed tomography of the brain was done without IV contrast enhancement. There no prior exams for comparison. The ventricles and extra-axial spaces are normal for age. The midline is not shifted. There are no regions of abnormally increased or decreased attenuation. There is no intracranial hemorrhage, mass, or mass effect. The bony structures are appropriate for age. The visualized paranasal sinuses and mastoid air cells are clear. Impression: Normal unenhanced CT scan of the brain. DICTATED: (10/16/2006 21:13) TRANS: (PSC/PS) ON: 10/16/2006 21:16 INTERPRETED AND REVIEWED BY: DOUGLAS J MARTIN, MD ELECTRONICALLY SIGNED: 10/16/2006 21:16 To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful interpretations. Accordingly, if the clinical team is in search of answers to specific questions, please include your questions(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Page created: Wednesday, November 29, 2006 2:18 PM For: JRIPOR Too of Page https://netaccess2.smshealthconx.netIPOMB-NTAP-1I webcfch.exelPRD/2?KEY=PT0001INV... 11/29/2006 Rudick, April Sex:F BD:02/18/1980 SCAPULA - RT DET View PACS Image VIEW ***Final Report*** SEIDLE RADIOLOGY DEPARTMENT PROCEDURE: SRD - 1227 - SCAPULA RIGHT PROCEDURE DATE: Oct 20 2006 3:56PM ACCESSION#: 5492757 Print this Page MR#:185603146 Oct 20, 2006 15:56 Exam: Right scapula, 2 views at 1548 hours History: motor vehicle accident October 16, 2006 Result: There are no prior studies for comparison. There are no fractures or other bony abnormalities. The visualized joint spaces are well-maintained. The overlying soft tissues are normal. Impression: Normal right scapula. DICTATED: (10/20/2006 16:02) TRANS: (PSC/PS) ON: 10/20/2006 16:28 INTERPRETED AND REVIEWED BY: BARBARA G. BRONITSKY, M.D. ELECTRONICALLY SIGNED: 10/20/2006 16:28 To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful interpretations. Accordingly, if the clinical team is in search of answers to specific questions, please include your questions(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Page created: Wednesday, November 29, 2006 2:18 PM For: JRIPOR Top of Page https://netaccess2.smshealthconx.net/POMB-NTAP-II /webcfch.exelPRD/2?KEY=PT0001INV... 11/29/2006 MECHANICSBURG FAMILY PRACTICE CENTER 122 South Filbert Street Mechanicsburg, PA 17055 717 795-6900 717 795-6955 Fax January 18, 2007 RE: RUDICK, APRIL DOB: 02/18/1980 Dear Mr. Lutz: PINNACLEHEALTH 1 am dictating this letter on behalf of April Rudick to. give you some information as far as her treatments here in this office. Patient has been evaluated by me four times. Patient was initially seen on the 191h of September for headaches. Patient then followed up on the 20`hof October as a follow=up for an evaluation of shoulder pain that happened as a result of a motor vehicle accident. Patient then returned again on the 14th of November and then again on the 11 th of January. Patient's condition seemed to be as a result of the motor vehicle accident that she had in October. My diagnosis was simply shoulder pain. I believed it was secondary to just a muscle strain and it was not internal damage to the shoulder, nothing more specific than that. Patient was given a prescription of muscle relaxer and referred to physical therapy initially, Patient continued with the physical therapy. Patient had seemed to be doing relatively well. At her second visit she was put in a shoulder sling to see if it took some tension off the shoulder and see if it would rest a little bit more, Patient did not seem to be improving and has been doing the physical therapy to try to help it. Patient did follow-up again in January with continued shoulder pain. My prognosis for this patient is excellent. I think this will eventually go away, with enough time and rest. My estimate on the cost of future treatment would probably be less than $1,000. 1 doubt that she is going to require much treatment in the future, maybe some more physical therapy and maybe an occasional muscle relaxer, but I do not believe this is going to be a long-term medical problem. If you have any further questions, do not hesitate to contact me at 717-795-6900. Sincerely, -- JAMES THOMPSON, III, MD ,/a d c: File D#: 2049593 MECHANICSBURG FAMILY CARE RUDICK, APRIL DOB: 02/18/1980 SS#: 185-60-3146 06/14/2007 S: Chief Complaint: Shoulder pain, urinary tract infection. History of Present Illness: Patient presents today stating that she has got this pain with intercourse that she noticed about three weeks ago. Patient states that she does not really have any dysuria or hematuda or notice any blood in the urine but she does notice that she has got this discomfort when she has intercourse. Has not noticed any vaginal discharge. Does seem to think that her symptoms improved a little bit when she used over-the-counter Monistat. Patient also complains of significant shoulder pain that seems to be aggravated when she lies down. Does not really notice it throughout the day. She states that she noticed it a couple of weeks ago when she was flying a kite and she was constantly using her right arm and that seemed to strain it. Past Medical History: Positive for migraines and hyperiipidemia. Social History: Patient is a smoker. Counseled to quit. Review of Systems: Denies any fevers, chills, sweats, shortness of breath, lightheadedness, dizziness, palpitations, leg swelling, visual changes, headaches, weakness and fatigue. Remainder of review of systems negative. O: HEENT: TM's were normal. Sinuses nontender. Neck: No adenopathy. Heart: Regular. Lungs: Clear. Abdomen: Soft. Extremities: Right shoulder range of motion within normal limits. Patient has no tenderness over the joint itself. Patient does have some tenderness over the bicipital tendon. Patient has some pain over the rhomboid muscle in the back. A/P: 1. Shoulder pain. Suspect this is a rhomboid muscle tear and perhaps maybe even a little biceps tendonitis and maybe a combination thereof. Will treat with Naprosyn 500 mg, one tablet po bid. Recommended heat, rest, perhaps physical therapy if the symptoms continue. Patient does not want it at this point in time. 2. Urinary tract infection. Patient does have a positive UA with large white blood cells in the urine. Will treat with Bactrim DS, one tablet po bid. There is the possibility though that this could be a yeast infection that is causing the white blood cell count. Will go ahead and send off a urine culture and follow up prn. PATIENT NAME: April Rudick DD: 06114/2007 XS OMPSON, III, MD DT: 06/19/2007 5:32 P/ttf D#: 2151140 Fa PINNACLEHEALTH FAMILY CARE RUDICK, APRIL DOB: 02/18/1980 SS#: 185-60-3146 04/24/2007 S: Chief Complaint: Migraines. History of Present Illness: Patient presents today really without any significant complaints. Here for a migraine follow up. Patient had a really severe migraine recently and she did not go anywhere for it. It lasted three days and did not clear up. The Relpax did not seem to work. She was vomiting almost continuously with it. Patient did not seem to address that issue very well. Patient states that it is cleared up at this point in time but her headache seemed to be entirely different this time. She had a lot more nausea associated with it. Seemed to be much more debilitating than the usual headaches that she had gotten in the past. Past Medical History: Positive for migraines. Past Surgical History: Negative. ALLERGIES: NO KNOWN DRUG ALLERGIES. Meds: None. GYN: GOPO. Patient has had no sexually transmitted disease in the past. Social History: Patient is a half pack per day smoker. Married. Drinks alcohol one to two per month. Caffeine, three to five per day. Family History: Maternal grandmother breast cancer and heart disease and diabetes. Review of Systems: Denies any fevers, chills or sweats. Had had nausea. Had photophobia. Had severe headache. Had weakness associated with the migraine. Patient's remainder of review of systems negative. O: HEENT: TMs were normal: Sinuses non tender. Neck: No adenopathy. Thyroid: No nodules. Carotid: No bruits. Heart: Regular. Lungs: Clear. Abdomen: Soft. Extremities: No edema. Pulses 2+. Neuro Exam: Cranial nerves 2 through 12 were intact. Romberg was negative. Cerebellar testing was normal. Muscle strength upper and lower extremities was 5/5. A/P: 1. Migraines. Treated with Relpax. Will continue with that. Seems to respond very well except for this one headache. I am concerned about this one headache. Concerned that possibly this was a reflection of something more sinister. Certainly the headache was very different than her usual migraines. As a result, will go ahead and refer patient for an MRI of the head just to make sure that we are not missing some sort of an aneurysm that had a sentinel bleed and then cleared. 2. Hyperlipidemia. Patient is going to work on her diet and continue with that. Will check a lipid panel and hepatic panel prior to visit and follow up in six months. PATIENT NAME: DD: 04/24/2007 DT: 04/27/2007 D#: 2115236 April Rudick 5:11 P/ttf ES THOMPSON, III, MD i AGE: c2SUBJECTIVE: YES NO SORE THROAT Ter ? / FEVER ? EAR PAIN B' ? NASAL CONGESTION ? kr POST NASAL DRAINAGE ? B' SYMPTOMS PRESENT FOR-?-DAYS HOME TREATMENTS ALLERGIES: F-4 I OTHER HISTORY: g)cp r" OBJECTIVE: NORMAL R ALAPREARANCE p/ ?7 TEMP II? TM'S p' NOSE ? CONJUNCTIVA E SINUSES THROAT ? NECK/NODES ? LUNGS HEART ABDOMEN p/ ASSESSMENT: YES NO MYALAGIAS .f ? COUGH ? HEADACHES p' ? FACIAL PAIN ? ,1' SPUTUM Z ? SMOKER ,0' ? SIGNIFICANT FINDING la-aroq PLAN: atient information received. ? ?' %??" tG?iZC?Z? L?J ???-G?'?` Ste-effects of prescribed medications discussed. Eg-P&jint verbalized understanding. ED-'-all if worse or not improving. Health Care Provider Signature: ?''?(?.?-t.? I?VL,ft1i k.?l:7llti4?- Family Care or Mechanicsburg 122 South Fibert Street Mechanicsburg, PA 17055 PINNACLEHEALTH (717) 795.6900 PROGRESS NOTE FOR URI Form 5046-22 (03/06) MR (InD) 2 Patient Name: LCIA, TV-t>LC,AC- Social Security #: Z.- t E5 - 8? Page #: DATE: 3 -2-8- (51 AGE: U? DATE: Chief Complaint: { 12, ti e C L- l4P h 4,0 L.Oc J '-T 1\ Cr C o, i? r ta (? V4? - i' ik+ SUBJECTIVE: YES NO l V YES ? NO Location "(,L vo ? o ? c b ence Trauma/ io . Duration % -' Nausea/Vomiti g ? Fever/Infection Stiff Neck - ?-tsUtt- ? a ? Sensitive to Light/Sound ? Excessive Malaise G N ? ? ?- E Perspiration ? euro) Prodrome(Visual, I, .. Paresthesia or Weakness ? '?. Assoc with Stress ? ?- Nasal Congestion ? Assoc with Straining ? Nature of Pain p--kW r s , gc(ti,3 Pain Scale a,k a-F S Home treatments/success Ik t 12 x s rr. Other History: Objective: (Y = Normal, Describe Abnormal) Prior History (Age at onset) eIG ssi col 1f'1 t tue,? Family History Medications, Ca#o ne, Nicotine, E*, As ine (Recent D/C Drug) tdrA.,, Q. trac afar-c ay LZA-&- fin. e I ( c1 a-odal- 'r, stn c.` -r J iio? A^ -f kc- e- General Apperance:V-P 60 ;W'WX? OBJECTIVE: TEMPOIT),BP t1 v Temporal Arteries Temporo Mandibular Joint HEENT/Sinuses Fundoscopy Neck Skin (Rash) Neuro Exam Gait Cranial Nerves Cerebella Sensation Motor DTRs ASSESSMENT: NORMAL SIGNIFICANT FINDING 2 llR?tl gyn.: ( rl:? S-l...tTd to ue l J t{/15lGn +W, NokrC-1 SPA -y? PLAN: Cf 14 (b Z C ys? `? C C ltiF(`{1SS 8J 0'. Patient information received. Side effects of prescribed medications discussed. Patient verbalized understanding. Call if worse or not improving in t days. av> PINNACLEHEALTH Health Care Provider Signature: Patient Identification MECHAMCSBURG FAMILY PRACTICE CENTER 122 South FbeR Street MKhw sNn. PA 17055 (717) 795-6900 PROGRESS NOTE FOR HEADACHE A 0A )-/6 Patent Name: L t ?s C- Birthdate: 9-t O O Page #: Form 5046-141 (3198) 2 06/18/2007 PinnacleHealth Hospitals • 15:05 James A. Piper, M.D., Medical Director Harrisburg, PA Pt. Name: RUDICK,APRIL Pt. Phone: 7176911867 Age/Sex: 27Y F DOB: 02/18/1980 Hosp. No.: 185603146 Account ##: 450426824 Loc.: PH FAMILY CARE MECHANICSBURG Ordering Physician H75919 COLL:-06/14/2007 16:00 REC: 06/14/2007 22:10 Dr. THOMPSON,JAMES III URINE CULTURE SPECIMEN DESCRIPTION CLEAN CATCH MIDSTREAM URINE SPECIAL REQUESTS PERFORMED AT HBG HOSP DIRECT EXAM SCREEN TEST NEGATIVE. NO GRAM STAIN PERFORMED. CULTURE MIXED CULTURE.OF 6 OR MORE ORGANISMS ISOLATED IN THIS CULTURE. CONTACT MICROBIOLOGY FOR ANY ADDITIONAL WORK-UP. 1,000 - 9,000 CFU/ML STREPTOCOCCI, BETA HEMOLYTIC GROUP B (IF THIS PATIENT IS PENICILLIN ALLERGIC, PLEASE CONTACT MICROBIOLOGY WITHIN 4 DAYS FOR SUSCEPTIBILITY STUDIES.) CALLED REPORT TO OFFICE (JANET GROVER) 6/18/07 @ 1100 ANN REPORT STATUS FINAL 06162007 Date: - !- o =?rd deb L e r ' ar reviaw r, %,kv, r' der {?H?)'3-WrMeti Mate --.......... J( 1`t . p=r D? .tated no+i ? ?e Note "" - 2 t101 Referrkig t't? D . r. ee i RUDICK,APRIL END OF REPORT PAGE 1 4 O6'/17/2007 PinnacleHealth Hospitals 07:05 James A. Piper, M.D., Medical Director Y Harrisburg, PA Pt. Name: RUDICK,APRIL Pt. Phone: 7176911867 Age/Sex: 27Y F DOB: 02/18/1980 Hosp. No.: 185603146 Account #: 450426824 Loc.: PH FAMILY CARE MECHANICSBURG Ordering Physician H75919 COLL: 06/14/2007 16:00 REC: 06/14/2007 22:10 Dr. THOMPSON,JAMES III URINE CULTURE SPECIMEN DESCRIPTION CLEAN CATCH MIDSTREAM URINE SPECIAL REQUESTS PERFORMED AT HBG HOSP DIRECT EXAM SCREEN TEST NEGATIVE. NO GRAM STAIN PERFORMED. CULTURE MIXED CULTURE OF 6 OR MORE ORGANISMS ISOLATED IN THIS CULTURE. CONTACT MICROBIOLOGY F 7u?TV nnnTTTr)NAL WORK-UP. ?TREPTOCO MOLYTIC GROUP B (IF THIS PATIENT IS PENICILLIN ALLERGIC, PLEASE CONTACT MICROBIOLOGY WITHIN 4 DAYS FOR SUSCEPTIBILITY STUDIES.) REPORT STATUS FINAL 06162007 JUN 18 20 Al, 6- 9?3 c" RUDICK,APRIL END OF REPORT Date: ' o 2 ILL Call or send NL Lob Letter Review on RN. Inform Pt. per Handwritten Note Inform Pt, per Dictated Note See Progress biota Qvpy-fo Referring M.D. Dr. .,..?. ad e PAGE 1 12-13-06; 8:45AM;FMC of D' sbur9 ;7174329296 Date . ,/ IN-HOUSE LAB REQUEST TimeStaff Practitioner Patlent narnp SS# Urinalysis Color Appearance Glucose Bilirubin Ketones Specific Grav. JdJ?. Blood PH Protein `-' Urobilinogen Nitrate Leuko cyte5 fifticro4cople exam WBC RSC - Epithelial Glucose (74-1 is mb/DL) Hemoglobin `W aN 12.8-16.6 GlDL) (Female 11.7=15.1 G/DL) Hemoccult Urine Pregnancy Rapid Strep Mono PPD KOH Wet prep- Fern Test. . Nitrazlnq.. . Pra"tiorier's Bacteria ` Other ? `•.,ta. ..•x:•• Ewa. .? ... • ? !? • cc ^? aa>• aa., .. ... ?.• :vG,w?.: s ? "lam S41Lp M r',-- CSSURG FAltliL:t` C' 7i C'E 1.-2 SOUTH FILBERT \4ECHANICSBURG, F'A 1Z-73-06; 8:45AM;.FMC of D' sburv. ;7174329296 IN-HOUSE LAB REQUEST Date 3 [2,&1 n Time a S^ Staff Kr Practitioner F atien# nart?e!'? L K?? C?L _ SGT Urinalvsis Color Appearance Glucose Bilirubin Ketones Specific Grav. Blood pH Protein Urobilinogen Nitrate Leukocytes Microscopic enm WBC Glucose (74-11 B MG/DL) Hemoglobin (Mala 12.8-16.6 G/DL) (Female 11.7=15.1 G/DL) Hemoccuit Urine Pregnanc Rapid Strep Mono PPD KOH Wet prep Fern Test _ Nitrazinea . RB C Practitioner's Initia141 Epithelial IME"HAWSSURG FAIlL 'T 122 SOUTH FiLBE i' ;.TK r f-T k1EGHAN10SBURG, PA 17035 B acteria ••• M.Y.` ?O:CYL 2{:• y?7GV "Yn- , Other Ara 7 03/07/2007 PinnacleHealth Hospita-- 00:25 James A. Piper, M.D., Medical Director Harrisburg, PA Phone: (717)782-5564 Fax: (717)782-5958 Pt. Name: RUDICK,APRIL Pt. Phone: 7176911867 Age/Sex: 27Y F DOB: 02/18/1980 Location: SEIDLE OUTPATIENT Hosp. No.: 185603146 Account #: 270219409 Dr. THOMPSON,JAMES III PINNACLEHEALTH FAMILY CARE MEC 122 S FILBERT STREET MECHANICSBURG, PA 17055 Ordering Physician T38853 COLL: 03/06/2007 10:57 REC: 03/06/2007 10:59 Dr. THOMPSON,JAMES III LIPID PANEL CHOLESTEROL FOR LIPO * 227 [0-200] MG/DL TRIGLYCERIDE 94 [<200] MG/DL HDL CHOLESTEROL 42 [29-89] MG/DL LDL (CALC) * 166.2 [0-130] MG/DL VERY LO DENSITY LIP (CALL 19 MG/DL RISK FACTOR LIP (CALL) 5.4 RISK FEMALE MADE 1/2 AVERAGE 3.3 3.4 AVERAGE 4.4 5.0 2X AVERAGE 7.0 9.5 3X AVERAGE 11.0 24.0 D? Oate: -S NL Cali or send NL Lab Letter Review on R.V. Inform Pt. per Handwritten Note Inform Pt. per Dictated Note See Progress Note Co Referring M.D. Dr. 4??* ?/-' / RUDICK,APRIL END OF REPORT PAGE 1 28 A/ LJ/ L. V V I / V RE: RUDICK, APRIL 14 S. Washington Street Mechanicsburg, PA 17055 DOB: 02/18/1980 SS#: 185 60 3146 DATE: APS#: RY 04/25/2007 APR 2 4 2007 STUDY: m #?? MRI of the brain REFERRING PHYSICIAN: James Thompson, MD CLINICAL HISTORY: 27 year old woman status post MVA 10-2006. Complaint of persistent severe headache. PULSE SEQUENCES: 3 Tesla; T1 sagittal; FLAIR, T2, T1, DWI axial COMMENTS: There are no prior studies for comparison. Reference made to the report of a normal head CT performed at Harrisburg CT department dated 10-16-2006. There is no evidence of diffusion signal abnormality to suggest recent infarction. No other acute intracranial abnormality is noted. The ventricular system, gray white matter differentiation and brain parenchyma are normal. Normal physiologic flow voids are seen in the intracranial vessels. The cerebellopontine angles are within normal limits. Incidental note is made of a small focal area of increased FLAIR signal intensity in the medial left cerebellopontine angle without corresponding T2 or T1 signal abnormality. This finding is only seen on one image, axial series 5 image 5, and is thought to most likely be related to artifact. The cerebellar tonsils, pituitary gland, orbits, skull and scalp are normal. There is a small mucosal retention cyst in the inferior medial right maxillary sinus. The remainder of the visualized paranasal sinuses and mastoid air cells are clear. CONCLUSION: Normal unenhanced brain MRI. Mild chronic sinusitis change in the right maxillary sinus. Thank you for referring this patient to us. RH /mgl Sincerely, Rhondey I. O. H 9 --ow. R eview o fi.V? 4i ma`y?.tak?ir Inform pt . =-® inform pt p r o4"rGryrit e'n f o See I?r er Dlcfatad Note ogre"; Note r?`? -?.....®. . C Cot "r PINNACLE HEALTH MEDICAL SERVICES Patient's Name HEALTH MAINTENANCE TESTING _ Date Performed Complete Physicals: e,1- /41.e,4w/ Breast Exam: ) PAP/Pelvic: Mammogram: Digital Rectal Exam: Stool for Occult Blood: Proctosigmoidoscopy: Testicular Exam: _ PSA: Cholesterol Screening: G L -6-02 Other: -7- PATIENT EDUCATION Seat Belts Skin & Oral Exam Breast !Testicular Self-Exam Exercise/Nutrition Stressors/Violence Sexual Issues Mobility/Falls Living Wills Tobacco/Drug/Alcohol Oth .- ?-? l iz pp(b cs Form 1531-23 (02/01) MR (PM) 30 Date Dose fC Freq Amt/Refill a i J Date Dose Freq Amt/Refill Date Dose Freq Amt/Refill Date Dose Freq Amt/Refill Date Dose Freq Amt/Refill Date Dose Freq Amt/Refill Date Dose Freq Amt/Refill Date Dose Freq Amt/RdU P?abxt kko coon Patient Name: lit t Iw a> PI NNACLEHEALTH MEDICATION LISTING Forth 548-81 (31M MR Social Security #: Birthdate: i Patient Name: PINNACLEHEALTH Social Security #: Medical Services Birthdate: VITAL sIGNS FLOW SHEET. . . Date l3- IU6 Height Weight 15 L Temp 911E BP/arm Io L? Pulse (a Resp. a L Vision/Note "C> CAA 0k5T- Cats e, CA? nl PCP ? s Nurse Vtv F 0 ? w-7 GI V-7 y • -7 t4 1`01-7t! :z N. /25& I 1 (o 9? 9' 7 l / RA e V T eY . 1 o) V7- T .3-t-g- F b Form 1531-98 (02JO1) PM 3 MECHANICSBURG FAMILY MEDICINE CENTER RUDICK, APRIL DOB: 02/18/1980 SS#: 185-60-3146 01/1 12007 CC: Shoulder pain. S: The patient presents today without any significant complaints. Here for routine evaluation of her shoulder. The patient needs a statement basically stating that she has no restrictions and can go back to work without complication. The patient was in an auto accident and her shoulder was injured. However, at this point in time she states that she is really not having any discomfort. Past medical history is positive for migraines. Social history: The patient is a smoker. The patient was counseled to discontinue smoking. Review of systems: Denies any fevers, chills or sweats. Denies any shoulder pain. Denies any numbness or tingling, weakness, fatigue. Remainder of review of systems negative. O: HEENT: TMs are normal. Sinuses nontender. Neck: No adenopathy. Thyroid: No nodules. Carotid: No bruits. Lungs: Clear. Heart: Regular. Abdomen: Soft. Extremities: No edema. Shoulder range of motion within normal limits. The patient has no pain with abduction. Has no palpable tenderness over the shoulder. No pain over the rhomboid. The patient has no bicipital tendon tenderness. A/P: 1. Shoulder pain. Appears to have completely recovered. No pain on exam today. The patient can return to work without restrictions. 2. Nicotine addiction. The patient was given a prescription for Chantix and told to quit smoking. 3. Migraines. The patient has a followup scheduled in another 4-5 months. PATIENT NAME: DD: 01/11/2007 DT: 01/15/2007 D#: 2044130 RUDICK, APRIL 3:35 P/Ijk yff THOMPSON, III, MD 3 MECHANICSBURG FAMILY MEDICINE CENTER RUDICK, APRIL DOB: 02/18/1980 SS#: 185-60-3146 11/14/2006 S: Chief Complaint: Shoulder pain. History of Present Illness: Patient presents today with pain in the right shoulder. Patient notes that she continues to have that discomfort. Has been going to physical therapy to try and help it. Patient was in a motor vehicle accident that seemed to start it. Does not seem to be getting markedly better. Back pain, physical therapy has worked wonders for that. Patient states that she continues to have the migraines but she has only had four migraines in the last two months. States that the Relpax has generally worked for them and generally within an hour to an hour and a half the headaches are gone. Very happy with that. Would like the headaches to completely leave but that seems to do the job for her. Past Medical History: Positive for migraines. Social History: Patient is a smoker, half pack per day. Review of Systems: Denies any fevers, chills, sweats, shortness of breath, lightheadedness, dizziness, palpitations, leg swelling, visual changes, headaches, weakness and fatigue. Remainder of review of systems was negative. O: Neck: No adenopathy. Thyroid: No nodules. Heart: Regular. Lungs: Clear. Abdomen: Soft. Extremities: No edema. Neuro Exam: Cranial nerves 2 through extremities 5/5. 12 were intact. Gait was normal. Muscle strength upper and lower A/P: 1. Migraines. Will treat patient with Relpax. Seems to be doing relatively well with it. Reluctant to go on any kind of preventative medicine at this point in time. Will continue to monitor. Will have the patient follow up in six months. Will keep a log of the number of headaches that she had and re- evaluate six months from now. 2. Shoulder pain. Will put the patient in a shoulder sling and see if that helps take some of the tension off and give it time. Recommend rest, continue to follow with physical therapy, continue to put her arms through range of motion so she does not develop a frozen shoulder but will see if trying to rest the shoulder helps it. Patient to follow up pm. - " PATIENT NAME: April Rudick DD: 11/14/2006 DT: 11/17/2006 6:47 P/ttf D#: 2007103 THOMPSON, III, MD 73 4 MECHANICSBURG FAMILY MEDICINE CENTER RUDICK, APRIL DOB: 02/18/1980 SS#: 185-60-3146 10/20/2006 S: Chief Complaint: Shoulder pain. History of Present Illness: Patient presents today really without any significant complaints other than the fact that she was in a motor vehicle accident. Patient states that she was seen over at First Place after the motor vehicle accident. Was sent to Harrisburg Hospital for a CT scan of her head. She was having a little bit of blurred vision. Patient notes that she was doing better and actually went back to work on Wednesday and worked half days Wednesday, Thursday and Friday this week. However, patient states that she has got significant pain on the right side from her scapula down to her lower back. Just has trouble really sitting. It becomes excruciating after she sits for more than about thirty minutes in a row. The only way she really feels comfortable is to lie down. Past Medical History: Positive for migraines. Social History: Nonsmoker. Review of Systems: Denies any fevers, chills, sweats, shortness of breath, lightheadedness, dizziness, palpitations. Patient admits to shoulder pain. Admits to back pain. Denies any numbness, weakness. Remainder of review of systems negative. O: RENT: TMs were normal. Sinuses nontender. Neck: No adenopathy. Thyroid: No nodules. Carotid: No bruits. Heart: Regular. Lungs: Clear. Abdomen: Soft. Extremities: No edema. Pulses 2+. Right Shoulder: Range of motion within normal limits. Patient has palpable tenderness over the scapula posteriorly. Back: Limited range of motion secondary to pain. Patient has significant pain that extends down the lower back and a little bit of spasm of the right paravertebral spinal muscle. Neuro Exam: Muscle strength in the lower extremities 5/5. A/P: 1. Shoulder pain. Will go ahead and check an x-ray of the right scapula. Will refer patient on to physical therapy. Will start the patient on Flexeril 10 mg, 1 tablet po tid, dispense #15. Patient counseled not to drive or work while she is on this medicine. Follow up prn if not getting better but will get her to physical therapy and see if we can get things turned around for her. 2. Health maintenance. Patient to get a lipid panel done some time at her convenience. Patient will get a flu shot at work. ,. r' PATIENT NAME: April Rudick DD: 10/20/2006 ;,-? MES THOMPSON, III, MD DT: 10/24/2006 6:16 P/ttf' D#: 1990751 Discharge Summary 1/5/07 Re: April Rudick DOB: 2/18/80 Dear Dr. Thompson, Thank you for the referral of April Rudick to Drayer Physical Therapy Institute for physical therapy for the diagnosis of LBP. She was seen in our facility for 33 visits between the dates of 10/23/06 and 1/5/07 for therapy consisting of functional activities, strengthening, neuro re-ed, posture, manual therapy, ROM, mobilization, HEP, spine stab, McKenzie, job skills, traction, infrared, e- stim, hot/cold Initially, April presented with: - Pain - Function -ROM - Poor posture - Inability to work at this time At the time of discharge, she had attained: - Pain level 0-1/10 cervical region, 0/10 lumbar pain, at worst 3/10 with sitting - Right shoulder AROM WNL - Lumbar spine ROM WNL with exception of 25% restriction with lumbar extension - MMT UE essentially 515 scapular musculature right 4+15, bilateral LE essentially 5/5 - Independent HEP - Returning to pre-morbid level of function April made good progress with physical therapy. 90% of established treatment goals were met. Goals were not met due to severity of dysfunction. She was discharged due to returning to normal, premorbid functional status. April was discharged on 1/5/07 with instructions to continue with functional UE strengthening, scapular stabilization, core stability and cervical isometrics. Instructions in proper body mechanics and posturing given. Thank you again for the opportunity to provide therapy services to April Rudick. Please feel free to contact me with any questions or concerns regarding her care. Sincerely, Therapist: Sh&Bronson DPT, ATC, CGFI, Cert MDT License: PTO 16294 Tx: JK Date: 1/5/07 t Gsta. {i•f? 4t:;tl ?iF fit:;.: •.s ff'l.. s'...to?i 1_t R? EeW an R,V, ._. ?... Inform Pt, ,per Handwritten- .._. Inform Pt, rer Dictated W+e See ProgresS, Note Copy to Ref ?r __..._..._ Dr. -? `: , ... . 1 Patient Name: April Rudick Mechanicsburg Center 5275 E. Trindle Road ® Suite 110 ® QJJFanicsburg, PA 17050 ® PRONE, 717-790-9920 ® FAX: 717-790-9923 Pinn of ra rn Patient Name: April Rudick ?a• V Date of Evaluation: 10/23/06 Date of Birth: 2/18/80 Sex: Female Date of Onset: 10/16/06 Diagnosis: LBP Sur ical Procedure: None Referring Physician: Dr. Thompson Date of Sure : NA tnzfitu CerdricaUoit Period cf/ectlpe Dale=: mom: 10/2J/0, Through: 11121/06 l ASSESSMENT: Rationale for the Need for Skilled Therapy Services: Signs and symptoms consistent with LBP, thoracic pain, cervical pain, secondary to muscle spasms, slip MVA. Patient would benefit from skilled PT intervention to decrease pain, improve postural awareness, ROM, strength, and ultimately improve functional abilities. Rehabilitation Potential: Good Objective Problems/Functional Limitations: - Pain - Function - ROM - Poor posture - Inability to work at this time Short Term Objective and Functional Goals: (to be achieved in 2-3 weeks): 1. Decrease pain to 3/10 at worst. 2. Improve trunk Flexion ROM WNL, cervical ROM Flex/Ext WNL. 3. Increase strength of deficits revealed by 1/2 MMT grade. 4. HEP for postural awareness and correction, muscle spasms control techniques. 5. Improve functional abilities for sleeping, sitting, returning to work. Long Term Objective and Functional Goals: (to be achieved in 4-6 weeks): 1. Decrease pain to 1/10 at worst. 2. Improve ROM cervical Rotation WNL, trunk Extension WNL. 3. Increase strength to 5/5 throughout any deficits that are revealed in the future. 4. HEP functional stabilization, body mechanics drills. 5. Return to pre-morbid functional level of lifting, walking, squatting, kneeling, performing basic household chores. Treatment Plan: functional activities, strengthening, neuro re-ed, posture, manual therapy, ROM, ROM, HEP, spine stab, McKenzie, job skills, traction, infrared, a-slim, hot/cold Treatment Frequency of: 3 times per week / have discussed the above findings, assessment, revised treatmentR Treatment Duration of: 4-6 weeks outcome; with the patient. Heahe is in phytieal/oecupational therapy services. agrees to Therapist's Signature: 06 "I License: PT016294 Date: 10/23/06 Sh Bronson DPT, ATC, CGFI, Cert MDT Certification: 1 hereby certify that rehabilitation services arc medically necessary for the above mentioned patient. 1 also understand that my signature signifies agreement with the initial Ping of litre, including the estimated frequency and duration, ar established by the licensed therapist, and this initial Plan sfCare supersedes the instructions outlined on the Prescription that initiated rehabilitation services. Physician's Comments: Physician's Signature: Tx: jK Date: Ci ' ?J Patient Name: April Rudick ne , n rn _ _ __ _ MechtsnieaUura Cp.ntvr A9.7r F. T14-11.T-?-d as Q,.:+.. I, n %A`--1_-_-- • FyO? DRAY Elf Physical Therapy Institute Leadmg the Way to Goad Health Initial Evaluation Patient Name: Aril Rudick Date of Evaluation: 10/23/06 Date of Birth: 2/18/80 Sex: Female Date of Onset: 10/16/06 Diagnosis: LBP Surgical Procedure: None Referring Physician: Dr. Thompson Date of Sure : NA SUBJECTIVE HISTORY: Subjective History: Ms. Rudick was referred to Drayer Physical Therapy Institute by Dr. Thompson for evaluation and management of LBP. Patient notes that on 10/16/06 she was involved in MVA when she was rear ended when attempting to merge and looking sharply back over her left shoulder. Patient notes that she had medical imaging that included x-rays and a CAT scan, that were both negative. Patient notes she just feels severe muscle spasms along the right side of her neck and shoulder blade, thoracic nb area and down to her right low back. Current Complaints: Right LBP > right shoulder pain. Function: Patient notes that she always has difficulty sitting >30 minutes, walking >20 minutes, performing work required duties primarily due to sitting and recreational activities. Frequent limitations with sitting < 10 minutes, standing in one position > 1/2 hour, walking > 10 minutes, performing household chores such as cooking and cleaning, difficulty bending over to pick up objects, sleeping, changing positions while sleeping, difficulty looking and carrying objects, dressing, grooming, attending to personal hygiene. Occasionally has difficulty getting out of a chair, standing < 10 minutes, getting out of a car. Pain Rating: Current: 5 /10 Worst: 8 /10 Best: 4/10 Patient notes she feels better standing or laying flat on her back, feels worse with sitting and bending. Occupation/Work Status: Patient is a Wick program manager, currently not working, unable to sit. Slated to return to work next week if able. Social History/Interests: None. PMHx: Previous MVA without significant injury. Medical Precautions/Contraindications: None. Medications: Flexural, decreases symptoms for -2 hours then pain returns. Patient's Goals for Therapy: To decrease her pain and to be able to return to work. OBJECTIVE FINDINGS: Observation/Inspection: Patient stands during subjective history intake due to being uncomfortable in sitting. Patient presents with no significant lateral shift, but maintains a slightly flexed and rotated right positioning in standing. Palpation: Patient has significant tenderness to touch along lumbar thoracic and cervical paraspinals on right, as well as the upper trap, middle trap, and lower trap on the right. Patient has significant increased resting muscle tension with this corresponding musculature also. ROM: Cervical ROM: Flexion minimally restricted with pulling along right upper trap; Extension moderately restricted with pain centrally along C5-C6. RROT WNL. LROT slightly limited. RSB WNL. LSB moderately restricted with contralateral tightness and pain. Lumbar ROM: Flexion severely limited with increased right LBP. Extension slightly decreased with no affect on symptoms. Right shoulder AROM grossly WFL all directions, but produces increased pain. Strength: MMT deferred at this time. Patient Name: April Rudick Mechanicsburg Center 5275 E. Trindle Road ® Suite no m Me Y urg, PA 17050 a PHONE: 717-790-8QM ? w- '!S -r - 11- Special Tests: Spring testing for cervical instability and thoracic instability, lumbar instability negative at all levels. SI Joint palpation testing negative. Patient has provocation of pain,with functional movements, such as attempting to do a squat and lift maneuver, as well as sit to stand. The above b jormatian represents all signlfuant ra6jmetlve and obje ive fmdings. Please refer to the andwed Plan ojCam for my asx=ment, treatment goals, and trealment plan. Please sign and return the Plan of care to Drayer Physical Therapy. Ifyou wish, make a copy for records. Thank you jor this referral. I %W keep you informed of any changes in the pade t s status or the treatment plan. Therapist's Signature: License: PT016294 Date: 10/23/06 Shane ronson DPT, ATC, CGFI, Cert MDT Tx: JK' Patient Name: April Rudick 739 D R AY E R® Physical Therapy Institute Leading the Way to Goad Huth PrnarPRC R,- „r„-.4-Patient Name: Aril Rudick Date: 12/20/06 Date of Birth: 2/18/80 Sea: Female Date of Evaluation: 10/23/06 Diagnosis: LBP Date of Onset: 10/16/06 Referring Physician: Dr. Thompson Total # of Visits: 26 # Cx: 1 # NS: 1 Surgical Procedure: None Date of Sure : NA Re.-e=t ccrrifon Period E ectfi)e Date: From: 12/20/06 Throe h: 1/18/07 SUBJECTIVE STATUS/PROGRESS: Current Complaints/Symptoms: Patient reports a 90% improvement in her current LB pain/functional status. Patient notes intermittent achiness right low back. No radicular symptoms are noted. Exacuvation of LBP is noted with prolonged sitting > 1 hour or carrying >51bs. Patient continues to note constant achiness right scapular region. Aggravation of symptoms with increased UE repetition or duration of activity. Improvement of Prior Functional Limitations: Patient able to wash tables at work and clean dishes. Patient is also able to scrub tub. Improvement noted with overhead function. Pain Rating: Best: 2/10 Worst: 5110 Current: 3/10 Best 0/10 Worst 4/10 Current 1/10 LB OBJECTIVE AND FUNCTIONAL STATUS/PROGRESS: Current Objective Status: • Tenderness palpable right interscapular region and mod tightness right UT. • Right UE AROM: Right shoulder flexion 0-173° Q 13°), EVER and Abd WNL. • Lumbar AROM: - Flexion to the floor (noting bilateral hamstrings/calf tightness at end range), 25% improvement - Extension 50% restricted (50% improved) - SB (L) 0-23°; (R) 0-26° - Rotation (L) 0-22° (T 12°): (R) 0-22° (T 10°) Left Hip Flex 515* 515* Hip Abd 4+/5/5* 515* Hip Ext 4+1515* (•j LB.?) 4+/5/5* (r LBP) Knee Flex/Ext 515 515 DF/PF 5/5 5/5 Denotes mcrease 1/2 m grade Right Left Shld Flex 4+/5/5* 515* Shld Abd 4+/5/5* 515* Shid 1R 515 515* Shld ER 515* 515 Latissimus 4+/5 4+/5 Upper Trap 515 515 Lower Trap 4/5 4+/5 Middle Trap 4/4+/5 4-15 Current Functional Limitations: Patient reports increased scapular pain with laundry activities (i.e. folding, sorting out laundry and transferring clothes from washer to dryer. Limitations are also noted with prolonged sitting >2 hours or carrying objects >51bs and overhead reach >51bs. Patient Name: April -Rudiclc Mechanicsburg Center 5275 E. Trindle Road ® Suite 110 ® kicWrsburg, PA 17050 m PHONE: 717.790-9920 ® FAX: 717-790-9923 ASSESSMENT OF STATUS/PROGRESS: Rationale for Need to Continue Skilled Therapy Services: Patient reports significant improvement in her LBP status. Patient demonstrates gains in bilateral UE and LE strength as well as lumbar ROM and right shoulder AROM values. Functional restriction remains with right scapular, right shoulder function, overhead and with repetitiorL Rehabilitation Prognosis/Potential: Good Updated Objective Short Term Goals (to be achieved in weeks): 1. Decrease pain to 1-2/10. 2. Increase strength to 5/5 in the bilateral UE and scapular region. 3. Independent with HEP. 4. Decrease tenderness right interscapular region. Functional Goals to be Achieved by Next Progress Report (to be achieved in weeks): 1. Increase functional ability to perform laundry restrictions without increase discomfort in right scapular region. 2. Patient to perform overhead reach with 5-61bs with good tolerance. PLAN: Treatment Plan: functional activities, strengthening, neuro re-ad, posture, manual therapy, HEP, a-stim, hot/cold pack. Treatment Frequency of: 3 times per week Treatment Duration of. 4 weeks I have discussed the above findings, nrrerrmant, revised treatment plan, and expeaY outcamer with the patient. He?She v aware ofthe diagnosis and prognosis and volunnarity agrear to continue participation in 1}_ / physhavUorsupational therapy service. Therapist's Signature: ???/ License: PT016294 Date: 12/20/06 Shane Bronson DPT, ATC, CGFI, Cert MDT Re-Cerrificrttion: I hereby certify that rehabilitation service are medically necersaryfor the above mentioned patimL I oleo undarriand that my signature signifier agreement with the Updated Mon of Carr including the artimated frequency and duration, as established by the licensed therapist. I understand this Plan of Care becomes effective on the date noted and remains affective far the dusetion of treatment outlined in the Plan of Ca,a. Physician's Comments: Date: ifr) -dz_ Physician's Signature: Tx: JK Please Refuse this Progress Report to Drayer Physical 77nerapy Patient Name: April Rudick 1 4? PINNACL,EHFAI:TH PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 EMERGENCY DEPARTMENT RUDICK, APRIL RM#: MRN: 185-60-3146 CASE: 00270096439 DOB: 02/18/1980 -, 1 ?'7 ADM: 10/16/200;0 _ CHIEF COMPLAINT: The patient is a 26-year-old female who cLme? eidle Hospital FirstPlace complaining of neck pain, back pain and vomiting. HISTORY OF PRESENT ILLNESS: She was the restrained driver of a car that was hit in the rear-ended about a 1-hour ago. She was jolted but did not hit anything in the car as far as she knows. She had immediate pain in the low back. Then she developed pain in the neck and upper back. Developed blurred vision and vomited x2 in the last 45 minutes. REVIEW OF SYSTEMS: She has migraine headaches. PAST HISTORY: NO ALLERGIES. Medications: She takes birth control pills and Relpax on a prn basis for migraines. She has had no surgeries. Family history of migraines. SOCIAL HISTORY: She smokes a pack of cigarettes a day. She drinks alcohol socially. PHYSICAL EXAM: Well-nourished, well-developed, 26-year-old female who does not appear to be in distress. She is alert and oriented. Affect and judgment are appropriate. Vital signs: Blood pressure 118/70. Pulse 76 and regular. Respirations 18 and not labored. Temperature 98.7. She complains of her vision seeming rather fuzzy but nothing is demonstrable. Pupils react equally. Extraocular movements are intact. Peripheral vision is normal. Cranial nerves are grossly intact. Neurological exam is completely normal. She is tender in the right posterior cervical and right trapezius muscle areas. She has limitation of motion of the neck due to pain. EMERGENCY DEPARTMENT COURSE: In lieu of the fact that she has vomited twice since the accident, she needs to have a CT scan of the head. That is scheduled to be done at Harrisburg Hospital as soon as she can get over there. DISPOSITION: She should go immediately to Harrisburg Hospital for a CT scan and a family member will take her. If it is positive she will go to the emergency department. If it is negative she should use heat on her neck and upper back 4 times a day. She should take ibuprofen 800 mg 3 times a day with food. She ER REPORT ER REPORT ER REPORT COPY FOR: JAMES THOMPSON, III, MD 142 1-0 •20/2006 12:19:3 PM -0 PAGE 1 OF 1 PINNACLEHEALTH System Radiology Imaging Report MR#: 185603146 NAME: RUDICK, APRIL SSN: 185603146 14 S WASHINGTON ST ADM: 000270096439 MECHANICSBURG, PA 17055 DOB: 02/18/1980 AGE: 26Y ORD DR: STAGG, RICHARD D BED: - ORD#: 90001 PTCLAS S: O RAID ATT DR: STAGG, RICHARD D REASON: MVA FUZZY VISION & VOMITING COMMENTS: CALL BACK RESULTS ***Final Report*** HARRISBURG CT DEPARTMENT PROCEDURE: CTS - 0450 - CT BRAIN W/O CONTRAST PROCEDURE DATE: Oct 16 2D06 9:00PM ACCESSION#: 5489224 Exam: CT scan of brain, unenhanced History: MVA, fuzzy vision and vomiting Result: Computed tomography of the brain was done without IV contrast enhancement. There no prior exams for comparison. The ventricles and extra-axial spaces are normal for age. The midline is not shifted. There are no regions of abnormally increased or decreased attenuation. There is no intracranial hemorrhage, mass, or mass effect. The bony structures are appropriate for age. The visualized paranasal sinuses and mastoid air cells are clear. Impression: Normal unenhanced CT scan of the brain. DICTATED: (10/16/2006 21:13) TRANS: (PSC/PS) ON: 10116/2006 21:16 INTERPRETED AND REVIEWED BY: DOUGLAS J MARTIN, MD ELECTRONICALLY SIGNED: 10/16/2006 21:16 C0 t?, }f and E'f?W+ Lab Letter a - ir1#,,; tk1 Ft ? YN 'an4 i?r?`atan Note ifwr I:aiw°sdted Note To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful interpretations. Accordingly, if the clinical team is in search of answers to speck questions, please include your questions(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Study interpretation provided by QUa17tUM Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby noted that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at 1-717-782-3240. 4 PINNACLEHEALTH System Radiology Imaging Report MR#: 185603146 NAME: SSN: 185603146 ADM: 000270100756 DOB: 02/18/1980 AGE: 26Y ORD DR: BED: - ORD#: PTCLAS S: O SRD ATT DR: RUDICK, APRIL 14 S WASHINGTON ST MECHANICSBURG, PA 17055 THOMPSON Ili, JAMES S 90002 THOMPSON III, JAMES S REASON: PAIN POST MVA COMMENTS: ***Final Report*** SEIDLE RADIOLOGY DEPARTMENT PROCEDURE: SRD - 1227 - SCAPULA RIGHT PROCEDURE DATE: Oct 20 2006 3:56PM ACCESSION#: 5492757 Exam: Right scapula, 2 views at 1548 hours History: motor vehicle accident October 16, 2006 Result: There are no prior studies for comparison. There are no fractures or other bony abnormalities. The visualized joint spaces are well-maintained. The overlying soft tissues are normal. Impression: Normal right scapula. DICTATED: (10/20/200616:02) TRANS: (PSC/PS) ON: 10/20/2006 16:28 INTERPRETED AND REVIEWED BY: BARBARA G. BRONITSKY, M.D. ELECTRONICALLY SIGNED: 10/2012006 16:28 To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful interpretations. Accordingly, if the clinical team is in search of answers to specific questions, please include your question(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. a... S.`'f `7 y?1 Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission Is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782- ft DATE / I • ALL.{' mr:c ABd ZMG FAMU PRACTICE CENTER PI1+1NACLEHEALTH 120 South Fmert Street Mechanicsburg, PA 17055 NARRATIVE PROGRESS NOTE Form 5046-D4 MR 14 E- Patient Name Birthdate Page aniern IcifHicaiion t t r, r ?j `( (?'`-"- C3' ? y irrr ?' / / ,fi : ?i. ?:?•? {' := ¢.1 l? - ? i.J - FCC Cj f f 3 ? ` ,, ?p1 ? ?3a F' r -uou jf! J?'? %? ?. f• tp' J G:?.'?,. l.C..?-`t-•?y `' ?CJ C3 ??? r`.? le Who Called Date of Birth 1 SS # I i.9 1 1?IJ Patie Name pate & Time Pharmacy Nam?phone # J 7 M,? P P 1 Covering P vid?r x i e Diagnosis an rt U SIG Message e"t strength OrdemLabslMeds b In;o ! Ash. Time Date 7. By pjged Message Taken By 61 For n 9349-117 (04-) Pk' AMT Refills a.m Time a•m 4 ' E r t r c.v:?1- - c- -- MECHANICSBURG FAMILY PRACTICE CENTER PI N NACLE H EALTH 120 south Filbert Street Mechanicsburg, PA 17055 NARRATIVE PROGRESS NOTE Forth SD46.04 MR iR ?? ahem IdernAwatron ?Patie ame ZC-L / irlhdate 9 t?v Page '^4 September 24, 2007 RE: April Rudick To Whom It May Concern: Mrs. Rudick began physical therapy with us on October 23, 2006 upon referral from Dr. Thompson. She presented with symptoms of low back pain and spasms on the right side of her body secondary to a MVA on October 16, 2006. Patient also complains of not being able to sit, stand, or walk for an average of greater than 15 minutes. She also complains of having difficulty performing work and household duties. At the patients initial evaluation her objective findings were as follows: Pain of 8/10 at its worst Functional disability score of 73% Limited range of motion Poor posture Inability to work With the above mentioned objective findings the patient was given a treatment plan that included functional activities, strengthening, neuro re-education, posture therapy, manual therapy, range of motion, mobilization, home exercise program, spine stab, McKenzie exercises, job skills, traction, infrared, electrode stimulation, and heat. At Mrs. Rudick's November 14, 2006 appointment we did a progress note on here to reassess here functional abilities. At this point in time the patient was found to be able to carry 5 pounds or less at work for a limited amount of time and was now able to lift and reach for a plate. Also, her walking and standing tolerance had improved to about one hour. At that point in time her objective findings were still the same. At patient's December 20, 2006 appointment the patient had another progress note done. At this point in time patient was still able to do previous mentioned tasks and was also now able to do table cleaning, dish washing, and tub scrubbing. Also, improvement of overhead reaching was noted. All objective findings remained the same, but improvement was noted with some. 4J ?h Mechanicsburg Center 5275 E. Trindle Road ? Suite 110 ? etaniosburg, PA 17050 - PHONE: 717-790-9920 - FAX 717-790-9923 At discharge patient had decreased her pain level to 0-1/10 in here cervical region, 0/10 in her lumbar region with in being 3/10 at its worst in a sitting position. Patient also increased range of motion in her right shoulder and lumbar spine area with the exception of a 25% restriction with lumbar extension. The manual muscle test showed much improvement in her right shoulder area at time of discharge. Even though only 90% of the patient's goals were met, the patient was discharged due to returning to premorbid functional status. Hopefully this letter gives you a better understanding of the treatment that was given to Mrs. Rudick while in our care. If you have any questions please do not hesitate to contact me at (717) 790-9920. Thank you very much for your time. Shane Bronson DPT, ATC, CSCS, CGFI, Cert. MDT 4 DRAYER7 Physical Therapy Institute Leading the way to Goad Health 1/5/07 Re: April Rudick DOB: 2/18/80 Dear Dr. Thompson, JAN 9 , 2007 Discharge Summary i i i r Thank you for the. referral of April Rudick to Drayer Physical Therapy Institute for physical therapy for the diagnosis of LBP. She was seen in our facility for 33 visits between the dates of 10/23/06 and 1/5/07 for therapy consisting of functional activities, strengthening, neuro re-ed, posture, manual therapy, ROM, mobilization, HEP, spine stab, McKenzie, job skills, traction, infrared, e- stim, hot/cold Initially, April presented with: - Pain -Function -ROM - Poor posture - Inability to work at this time At the time of discharge, she had attained: - Pain level 0-1/10 cervical region, 0/10 lumbar pain, at worst 3/10 with sitting - Right shoulder AROM WNL - Lumbar spine ROM WNL with exception of 25% restriction with lumbar extension - MMT UE essentially 515 scapular musculature right 4+/5, bilateral LE essentially 5/5 - Independent HEP - Returning to pre-morbid level of function April made good progress with physical therapy. 90% of established treatment goals were met. I Goals were not met due to severity of dysfunction. She was discharged due to returning to normal, premorbid functional status. April was discharged on 1/5/07 with instructions to continue with functional UE strengthening, scapular stabilization, core!stability and cervical isometrics. Instructions in proper body mechanics and posturing given. i Thank you again for the opportunity to provide therapy services to April Rudick. Please feel free to contact me with any questions or concerns regarding her care. i Sincerely, Therapist: Shale Bronson DPT, ATC, CGFI, Cert MDT License: PT016294 Date: 1/5/07 Tx: JK Patient Name: Apia-fl Rudick Mechanicsburg Center 5275 E. T?indle Road - Suite 110 - Mechanicsburg, PA 17050 - FHoNE: 717-790.9930 - FAX- 717- 4 DRAYEW Physical Therapy Institute Leading the Way ro Good hleakh January 8, 2007 To Whom It May Concern: April Rudick was a patient seen at our clinic from October 23, 2006 to January 5, 2007. April was discharged and is able to return to work without restrictions and should continue the home program that she was given. Should you have any questions, please contact me at (717)790-9920. Respectfully, Shane ronson DPT, CSCS, ATC, CGFI, Cert. NOT Mechanicsburg Center 5275 E. T indle Road - Suite ll echanicsburg, PA 17050 - PRmm: 717-790-9920 - 4a-- 717-790.993 1~rn 1 n ?! 7 :_In;mai 0 )RAYER PHYSICA r ;. "E?aU?a L TH ? ERAPY IN ` STI'zUTE ' z asec4 a', MOM ' .? .- f u ? tt ae?Ptocei l rssl5 he t ? s scriDtion CPT I UNITS 59 Description CPT UNITS 59 Description CPT UNITS fal Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 evaluation PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 ial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation-OT 97004 1 '. ce3?ase?4?jnceu a?IPH e?lic ftiiftacl NitY"Regw : Prosthetic Training (ea.15 min) 97761 ysical Performance Test/Meas 97750 Hot/Cold Pack 97010 Electrodes (per pair) A4556 :.E. Functional Drills ea.15 min) Mechanical Traction 97012 Splint: :tryst'P"tds?d"t rEt vt'?tegtilr?,d ? z: E-Slim Unattended 97014 Splint: erapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: arapeubc Procedures (ea. 15 min) 97110 Paraffin Bath 97018 uromuscular Reed (ea. 15 min) 97112 WhidpooUFluidotherapy 97022 - Tradrag ;'' `IUleti icai sn Me»it~ anual Therapy (ea. 15 min) 97140 Infrared 97026 Time In dt Training (ea. 15 min) 97116 Group Therapy 97150 Time Out L assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time luatic Therapy (ea. 15 min) 97113 ,r . w:??IJ?ts ; : , , Total Service Based Time ilf Care/Home Management 1 97535 Wound-Selective < 20SQ. CM 97597 Total Time Based Time j --Z ct >mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units >gnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB TB) LOW BACK PAIN 724.2 objective: Patient's perceived changes/progress toward functional goals: 116? atient's chief complaint: Cher: bjective: Please refer to this patient's flow sheet for details sp, •eatment progression: the specific exercises utilized during today's treatment. GIRTH: -?....?-.- ,ther (Function, Special Tests, Sensation): ssessment: Patient's progress towards functional STG/LTG: )ther: yy2. Ian: -Pr6gress/modify current treatment plan c' -Achieve by next visit / week Brief Re-eval/Progress Report next visit D/C patient Other: -Total # visits s 'herapist Signature License # ?. .:ii?lf3i!CNE?'h1AtV1EN?.'i4DFtESS PATIEN;7VD.AEhii=:Y?IAME ?dG30 4N 0;._. [)A 1 oil RUDICK, APRIL 38 404902 R DICK APRIL 14 745 14 S WASHINGTON ST DATE OF iMj&4idNE„ VECHMICSBURG, PA 17055 2 !8/80 717 91 1867 900 A 0 INSURANCE Ticket! 140096929 PTppc# 40 i FED. I.D. # 75-3050291 ?( )BAYER PHYSICA z-Evalda L THERAPY 1Nb l?on =t>c .„'11i u 1 h ., m `measeVioiaHjiess-attitakP.?ata h ':? Dther'socedit%esiS)Si'ies ,' ascription CPT UNITS 59 Description CPT + UNITS Description CPT UNITS :ial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 l TENS Instruction 64550 -evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 gal Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Checkout (ea. 15 min) Orthotic 97762 !-evaluation-OT 97004 der+rutce ased r breslljlod?l?_ es ?l60 ,0.- a406i,*. ' rr d Prosthetic Training (ea. 15 min) 97761 ysical Performance TestlMeas 97750 Hot/Coid Paclc 97010 Electrodes (per pair) A4556 ,.E. functional Drills-ea. 15 min) Mechanical Traction 97012 Splint: Tam used iroaedu>es ?r C A[ tac iNI .r E-Slim Unattended 97014 Splint I erapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: srapeubc Procedures (ea. 15 min) uromuscular Reed (ea. 15 min) anual Therapy (ea. 15 min) iit Training (ea. 15 min) 97110 97112 97140 97116 Paraffin Bath WhirlpooVFluidotherapy Infrared Group Therapy 97018 97022 97026 97150 elt4ri3` + .' tAedl?ar$ Time In Time Out ,,Alvn'llflso4c r7 5-7 assage (ea. 15 min) 97124 i Biofeedback 90901 Total Treatment Time luatic Therapy (ea. 15 min) !If Care/Home Management 97113 97535 } ` R ;?onntaie " Wound-Selective 20SQ. CM 97597 - Total Service Based Time Total Time Based Time )mmunityNVork Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units >gnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB + TB) P i ® f1 • ®. D rY NS R/S Date L01 BACK PAIN objective: Patient's perceived changes/progress toward functional goals: I 1 L r' stlent s chief complaint bjective: Please refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. i •eatment progression: a OM: ST ENGTH: GIRTH: -ther (Function, Special Tests, Sensation): ssessment: Pa" nt's progres towards functional STG/LTG: ether: - Ian: v Progress/modify current treatment -Achieve by next visit / week Other: -Total # visits -- y 'herapist Signature n'n+leerr.evm wren W-wIri rwnr%6=Q RUDICK, APRIL 14 S JASHINGTON ST YECHANICSBURG, PA 17855 724.2 Re-eval/Progress Report next visit D/C patient PATIEI 38 484962 v Reason: C-? License # RE = .' • pQGTQRTIO : , _:DAT DICK APRIL 2A18/88 717 491 1867 NE' :- 'CbDE, DES`C IP3iC?N 1966 A TO INSURANCE 1/84/6 14 145 Jt•3ykNGE' _ '?GEi3l1FICATf=NO ' Ticl:ctl 146896768 PTypet 0 52 FED. Z.D. # 75-3050291 FIR AVVR P14Y.qT4-'AT, TTY FR APV YN, _.e a CTTTIF, y'valua fipn ? 110 n`.?cfiegtiired t3dr Frac?r3ares73uppLe s escripfion CPT UNITS 159 Description CPT UNITS 59 Description I CPT UNITS ifial Evaluation-PT 97001 i Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 revaluation-PT 97002 1 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 ilia! Evaluation-OT ) 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 e evaluation-OT 97004 uin3c t fid Prosthetic Training (ea.15 min) 97761 iysical Performance Test/Meas 97750 old Pack 97010 Electrodes (per pair) A4556 .C.E. Functional Drills-ea.15 min) T anical Traction 97012 Splint: .,, Unattended 97014 E-Stim Splint: ierapeubc Activities (ea. 15 min) 97530 1 neumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 auromuscular Reed (ea. 15 min) 971121 Whirlpool/Fluidotherapy 97022 >skeng = --: _. TVAed re rs ! Icrr Mle c anual Therapy (ea. 15 min) 97140 Infrared 97026 Time in r all Training (ea. 15 min) 97116 Group Therapy 97150 Time Out ; assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time auatic Therapy (ea. 15 min) 97113 r"s ??, _? +*°? e'Vatttrdatr v';:;. Total Service Based Time I '- alf Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time ommunity/Work Reintegration 97537 Wound Selective > 20SQ. CM 97598 Total Time Based Units ognitive Skills/Training 97532 Wound-Non Selective 97602 -llllllJ Total Units (SB + TB) LON BACK PAIN 724.2 ? Cx _ Reason: ubiective: Patient's perceived changes/progress toward functional goals: , ? lam.-??.? .? atient's chief complaint: >ther: I— Objective: Please refer to this patient's flow sheet for details specific reatment progression: IOM:- r S rises uttlize? during today's treatrr?ent. / c- GIRT )ther (Function, Special Tests, Sensation): assessment: Patient's progress towards functional STG/LTG: / )they: ,Ian: Jl?Progresslmodify current treatment -Achieve by next visit / week Other: --Total # visits -herapist Signature i GfiJ?K7iAiNTDFi:7stllME ?1ND_ADI3RtS RUDICK, APRIL 14 S WASHINGTON ST KECHANICSBURG, PA 17055 Brief Re-eval/Progress Report next visit D/C patient ~- License # PATIENT°NAME FB 38 404902 R DICK APRIL 14 300p DAT ,010 TEtEPHDNfi lNSUR;:tAlCE c zBiRTH hft3:' 1 AE :.1DE CRIPTion, ERTIFlGATEi10:., 2 18/80 717 91 1867 J 900 -1111 INSURANCE ? Ticket4 140096185 PTYPe# 40 NS R/S Date 53 FED. I.D. # 75-3050291 )1ZAYEK F1iYSIUA L'1'MERAvY INS11 1'U't'L ?'` 'r `` ??-+?'? 3?a7ri ?an,??????~'??s ;?y t??z?*<-?tne'?Based uid,,''?7yp?.?yp.'1 3?t'?Cp tttas??p?trlr?rit. :.?. '- t?titefl'rOC?i3?reslSaeyphe.. scription CPT I UNITS 59 Description CPT UNITS 59 Description CPT UNITS aai Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 -evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mqmt Training (ea. 15 min) 97760 iial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation-OT 97004 Basedria:Sr$,s11(A" ` ,,Giiec t*aratf?lot?equire(i ProstheticTraining(ea.l5min) 97761 ysical Performance Test/Meas 97750 Hot/Co Pack 97010 Electrodes (per pair) A4556 1E. Functional Drills-ea. 15 min) . apical Traction 97012 Splint: urge ase? 'ra ce ones 3lreirt?C ai cfRegu€r * E-Slim Unattended 97014 Splint: erapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: erapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 !ummuscular Reed (ea. 15 min) 97112 WhirlpDOW)uidotherapy 97022 racking Mer itcate , ' an, Medic 9nual Therapy (ea. 15 min) 1 97140 Infrared 97026 Time In lit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out 3ssage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time luatic Therapy (ea. 15 min) 97113 j alNonnB dare , Total Service Based Time elf Care/Home Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time j )mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units >gnitive Skills/Training B 97532 1 9 Wound-Non Selective 97602 B ® B Total Units (SB + TB) LOW BACK PAIN objective: Patient's perceived changes/progress toward functional atient's chief complaint: ther: -0 Cx _ Reason: •.v !,% c NS R/S Date bjective: Please refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. •eatment progression: i6nd 6-, OM: STRENGTH: GIRTH: ether (Function, Special Tests, Sensation): .ssessment: Patient's progress towards functional STG/LTG: A r 1-r It r w 1 t __ )ther: t Li LV 414j ^l ruNwr Ian: Progress/modify current treatment plan -Achieve by next visit / week ( Brief Re-eval/Progress Report next visit D/C patient Other. - Total # visits !?& herapist Signature License # _n . iU7?Rx2lhtSd3R NAIUIEANDJIDt)RESS._ ATIEN 7?1t3 ..i; ATIENT DIME` r ' ot:Tbn.: 1W 3 ."' ii?A1 RUDICK, APRIL 14 S NkSHINGTQH ST MECHANICSBURG, PA 17655 38 464962 RUDICK 1= ?. , t . 2)18/80 717 611 1867 DA'fsE F. :?,E'L RHO 'BIRT.J?, 724.2 APRIL 966 AUTO INSURANCE 14 ``CEFtTAFICA7E Ticket 1: 146695611 PTypef: 46 745 O. u ,,rs a Qr? as T?T547C?Ti- A T rrITVD A DV YWQTe d'iTrl^1Gi'. FED. I.D. # 75-3050391 3=valua tion ,_ 7f ne?$ased lllodal es f < tr ntacE quired. z, fz C ffne>YPraxe?iur s Supplies ' ; .; .scription CPT UNITS 59 Description CPT UNITS 59 Description CPT- I UNITS tiai Evaluation-PT 1 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 !-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 tial Evaluation-OT 1 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea.15 min) 197762 > evaluation OT 97004 mceused ?roce?uxesllMoaalibe Dirert ortacllot3tegu?e Prosthetic Training (ea. 15 min) 97761 ysical Performance Test/Meas 97750 o Cold Pack ) 5 ' 97010 Electrodes (per pair) A4556 '.E. Functional Drills-ea. 15 min) I Mechanical Traction 97012 Splint: Tma3ased Piceiiures Directo)i4act f?euired E tim Unattended - j ' 97014 1 Splint: erapeutic Activfties (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: erapeutic Procedures (sa.15 min) 97110 Paraffin Bath 97018 luromuscular Reed (ea. 15 min) 97112 WhirlpooVFluidotherapy 97022 u'" b Traeidng - ` : :'Med icare. Non-Medic 3nual Therapy (ea. 15 min) 97140 Infrared 97026 Time In O 9 ?S Sit Training (ea. 15 min) 97116 Group Therapy 97150 Time ut 3ssage (ea. 15 min) 97124 Biofeedback 90901 ] Total Treatment Time luatic Therapy (ea. 15 min) 97113 -?-.??Wound?ar? Total Service Based Time .If Care/Home Management 97535 Wound-Selective 20SQ. CM 97597 Time Based Time Total )mmunity/Work Reintegration I 97537 Wound Selective > 20SQ. CM 97596 Total Time Based Units ZZ _ >gnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB + TB) Ux IVJ nro Lima LOW BACK PAIN 724.2 Reason: ubjective: Patient's perceived changes/progress toward functional goals: ti A atient s chief complaint 1 5 ther: bjective: Please refer to this patient's flow sheet for detail V pecific to tf?eprocedures/modalities and specific exercises utilized during today's treatment. •eatment progression: ,.-r ? V ? OM: STRENGTH: GIRTH: Ither (Function, Special Tests, Sensation) ssessment: Patient's progress towards functional STG/LTG: rther [? ll,r fY 1?'?, ?. ,. Ian: Progressimodify current treatment plan _Ac e by next visit /week Other: . K Brief Re-eval/Progress Report next visit D/C patient Total # visits Z.? 'herapist Signature License # _GUARAr1TOT3 NAME.ANDADDRESS FATIENT.ND- -' P.ATIENTNAME:.: DDCTDRNO ': X)AT RUDICK, APRIL 38 404902 R DICK APRIL 12/26J0 14 745 14 S WASHINGTON ST "DATE"OF 'TELEI?HDNE INSURANCE -.: $IRTI4 3 COD= )ESCRIPTION .. CERTIFIcATE'N0. KECHANICSBURG, PA 17@55 2 18/80 717 91 1867 9@0 A TO INSURANCE Tickett 140095610 PType# 40 FED. I.D. # 75-3050391 TRANr ,TT PITY.STC'.AT. THF.,RAPY TNS'T'TTTYM,, t U w-, vaa 17 rflccedureslaeappiia ascription CPT Description CPT UNITS 59 Description CPT UNITS dal Evaluation-PT ( 97001 1 Ultrasound (ea.15 min) 97035 TENS Instruction 64550 ?vaiuation-PT 1 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 1 97760 tial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea.15 min) 197762 evaluation-OT 97004 quined Prosthetic Training (ea.15 min) 197761 1 ysical Performance Test/Meas 97750 Hot/Cold Pack 97010 Electrodes (per pair) A4556 =. Funclional Drills ea.15 min) l Mechanical Traction 97012 Splint: °:T?rnced:,Conta qu E-Stim Unattended 97014 Splint: erapeuticActivities (ea. 15 min) 97530 1 Vasopneumatic 97016 Supplies: erapeufic Procedures (ea.15 min) 97110 Paraffin Bath 97018 •uromuscular Re-ed (ea.15 min) 97112 WhirlpooVFluidotherapy 97022 Traakis g ,Medicare .Non=Medic inual Therapy (ea. 15 min) 97140 Infrared 97026 Time In j .3 iC) iit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out : j assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time luatic Therapy (ea. 15 min) 1 97113 Vitaund Qafe = _ Total Service Based Time y ilf Care/Home Management 97535 Wound-Selective :5 20SQ. CM 97597 Total Time Based Time ! )mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units >gnitive Skills/Training 975321 Wound-Non Selective 97602 ® a o e Map-M Total Units (SB + TB) j Cx NS R/S ate LOW SACK PAIN 724.2 ubjective: Patient's perceived changes/progress toward /% atient's chief complaint: they: Reason: bjective: Please refer to this patient's flow sheet for details specific tie procedures/modalities and specific exercises utilized during today's treatment. 'eatment progression: NY 3--I 1• OM: ?- STRENGTH: GIRTH: /Z ther (Function, Special Tests, Sensation): ssessment: Patient's progress towards functional STG/LTG: Qher: L Ian: Progress/modify current treatment plan _Ac e by next visit / week Brief Re-evaVProgress Report next visit D/C patient -Other. -Total # visits oZ?J herapist Signature License # ( V •G!)AI3ANToR NAMEANDADDRESS _: P.ATIENTiNO. ;, - '_PATIENT'NAME.' , ;; zDOCTDRNO D'11 RUOICK, APRIL 14 S WASHINGTON ST KECHANICSBURG, PA 17055 38 404902 R DICK APRIL 14 3 DATE OF TELEFJ-iONE iNSilfiANL:E `BIR?#3 ; N©: :iCDDE. ~DESGRIP770N:,, .-,,ERTJFICATE`N.,0 .'.'' 2 18/80 717 6 1 1867 900 A TO INSURANCE Ticlat 1: 146095609 PTypef: 40 Z-00 G PTEX Home Exercise Program Page: I D RAYE R /Z- ftsiW Tbrrapv Institute l12 :irr m;::a.-s i eu_.•. "'_ J 1. Knee to Chest, Single, 1 set of 10 Lie on your back, knees bent with your feet flat on floor. Tilt your pelvis, flattening your lower back. Lift one leg, knee to chest, pulling gently with your hands. Return to starting position and relax. Repeat with your other leg. Do 1 set of 10. 2. Adductor Sets, 3 sets of 10 This is an isometric exercise: no motion occurs. Lie on your back squeeze a pillow between your knees. Hold for 5 seconds. Relax. Do 3 sets of 10. =r 3. Hamstring Stretch, I set of 10 Lie on your back. Keeping one leg straight, bend the other and grab the back of your thigh as shown in the picture. Then slowly straighten the leg to the point of tightness. Slowly pull your toes toward your face. Hold for 5 seconds and then relax. Repeat with each leg. Do 1 set of 10. 5. Lower Abdominals Level One, 3 sets of 10 Lie on your back with hips and knees bent and feet on the floor. Place your fingertips on each side of the abdomen just under the rib cage. Pull the abdomen up and in. Lift one foot off the floor and stop when the hip is bent 90 degrees and the thigh is vertical. Bring the other leg to the same position. Lower one leg at a time to the starting position and then relax the abdomen. Alternate the first foot to be lifted. Do 3 sets of 10. 4. Hip Abduction with Band, 3 sets of 10 Sit on firm surface with band around thighs, near knees. Lift one leg and pull away from the other leg. Hold. Return to starting position. Do 3 sets of 10. Please check when you have com lefed your exercigeg! 12/16 12/17 12/18 12/19 12/2012/21 12/22 ® 2000 by PTEX Systems. All Rights Reserved. 800.653.2510 or 413.596-5041 7 6. Hip Flexion, Supine, 3 sets of 10 Slowly bend your hip and knee. Hold for 5 seconds, then slowly lower your leg to the starting position. Do 3 sets of 10. )RAVER PHYSICAL TIIER"Y INSM UTE FED. ?.D. # 75-305024 t = _vallia 6oR.. ' i[sBasedPlodalies' ?iractn irta>5gulr*l bther;ProcediiresJSupplies scription CPT UNITS Description CPT I UNITS 59 Description , CPT UNITS Gal Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 evaluation-PT 1197002 1 Iontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 tial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation-OT 97004 I ennce aced iocedtiresfNl` aTih es: Irect o; NofRequ rci'd ProstheticTraining (ea.15 min) 97761 ysical Performance Test/Meas 97750 ] Hot/Cold Pack 1 ( Electrodes (per pair) A4556 ?.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint meSasedProcedures,_ lrectContartfseq E-StimUnattended TB4 Splint j erapeuticAciivities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: ;rapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 ( i uromuscular Reed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 Traclcartg - , . ifAed lcare<` tNon'sMadic inual Therapy (ea. 15 min) 97140 infrared 97026 Time in 7 pit Training (ea. 15 min) 97116 Group Therapy 11 97150 Time Out -o 0 issage (ea. 15 min) 1 97124 Biofeedback 90901 Total Treatment Time uatic Therapy (ea. 15 min) 97113 ] ._ x w i {Hound Cage • ` ','- Total Service Based Time / - -If Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time S 3 immunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ignitive Skrilsfi raininq 1 97532 l Wound-Non Selective 97602 Total Units (SB + TB) (c itient's chief :her. LOW BACK PAIN bjective: Please refer to this patient's flow sheet for details sped eatment progression: _ 14 OM: Z STRE ther (Function, Special Tests, Sensation): ssessment: Patient's progress towards functional STG/LTG: C' ther: ian: rogress/mod fy current treatment plan -Achieve by next visit / week Other: Brief Re-eval/Progress Report next visit D/C patient Total # visits ierapist Signature License # ! GJAttANI OR NAME AVID ADORES PATIENT:iIO -': PATIENT NAME = DDCTDR'ND f7AT RUDICI, APRIL 38 404902 R DICK APRIL 14 745 14 S WASHINGTON 8T }"DATE ZF a LEP.H HONE _ 1 NSi]R Ate-is.r. ? a M6CHAHICSBURG PA 17055 =BIRTH` ?t0<'. CODE' ' wbESCRiPTION : CERTIftianENO:. , 2 18/80 717 91 1867 900 A TO INSURANCE Ticket# 140095985 PTppe# 46 d o 0 NS 724.2 Cx Reason: the i specific G R/S Date today's treatment. i DRAYERa F,... ? .,? .? DEC 2 9 2n, Physical Therapy Institute Lwdmg dw Way to Gwd NeWth Progress Report Patient Name: Aril Rudick Date: 12/20/06 Date of Birth: 2/18/80 Sex: Female Date of Evaluation: 10123/06 Diagnosis: LBP Date of Onset: 10/16/06 Referring Physician: Dr. Thom son Total # of Visits: 26 # Cx: 1 # NS: 1 Surgical Procedure: None Date of Surgery: NA Re-Certification Period g ective Date: From: 12/20/06 Through: 1/18/07 SUBJECTIVE STATUS/PROGRESS: Current Complaints/Symptoms: Patient reports a 90% improvement in ierC urri?n?LD pain/functional status. Patient notes intermittent achiness right low back. No radicular symptoms are noted. of LBP is noted with prolonged sitting > 1 hour or carrying >Slbs. Patient continues to note constant achiness right scapular r gion. ggravation of symptoms with increased UE repetition or duration of activity. Improvement of Prior Functional Limitations: Patient able to wash tables at work and clean dishes. Patient is also able to scrub rub. Improvement noted with overhead function. Pain Rating: Best: 2 / 10 Worst: 5 / 10 Current: 3 / 10 Best 0/10 Worst 4/10 Current 1/10 LB OBJECTIVE AND FUNCTIONAL STATUS/PROGRESS: Current Objective Status: • Tenderness palpable right interscapular region and mod tightness right UT. • Right UE AROM: Right shoulder flexion 0-173° (113°), IR/ER and Abd WNL. • Lumbar AROM: - Flexion to the floor (noting bilateral hamstrings/calf tightness at end range), 25% improvement - Extension 50% restricted (50% improved) - SB (L) 0-23°; (R) 0-26" - Rotation (L) 0-22° (T 12°); (R) 0-22° (r 10°) 1VIMT LE Right Left Hip Flex 5/5* 515* Hip Abd 4+/5/5* 515* Hip Ext 4+/5/5* (r LBP) 4+/5/5* (r LBP) Knee Flex/Ext 515 515 DF/PF 5/5 5/5 * Denotes increase 1/2 m grade N111IT`L1? Right Left Shld Flex 4+1515* 515* Shld Abd 4+1515* 515* Shld IR 515 5/5* Shld ER 515* 515 Latissimus 4+15 4+15 Upper Trap 515 515 Lower Trap 415 4+/5 Middle Trap 414+15 445 Current Functional Limitations: Patient reports increased scapular pain with laundry activities (i.e. folding, sorting out laundry and transferring clothes from washer to dryer. Limitations are also noted with prolonged sitting >2 hours or carrying objects >51bs and overhead reach >51bs. Patient Name: April Rudick Mechanicsburg Center 5275 E. Trindle Road ? Suite 110 - Mechanicsburg, PA 17050 - PHONE: 717-790.9920 - ?Ax: 717-790-9923 59 ASSESSMENT OF STATUS/PROGRESS: Rationale for Need to Continue Skilled Therapy Services: Patient reports significant improvement in her LBP status. Patient demonstrates gains in bilateral UE and LE strength as well as lumbar ROM and right shoulder AROM values. Functional restriction remains with right scapular, right shoulder function, overhead and with repetition. Rehabilitation Prognosis/Potential: Good Updated Objective Short Term Goals (to be achieved in weeks): 1. Decrease pain to 1-2/10. ' 2. Increase strength to 515 in the bilateral UE and scapular region. 3. Independent with HEP. 4. Decrease tenderness right interscapular region. Functional Goals to be Achieved by Next Progress Report (to be achieved in weeks): 1. Increase functional ability to perform laundry restrictions without increase discomfort in right scapular region. 2. Patient to perform overhead reach with 5-6lbs with good tolerance. Treatment Plan: functional activities, strengthening, neuro re-ed, posture, manual therapy, HEP, e-stim, hot/cold pack. Treatment Frequency of: 3 times per week Treatment Duration of: 4 weeks 1 have discursa1 the above findings, assessmoa, revisal treannou plan, and expect outcomet with the patient. HalAt is awrsre ofihe diagnosis and prvgnvsis and volunaril.v agrees to continue panicituuion in /phvsicaUoecupationo! therapy services. Therapist's Signature: I/ License: PT016294 Date: 12/20/06 Shane Bronson DPT, ATC, CGFI, Cert MDT Re-Crrti [cation: 1 hereby cart fv that rehabilitation servicer are nrerlica//v necersaryfor the above mottioned patient[. 1 also unrlars[nnrl that my sigraturc sigrtifict ngreeruon with rlre Uprhrterl Plmr ojCnre, iududing the rstinatl& jrnhue nev and rltrration, its established by the liconsed therapist. I understand ilr@ Plan of Care becomes effective on the dine noted and remains effective for the duration ofrreatment ai dutol bn the Man of Care. Physician's Comments: Physician's Signature: Date: fC:) -1)Z-e5'- Tx: JK Plense Return this Progress Reporr to Drover Physical Therapy Patient Name: April Rudick sib 6 FED T.D. # 75 305029) l1D A'87Y'i 3D >DTT?_1CTC A T TT-TW'.32 A PV TNCT-[', (T'PlF+'. x =va9ua >[ioTi;s :'.s? .. 'sm?;iasealtties? leCx factquirez! OtherDroceduresY5uplfes scription CPT UNITS 59 Description CPT UNITS 59 Description CPT I UNITS ial Evaluation-PT 97001 U)trasound (ea. 15 min) 97035 TENS Instruction 1 64550 -evaluafion-PT !9700_2 1~ ntophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 ial Evaluation-OT 1 97003 -Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 -evaluation-OT 197004 15etvlce ased piocetluces_1lilddoo l;s Dueet egm re Prosthetic Training (ea. 15 min) 97761 ysical Performance TestlMeas 97750 Hot/Cold Pack 0 ( Electrodes (per pair) I A4556 ,.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint: ime Based Procedures . 3itectJLntrtact fregpfref3 E-Slim Unattended 97 Splint: arapeutic Activities (ea. 15 min) ( 97530 Vasopneumatic 97016 Supplies: srapeutic Procedures lea. 15 min) 97110 n Bath 97018 uromuscular Reed (ea. 15 min) Inual Therapy (ea. 15 min) 97112 97140 t idpool/Fluidotherapy ared 97022 97026 Tracking - =Meidi?are' 'Hart=7Nedic lime In I `,rl iii Training (ea. 15 min) 97116 up Therapy 97150 Time Dut' 3ssage (ea. 15 min) 97124 BiDfeedback 90901 ] Total Treatment Time j vatic Therapy (ea. 15 min) 97113 Wvund "Cate Total Service Based Time ff Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time j )mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units >gniiive Skil)s/Training ! 975321 Wound-Non Selective 97602 Total Units (SB + TB) D . p D • ® D LOW BACK PAIN objective: Patient's perceived changes/progress toward functional atient's chief complaint: Snvi the - 724.2 bjective: Please refer to this patient's flow sheet fo ailespecific to the re atment progression: 1,1 11 _ OM: : STRENGTH:- Ither (Function, Special Tests, Sensation): ,ssessment: Patient's progress towards functional STG/LTG: )the r: ,Ian: ogress/modify current treatment plan____,_;__ -Achieve by next visit / week 4 Other: 04 -Total # visits kol 7herapist Signature 1l?.P a, Cx Reason: q o N5 H/5 Uate d' and specific exercjses ujilized during today's treatment. GIRTH: Brief Re-eval/Progress Report next visit D/C patient License # -GOAtt 4NTOR`NANIE AND:ADDRESS P.ATIENTtNO.' , 1'ATIENT:NAME, _ DOCTOR NO DA 12/2@J@ RUDICK, APRIL 38 404902 R DICK APRIL 14 745 `DATE;DF- TE(.MPHONE r n ` ,BIRTtI NO GORE DESCRIPTION, "CERTIFICATE:NO.. NECHANICSBURG, PA 17055 2 18/80 717 91 1867 900 A TO INSURANCE Ticket$ 14009526B PTypeB 40 G:i ED. I.D. # 75-3050291 )RAY'ER PHYSICAL THERAPY- INSTTi,UTE ..- `;valuaion "" t: ,`a y q; yasetlkMntlalltlesifre. ulred = nac . Dthe ProcedtlreslSiiD les scription CPT UNITS 59 Description CPT UNITS 59 Description 1 CPT I UNITS ial Eva)uafon-PT ; 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 -evaluation-PT ; 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 i fal Evaluation-OT ; 97003 E-S6m Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 -evaluation-OT 97D04 h5ew?ceasedaedirtesModal?t4 es?re o`' otRegUrer Prosthe tic Training (ea. 15 min) 97761 ysical Performance Test/Meas 97750 1 3 Hot/Cold Pack 9701 Electrodes (per pair) A4556 '.E. Functional Drills-ea. 15 min) f Mechanical T raction ci- 012 Splint: me ase91?rocedttres i? cfCv_itaac#12equinYd `` E-Slim Unattended Splint I srapeutic Activities (ea. 15 min) 97530 Vasopneumabc 97016 Supplies: I erapeubc Procedures (ea. IS min) 97110 Paraffin Bath 97018 uromuscular Re-ed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 tocidng {i med icare'. 'Nor-Medic. 3nual Therapy (ea. 15 min) 97140 Infrared 97026 Time in , q )it Training (ea.15min) 1 97116 Group Therapy 97150 Time Out 9ssage (ea. 15 min) 97124 1 Biofeedback 90901 Total Treatment Time 1 4-2 0 i luatic Therapy (ea. 15 min) 97113 " Wountl;Gace ; Total Service Based Time 1 f tIf Care/Home Management 1 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time )mmunity/work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units "7 )gnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB + TB) D ? ® D i D Cx NS R/S Date LOW BACK FAIN 724.2 Reason: ubjective: Patient's perceived changes/progress toward functional goals: atient's chief complaint: Q -'?? - thee: ?bjective: Please refer to this patient's flow sheet for details ific to the pro edures/ odalitie reatmenf progression: OM: L _ STREN H: and spectt?' xercises utilized during today's treatment. / (-- 1 c sly - ?` c ?-? /?® _ y??` '7dY-,-v a ' 2 )then (Function, Special Tests, Sensation): - kssessment: Patient's progress towards functional STG/LTG: ? 67 C, )then. 'Ian: ?gress/modi y current treatment plan ,-Achieve by next visit / week Other: OF Brief Re-eval/Progress Report next visit D/C patient -Total # visits Therapist Signature License # _ ;GI7ARANTOR N A0 ANDADDRESS FfA3IEtdT?ND "RATWkT?NAME' :. DOGS OR 1?IQ DA RUDICKr APRIL 311 404902 & DICK APRIL 1216/0 14 745 14 S WASHINGTON ST DATE OF ? E?RHQNE iN51J1-111yf= >> ? - IdBCHANICSBU 9 G FA ?1R #f ? NO y " u CADS, „ DESCJ31PTI014 'CERTIFxd .Tit N6.,` , 17 55 R 2 18/80 717 91 1867 909 A TO INSURANCE Tickett 140095267 PTypBI 40 D R.AYE If Physical Therapy Institute Leading the Way to Good Heal& Patient: April Rudick Date of Birth: 2-18-80 Sex: F Diagnosis: LBP Referring Physician: Dr. Thompson Surgical Procedure: N/A Ms. April Rudick was referred for a job site evaluation to determine safe ergonomic working conditions while at work. Ms. Rudick is employed by the Department of Health as a WIC Program Representative. Ms. Rudick complains of increased pain and soreness while working on her computer and writing. Assessment: Ms. Rudick states she works 5 days per week, 37 '/2 hours per week. She receives a 1 hour lunch break with two 15 minute a m./p.m. mini breaks. She states she is sitting 70% of her day along with: computer use of 60% (50% mouse, 50% keypad), phone use 15%, writing 50%, walking 5%, Driving 8 weeks out of the year, forward reaching at shoulder level seldom, desk level frequently, and below desk level occasionally. JOB SITE EVALUATION Date: 11/28/06 Date of Evaluation: 12-15-06 Date of Onset: 10-16-06 Date of Surgery: N/A Ms. Rudick was observed sitting in a good posture, with her arms reaching forward with little to no bend at the elbow. Ms. Rudick needs additional support (elevation) for her forearms while sitting. Ms. Rudick does not use a headset/ nor a shoulder cradle for her phone (pinches phone between ear and shoulder). Ms. Rudick's keyboard & mouse were placed too high (on desk surface), and her monitor was positioned too low on the desk in order for her to sit in good ergonomic posture. Measurements: Floor to Chair: Floor to Armrest: Floor to Keyboard/mouse: Floor to Desk: (pre-eval.) 17.5 inches 25 1/2 inches 29 inches 28 inches (post eval.) no change no change no change no change Mechanicsburg Center 5275 E. Trindle Road -Suite 110 .? Mechanicsburg, PA 17050 ? PHONE: 717-790-9920 ? FAx: 717-790-9923 6 Recommendations: It is our recommendation that Ms. Rudick: 1) Use/Add a phone headset or shoulder cradle while talking on the telephone. 2) Adjust her computer monitor height up 2 %z inches for improved viewing. 3) The addition/use of a document holder for viewing documents/papers for data entries on the computer. 4) Moving (to corner of desk) and utilizing her keyboard/mouse tray to 27-28 inches from the floor. 5) Perform cervical spine and shoulder exercises/stretches (enclosed) every 1-2 hours, and not lasting more than 2 minutes in duration. 6) Add armrest cushions to her chair to enable her arms to rest at 28 inches from the floor (90 degree angle at the elbow). 7) Use an incline writing board while reviewing documents. 8) Use of an earpiece/headset for her cell phone while traveling for work. Thank you for referring Ms. April Rudick to Drayer Physical Therapy Institute for this evaluation. If you should have any questions regarding this report or evaluation please do not hesitate to contact me. Thank you. Shawn Lesh Phone: 717-920-2620 Enclosures G 14 Routine For: April Rudick Dec 19, 2006 Created By: Shawn Lesh CERVICAL SPINE - 2 AROM: Lateral Neck Flexion Slowly tilt head toward one shoulder, then the other. Hold each position 5 seconds. Repeat 10 times per set. Do. 2 sets per session. Do 5 sessions per day. CERVICAL SPINE - 3 AROM: Neck Flexion i r el Bend head forward. Hold 5 seconds. l? ??? Repeat 10 times per set. Do 1 sets per session. Do 5 sessions per day. SHOULDER - 72 ROM: Posterior Capsule Stretch Gently pull on hght forward elbow with other hand until stretch is felt in shoulder. Hold 15 seconds. Repeat 1 times per set. Do 1 sets per session. Do 5 sessions per day. HAND - 14 Wrist Extensor Stretch Keeping elbow straight, grasp ri ht hand and slowly bend wrist forward until stretch is felt. Hold 5-10 seconds. Relax. Repeat 1 times per set. Do 1 sets per session. Do 5 sessions per day. HAND - 13 Wrist Flexor Stretch Keeping elbow straight, grasp right hand and slowly bend wrist back until stretch is felt. Hold 5 seconds. Relax. Repeat 10 times per set. Do 1 sets per session. Do 5 sessions per day. SPINAL MOBILIZATION - 15 Thoracic Self-Mobilization (Sitting) With small rolled towel at lower ribs level, gently lean back until stretch is felt. Hold 10 seconds. Relax. Repeat 2 times per set. Do 1 sets per session. Do 5 sessions per day. CopyrightO 1999-2005 VH1 Page 1 of 2 N 0 N I dD Fem. ?D O O N O? U U A b?D ^C U N r U LF) 3 0 o En cn fl) U N c? y I U--? o AAA U y c% fs, P? U -t7 Y U z In, U N CJa U SMC3 W N 0 o o o •? ?Q o ? v 0 -d "?O 3 b ' S- "C3 r ? ? o ?A C? 0 U i O ^* v ? o N 0. U m ob N L3, ? Cy p?AA 66 7 ?'' D RAYS R Physical Therapy institute Leading the Way to Good Health Patient: April Rudick Date of Birth: 2-18-80 Sex: F Diagnosis: LBP Referring Physician: Dr. Thompson Surgical Procedure: N/A Date: 11/28/06 Date of Evaluation: 12-15-06 Date of Onset: 10-16-06 Date of Surgery: N/A JOB SITE EVALUATION Ms. April Rudick was referred for a job site evaluation to determine safe ergonomic working conditions while at work. Ms. Rudick is employed by the Department of Health as a WIC Program Representative. Ms. Rudick complains of increased pain and soreness while working on her computer and writing. Assessment: Ms. Rudick states she works 5 days per week, 37 l/2 hours per week. She receives a 1 hour lunch break with two 15 minute a.m./p.m. mini breaks. She states she is sitting 70% of her day along with: computer use of 60% (50% mouse, 50% keypad), phone use 15%, writing 50%, walking 5%, Driving 8 weeks out of the year, forward reaching at shoulder level seldom, desk level frequently, and below desk level occasionally. Ms. Rudick was observed sitting in a good posture, with her arms reaching forward with little to no bend at the elbow. Ms. Rudick needs additional support (elevation) for her forearms while sitting. Ms. Rudick does not use a headset/ nor a shoulder cradle for her phone (pinches phone between ear and shoulder). Ms. Rudick's keyboard & mouse were placed too high (on desk surface), and her monitor was positioned too low on the desk in order for her to sit in good ergonomic posture. Measurements: Floor to Chair: Floor to Armrest: Floor to Keyboard/mouse: Floor to Desk: (pre-eval.) 17.5 inches 25 1/2 inches 29 inches 28 inches (post evaI.) no change no change no change no change Mechanicsburg Center 5275 E. 7Yindle Road -Suite 110 -Mechanicsburg, PA 17050 a I•HONE: 717-790.9920 -FAX: 717-790.9923 Recommendations: It is our recommendation that Ms. Rudick: 1) Use/Add a phone headset or shoulder cradle while talking on the telephone. 2) Adjust her computer monitor height up 2 %z inches for improved viewing. 3) The addition/use of a document holder for viewing documents/papers for data entries on the computer. 4) Moving (to corner of desk) and utilizing her keyboard/mouse tray to 27-28 inches from the floor. 5) Perform cervical spine and shoulder exercises/stretches (enclosed) every 1-2 hours, and not lasting more than 2 minutes in duration. 6) Add armrest cushions to her chair to enable her arms to rest at 28 inches from the floor (90 degree angle at the elbow). 7) Use an incline writing board while reviewing documents. 8) Use of an earpiece/headset for her cell phone while traveling for work. Thank you for referring Ms. April Rudick to Drayer Physical Therapy Institute for this evaluation. If you should have any questions regarding this report or evaluation please do not hesitate to contact me. Thank you. Pt I- Shawn Lesh Phone: 717-920-2620 Enclosures Routine For: April Rudick Dec 19, 2006 Created By: Shawn Lesh CERVICAL SPINE - 2 AROM: Lateral Neck Flexion Slowly tilt head toward one shoulder, then the other. Hold each position 5 seconds. Repeat 10 times per set. Do 2 sets per session. Do 5 sessions per day. CERVICAL SPINE - 3 AROM: Neck Flexion Bend head forward. Hold 5 seconds. l . Repeat 10 times per set. Do 1 sets per session. Do 5 sessions per day. SHOULDER - 72 ROM: Posterior Capsule Stretch Gently pull on right forward elbow with other hand until stretch is felt in shoulder. Hold 15 seconds. Repeat 1 times per set. Do _ I sets per session. Do 5 sessions per day. HAND - 13 Wrist Flexor Stretch Keeping elbow straight, grasp right hand and slowly bend wrist back until stretch is felt. Hold 5 seconds. Relax. Repeat 10 times per set. Do 1 sets per session. Do 5 sessions per day. HAND - 14 Wrist Extensor Stretch Keeping elbow straight, grasp right hand and slowly bend wrist forward until stretch is felt. Hold 5-10 seconds. Relax. Repeat 1 times per set. Do 1 sets per session. Do 5 sessions per day. SPINAL MOBILIZATION - 15 Thoracic Self-Mobilization (Sitting) With small rolled towel at lower ribs level, gently lean back until stretch is felt. Hold 10 seconds. Relax. Repeat 2 times per set. Do 1 sets per session. Do 5 sessions per day. CopyrightO 1999-2005 VHI Page 1 of 2 6 9 Routine For: April Rudick Dec 19, 2006 Created By: Shawn Lesh CERVICAL SPINE - 2 AROM: Lateral Neck Flexion i y F Slowly tilt head toward one shoulder, then the other. Hold each position 5 seconds. Repeat 10 times per set. Do 2 sets per session. Do 5 sessions per day. CERVICAL SPINE - 3 AROM: Neck Flexion Bend head forward. Hold 5 seconds. Repeat 10 times per set. Do I sets per session. Do 5 sessions per day. SHOULDER - 72 ROM: Posterior Capsule Stretch Gently pull on right forward elbow with other hand until stretch is felt in shoulder. Hold 15 seconds. Repeat I times per set. Do I sets per session. Do 5 sessions per day. HAND - 14 Wrist Extensor Stretch Keeping elbow straight, grasp right hand and slowly bend wrist forward until stretch is felt. Hold 5-10 seconds. Relax. Repeat 1 times per set. Do 1 sets per session. Do 5 sessions per day. HAND - 13 Wrist Flexor Stretch Keeping elbow straight, grasp right hand and slowly bend wrist back until stretch is felt. Hold 5 seconds. Relax. Repeat 1_ times per set. Do I sets per session. Do 5 sessions per day. SPINAL MOBILIZATION - 15 Thoracic Self-Mobilization (Sitting) With small rolled towel at lower ribs level, gently lean back until stretch is felt. Hold 10 seconds. Relax. Repeat 2 ' times per set. Do I sets per session. Do 5 sessions per day. CopyrightO 1999-2005 VH1 Page 1 of 2 7 FED. I.D. # 75-3050291 I) YL+'K YHYSICAL 11JE "Y ILN {r_Iualion?1?`r? SI't i UTE tneBaset9llyd1i?esirelf`nti uid r- Dttief3'roce'duresl5ti 1'les ?1. ascription CPT UNITS 59 Description CPT UNITS 5 Description CPT UNITS itial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 a-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 itial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 I Orthotic Checkout (ea. 15 min) 97762 -evaluation-OT 97004 erxiei=$asetlroce'7t _ "iltectofEepn i Prosthetic Training (ea.15 min) 97761 hysical Performance Test/Meas 97750 Hot/Cold Pack 010 Electrodes (per pair) A4556 .C.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint: l E-Stim Unattended 014 Splint: ierapeuticActivities (ea. 15 min) 97530 Vasopneumatic 9701 Supplies: ierapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 euromuscular Reed (ea. 15 min) 9711 ?1 Whir.lpool/Fluidotherapy 97022 Tracking lilled tcare AIDn=Meth ianual Therapy (ea. 15 min) 97140 Infrared ` 97026 f Time In ait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out lassage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time quatic Therapy (ea. 15 min) 97113 ?? $ aund Total Service Based Time elf Care/Home Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time ommuni y/Work Reintegration 1 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units q7- -7 ognitive Skills/Training 1 97532 Wound-Non Selective 97602 P 1 o e 0 0 Total Units (SB + TB) I Cx NS R/S ;,A Date LOW BACK PAIN Reason: 724.2 subjective: Patient's perceived changes/progress toward functional goals:?? .11? /l 'atient's chief complaint: )then. )bjective: Please refer to this patient's flow sheet for details specific to .reatment progression: and specific exercises utilized during today's treatment. G I RTH: )ther (Function, Special Tests, Sensation): 6'? assessment: Patient's progress towards functional STG/LTG: ? a )ther: 'Ian: ogress/modify current treatment plan `?-- > -Achieve by next visit / week GS Brief Re-eval/Progress Report next visit D/C patienl Other: -Total # visits -herapist Signature License # UAi i4NTOR'NAIIfIEAND_4 DF3ESS PAT] b4t1[O. , P,ATiENT'NAME . ADCTOR`NQ - Iip 12 15 RUDICK, APRIL 38 404902 R DICK APRIL 14 745 14 5 WASHINGTON ST INSUc DATE;}7P TELfJLi1NE l1ECHAHICSBURG, PA 17055 B1R?'#i ND Cp?E" ^:43ES.GRII?7I?N `:Gi=RTIFICfITE t10 2 18/80 717 91 1867 900 A TO INSURANCE Ticlet4 140094415 PTppe4 40 i FEED. I.D. # 75-3050291 )PAYER PHYSICAL THERAPY INS Tuatrofi w' t#m? TI TUTE u maseMrndaTitjes anta u11£aS? r E (7tlitr?rdce?iires?Su lies ascription CPT UNITS 59 Description CPT UNITS 59 Description CPT UNITS fiat Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 )-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 tial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation-OT 97004 errce;8'as"ed Pr ae?u1NYoda_li4 eire aiifacftlotegw re , Prosthetic Training (ea. 15 min) 97761 )ysical Performance Test/Meas 97750 Hot/Cold Pack 1 9701C' , Electrodes (per pair) A4556 C.E. Functional Drills-ea. 15 min) Mechanical Tract' n 2- - " Splint: Tirn? Bas?dr7nres r`' 3Fect rvnnta ulre ,.. E-Slim Unattend d 1 4 Splint: ierapeutic Activities (ea. 15 min) 97530 Vasopneumabc 97016 - Supplies: erapeutic Procedures (ea. 15 min) 97110 a3) Paraffin Bath 97018 auromuscular Reed (ea. 15 min) 97112 WhirlpooVFluidotherapy 97022 = Traclang 1hAet? ica it Non=Medic anual Therapy (ea. 15 min) 97140 Infrared 11-5 97026 Time In Sit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out c2S assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time i & auatic Therapy (ea. 15 min) 97113 s ?xa?Vltound Dare ..- -"- " Total Service Based Time C!S )If Care/Home Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time )mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ' J Dgnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB + TB) Cx NS R/S Date LOW SACK PAIN ubjective: Patient's perceived changes/progress toward I atient's chief complaint: ether: 1L4.1 +bjective: Please refer to this patient's flow sheet for details specific to the reatment progression: OM: STRENGTH:- Reason: exercises utilized during today's treatment. GIRTH: Aher (Function, Special Tests, Sensation): LWll.- --?! CV -S Lssessment: Patient's progress towards functional STG/LTG: 2, )ther: 4an: ress/modify current treatment plan A _ -Achieve by next visit / week Other: Total # visits -herapist Signature URX?N7 DR'NAt1fIE4ND;DDFiESS Brief Re-eval/Progress Report next visit D/C patient RUDICK, APRIL 38 404902 R DICK 14 S WASHINGTON ST _ :DATE,0 z'TfLT KECHANICSBURG, PA 17055 B1R" F° 18/80 717 91 1867 License # .PATIENT14AME: DD>rTORNQ y , :DAj 11. 1 3 APRIL 14 745 'ODE" s DESCRIPidO:N CERT Fit , ATE"N . 908 A TO INSURANCE Ticket;? 140094414 PTyue4 40 2 FED. I.D. # 75-3050291 P MAYER PHYSICA Eyalua L THERAPY INS 1I t?ort, F Fsr t :` TIJTE ti, me as'ed a?aTi e"s irei t :pn_E c uite ', ?, tither:PrncedOres/Supplies r scription CPT UNITS 59 Description CPT UNITS 59 Description CPT I UNITS 1al Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 -evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 iial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea.15 min) 97762 evaluation-OT 97004 erc`$asitoc??'? 0ifJ esirec fo €R_equ M` Prosthetic Training (ea.15 min) 97761 ysical Performance Test/Meas 97750 Hot/Cold Pack 97010 Electrodes (per pair) A4556 ;.E. Functional Drills-ea. 15 min) Mechanical Traction i2 Splint: 'measetiicedgres 3treCt?Contacf [iIF - -Stim Unattended 97014 Splint: erapeutic Activities (ea. 15 min) . 97530 Vasopneumatic 9 Supplies: Brapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 •uromuscular Reed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 Traakmg - Med j64e Non-Med I1 inual Therapy (ea. 15 min) i 97140 Infrared 97026 { Time In lit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out c 3ssage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment 1 ime luatic Therapy (ea. 15 min) 97113 }Noorid Ca"= Total Service Based Time :If Care/Home Management 97535 Wound-Selective 20SQ. CM 97597 Total Time Based Time 4 )mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units )gnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB + TB) e a ? e ry NS R/S Date LOW BACK PAIN 724.2 ubjective: Patient's perceived changes/progress toward functional l>7 /1 T. ?- atient's chief complaint: ther• ,bjective: Please refer to this patient's flow sheet for details spe '15;16 the reatment progression: OM: STRENG _ Reason: sy-./1%? sc ?<L D ms's 51itiesa sp efrlL\exercises utilised cluningyti f? .S Ither (Function, Special Tests, Sensation): ,ssessment: Patient's progress towards functional STG/LTG: )ther: 'fan: Progress/modi y current treatment plan -Achieve by next visit / week ZZ _5 Brief Re-eval/Progress Report next visit D/C patient -Other: - -Total # visits 1 7 l! f (/??J 7 r / -herapist Signature ?L / I rt/ License # 7 i `'1 f is ! GUARANTDR RIAIi71E AND ADDRESS PATIENT;ncx J2 IENTNAME ` DOCTORM' DA' RUDICK, APRIL 38 404902 R DICK APRIL 14 S WASHINGTON ST DATE OF ';TELEPHONE NECHANICSBURG, PA 17055 BIRCH, NO,` >rpQE DESCRIPTION 2)19/81 117 6 1 1867 900 A TO INSURANCE 12/12/ 6 14 745 TRANCE: :'.CERTIFICATE m Ticket 140@95036 PTypel- 4@ FED. I.D. # 75-3050291 )RAPER PHYSICA L THERAPY INS Tr l'UT E: y p? y e 2f9'd.SP.d,'IY?I?Ya Ales ."43tr i9??Fact?7te ulred scription CPT UNITS 59 Description CPT UNITS Description CPT UNITS ial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 1 TENS Instruction 64550 -evaluation-PT 97002 lontophoresis (ea.15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 ial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Checkout (ea. 15 min) 0rthotic 97762 -evaluation-OT 97004 25eia000PPrbe?U esYllrtl 3irec C4:arilact7fot Regmrer Prosthetic Training (ea. 15 min) 97761 ysical Performance Test/Maas 97750 Hot/Cold Pack 97010 Electrodes (per pair) A4556 ;.E. Functional Drills-ea. 15 min) ] Mechanical Traction 97012 Splint lane asedP?ocedures , _ irect1 *facfmei{iured 11 E-Stim Unattended 97014 Splint: srapeutic Activities (ea. 15 min) 97530 Vasopneumafic 97016 Supplies: i :rapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 uromuscular Re-ed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 TTacking '' Nled leare'', Mori-Medic: inual Therapy (ea. 15 min) 97140 Infrared 97026 Time In R Training (ea. 15 min) 97116 Group Therapy 97150 Time Out issage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time uatic Therapy (ea. 15 min) 97113 a1lfound ae? ] Total Service Based Time If Care/Home Management 97535 Wound-Selective :5 20SQ. CM 97597 1 --A Total Time Based Time immunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ignitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB + TB) d s e e.® r:r NS R/S Date 1-2/1.2 LOW BACK PAIN 724.2 Reason: f S A?L 0, jbjective: Patient's perceived changes/progress toward functional goals: atient's chief complaint: I then. lojective: Please refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. •eatment progression: OM: STRENGTH: GIRTH: ther (Function, Special Tests, Sensation): .ssessment: Patient's progress towards functional STG/LTG: Ither: 'Ian: Progress/modify current treatment plan -Achieve by next visit / week Brief Re-eval/Progress Report next visit D/C patient Other: Total # visits -herapist Signature RUDICK, APRIL 14 S WASHINGTON ST MECHANICSBURG, PA 17055 104902 2118180 717 X91 1867 APRIL NE `; 'rt0D ._ .DESCRIPT1l0 900 AOTO INSURANCE 1211/0 14 745 SURANCE '' CERTIEIGATE NOr", Ticketf 140094413 PTYpe# 40 4 License # AE : . FETE- 71.7`7. # 75-305(7291 t /_ 'LAYER PHYSICAL THERAPY IN STI TUTE `> '?? ?'?. ,°`E?? cir7 `_',- ,?.. ..?;?? -:.. .? ??,niteD3ased?lA?da"I?-._.. irec-t?`b tafac?Re??ir?cl , ..{ w ? .',`." paler"PrcceF3ures15upplias - scription CPT UNITS 5 Description CPT UNITS 59 Description CPT I UNITS ial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 -evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 ial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation-0T 97004 l `_avkeased ?coceul'ddattti eslrec t'oitactlottegw red; Prosthetic Training (ea. 15 min) 97761 ysical Performance TesUMeas 97750 H )I/Cold Pack 'f 10 Electrodes (per pair) A4556 ,.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint 73me'3?ased Procedures ` Irec# ContadFRegulred E-Slim Unattended I ? 9 P Splint arapeuticActivities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: srapeutic Procedures (ea. 15 min) 9114 Paraffin Bath 9701 B uromuscular Reed (ea. 15 min) IMIP2 2 WhirlpooVFluidotherapy 97022 :-Ti'a cklr.9,.-4-Medi care` Alon=Medic inual Therapy (ea. 15 mi (0% Infrared 7 Time In ! jZ d Training (ea. 15 min) 97116 Group Therapy 1 97150 Time Out -t issage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time vatic Therapy (ea. 15 min) 1 97113 `_- YVpuntl' tiar? ' Total Service Based Time Z o If Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time 7¢ . immunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ignitive Skills/Training 1 97532 j Wound-Non Selective 97602 Total Units (SB + TB) I ® F1 k, I o s ® a LOW BACK PAIN 124.2 Cx Reason: NS _ R/S Date jbjective: Patient's perceived changes/progress toward functional goals: L 8 w. tom, ?!? ?e atient's chief complain then. bjective: Please refer to this p?;?nt's flow sheet for details specific to the procedures/modalities and specific ex rcises utilized ing today's treatment. -fi+r t , - cA -eatment progression: tT&_%, G+! OM: STRENGTH: GIRTH: ther (Function, Special Tests, Sen ssessment: Patient's progr ss towards functional TG/LTG- ether: Ian: Progress/modify current treatment plan -Achieve by next visit / week Brief Re-eval/Progress Report next visit D/C patient Other: -Total # visits herapist Signature License # 9Gl1ARANT.,OR`JIAt1YlEAN0 ADDRESS . PATfENT9N0 P-AT.IENT°NAME, A'OCTOR.NQ .:DA1 12/08/0 RUDICK, APRIL 38 404902 R DICK APRIL 14 745 ...- 14 S WASHINGTON 57` DA?bF TELEPJ-IONE JNSURANCE , BIt3TFI TfO. 0ODE DESCRIPTION `CERTIFICATE No. KECHAHICSBURG, PA 17055 2A18/81 717 191 1667 900 A TO INSURANCE Ticket# 140093971 7 I3RAYER PHYSICAL THERAPY INS1rr€J3'E FEED. I.D. # 75-3050391 - ? , ? %31ua 1afln .: 2A X, s ' x<< tr ased Itot aliiNes f ©ec fi _..,. r a tii d = z, . ? r? C3Oier PsocetiwreslSuppiies lescription CPT UNITS 59 Description CPT UNITS 59 Description I CPT i UNITS AM Evaluation-PT i 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 ;e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orlhotic Mgmt Training (ea.15 min) 97760 iftial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 ,e e valuation-OT - 97004 1 e_rvic? 8asedProcs uiesf at alitfe lirr•c t pta4ctdJot3*d ifi-p Prosthetic Training (ea. 15 min) 97761 'hysical Performance Test/Meas 97750 Cold Pack ?S' 97010: ' j' Electrodes (per pair) j A4556 -.C.E. Functional Drills-ea. 15 min) Mechanical Tractio 97012 - -''-" Splint: me 8aset} P?acedurss ??recEJontaCf Requiredtr E tim nded ( 97014" Splint: herapeuticActivities (ea. 15 min) 97530 Vasopneumatic 97016 - -? Supplies: herapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 leuromuscular Reed (ea. 15 min) , 97112 Whirlpool/Fluidotherapy 97022 "Tracking' :` `"Med icare 0;M d! ianual Therapy (ea. 15 min) 97140 Infrared 1 97026 Time In y fait Training (ea- 15 min) 97116 Group Therapy 97150 Time Out iassage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time I e ,quatic Therapy (ea. 15 min) 97113 _ __' I1oulyd Late - _ ° :-_ Total Service Based Time ;elf Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time :ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units :ognitive Skills/Training ® 97532 •' Wound-Non Selective 97602 10 M. • • Total Units (SB + TB) i im Cx NS R/S Date LOW BACK PAIN 724.2 Reason: mil subjective: Patient's perceived cha.ges/progress toward functional goal $; o d '; t i"f y 'atient's chief c pl omaint: 1 -! ' s ha () "a k- 141;'7_ n -4 k: 4 6 )ther: Ix 21, 47 )bjective: Please refer to this patient's flow sheet for details specc" o the proc res/modalibes nd sp c" is exercise uti ized durin Coda 's treatment. reatment progression: 1OM: °'---b?TRENGTIL- -P LA- o% GIRTH: )ther (f=unction, Special Tests, Sensation): f _"kssessment: Patient's progress towards functio al STG/LTG: )ther: -n -? 'Ian: 'Progresslmodi y current treatment plan -Achieve by next visit /week Brief Re-eval/Progress Report next visit D/C patient -Other. Total # visits f rherapist Signature / f ??' License # Ciq* . ANT0R_N* A.ME A-ND ADDRESS , . PATIENT3N0 .' PATIEhITNAME.: D0CTDR..N6..r :DA RUDICK, APRIL 14 S WASHINGTON ST NECHANICSBURG, PA 17055 12/07/ 6 38001902 R DICK APRIL 14 745 DATE-017 TELEPHONE IfVSURAiJCE ; r- BIRTH ND OD1=. 3)ESGRIP IOM; tERT,IFICATE,N0_ 2118/80 717 611 1867 900 A TO INSURANCE Ticket 1: 140094728 PTYAel: 40 7 FED. I.D. # 75-3050391 DRAYER PIIYSICAI. TRFR APY TN?TfTTTTF. " iescription CPT escription CPT UNITS 59 Description CPT UNITS iitial Evaluation-PT 97001 ltrasound (ea. 15 min) 97035 TENS Instruction 64550 :e-evaluation-PT 97002 ontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 iitial Evaluation-OT 97003 -Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea.15 min) 97762 valuation-OT 97004 CEks'etlP:rroc idurd s e q . , Prosthetic Trainin ea.15 min 97761 'hysicai Performance Test/Meas 97750 1 ot/Coid Pack 97010 Electrodes (per pair) A4556 =.C.E. Functional Drills-ea. 15 min) echanical Traction 97012 Splint: `61 li, -Stim Unattended 97014 Splint: herapeuticActivities (ea. 15 min) 97530 asopneumatic 97016 Supplies: herapeutic Procedures (ea.15 min) 97110 araffin Bath 97018 leuromuscular Reed (ea.15 min) 97112 hirlpool/Fluidotherapy 97022 'Tacking " Med icare °'N66m.Medi 4anual Therapy (ea. 15 min) 97140 frared 97026 Time In fait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out 4assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time aquatic Therapy (ea. 15 min) 97113 1Niiynd' Cre ?. 1_ Total Service Based Time ;elf Care/Home Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time :ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units :ognitive Skills/Training 97532 KEN Ll -e Wound-Non Selective 97602 B • m r. Total Units (SB + TB) Cx V NS R/S Date ice] LOW BACK PAIN 724.2 Reason: i G-fL?Irt } subjective: Patients perceived changes/progress toward functional goals: 'atient's chief complaint: )ther: )bjective: Please refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. -reatment progression: 30M: STRENGTH: GIRTH: )ther (Function, Special Tests, Sensation): kssessment: Patient's progress towards functional STG/LTG: )ther: 'tan: Progress/modify current treatment plan -Achieve by next visit / week Other: Brief Re-evaVProgress Report next visit D/C patient -Total # visits _ therapist Signature GUAt3A9 RUDICK, APRIL 14 S WASHINGTON ST KECHANICSBURG, PA 17055 License # 'PATIENT NAME' ` 38 404902 R DICK _ DA3EDF <TELEI BIRTH. ` 1J 2,18/86 717 [91 1867 12/06/0 APRIL 14 745 "INSURANCE' `ODE" ., t}FSGRIPTIDN . ' . ? '' CERTIFICATEIIrJ. . ??:' 900 A TO INSURANCE Ticket4 140093970 PTypef 4@ g ?? T-CT T T ?\_ DKAY-UK FitYSIUAL "TH 'Tha escription CPT ERAPY IN NITS Sli ..: 59 fUTE _ CLiM6CSla7. V.?n '.,{?'?ya ,...«, yr r ?. . _...... , ......e. .??, z .: ..:.. .'R'c`, +• ?:+_ .. , : ?tE75';?iw9C ..:... .. I1?rfe5 c 3• .. -. Description CPT UNITS 59 Description I CPT I UNITS iitial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 ,e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 iitial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 i le evaluation-OT 97004 Prosthetic Training (ea. 15 min) 97761 'hysical Performance TesttMeas 97750 Hot/Cold Pack 97010 Electrodes (per pair) A4556 =.C.E. Functional Drills-ea. 15 min) Mechanical Tractio 97012 Splint: E-Stim Unattended ] f 97014 Splint: herapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: herapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 euromuscular Reed (ea.15min) 97112 3 WhirlPool/FluidotheraPY 97022 3clang .JRed lare" Aeci Ianual Therapy (ea. 15 min) 97140 Infrared ' 97026 Time In f 'ait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out iassage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time j? vatic Thera ea. 15 min '9 PY ( ) 97113 era .,R`,,,4?ottW? ?a. _ Total Service Based Time •elf Care/Home Management 97535 Wound-Selective _< 20SQ. CM 7 I Total Time Based Time :ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CIA 8 Total Time Based Units :ognitive Skills/Training 97532 Wound-Non Selective 2 Total Units (SB + TB) Cx NS R/S Date LOW BACK PAIN 1 nher: =a t' perceived complaint: 'S s_ 724.2 Reason: ?bjective: Please refer to this patient'?il w sh t for d reatment progression: IOM: nher (Function, Special Tests, Sensation): .ssessment: Patient's progress towards functional STG/LTG: ether. 'Ian: ___?_,erogress/modify current treatment plan C?-?% -Achieve by next visit / week Other: .-sue Brief Re-e aVProgress Report next visit D/C patient -Total # visits herapist Signature !"ao RUDICK, APRIL 14 S WASHINGTON ST 'ECHANICSBURG, PA 17055 3804@4902 71T 91 1867 r= and specific exercises utilized during today's treatment. GIRTH: License# ?ATIEN.T 1 'IYIE' , DOCTORial6 `.Q111T 12/04/0 APRIL 14 745 INS1iR4N1;1c DDE . 'DES CR(PTJQI}' GERT1F14?f1t3 900 AUTO INSURANCE Ticket4 14061,3969 FTppet 40 PPn T n di7;-in n,)o i ?.? ® YER PHYSICA .4 ?,? ?` va1u escription L TH ?'n?-? CPT ERAPY INSTI ??.•,?-? UNITS 59 TUTE ?' ;,.r?r?'se'x`?$.lVl.,,o16es1#?!?'?#?u...?*,.? ;?.? ???'????her:?nced?restSUpplies• '"'?' Description CPT UNITS 59 Description CPT UNITS dial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 54550 e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 itial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 e-evaluation-OT 97004 '"" a' 1I1 t3f" equ re_ Prosthetic Training (ea. 15 min) 97761 hysical Performance Test/Meas 97750 Hot/Cold Pack 9701 Electrodes (per pair) A4556 .C.E Functional Drills-ea. 15 min) Mechanical Traction 7012 Splint: -?V E-Stim Unattended -97044_ Splint: ierapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 euromuscular Reed (ea. 15 min) 97112 WhirlPool/FluidotheraPY 97022 ? x>eE9? r,? ??AIA»d 4car anual Therapy (ea. 15 min) S 97140 Infrared ( 97026 Time In Mt Training (ea. 15 min) 97116 Group Therapy 97150 Time Out ;assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time quatic Therapy (ea.15 min) 97113 w,t*: q. ., s 25 ' ham,, ,ur1_ #+ re ??z` Total Service Based Time elf Care/Home Management 97535 Wound-Selective S 20SQ. CM 97597 Total Time Based Time ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units 7 ognitive Skillsfrraining 97532 Wound-Non Selective 97602 Total Units (SB + TB) LOW BACK PAIN ubjective: Patient's perceived atient's chief complaint: Ither: ress toward 724.2 Cx NS R/S Date Reason: Ibjective: Please refer to this patient's flow sheet for details specific to the proce ures/modalities and sp9ecific exer ses utilized du ing tod y's treatment. reatment progression: ?x r'r".A Z"? z!?r- I IOM: STRENGTH: GIRTH: nner truncnon, -)peciai lesrs, 5ensanon): - assessment: Patient's progress towards functional STG/LTG: X.' fit. ether. -? -•- -? L? £ 'tan: rogress/modify current treatment plan 1 -Achieve by next visit / week Brief Re-eval/Progress Report next visit D/C patient Other: -Total # visits 'herapist Signature License # ?!i>e1R54i$T0R 114ME,i4 1D{ADDRESS :; , P lT1EiYi O .Tv ; 4 ° ;`. 1?Q77Ekt,441AME D.i]C7OR` d, :DA? 11/3e/0 RUDICK, APRIL 3B 404902 R DICK APRIL 14 215p 14 S WASHINGTON ST DATE VF X-Et- tNSi>3AWt x ?IRTH_ ` ? . ND ?s bb 3. [St Gt31PTfONt;ERTIFlG 7E 70s. MECHANICSBURG, PA 17055 2 18/80 717 91 1867 900 AU TO INSURANCE Ticket;t 140093661 1 PType€ 40 79 TFT) TT) o 7s-,4nsn?Q1 1 n D YER PHYSICA K.- . ?• -. 41.. 00 )ascription L TII +o. ,, CPT ERAPY INS1 a UNITS 59 rUTE Description CPT UNITS 59 Description CPT UNITS iitial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 ;e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 iitial Evaluation-07 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 to-evaluation-OT 97004 ONeir??ca??;, Prosthetic Training (ea. 15 min) 97761 'hysical Performance TestlMeas 97750 Hot/Cold Pack t Electrodes (per pair) A4556 -.C.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint: R 9, W.? , M 0a utfN a? !? E-Slim Unattended Splint: herapeuticActivities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: herapeutic Procedures (ea. 15 min) 97110 3 Paraffin Bath 97018 leuromuscular Reed (ea. 15 min) 97112 Whirlpoof/Fluidotherapy 97022 1r oklCi _ lidi3d 11car ? a ."W"ei 7anual Therapy (ea. 15 min) 97140 f Infrared 97026 / Time In C? gait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out p iassage (ea. 15 min) 1 97124 Biofeedback 90901 Total Treatment Time j U aquatic Therapy (ea. 15 min) 1 97113 .. ..... Total Service Based Time ;elf Care/Home Management 97535 Wound-Selective S 20SQ. CM 97597 Total Time Based Time ;ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ,ognitive Skills/Training ® 97532 e Wound-Non Selective 97602 Total Units (SB + TB) [3 LOV BACK PAIN 724.2 tubjective: Patient's perceived changes/progress toward functional goals, z d " 'atient's chief complaint: - t;2?_S hher: )bjective: Please refer to this patient's flow sheet for details specific the procedFs/modalitjes and specif* exercises utilized during today's reatment progression: iOM: ,r1-- STRENGTH: Hf• S'am' . l ? - - --, = S ,l -7' S' )ther (Function, Special Tests, Sensation): assessment: Patient's progress towards functional STG/LTG: _ )ther: 'Ian: _J?Progress/modify current trea -Achieve by next visit / week Other: _Total # visits ?- 'herapist Signature / : %1>> RUDICK, APRIL 14 S WASHINGTON ST MECHANICSBURG, PA 17055 3B 404902 IRDICK 2 o Brief Re-eval/Progress Report next visit D/C patient License # ??T?EE,r fil AE = ?locr?R sut ; } :, : ? 7 11/28(0 APRIL 14 745 DItE Y: DES RIPaiOl?i n ;GEE#TIFICATEVQ.' 900 A TO INSURANCE Tickett 140093394 PTypeG 4B FED- T-D. # 75-3()50091 IUKAYL''K YHYSIUAL111EX"Y 1N escription CPT UNITS 5` I 59 TUTE Description CPT UNITS I59 Description CPT I UNITS itial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 itial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 e-evaluation-OT 97004 Pro sthetic Training (ea.15 min) 97761 hysical Performance Test/Meas 97750 Hot/Cold Pack ?\ 97 / Electrodes (per pair) A4556 :C.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint: E-Stim Unattended 9 Splint: ierapeubc Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 euromuscular Reed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 °?cac"3cin IUlexi icaeN t?nlAeii lanual Therapy (ea. 15 min 97140 `// Infrared 97026 _ f Time In - ?, ait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out lassage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time quatic Therapy (ea. 15 min) 97113 Total Service Based Time I ' elf Care/Home Management 97535 Wound-Selective :5 20SQ. CM 97597 Total Time Based Time ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ognhive Skills(Training 97532 Wound-Non Selective 97602 Total Units (SB + TB) o s o o LOW BACK PAIN ,ubjective: Patient's perceived changes/progress toward fu 'atient's chief complaint: )ther: )bjective: Please refer to this patient's flow sheet for details reatment progression: IOM: 724.2 the Cx NS R/S Date Reason: and specific exercises utilized during today's treatment. )ther (Function, Special Tests, Sensation):, assessment: Patient's progress towards functional STC )ther: GIRTH: 'Ian: Progress/modtfy current treatment -Achieve by next visit / week Other. -Total # visits -herapist Signature t ?- ?°?l?AR9?PITOF3'N. J1! RUDICK, APRIL 14 S HASHINGTON ST MECHANICSBURG, PA 17655 _ Brief Re-eval/Progress Report next visit D/C patient License #. r PATlEN:NO PATJENTTIAME ` y ?pGTDR'NO h -:DAT 11/27/6 38140490a R DICK APRIL 14 236p DA?i= OF 7 ELEPH?NE s INSURANCE BIE?T a .ar kT_ BODE, '-y DESIvR[PTIDN FICfITf ND:'"', 2 1B/86 717 91 1867 900 A TO INSURANCE Tickett 146693659 I PTypeO 40 P'Pn TT) i+??_zncn?oi 0RAYER PHYSICA 45 °,.. ;:. escription L TH PT ERAPY t, :. NITS T1 9 --- ------- fUTE .. I -• Ft?dS 5,11µ?rBCt?4tiiF u,fl?'coredres?Supphes+?i*t`F? j wa 01 WIN- Description CPT UNITS 59 Description CPT UNITS iitial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 :e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 iitial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 :e evaluation-OT 97004 e - h d i(a Iff fte nReP '._ Prosthetic Training (ea. 15 min) 97761 'hysical Performance Test/Meas 97750 Hot/Cold Pack 97010 Electrodes (per pair) A4556 '.C.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint: E-Stim Unattended 97014 Splint: herapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: herapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 euromuscular Reed ea.15min ( ) 97112 Whirl ool/Fluidothera P py 97022 ic_jrt lp"llfrrtij lanual Therapy (ea. 15 min) 97140 Infrared 97026 Time In fait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out lassage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time quatic Therapy (ea. 15 min) 97113 _ dare ? Total Service Based Time elf Care/Home Management 97535 Wound-Selective S 20SQ. CM 97597 Total Time Based Time .ommunityNVork Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units •ognitive Skills/Training 97532 Wound-Non Selective 97602 V?k LOW BACK PAIN 19d ?-I Total Units (SB + TB) Cx NS n? F R/S to Raacnn• I I1j/? 1I .t ) ('? t b _J;l ubjective: Patient's perceived changes/progress toward functional goals: 'atient's chief complaint: )ther: )bjective: Please refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. reatment progression: IOM: STRENGTH: GIRTH: )then (Function, Special Tests, Sensation): Lssessment: Patient's progress towards functional STG/LTG: )ther: 'Ian: Progress/modify current treatment plan -Achieve by next visit / week Brief Re-eval/Progress Report next visit D/C patient -Other. -Total # visits 'herapist Signature License # ` G11;t1R l?TlOR TIl1IVIEI4ND:ADbRESS ,. .A'TIENTRiCi: P;4TIENL N IIUIE '. DDC]O %NO.. DA7 11/25/6 RUDICK, APRIL 38 464962 R DICK APRIL 1114 1666 14 S WASHINGTON ST D?TEF 7ELEPJiANE T - tNSUl?X1?iDE- 51RTf 1)1Q`. CDDE 7`. DESGRIPTlO1J CER?IFIGA'fE.fdt?: MECHANICSBURG, PA 17655 2 18/136 711 191 1B67 966 A TD INSURANCE Ticket# 146692829 PTypef 40 82 # ?S_?n;mot i f PRY) TT) DRAYLRPHYSICA L TH ERAPY INS'I•a fUTE --- -- - ----? . r r escription CPT UNITS 59 Description CPT UNITS 59 Description CPT UNITS iitial Evaluation PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 e evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 iitia! Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 .e-evaluation-OT 97004 $" _ F otp m Prosthetic Training (ea. 15 min) 97761 hysical Performance Test/Meas 97750 Hot/Cold Pack 97010 Electrodes (per pair) A4556 .C.E. Functional Drills-ea. 15 min) Mechanical Traction 9 Splint: J E Slim Unattended 97014 Splint: rierapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 euromuscular Re-ed (ea. 15 min) 97112 3 Whirlpool/Fluidotherapy 97022 r krng, aj o_n 18 ?k lanual Therapy (ea. 15 min) 97140 Infrared 97026 ( Time In - - ait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out q, 32 lassage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time f quatic Therapy (ea. 15 min) 97113 9190 .: -? a? a%rd Total Service Based Time elf CarelHome Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ognitive Skills/Training 11 ® 97532 I ® Wound-Non Selective 97602 0 ° ® D Total Units (SB + TB) 724.2 CX Reason: NS R/S Date I bjective: Please refer to this patient's flow sheet for details specific to the, procedures/modalities and specific exercises utilized during today's treatment. •eatment progression: ther (Function, Special Tests, Sensation): ssessment: Patient's progress towards functional STG/LTG: ther: Ian: Progress/modify current treatment -Achieve by next visit / week -Other: -Total It visits ! -ierapist Signature RUDICK, APRIL 14 S WASHINGTON ST MECHANICSBURG, PA 11035 p -.nEIQ NO ' 7,, 38 404902 R DICK 2 18/80 111 91 1867 83 Brief Re-eval/Progress Report next visit License APRIL _bDEk : w DESOl31PT?GiN. 900 A TO INSURANCE D/C patient I 11/22/0 14 745 1Ei;:17J'CE ?- - - Ticked 140092827 PType4 40 DRAYER PHYSICA ??,'°, ???-r..?M'° L TH ?'?... ERAPY IN ?? . - _ STf ? fUTE ' i x " , : ?itpltia , e _et?PiiF?1 ? '?,'?C: ? ?•he"r?,.racedriios7Sug13ires?, m?`?-rya escription CPT UNITS 59 Description CPT UNITS 59 Description CPT UNITS 0tial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 iiiial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 e-evaluation-OT 97004 _ _ _ - tlReyp W. (ie; Prosthetic Training (ea. 15 min) 97761 hysical Performance Test/Meas 97750 Hot/Cold Pack t 97010 Electrodes (per pair) A4556 .C.E. Functional Drills-ea. 15 min) Mechanical Traction 012 Splint: a w ?1 - E-Slim Unattended 9701 Splint: ierapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 e1 Paraffin Bath 97018 euromuscular Reed (ea. 15 min) 97112 Whidpool/Fluidotherapy 97022 g ?? .., , 'sl icers n>r l441i lanual Therapy (ea. 15 min) 97140 Infrared 97026 j Time In alt Training (ea. 15 min) 97116 Group Therapy 97150 Time Out lassage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time quatic Therapy (ea. 15 min) 97113 r Total Service Based Time elf Care/Home Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units (p ogniitive Skills/Training o 97532, ? o Wound-Non Selective 97602 ® o Total Units (SB + TB) lbjective: Please refer to this patient's flow sheet for details specific to th reatment progression: OM:"" -- ?? STRENGTH: during today's-treatment. ether (Function, Special Tests, Sensation):. ssessment: Patient's progress towards functional STG/LTG: Ian: Progress/modity current treatment plan- -Achieve by next visit / week G Other: -Total # visits r herapist Signature 'DICK, APRIL ' WASHINGTON ST "SBURG, PA 17055 PA iFttrN0 381404902 R DICK ;DarE ni= zf7ELEI Brief Re-eval/Progress Report next visit License # 2418/80 717 J91 1867 D/C patient ATIENTTI,4ME 0 GTS3R;7y1Ca 11/2Q APRIL 14 745 flalE ""f ? ? dNSt7Ft?lNCE i E :.CDDE; 73ES`CF31P IQN.'ERT1FlG 900 A TO INSURANCE Ticket# 140092828 PTypel 40 4 FPn T n S_?nsn?or t DRAPER PHYSICA L TH ERAPY IN STt fUTE lescription CPT UNITS 59 Description CPT UNITS 59 Description CPT I UNITS iitial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 :e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 iitial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea.15 min) 97762 :e-evaluation-OT 97004 #?Iai#aI_ i eg iir. Prosthetic Training (ea.15 min) 97761 hysical Performance Test/Meas 97750 Hot/Cold Pack 97010 / Electrodes (per pair) A4556 '.C.E. Functional Dril". 15 min) Mechanical Traction ` 97 Splint: r _ftl} ,pes' e"o1 E-Slim Unattended 14 Splint: herapeuticActivities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: herapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 euromuscular Re-ed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 ^ ? c ')11? IAeti iiratae ? it oia ji lanual Therapy (ea. 15 min) 97140 Infrared 97026 J Time in rj fait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out lassage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time quatic Therapy (ea. 15 min) 97713 az.,eiti>i " . Total Service Based Time ! elf Care/Home Management 97535 Wound-Selective _5 20SQ. CM 97597 Total Time Based Time 5' C? ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ognitive SkilislTraining B 97532 ogle Wound-Non Selective 97602 B e B Total Units (SB + TB) 1Cx LOW BACK PAIR 724.2 Reason: objective: Patient's perceived changes/progress toward functional 'atient's chief complaint: )ther: )bjective: Please refer to this patient's flow sheet for details specific reatment progression: IOM' t1 i? CTR ? AIr,TP NS R/S Date )ther (Function, 9 ecial Tests, Sensation): Lssessment: Patient's progress towards functional STG/LTG: ?? - ific? 5 -rte. ? G-- )ther. 'Ian: rogress/modify current treatment plan -Achieve by next visit / week i ` - Brief Re-eval/Progress Report next visit D/C patient -Other:-,` Total # visits 'herapist Signature License # V } K .: Ct RfANT?Ft?1+1 A ?lE D;ADDEtESS , = P14TIETIT I+10 ,. ''_ 'PATIEh T1 AME Dt C?L?R' I©_ .., . DA1 RUDICK, APRIL 14 S WHINGUN ST 1ECHANICSBURG, PA 17055 3B1404902 R DICK S)AT??F' X;?LE m 2/18180 717 491 1867 APRIL utilized during today's treatment. 11/17/0 14 745 N0. 900 AUTO INSURANCE Tickett 140091889 PTypet 40 U3 S P'T) TT) R 7;_'3n;MGi DRAYER PHYSICA 'wf .{_...??? L TH ?? ERAPY- IN s STI TUTE tiSPS?a$g7 ICdB?1$T 12X31.. WP z a? ascription CPT UNITS 59 Description CPT UNITS 59 Description CPT UNITS itial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 a-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 itial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation-OT 97004 - Prosthetic Training (ea. 15 min) 97761 iysical Performance Test/Meas 97750 Hot/Cold Pack 9 , Electrodes (per pair) A4556 .C.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint: _ E-Slim Unattended 970 Splint: ierapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: rerapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 auromuscular Reed (ea. 15 min) 97112 WhidpooVFluidotherapy 97022 c 7 1?eu (icali l? r b - 11>rdu anual Therapy (ea. 15 min) 97140 Infrared 97026 f Time In alt Training (ea. 15 min) 97116 Group Therapy 97150 Time Out assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time uaticTherapy ea. 15 min 97113 Total Service Based Time elf Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time Dmmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ognitive Skills/Training 97532 Wound-Non Selective 97602 e ? • e e Total Units (SB + TB) Cx NS R/S Date LOW BACK PAIN 724.2 Reason: ubjective: Patient's perceived changes/progress toward functional goals atient's chief complaint: Ether: lbjective: Please refer to this patient's flow sheet for details specific to th reatment progression: fT IOM: STRENGTH: )ther (Function, Special Tests, Sensation): assessment: Patient's progress towards functional STG/LTG: ? h nher: 'Ian: rogress/modify current treatment plan _Achieve by next visit / week C Other: Flozz P;ocedure modaand sp cific exercises utilized during today's treatment. GIRTH: Re-eval/Progress Report next visit D/C patient _Total # visits ) C, -herapist Signature ?1 L. License # k, ,>GlJA7 AN3013?NA1111E Tsl , <CC l3EtESS. '. FATIENT:ND x 't?ATIENT'NAl?I 11/16/8 RUDICK, APRIL 38 464902 R DICK APRIL 14 815 14 S VA99INCTOR 9T ?tasuRAN s - DAT3= CTF? TELEPF30NE fi i r v BTRT??; ?' z1b, . ; G)?T) ;DGRTP7IDN` `)CT37dFIClLTE T+1D VHANICSBURG, PA 17055 2 8/80 717 ?91 1867 900 ALTO INSURANCE I TPckeete4 1404962711 D RAYE R Physical Therapy Institute Leading the Way to Good Health 2 NOV 2 9 2006 Progress Report Patient Name: April Rudick Date: 11/14/06 Date of Birth: 2/18/80 Sex: Female Date of Evaluation: 10/23/06 Diagnosis: LBP Date of Onset: 10/16/06 Referring Physician: Dr. Thompson Total # of Visits: 11 # Cx: 1 # NS: 0 Surgical Procedure: None Date of Sure : NA Be-Certification Period E fective Date: From: 11/21/06 Through: 12/20/06 SUBJECTIVE STATUS/PROGRESS: Current Complaints/Symptoms: Patient is reporting a gradual decrease of LB discomfort. Patient notes intermittent right LB ache. Patient reports taking no pain meds. Improvement of Prior Functional Limitations: Patient able to carry a tray base <5Ibs at work and she is now able to lift and reach for a plate. Walking, standing tolerance is good. Pain Rating: Best: 3/10 Worst: 8-9 / 10 Current: 5-6 / 10 shoulder Best: 0/10 Worst 8/10 Current 3/10 Lumbar OBJECTIVE AND FUNCTIONAL STATUS/PROGRESS: Current Objective Status: a Tenderness palpable right lumbar paraspinals and right sciatic region. Tenderness also palpable inferior angle of left scapular and lateral scapular border. • Lumbar AROM: - Flexion mid shins (T of 50°). - Extension significant limitations - SB (L) 0-10°, (R) 0-12° • AROM right shoulder Flexion 0-160° (P 0-170°), Abduction VR L, IR 0-60° (P 0-65°), noting "sharp" joint ache produced), ER • (+) Slump test right 11?Il1LE'`' _ ;: Right Left Hip Flex 4/4+/5 4/4+/5 Hip Abd 4+/5/5 4/5 Hip Ext 4/5 4/5 Hip Add 445 4/5 Knee Flex/Ext 4+15 4+15 DF/PF 5/5 5/5 • Transverse abdominis fair (+). Multifidus (R) fair, (L) fair (+). hl1VIT TJ Right Left Shld Flex 4/5* 4/5 Shld Abd 4+/5 4+/5 Shld IR 5/5* 4+/5 Shld ER 4+15 515 Latissimus 445 4+/5 Upper Trap 515 5/5 Lower Trap 4/4+/5 (pain)* 4/5 Middle Trap 4/5 (pain) * 4/5 * denotes right scapular pain produced Current Functional Limitations: Limitations are noted with repetitive usage of right UE to include washing down of tables at work, dishes (able to wash 6 dishes before increased scapular pain is noted) scrubbing her tub and doing laundry. Sitting tolerance -2 hours. ASSESSMENT OF STATUS/PROGRESS: Patient Name: April Rudick Mechanicsburg Center 5275 E. Trindle Road -Suite 110 -Mechanicsburg, PA 17050 a Paoxa: 717-790-9920 -Fax: 717-790-9923 7 Rationale for Need to Continue Skilled Therapy Services: Patient is demonstrating slow improvements in terms of palpable tenderness and pain level. Gradual functional improvement is noted. Patient would benefit from continued PT to address remaining treatment goals and to maximize function. Rehabilitation Prognosis/Potential: Fair Updated Objective Short Term Goals (to be achieved in 2 weeks): 1. Decrease pain to 1-2/10 lower mid back. 2. Increase ROM to WNL right shoulder and lumbar spine. 3. Increase strength by 1/2 in grade in bilateral LE and right scapular region. 4. Independent with HER 5, Decrease palpable tenderness right scapula region. Functional Goals to be Achieved by Next Progress Report (to be achieved in 4 weeks): 1. Increase functional ability to overhead reach and dress without difficulty. 2. To perform household chores of cooking, dishes, laundry and carrying < 51bs with good tolerance. PLAN: Treatment Plan: functional activities, strengthening, neuro re-ed, posture, manual therapy, A/AA/PROM, HEP, spine stabilization, e-stim, hot/cold pack. Treatment Frequency of: 3 times per week Treatment Duration of: 4 weeks I have discussed the above findings, assessment, revised treatment plan, and erpectel outcomes milli the patient. Ha/she is amtre of die diagnosis and prognosis and voluntarily agrees to continue participation in physi upational therapy services. Therapist's Signature: License: PT016294 Date: 11/13/06 Shane Br nson DPT, ATC, CGFI, Cert MDT Re-Certification: l heralry certify that rehabilhation services are medically neeessatyfor the above mentionel patient. l also understand that mysignature signifies agreement iwth the Updated Plat of Care, including the estimael frequency and duration, as established by the licensed therapist. 1 understand this Plat of Care hemmer afjactive on the date noted and remahts effective for the duration of trentmet outlined in the Plan of Care. Physician's Comments: Date: Physician's Signature: Tx: JK Please Return this Progress Report to Dmver Physical 771erapv Patient Name: April Rudick CERVICAL SPINE FUNCTIONAL QUESTIONNAIRE 7777777 Please answer each question and choose the response that most accurately describes your current functional limitations due to your neck or upper back injury. Gam-.. .... Functional Activity Never Seldom Occasionally Frequently Always I have difficulty dressing (i.e., putting on jacket, pulling shirt overhead) T have difficulty bathing or attending to personal hygiene I have difficulty gripping objects when writing, cutting food, etc. I have difficulty performing work tasks / V I have difficulty preparing meals / V I have difficulty performing daily household, work, or recreational tasks due to headaches I have difficulty placing an object overhead (i.e., into a cupboard) I? _F have difficulty performing heavy household chores (i.e., cleaning floors and walls) I have difficulty carrying laundry-basket, shopping bag, briefcase or handbag I have difficulty carrying objects greater than 10 pounds I have difficulty washing, brushing, or blow drying hair z/ 1 have difficulty reading I have difficulty with gardening or yard work I have difficulty performing light recreational activities including playing cards or knitting 1 have difficulty performing recreational activities such as golf, tennis I have difficulty driving such as when turning my head to look over my shoulder I have difficulty sleeping through the night due to my injury I have difficulty with daily tasks due to dizziness or loss of balance related to my injury I have difficulty looking up to perform overhead activities Please note an other functional limitations that were not a ddressed a bove: r? n 1 Patient Signature: MJL- Date: Therapist Signature: - ' Date: Drayer Physical Theraestitute Functional Questionnaire LUMBAR SPINE FUNCTIONAL QUESTIONNAIRE Please answer each question and choose the response that most accurately describes your current functional limitations due to your low back injury. Functional Activity Never [Seldom Occasionally Frequently Always I have difficulty rising from a chair or seated position I have difficulty tolerating a seated position for less than ten minutes I have difficulty tolerating a prolonged seated position for more than 30 minutes I have difficulty tolerating a standing position for less than 10 minutes I have difficulty tolerating a prolonged standing position for greater than 1/2 hour I have difficulty walking 5 minutes or less 1 have difficulty walking approximately 10 minutes f I have difficulty walking 20 minutes or greater I have difficulty getting into and out of a car I have difficulty performing household chores such as cleaning, cooking, and laundry I have difficulty bending over to pick up an object I have difficulty sleeping through the night due to my injury I have difficulty changing position when lying or sleeping including sitting up from a lying down position I have difficulty lifting and carrying objects I have difficulty dressing, grooming, or attending to personal care f I 1 I have difficulty with activities and feel unsafe due to feelings of my legs buckling or giving out 1 have difficulty performing recreational activities such as golf, walking, or traveling I have difficulty performing overhead activities Please discuss any other functional limitations that were not addressed above: Patient Signature: Date: Therapist Signature: Date: Drayer Physical Therapy Institute Functional Questionnaire -90 FED. I.D. # 75-3050291 -)KAYER PHYSICA L TH ERAPY INSTl k-JTE - HI?)?ntafeui.51",?IopedinerslSupa?1ies'.?? . cri ption CPT UNITS 59 Description CPT UNITS 59 Description CPT UNITS fial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 evaluation PT 97002 lontophoresis (ea. 15 min) 97033 I Orthotic Mgmt Training (ea. 15 min) 97760 tial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 :-evaluation-OT 97004 Ba tr..: ., -- Prosthetic Training (ea. 15 min) 97761 iysical Performance Test/Meas 97750 Hot/Cold Pack t 9701 j Electrodes (per pair) A4556 C.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint _ _ ?ts> a E-Stim Unattended 014 Splint: erapeutic Activities (ea. 15 min) 97530 Vasopneumatic 9701 Supplies: erapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 :uromuscular Reed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 a ? qtr r tsa_=ylgelR 3nual Therapy (ea. 15 min) 15 97140 Infrared 97026 Time In y Sit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out y 3ssage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time iuatic Thera ea. 15 min 97113 "? F _ "?f ; , P Total Service Based Time If Care/Home Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time immunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97596 Total Time Based Units )gnitive Skills/Training 97532 Wound-Non Selective 97602 o ? ® o e e Total Units SB + TB) Cx NS R/S Date LDY BACK PAIN and specific exercises utilized during today's treatment. jbjective: Patient's perceived changes/progress toward fur al goals: w 6-/ atienYs chief complaint: e? .. ther. ?e ?o ? a---?- ?•? .fir--z_d° ?" ??T/J bjective: Please refer to this patient's flow sheet for details specific to eatment progression: .C DM: STRENGI GIRTH: /_ _ -/ _ ther (Function, Special Tests, ssessment: Patient's progress towards functional STG/LTG: then. T ian: ?Fogress/modify current treatment plan -Achieve by next visit / week Brief Re-eval/Progress Report next visit D/C patient Other: -Total # visits ierapist Signature RUDICK, APRIL 14 S USHINGM ST MECHANICSBURG, PA 17055 124.2 - P.ATIEN7?a .` 38 404902 R DICK 2 18J80 711 91 1667 APRIL Reason: License # 11/14J0 14 745 900 ALTO INSURANCE I Tickett 140091887 PTypeK 40 FED. 1.D. # 75-3050291 ) AYER PHYSICEiI, THERAPY INS - r . TY - P fU"I'E al+ies` n [cec#antatequ?rd Ofher,i'nocetlucesl??pplies , , d V. same?BasgPg ?scrlption CPT UNITS 59 Description CPT UNITS $g Description I CPT I UNITS tial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 l TENS Instruction 64550 evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthofic Mgmt Training (ea.15 min) 97760 tial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthobc Checkout (ea. 15 min) 97762 :-evaluation-OT 97004 ServYce 6 se3 Procedur s/l?ilnrlahb es'yDir t i ai fac lotRe?u6 Prosthetic Training (ea.15 min) 97761 iysical Performance Test/Meas 97750 Hot/Cold Pack 97010 Electrodes (per pair) A4556 C.E. Functional Drills-ea. 15 min) Mechanical Traction 97012 Splint: E-Slim Unattended 97014 Splint: erapeubc Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies : erapeutic Procedures (ea. 15 min) uromuscular Reed (ea. 15 min) 97110 97112 I Paraffin Bath WhirlpoollFluidotherapy 97018 97022 Trac try ; IVlec king >rare lafon='Rhec7ie anual Therapy (ea. 15 min) 97140 Infrared 97026 Time In Sit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time luafic Therapy (ea. 15 min) 97113 s _ ?iNdtintl dare . < Total Service Based Time elf Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time )mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units )gnitive Skills/Training s 97532 e Wound-Non Selective 97602 s ® o Total Units (SB + TB) Ux IVJ rvo Uclttl LOW BACK PAIN 724.2 Reason: I ubjective: Patient's perceived changes/progress toward functional goals: I atient's chief complaint: I ther: lbjective: Please refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. reatment progression: ;OM: STRENGTH: GIRTH: I )ther (Function, Special Tests, Sensation) assessment: Patient's progress towards functional STG/LTG: I )ther: 'Ian: Progress/modify current treatment -Achieve by next visit / week Other: Total # visits -herapist Signature RUDICK, APRIL 14 S WASHINGTON ST NECHANICSBURG, PA 17055 Brief Re-eval/Progress Report next visit D/C patient ATIE IT=NO PATfEN 3BJ404902 R DICK APRIL 2119/B0 717 91 1667 92 License # 11/11/ 1 14 945 960 ALTO INSURANCE I Ticket# 140091567 PTypef 40 DRAYER Physical Therapy Institute Leadetg the Way to Good Health November 8, 2006 To Whom It May Concern: April Rudick is being seen at our physical therapy clinic for neck and low back pain. Dates of treatment thus far has been: October 23, 2006 October 24, 2006 October 25, 2006 October 26, 2006 October 27, 2006 October 30, 2006 November 1, 2006 November 3, 2006 November 6, 2006 April has appointments scheduled for the following days: November 8, 2006 November 11, 2006 November 14, 2006 November 15, 2006 November 17, 2006 April is progressing well but is expected to need therapy at a minimum of one additional month from the last noted appointment. Please contact my office with any questions. Respectfully, Shane Bronson DPT, ATC, CSCS, CGFI, Cert. MDT Mechanicsburg Center 5275 E. Trindle Road -Suite 11D t_Mechanicsburg, PA 17050 -PHONE: 717-790-9920 - rm: 717-790-9923 93 FED. I.D. # 75-3050392 1 DRAYER PHYSICAL, TH ERAPY INS Tt fUTE „E ralua finn. tiµ r . `° * ?¢, . ?_ me 3ased Mod litres Irecc Cbnta t?tequiced Dili ?roce?itras75upplres ascription CPT ' UNITS 59 Description CPT UNITS 59 Description I CPT UNITS itial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 e-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 I itial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 e-evaluation-OT 197004 cel3asedrocetTuresfNiglih es4 DirectCA#itacllotaqurr"e. Prosthetic Training (ea.15 min) 97761 hysical Performance TestlMeas 97750 o4Cold Pack ) 97010 Electrodes (per pair) A4556 .C.E. Functional Drills-ea. 15 min) echanical Tracti 97012 Splint: Tr?eas2_drecedutes"i 31t> ontactegi(rer? _'• E Slim Unattende 97014 Splint ierapeuticActivities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 ) Paraffin Bath 97018 euromuscular Reed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 Iiaclct»g- ?fled rea °Noia-lGleiin lanual Therapy (ea. 15 min p 97140 Infrared 97026 Time in SOO alt Training (ea. 15 min) 97116 Group Therapy 97150 Time Out lassage (ea. 15 min) 97124 I Biofeedback 90901 Total Treatment Time j quatic Therapy (ea. 15 min) 97113 - x` rr.:;; 9NQUnrI Caxe s.' :. Total Service Based Time elf Care/Home Management 97535 Wound-Selecfive 5 20SQ. CM 97597 Total Time Based Time ommunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units ognitive SkillsiTraining 97532 Wound-Non Selective 97602 Total Units (SB + TB) ! ? O B O B 1 )ther: )bjective: Please refer to this patient's fl w sheet for details specific to the oce ures/mod lit s an fic exercises utilized during today's treatment. reatment progression: ` ) IOM: ST NGTH: GIRTH: )ther (Function, Special Tests, Sensation): rssessment:,, Patient's progress towards functional STG4LTG: r,'- 77 C ?- )they. I'lan: Progress/modify current treatment plan -Achieve by next visit / week Other. Total # visits I C> -herapist Signature ;GU3A?iANT?i3 RYAIVI i400*013RE55' " PATI NT, ND } P,UDICK, APRIL 38 464962 ft DICK 14 S WASHINGTON Si a 4 "t3ATz F 'TEL'Ef'i stll __ µ MECHANICSBURG, PA 17635 18/86 717 491 1867 Report next visit D/C patient r~ License # PATIENT=1'JAAAE < DQCTdR_IA; 11/68/6 APRIL 14 745 ?` _ I??St?fL?1CE??4 _ <, ..tsctlir rt xM)CE1tT]F1>1ZE 966 AUTO INSURANCE I Ticket;t 146691566 PType4 46 4 FED. I.D. # 75-3050?91 -7??' lR AVWR PY-TVQTf A Y. ''Y?Fi'.R A PV Y1V..RT] B'Y T'f"Y+. L/ Lwalua fi', r,. „t H'„ ` € _ Tme$ased?IlfodalfJ)eslD dret'Cantac€eguired, Qtherroceduresl3uppfes ?scription I CPT UNITS 59 Description CPT UNITS 59 Description CPT UNITS tial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 l TENS Instruction 64550 evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 tial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation OT 97004 p ice$asedioce8ureslJodalttf esbirec 'tC>;tactlutRegu _:. ir"e_. Prosthetic Training (ea.15 min) 97761 iysical Performance Test/Meas 97750 o C ack D' ij 97010 Electrodes (per pair) A4556 C.E. Functional Drills-ea. 15 min) echanical Traction 97012 Splint Tmeasedl'cacedui ir?otoiaclie>tirrr E-Stim Unattended ' 97014 Splint: ierapeuticAc6vities (ea. 15 min) 97530 n' Vasopneumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 I Paraffin Bath 97018 >uromuscular Reed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 `Trackfrsg _:- Tlflerl lcare 1Vbif:Yllfeclic anual Therapy (ea. 15 min) 97140 Infrared 97026 Time In JO alt Training (ea. 15 min) 97116 Group Therapy 97150 Time Out assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time j auatic Therapy (ea.15min) 97113 2 'IYDugs? lGa% _ °, n Total Service Based Time :If Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time Dmmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598, Total Time Based Units ?. cgnitive Skills/T raining 97532 Wound-Non Selective 97602 Total Units (SB + TB) LOV BACK PAIN u ective: rauent's pe Tn\?-' ,ej(?, a tent's chief complaint: ether: lbjective: Please refe?r: reatment progressionl OM: I? )they (Function, Special Tests, Sensation): 6& __c_. ,ssessment: Patient's progreAs towards functional STG/LTG: )ther: - - 'fan: Progress/modify current treatment plan L'1 -Achieve by next visit / week Other: 724.2 a ? - o changes/progress toward #unctional goals: Cx NS R/S Date Reason: s flows eet for c _n the proced res/modalities and specific exercises utilized during today's treatment. t d/ GI TH:f?;r L H: s f - ?s Brief Re-eval/14rogress Report next visit D/C patient Total # visits 'herapist Signature License # 1 v ' GUARXI TOR NAMEAND ADDRESS i. P:4TIENT:NO. PATIENT=NAME r- T3,b.GlOR'1)10. ' 11/66/0 RUDICK, APRIL 38 404902 R DICK APRIL 14 745 14 S WHINVOR ST - "` -- iNS#Jf3lNCE: `_ AT OF TELEPHONE ?iR3H'` - . N© -CODEESGR{PTfOhf .::CERTIFIGAT# NECHANICSBURG, PA 17055 2 18/80 711 91 1867 906 A TO INSURANCE Ticket;I 140091565 PType# 40 FED. I.D. # 75-305029I i )RAYUR PHYSICAL >*ttaiua , THERAPY INS tion TI ;. TUTE ?7mfeasl?Vlratla#ii:,3i?cttsl?#aRegrtlre tlthErroced?srestSuppies ascription CPT UNITS 59 Description CPT UNITS 159 Description CPT I UNITS Gal Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 F truction 64550 evaluation PT 97002 lontophoresis (ea. 15 min) 97033 gmt Training (ea.15 min) 97760 tial Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 heckout (ea. 15 min) 97762 ?-evaluation-OT 97004 'der uaBasedErou? y s hoBelil e 3?ir c Gn` _ Regu?re Prosthetic Training (ea. 15 min) 97761 lysical Performance Test/Meas 97750 HotlCold Pack t 97010 Electrodes (per pair) A4556 C.E. Functional Drills-ea. 15 min) Mechanical Traction 7012 Splint: :am?ease7Pcoce?tares rect? ffrri_iitar?equlr _ E-Slim Unattended 970 Splint: ierapeubc Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: erapeutic Procedures (ea. 15 min) 97110 I Paraffin Bath 97018 auromuscular Reed (ea. 15 min) 97112 ?> Whirlpool/Fluidotherapy 97022 Trackilcl9 #91ed leat Nnn lfledli anual Therapy (ea. 15 min) 97140 Infrared 97026 Time in C ait Training (ea. 15 min) 97116 Group Therapy 97150 Time Out assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time auatic Therapy (ea. 15 min) 97113 ©und, Gare u'. Total Service Based Time :If Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time )mmun4/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units s' Dgnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB +TB) LOW BACK PAIN ubjective: Patient's perceived changes/progress toward fui atient's chief complaint: Ither: C Ibjective: Please refer to this patient's flow sheet for details reatment progression: 724.2 rssessment: Patient's progress towards functional STG/LTG: )ther: 'Ian: rogress/modify current treatment plan -Achieve by next visit / week y Other: Total # visits -herapist Signature f 14 Cx NS Reason: R/S Date dalities a specific exercis s utilized during GIRTH: I Brief Re-eval/Progress Report next visit D/C patient I li3?Ri4AlTOR 1?1411AE ANI3 ?DDRES PATIENT'NO .?ATfEN RUDICK, APRIL 38 404902 R DICK APRIL 14 S WHINVON ST -DATE OR IELEPFION£ MECHANICSBURG, PA 17055 BIR X10:=t Ga0i7E' 2 1Bf80 117 91 lBfiT License # nE<' DD CTQR,ND 11/03 14 330p SGRIP?D7!I,- _'- ?`•`?: ?Ef?TIFiG 900 ALTO INSURANCE I Ticket# 140091048 PType# 40 FED. LD. # 75-3050291 i 3RAYER PHYSICAL THERAPY INS -? z Val08#ORx?.?s„tom TI TUTE rflle$drie?7Ltle i1311EGtYiDTiGsirfd 1}ti;eTP3ACeI?iIC£Sj.?4Up?tIeS ascription I CPT UNITS Description CPT UNITS 59 Description CPT UNITS tial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 3-evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 tial Evaluation-OT 97003 ] E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation-OT 97004 ?S IaM' Mroeetl7ries#h1oF1 i> ' Directi;d'; A' squ ired Prosthetic Training (ea. 15 min) ( 97761 lysical Performance Test/Meas 97750 Hold Pack 97010 t, U Electrodes (per pair) A4556 C.E. Functional Drills"a. 15 min) Traction Mechanical wa-ff Splint: Based'[?fflgetllu{s irbt* 60 ct?Requiled " E-Slim Unattended 14 Splint: ierapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: erapeutic Procedures (ea. 15 min) 97110 l Paraffin Bath 97018 :uromuscular Reid (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 T[ac ng ,`J "`1JIe lcace 407 di anual Therapy (ea. 15 min) 1,51 97140 Infrared 97026 Time in sit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out - i lo assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time luatic Therapy (ea. 15 min) 97113 IGaon? dare Total Service Based Time :If Care/Home Management 97535 Wound-Selective :5 20SQ. CM 97597 Total Time Based Time )mmunityMork Reintegration 97537 ective > 20SQ. CM Wound S 97598 Total Time Based Units )gnitive Skills/Training 97532 Wound N ;oielective 97602 Total Units (SB + TB) v E•? ® • LOW BACK PAIN 724.2 ubjective: Patient's perceived changes/progress toward functional goals: atient's chief complaint: ther: R/S Date bjective: Please refer to this patient's flow sheet for details spe n to the reatment progression: _?j? OM: STRENGT 1:_ CX NS Reason: pnd specific exercises utilized during today's treatment. GIRTH: ether (Function, Special Tests, Sensation): 2 .ssessment: Patient's progress towards functional STG/ TG: _ Yther: J(I r G' -Ian: Progress/modify current treatment plan .ao -Achieve by next visit / week Brief Re-evaVProgress Report next visit D/C patient Other: Total # visits - ' Li herapist Signature cense tli?Rl41 OR N)4iillE xlN©'AZ3I7EtESS P,.ATlENT N©: ' .' F i4TIEtY tVk?ME f7p?TflFt hlD, s, DAI 11/01/0 RUDICK, APRIL 38 404902 R DICK APRIL 14 745 14 S MURTON ST DATE #?', F tOm-0146WE - INSURANCE r OC3E , DiESRIPl7DN s sL y ': = `ERTIFiC7?l E ND. E - ' MECHANICSBURG, PA 17055 , . 2 FS 80 717 91 1867 900 Al?TO INSURANCE I Tickett 140091047 PType# 40 19-7 FFT) T-n_ # 75-1050')Q 1 .RAPER PHYSICA L THERAPY IN STI TUTE nsk? G+ ` atP?nVdl9? -? .._.., ttDA?"N ?h airne?t3xs or?aTiies 31r Lt ?SYit?7G e?tLlrEt?, } t18 -*PfDCEfU]Sltl Iles •scription CPT UNITS 59 Description CPT UNITS Description CPT UNITS :ial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 164550 -evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 ial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 -evaluation-OT 97004 ceaseroceduslAs i 3Ged tp?'c#tntequ 7re' Prosthetic Training (ea. 15 min) 97761 ysical Performance Test/Meas 97750 H Cold Pack 97010 Electrodes (per pair) A4556 ..E. Functional Drills ea 15 min) Mechanical Traction 97012 Splint: masatl?ibcr?tus [e rntal;fequitetfF ` E-Stim Unattended 97014 Splint: erapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: j arapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 1 -uromuscular Reed (ea. 15 min) 97112 Whidpool/Fluidotherapy 97022 " _ a larlg "• lllferllcare on Medie tnual Therapy (ea. 15 minjL5 ` 97140 f Infrared 97026 Time in 7' lit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out )ssage (ea. 15 min) 97124 Biofeedback - 90901 Total Treatment Time luatic Therapy (ea. 15 min) 97113 7-17 777 ?_Olifintl aie , - Total Service Based Time :If Care/Home Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time >mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units )gnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB + TB) Loa BACK PAIN 724.2 Cx NS R/S Date Reason: ,jbjective: Patient's perceived changes/progress toward functional goals: irk atient's chief complaint: D then. , • •r ' ?' bjective: Please refer to this patient's flow sheet for details spec' is to the i 'eatment progression: OM: STRENG `T s and specific exercises utilized during today's treatment. -ther (Function, Special Tests, .ssessment: Patient's progress towards functional STG/LTG: /? f l??--T»-fr-----f---? Ither. ,;r Ian: !/Progress/modify current treatment plan -Achieve by next visit / week T Brief Re-eval/Progress Report next visit D/C patient Other: _Total # visits herapist Signature -?? License # RUDICK, APRIL 14 S WHINGTQN ST NECHANICSBURG, PA 17055 380404902 RIDICK 2 18/80 717 $91 1867 APRIL 900 AITD INSURANCE 10/30/0 14 745 Ticket# 140091046 PType# 40 ¦ f)RAV'FR PffYCif'.AT,'T'TFTF.RAPV YN.,RTi rYTT'F. FED. I.D. # 75-3050291 ?? ` - nsIlla 6c3n ?Y"`tla` Till#e1323Ef?IDf?IEI Dltbip e$" Atitt`1tefit p12fiOG't?J2TES ?SLRj}?ie5 ascription CPT UNIT ption CPT UNITS 59 Description I CPT i UNITS itial Evaluation-PT 97001 I ound (ea. 15 min) 97035 TENS Instruction 1 64550 evaluation PT 97002 1 horesis (ea. 15 min) 97033 Orthotic Mgmt Training (ea.15 min) 97760 itial Evaluation-OT 97003 Attended (ea. 15 min) 97032 0rthotic Checkout (ea. 15 min) 97762 '-evaluation-07 97004 j cs Prosthetic Traini ng (ea.15 min) 97761 iysical Performance Test/Meas 97750 old Pack Electrodes (per pair) A4556 C.E. Functional Drills-ea.15 min) nical Traction 97012 Splint: aut? ?:l ?trsctl; -VP;0 R3etj Unattended 4 Splint: ierapeutic Activities (ea. 15 min) 97530 neumatic eumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 auromuscular Re-ed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 T bk?c?g t'fitaecl tcao e° Ldon`=RBeEliK anual Therapy (ea. 15 min) '97140 Infrared 97026 Time in all Training (ea. 15 min) 97116 Group Therapy 97150 Time Out s- L assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time auatic Therapy (ea. 15 min) 97113 Afovtttiar Total Service Based Time j ! ,If Care/Home Management 97535 Wound-Selective 5 20SQ. CM 97597 Total Time Based Time ? S ommunityMork Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units -s ognitive SkillrJraining o 97532 a a Wound-Non Selective 97602 ® o e Total Units (SB + TB) LOW BACK PAIN 724.2 All Cx NS R/S Date Reason: rL <B I ther: Objective: Please refer to this patient's flow sheet for details specific to reatment progression: yl? OM: STRENGTH: Ither (Function, Special Tests, y mac. ssessment: Patient's progress towards functional STG/LTG: )ther. )ce urres/modalities esand specific exercises utilized during today's treatment. GIRTH: z; Y 41 All 'Ian: -Flrogress/modi y current treatment -Achieve by next visit / week Other: -Total # visits 'herapist Signature RUDICK, APRIL 14 S WASHINGTON ST NECHANICSBURG, PA 17055 Brief Re-eval/Progress Report next visit D/C patient License # .1PATiENTTN-0- I?ATitr4T'NAME _`. :DO0T6R:ND. 10/27/0 361404902 R DICK APRIL 14 1030 I3fiTE t33F 7E4EP,kdONE 3. .. tDtSl?BANCE:y BIiiTF3 NOODiti, D3=SCRIPT?DN tiCERTIFiCA7E NO' . 2 1B/B0 717 191{iB67 900 AUTO INSURANCE TicketK 140090859 PType4 40 3RAVVR PNY?TCAT.TffRRAPV3N..gTe e IfTTF, FED. I.D. # 75-3050291 Inp. n `• °a i , ame a d fndaii es 3`ir Cn c guiri~ "` +3theE_Pra Prep, es c !scription CPT I UNITS 59 Description CPT UNITS Description CPT I UNITS tial Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 1 64550 evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 tial Evaluation-OT 97003 E-Slim Attended (ea. 15 min) 97032 0rthotic Checkout (ea. 15 min) 97762 evaluation-0T 97004 erv!ce'Ba e? eedures lodJffti ewice'ct bh ; gqu-M. Prosthetic Training (ea. 15 min) _, 97761 iysical Performance Test/Meas 97750 Hot/Cold Pack L 9701 Electrodes (per pair) A4556 C.E. Functional Drills-ea. 15 min) i Mechanical Traction 97012 Splint rnased A04 E Slim Unattended Splint: erapeuticActivities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: erapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 :uromuscular Reed (ea. 15 min) 97112 Whiripool/Fluidotherapy 97022 3raC?clrlg b Viler? lcare_ Mori iii anuai Therapy (ea. 15 min) 97140 Infrared 97026 Time in S lit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out 1 Z assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time luatic Therapy (ea. 15 min) 97113 a , . w °- riltralltld a?e -= Total Service Based Time !If Care/Home Management 97535 Wound-Selective <_ 20SQ. CM 97597 Total Time Based Time immunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units )gnitive Skills/Training 7 97532 F T91 Wound-Non Selective 97602 a B Total Units (SB + TB) rRX NS R/S Date LON BACK PAIN 724.2 eason: objective: Patient's perceived changes/progress toward functional Is: itient's chief complaint: cJ' Cher: bjective: Please refer to this patient's flow sheet for details specific to t procedures/modalities and specific exercises utilized during today's treatment. eatment progression: DM: STRENGTH: GIRTH: Cher (Function, Special Tests, Sensation): ssessment: Patient's progress towards functional STG/LTG: an: Progress/modify current treatment plan ?-? -Achieve by next visit / week Other. -Total # visits ierapist Signature RUOICK, APRIL 14 S HSHINVON ST MECHANICSBURG, PA 17055 Brief Re-eval/Progress Report next visit D/C patient I License # 380404902 RIOICK 18/80 717 $91 1B67 APRIL 900 AUTO INSURANCE 10/25/6 14 200p Tickei4 140090796 PTypeK 40 i 00 • FP1) T n u ?;-1n;moi t 1 )KA-Yh,'K PHYSICA a?1l L THERAPY IN tlanz STa r UTE - -- -- f -.neasee?ate3e#CaEacRog f?re,d x? >?'(3ffterPscedtiEe0000lizs. ascription CPT UNITS 59 Description CPT UNITS 59 Description CPT I UNITS Gal Evaluation-PT 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 tiai Evaluation-OT evaluation-OT 97003 97004 , E-Stim Attended (ea. 15 min) asedl?roaed „tin 97032 es°©Srec tgnctefFte w 9 '.' - Orthotic Checkout (ea. 15 min) ProstheticTrainin9 (ea.15min) 97762 97761 iysidal Performance Test/Meas 97750 Hot/ old Pack 5' 97010 Electrodes (per pair) A4556 C.E. Functional Drills-ea. 15 min) m3ase?!ei fJt nzc acegulred echanical Traction E Sfim Unattended t 97012 97014 Splint: Splint: erapeutic Activities (ea. 15 min) 97530 Vasopneumatic 97016 Supplies: erapeutic Procedures (ea. 15 min) 97110 Paraffin Bath 97018 :uromuscular Reed (ea. 15 min) 97112 Whirlpool/Fluidotherapy 97022 ?7rakir?g ;,1` M13 taare++ 7Ac?illic anual Therapy (ea. 15 min) L(9 97140 / Infrared ; 97026 Time In Sit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out 3ssage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time luatic Therapy (ea. 15 min) 97113 ?Natind Carey ?' _ v Total Service Based Time ?If Care/Home Management 97535 Wound-Selective _20SQ. CM 97597 Total Time Based Time >mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units >gnitive Skills/Training e 97532 • Wound-Non Selective 97602 ® 1 ® e Total Units (SB + TB) 7 Cx NS R/S Date Reason: I atient's chief complaint: I ther: bjective: Please refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. eatment progression: DM: STRENGTH: GIRTH: ther. Ian: Progress/modify current treatment plan e!L, fn - -Achieve by next visit / week f Brief Re-evaUProgress Report next visit D/C patient -Other: -Total # visits f nerapist Signature ?/? License # RUDICK, APRIL 14 S WASHINGTON ST MECHANICSBURG, PA 17055 380464962 RIDICK 2 18180 717 ip91 1667 10/2 APRIL 14 845 Ticket# 140090797 PTypet 40 1 r1PAgVWP PT4VQY(-'AY TYFTRAP'V YAJ4ZTis'7TTIP.. FED. !.D. # 75-3050291 „ -_valulia ' f?on? meBsedsPtlalies,D , A1 3reGGa ntactRequired ; t]fnef:PraeeduieslSuppiies ascription CPT UNITS 59 escription CPT UNITS 159 Descripfion CPT UNITS Mal Evaluation-PT o 97001 Ultrasound (ea. 15 min) 97035 TENS Instruction 64550 evaluation-PT 97002 lontophoresis (ea. 15 min) 97033 Orthotic Mgmt Training (ea. 15 min) 97760 Mal Evaluation-OT 97003 E-Stim Attended (ea. 15 min) 97032 Orthotic Checkout (ea. 15 min) 97762 evaluation-OT 97004 1 1 ' iceasetltProldureMda'fi ef{ec t?ontatd flnti#equ ?rt Prosthetic Training (ea.15 min) 97761 iysical Performance Test/Meas 97750 Ho old Pack ; 97010 Electrodes (per pair) A4556 C.E. Functional Drills-ea. 15 min) echanical Traction 97012 Splint: czteased Poc>iai?s uec nlaegA¢e Y E-Stim Unattended If 97014 Splint: j ierapeuticActivities (ea. 15 min) 975301 1 Vasopneumatic 97016 Supplies: ierapeutic Procedures (ea. 15 min) 97110 arafnn Bath 97018 -uromuscular Reed (ea. 15 min) 97112 WhiripooUFfuidotherapy 97022 + clzTing .' et 31 uat *11 e. R anuai Therapy (ea. 15 min) 97140 Infrared •97026 Time In Sit Training (ea. 15 min) 97116 Group Therapy 97150 Time Out p3 assage (ea. 15 min) 97124 Biofeedback 90901 Total Treatment Time auatic Therapy (ea. 15 min) 97113 ," Q`` gtlAri are ,' f'„4 - µ Total Service Based Time Af Care/Home Management 97535 Wound-Selective _5 20SQ. CM 97597 Total Time Based Time )mmunity/Work Reintegration 97537 Wound-Selective > 20SQ. CM 97598 Total Time Based Units )gnitive Skills/Training 97532 Wound-Non Selective 97602 Total Units (SB +TB) Cx NS R/S 1 Date ubjective: Patients perceived changes/progress toward functional atient's chief complaint: 15 .,. -1 qu ther. bjective: Please refer to this patient's flow sheet for details specific to the procedures/modalities and specific exercises utilized during today's treatment. 'eatment progression: OM: STRENGTH: GIRTH: I ther (Function, Special Tests, I ssessment: Patient's progress towards functional STG/LTG: ther. Ian: Progress/modify current treatment -Achieve by next visit / week -Other. Total # visits ierapist Signature RUDICK, APRIL 14 S WASHINGTON ST MECHANICSBURG, PA 11655 L-6 r :PATfENTlkb. 1?ATlel 38 464962 RIIDICK ' APRIL 8/B6 717 191 1867 Brief Re-eval/Progress Report next visit D/C patient I / 'f _ f • )L- Reason: License # 8E, !D'OICTOR 16/23/6 14 1169 Ticket# 146696157 PTypef 49 :L02 Initial. Evaluation Patient Name: Aril Rudick - - - ------------ Date of Evaluation: 10/23/06 Date of Birth: 2/18/80 Sex: Female Date of Onset: 10/16/06 Diagnosis: LBP Surgical Procedure: None Referring Physician: Dr. Thompson Date of Surgery: NA SUBJECTIVE HISTORY: Subjective History: Ms. Rudick was referred to Drayer Physical Therapy Institute by Dr. Thompson for evaluation and management of LBP. Patient notes that on 10/16/06 she was involved in MVA when she was rear ended when attempting to merge and looking sharply back over her left shoulder. Patient notes that she had medical imaging that included x-rays and a CAT scan, that were both negative. Patient notes she just feels severe muscle spasms along the right side of her neck and shoulder blade, thoracic rib area and down to her right low back. Current Complaints: Right LBP > right shoulder pain. Function: Patient notes that she always has difficulty sitting >30 minutes, walking >20 minutes, performing work required duties primarily due to sitting and recreational activities. Frequent limitations with sitting < 10 minutes, standing in one position > 1/2 hour, walking > 10 minutes, performing household chores such as cooking and cleaning, difficulty bending over to pick up objects, sleeping, changing positions while sleeping, difficulty looking and carrying objects, dressing, grooming, attending to personal hygiene. Occasionally has difficulty getting out of a chair, standing < 10 minutes, getting out of a car. Pain Rating: Current: 5110 Worst: 8/10 Best: 4/10 Patient notes she feels better standing or laying flat on her back, feels worse with sitting and bending. Occupation/Work Status: Patient is a Wick program manager, currently not working, unable to sit. Slated to return to work next week if able. Social History/Interests: None. PMHx: Previous MVA without significant injury. Medical Precautions/Contraindications: None. Medications: Flexural, decreases symptoms for -2 hours then pain returns. Patient's Goals for Therapy: To decrease her pain and to be able to return to work. OBJECTIVE FINDINGS: Observation/Inspection: Patient stands during subjective history intake due to being uncomfortable in sitting. Patient presents with no significant lateral shift, but maintains a slightly flexed and rotated right positioning in standing. Palpation: Patient has significant tenderness to touch along lumbar thoracic and cervical paraspinals on right, as well as the upper trap, middle trap, and lower trap on the right. Patient has significant increased resting muscle tension with this corresponding musculature also. ROM: Cervical ROM:. Flexion minimally restricted with pulling along right upper trap; Extension moderately restricted with pain centrally along C5-C6. RROT WNL. LROT slightly limited. RSB WNL. LSB moderately restricted with contralateral tightness and pain. Lumbar ROM: Flexion severely limited with increased right LBP. Extension slightly decreased with no affect on symptoms. Right shoulder AROM grossly WFL all directions, but produces increased pain. Strength: MMT deferred at this time. Patient Name: April Rudick i0 Special Tests: Spring testing for cervical instability and thoracic instability, lumbar instability negative at all levels. SI Joint palpation testing negative. Patient has provocation of pain with functional movements, such as attempting to do a squat and lift maneuver, as well as sit to stand. The above it fonnaion represenu all sign f cant subjective and objective findings. Please refer io the enclosed Plan of Cara for ray asseamenl, treatment goals, tmd treatment plan. Please sign and return the Plar of Cam to Drnver Phvsical Theraw. /f you wish, make a rn/ry for your records. Tlmnk you for this referral. /will keap you h formed of nnv dung= in 1he patient's status or the treatment plan. Therapist's Signature: Tx: JK' License: PT016294 Date: 10/23/06 Shane Bronson DPT, ATC, CGFI, Cert MDT Patient Name: April Rudick 104 DRAPER Physical Therapy Institute Lending the Way to Good HeaUh Patient Name: April Rudick Date of Evaluation: 10/23/06 Date of Birth: 2/18/80 Sex: Female Date of Onset: 10116106 Diagnosis: LBP Surgical Procedure: None Referring Physician: Dr. Tho son Date of Sure : NA Initial Certification Period E fectiveDate: Through: 11/21!06 From: 10/23/06 ASSESSMENT: Rationale for the Need for Skilled Therapy Services: Signs and symptoms'consistent with LBP, thoracic pain, cervical pain, secondary to muscle spasms, sip MVA. Patient would benefit from skilled PT intervention to decrease pain, improve postural awareness, ROM, strength, and ultimately improve functional abilities. Rehabilitation Potential: Good Objective Problems/Functional Limitations: - Pain -Function -ROM - Poor posture - Inability to work at this time Short Term Objective and Functional Goals: (to be achieved in 2-3 weeks): 1. Decrease pain to 3/10 at worst. 2. Improve trunk Flexion ROM WNL, cervical ROM Flex/Ext WNL. 3. Increase strength of deficits revealed by 1/2 MMT grade. 4. HEP for postural awareness and correction, muscle spasms control techniques. 5. Improve functional abilities for sleeping, sitting, returning to work. Long Term Objective and Functional Goals: (to be achieved in 4-6 weeks): 1. Decrease pain to 1/10 at worst. 2. Improve ROM cervical Rotation WNL, trunk Extension WNL. 3. Increase strength to 515 throughout any deficits that are revealed in the future. 4. HEP functional stabilization, body mechanics drills. 5. Return to pre-morbid functional level of lifting, walking, squatting, kneeling, performing basic household chores. PLAN: Treatment Plan: functional activities, strengthening, neuro re-ed, posture, manual therapy, ROM, mobilization, HEP, spine stab, McKenzie, job skills, traction, infrared, a-stim, hot/cold Treatment Frequency of: 3 times per week Treatment Duration of: 4-6 weeks outcomes with die patian. H&Wie is award p)Wirnlloccupational theragvservices. Therapist's Signature: 0 L License: PT016294 Date: 10/23/06 S Bronson DPT, ATC, CGFI, Cert MDT NOV 0 3 2000 Plan of Care agrees to continue participation in Certification: /hereby certify that rehabilitation services are medically necersarv for t/te above me boned patient. l also understand that my signaturesignifies agreement with the Initial Plan of Care, including the atitn ual frequency and duration, as established by the licensed therapist, and this Initial Plan of Care supersales the instrucdorts outlined on the Prescription that initiated rehabilitation services. Physician's Comments: Physician's Signature: Date: f'/.J ',j` M Tx: jK Patient Name: April Rudick Mechanicsburg Center 5275 E. Trindle Road -Suite 110 -Mechanicsburg, PA 17050 - PAoNE: 717-790-9920 -m: 717-790-9923 ices DEPAtTMENTOF fWALIE February 2, 2007 David L. Lutz Angino & Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110-1708 Dear Mr. Lutz: As requested, the information for April Rudick regarding her automobile accident: 1. Commonwealth of Pennsylvania, Department of Health. 2. WIC Program Representative. 3. Job description attached. 4. Date of employment 11103/05. April missed 121.55 hrs. of work as a result of the accident. 5. The employee's rate of pay at the time of accident was $19.67 hourly, 37.5 hrs. per week. 6. Yes, employee was entitled to raises: 1/1107- hourly rate $20.36. 1/6107 - hourly rate $20.82. 7. Per Department of Health, Office of Budget: Social Security - 7.659% of salary Retirement - 3.3690% of salary Workers Comp -1.6383% of salary Healthcare Benefits - $550 per pay period Life Insurance - $5.04 per pay period 8. No disability insurance offered. Since ely, Monique L. own Human Resource Assistant Attachment 3J E- Bureau of Human Resources ? Room 126 Health & Welfare Building o 7th & Forster Streets ? Harrisburg, PA 17120 109 °v' Id 3105 it ?a--Ir3 Commonwealth of Pennsylvania STD-370 POSITION DESCRIPTION Last Name First Name MI Employee Number Rudick April 00623032 Job Title Job Code Working Title Position Number Wic Prgm Rep 39080 Wic Prgm Rep 00077405 Department Organization Code Health HL Div of WIC 9411 Supervisor's Last Name Supervisor's First Name supervisors job Title Supervisor's Pos Number Sadler Renee Vic Prgm Supv 00000862 Days Worked Start Time End Tune Hours/Week (Check an that awly) Explain any schedule variations: 8:00 4:30 37.5 ?S j E9 T RW T Fj Sr .l Purpose: Describe the primary purpose of this position and how it contributes to the organization's objectives. Provides clerical and office support within the Division to ensure its operations are conducted efficiently and v. WIC Program Representative assists in the monitoring of contractor's compliance with Federal lations and State policy by evaluating management, certification, nutrition education, participant ices, civil riahts compliance and accountabilitv. Won of Duties: Describe in detail the duties and responsibilities assigned to this position. Descriptions should the major end result of the task Example: Types correspondence, reports, and other various documents from itten drafts for review acrd signature of the supervisor. on-site Program Reviews of up to 12local agencies a year. flyzes local agency Program Review findings to monitor compliance with Federal regulations and to policy; measures the adequacy of the local agency's WIC Program operational practices; and zpares the local agency performance with WIC-Program objectives; completes specified portions of Program Review report, and coordinates and writes the final Program Review report itemizing ,ciencies, observations and requirements/recommendations for compliance for issuance by WIC °,ctor. uates local agency Corrective Action Plan (CRP's) to ensure that proposed corrective actions are Dpriate and adequately address review findings. Ensures that plans are received and implemented in required schedule. as lead or co-trainer in training program review staff in both general aspects of program review as as areas for which the employee has specific programmatic responsibility in the Planning and itoring Section. lops new and revised content for inclusion in Program Review documents in consultation with Agency, Federal, and local staff. 'oordinates the WIC Director's Meeting agenda; makes all necessary arrangements with hotel sales ersonnel for meeting room, overnight accommodations and snacks; invites guest speakers and repares all necessary paperwork to notify the local agency directors, the Bureau of Information echnology and all other interested parties of the meeting date, place, time, and agenda; and acts as a it at each meeting. as needed, for inquiries concerning Substance Abuse, Civil Rights, Voter Registration and :ors and assists local agencies' compliance to policies and procedures and follows up on any encies in areas of Income Eligibility, Program Abuse and Sanctions, Confidentiality, and ipant Fair Hearings. Compiles a yearly report on number and type of program abuses, which ed in disqualification. processing and analyzing data of Dual Participation reports, Commodity Supplemental Food (CSFP) Dual Participation reports, and Redeemed/Voided, Lost or Stolen Food Instrument ?s and revises, as needed, Standard operative Procedures (SOP" s) for Planning and Monitoring functions. in development or clarification of WIC Reports with Bureau of Information Technology (BIT). other related duties as assigned. in planning and conducting statewide training for local agencies. s changes in Federal regulations and revises state agency policy and procedures as needed to with Federal Regulations. in Making: Describe the types of decisions made by the incumbent of this position and the types of decisions d to others. Identify the problems or issues that can be resolved at the level of this position, versus those that must be d to the supervisor. Example: In response to a customer inquiry, I research the status of an activity andprepare a response for my supervisor's signature. pendently reviews assigned reports for accuracy and recommends corrective action. Provides local kcy WIC staff with technical assistance in assigned areas of responsibilities. Responds to general iries and questions from participants and the general public regarding the program. Supervisor :ws most correspondence and reports. irements Profile. Identify any requirements, such as a licensum registration, or certification, which may be sary to perform the functions of the positions. Position-speck requirements should be consistent with a Necessary al Requirement or other criteria identified in the classification specocation covering this position. Example: ssional Engineer License 1. N/A N/A N/A Functions: Provide a list of essential functions for this position. Example: Transports boxes weighing up to 60 1. Conducts on-site program reviews. 2. Analyzes program review findings. 3. Writes comprehensive reviews. 4. Conducts telephone interviews. 5. Writes letters and reports. i 4. '? 6. Conducts training of WIC staff. 7. Drafts policies. 8. Provides technical assist. to staff. 9. Uses a personal computer. 10. Ability to communicate effectively. CERTIFICATION By entering my name below, I certify to the best of my knowledge all statements contained in this position description are correct. Employee's Acknowledgement April D. Rudick Job Title: Wic Prgim R r106 1/2006 3:03:00 PM Supervisor's Acknowledgement Job Title: Date Renee Sadler Wic PM S v 10/31/2006 2:5.8:21 PM Reviewing Officer's Job Title: Date Acknowledgement Milo Y. Woodward Pub Mth Prgm Mgr 10/31/2006 3:05:28 PM jig N C1 c ` t:" rte " GJ' ? 4t;;yT " PRAECIPE FOR LISTING CASE FOR TRIAL (Must be typewritten and submitted in duplicate) TO THE PROTHONOTARY OF CUMBERLAND COUNTY Please list the following case: (Check one) (XX) for JURY trial at the next term of civil court () for trial without a jury CAPTION OF CASE (entire caption must be stated in full) APRIL and JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant (check one) () Assumpsit Q Trespass (X) Trespass (Motor Vehicle) () Other The trial list will be called on -s-a-?-at and I E. Trials commence on &- a3 - tit . Pre-trials will beheld on (o - 4 -USA (Briefs are due 5 days before pre-trials.) (The party listing this case for trial shall provide forthwith a copy of the praecipe to all counsel, pursuant to local Rule 314-1.) No. 07-846 CIVIL TERM Indicate the attorney who will try case for the party who files this praecipe: David L. Lutz, Esquire, 4503 N. Front Street, Harrisburg, PA 17110. Indicate trial counsel for other parties if known: Stephen L. Banko, Jr., Esquire, Margolis Edelstein, P.O. Box 932, Harrisburg, PA 17108-0932. This case is ready for trial. Signed: Print Name: David L. Lutz, Esquire Attorney for Plaintiff(s) Date: 2-19-08 377151 e? ?a Q r G i 1• ti APRIL AND JOHN PETER RUDICK,: IN THE COURT OF COMMON PLEAS OF PLAINTIFFS : CUMBERLAND COUNTY, PENNSYLVANIA NO. 07-0846 CIVIL V. LISA BUENAVENTURA, DEFENDANT JURY TRIAL DEMANDED IN RE: PRE-TRIAL CONFERENCE ORDER OF COURT AND NOW, this 4th day of June, 2008, after pre-trial conference in the above referenced case, IT IS HEREBY ORDERED AND DIRECTED: 1. Trial counsel in this case shall be David L. Lutz, Esquire for the Plaintiff and Stephen L. Banko, Jr., Esquire, for the Defendant. 2. Counsel have indicated that the trial will take approximately 1 day and will not exceed 2 days and will proceed pursuant to Pa. R.C. P. 1311.1. 3. Each party will be granted four peremptory challenges. 4. Given the brief nature of the case, Counsel have agreed that the jurors will not be allowed to take notes. 5. Both parties have been directed to prepare an exhibit list pursuant to the example attached. Two copies of this exhibit list shall be provided to the Court prior to the commencement of trial. All visual aids used in the case shall be disclosed to the opposing party. 6. Counsel for each party is directed to file with the Court on or before the close of business on June 18, 2008, a list of the numbered standard jury instructions the party is requesting. If a party is proposing a unique jury instruction or requesting significant modification of a standard instruction it shall provide the full text of the proposed instruction to the Court. 6h=IM S- " AWIQN :0 y N 7. On or before the close of business on June 18, 2008, the parties will provide a proposed verdict slip to the Court for review. 8. Evidentiary issues: Both Counsel have agreed that medical records presented in this case will be displayed to the jury in open court but will not accompany the jury to the deliberation room. Z David L. Lutz Esquire Attorneys for Plaintiff ?Stephen L. Banko, Jr., Esquire Attorney for Defendant Court Administrator -PEAS bas 06 ES rnt tt CAL G?s?og ?Lrr? By the Court, 14? M. L. Ebert, Jr. UV4AX\ COMMONWEALTH OF PENNSYLVANIA V. ANTYANB ROBINSON . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA 96-1183 CRIMINAL CHARGE: (1) CRIMINAL EDMICIDE - MURDER OF THE FIRST DEGREE (2) CRIMINAL, ATTEMPT TO MURDER (3) AGGRAVATED ASSAULT (4) CRIMES CONNITTED WITH FIREARMS (6) FIREARMS NOT TO BE CARRIED WITHOUT A LICENSE AFFIANT: DETECTIVE RONALD EGOLF COMMO Ar TH' S IHTT LIST EXHIBIT NU,M - DESC PT O 1 Photograph of injury to Tara Badgers head 2 Used envelope bearing handwriting of Tara Hodge 3 Photograph of the front of building at 117-119 West Louther Street 4 Exterior side view of Tara Badge's apartment 3 Photograph of body of Rashawn Bass in shower 6 Closeup photograph of Rashatn Bass with bullet casing on shoulder 7 Diagram of Tara Hodge Is apartment 8 Plastic shower enclosure from Tara Hodges apartment 9 Address book of Tara Hodge 10 Date book of Tara Hodge A a APRIL RUDICK AND JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant : IN THE COURT OF COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA NO. 2007-0846 CIVIL TERM VERDICT QUESTION # 1 1. Do you find that the conduct of the Defendant was negligent? (9- NO If your answer to question #1 is "No," do not answer any further questions and return to the Courtroom. If your answer to #1 is "Yes," proceed to question #2. QUESTION # 2 Was the negligence of Defendant a factual cause of harm to Plaintiff April Rudick? YES NO If your answer to question #2 is "No," do not answer question #3 and return to the Courtroom. Otherwise, proceed to questions #3 and #4. QUESTION # 3 State the total amount of damages sustained by April Rudick QUEST ON # 4 State the amount of damages sustained by Plaintiff John Peter Rudick for loss of consortium. aao 1 4TEA.L- FOREPERSON ?? 1 i W" Nplr oooz Ar1G'. 'd Ni 30 STEPHEN L. BANKO, JR., ESQUIRE Pa. Supreme Court I. D. No. 41727 MARGOLIS EDELSTEIN 3510 Trindle Road Camp Hill, PA 17011 Telephone: (717) 760-7501 Attorney for Defendant, FAX: (717) 975-8124 Lisa Buenaventura E-mail: sbanko(&marciolisedelstein.com IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA APRIL AND JOHN PETER RUDICK, Plaintiffs V. NO. 07-846 CIVIL ACTION - LAW JURY TRIAL DEMANDED LISA BUENAVENTURA, Defendant --------------------------------------------------------------------------------------------------------------------- PRAECIPE TO ENTER JUDGMENT UPON VERDICT TO THE PROTHONOTARY OF CUMBERLAND COUNTY, PENNSYLVANIA: In accordance with the provisions of Pennsylvania Rule of Civil Procedure 227.4(1)(a), kindly enter judgment upon the jury's verdict which was rendered in favor of Defendant and recorded on June 24, 2008. MAR OLIS EDELSTEIN Date: ? 1 By: Steph . Ba ko, Jr. Attorney No. 41727 Counsel for Defendant 'r CERTIFICATE OF SERVICE I hereby certify that I served a true and correct copy of the foregoing on all parties of record by placing the same in the United States mail at Camp Hill, Pennsylvania, first- class postage prepaid, on the day of , 2008 and addressed as follows: David L. Lutz, Esquire 4503 North Front Street Harrisburg, PA 17110-1708 (Counsel for Plaintiff) JA+Iq?. ""2 Angela M. ayman, Secr t ry " -rt C ? ? y , cy IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA APRIL AND JOHN PETER RUDICK, Plaintiffs V. LISA BUENAVENTURA, Defendant NO. 07-846 CIVIL ACTION - LAW JURY TRIAL DEMANDED --------------------------------------------------------------------------------------------------------------------- ENTRY OF JUDGMENT UPON JURY VERDICT AND NOW, this 1?day of 2008, upon Praecipe of Defendant and pursuant to Pa. R.C.P. No. 227.4(1)(a), Judgment is entered in favor of Defendant and upon the verdict of the jury which was rendered and recorded on June 24, 2008. Notice of the Entry of Judgment is to be provided to the parties pursuant to Pa. R.C.P. No. 236. Date: r? H.020?? DISTRIBUTION LIST: Plaintiffs, April and John Peter Rudick c/o David L. Lutz, Esquire 4503 North Front Street Harrisburg, PA 17110-1708 Defendant, Lisa Buenaventura c/o Stephen L. Banko, Jr. Margolis Edelstein 3510 Trindle Road Camp Hill, PA 17011 By: 15t 6kL- Xf .i Prothonotary J?,?