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HomeMy WebLinkAbout07-1169 t- z d h f , Ul L SHERIFF'S RETURN - OUT OF COUNTY ?CASA NO: 2007-01169 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND LEIDIGH MARY ANN ET AL VS MILLER CHARLES E SR R. Thomas Kline Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT to wit: MILLER CHARLES E SR but was unable to locate Him deputized the sheriff of FRANKLIN in his bailiwick. He therefore serve the within WRIT OF SUMMONS County, Pennsylvania, to On April 3rd , 2007 this office was in receipt of the attached return fr om FRANKLIN Sheriff's Costs: So answers, '. ~~ Docketing 18.00 = Out of County 9.00 - Surcharge 10.00 R'. Thomas Kline Dep Franklin Co 23.00 Sheriff of Cumberland County Postage 1.02 61 ()1) ? 04/03/2007 SALTZMANN HUGHES Sworn and subscribe to before me this day of A. D. •` In -The Court of Common Pleas of Cumberland County, Pennsylvania Mary Ann Leidigh et al VS. Charles E. Miller Sr. No. 07-1169 civil March 6, 2007 Now, I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of Franklin deputation being made at the request and risk of the Plaintiff. County to execute this Writ, this Sheriff of Cumberland County, PA Affidavit of Service Now, 13 , 20_?L, at /0: 25 o'clock it M. served the within W A-I-W' V su w `w up at ltd i a CaJ?f copy of the original GCJtic./`GUcc..u.h?.d and made known to AA VW-'-- contents thereof. So answers, Sheriff of Ce . COSTS Sworn and subscribed fore SERVICE $ me this o? day of , 20 a 7 MILEAGE AFFIDAVIT Nol?h13?N $ Ricfwd D. ?. Nohry Public My Cow Fla Cq? E?lnr J,n. Z9.2MM1 County, PA by handing to %??- ? f SCE UdMT I RAMER PC BY: GERARD C. KR.AMER, ESQUIRE Attorney I.D. #44715 209 State Street Harrisburg, PA. 17101 (717) 232-6300 Fax No. (717) 232-6467 Attorneys for Plaintiffs gkramer(i? srkl aw. c om MARY ANN LEIDIGH AND RONALD T. LEIDIGH, JR., INDIVIDUALLY AND IN THEIR OWN RIGHT AND MARY ANN LEIDIGH AND RONALD T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs V. CHARLES E. MILLER, SR., Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY COUNTY, : PENNSYLVANIA No. 2007-1169 CIVIL ACTION -LAW JURY TRIAL DEMANDED PRAECIPE TO WITHDRAW TO THE PROTHONOTARY: Please withdraw the appearance of the law firm of SALZMANN HUGHES, P.C., as attorney of record for the Plaintiffs in the above-captioned action. Respectfully submitted, SALZMANN HUGHES, P.C. Date: jtD /)q /0-7 By Atto ey. o. ?D 9 354 Alexander Sprint Road, Ste. 1 Carlisle, PA 17015 (717) 249-6333 40. PR.AECIPE TO ENTER APPEARANCE TO THE PROTHONOTARY: Please enter the appearance of GERRD C. KRAMER, ESQUIRE of SCHMIDT KRAMER PC as attorney of record for the Plaintiffs in the above-captioned action. Respectfully submitted, ?Y Ilia 1114 1??61 Date: Id -2 -2 "d ') By Oerard C. Kramer, Esquire Attorney I.D. No. 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 ',. i f .7 _;; Leal CJ ".1 SCHMIDT KRAMER PC BY: Gerard C. Kramer Attorney at Law Attorney ID No.: 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Fax (717) 232-6467 gkramerCa! schmidtkramer. com Attorney for Plaintiff MARY ANN LEIDIGH AND RONALD : IN THE COURT OF COMMON PLEAS T. LEIDIGH, JR., INDIVIDUALLY : CUMBERLAND COUNTY COUNTY, AND IN THEIR OWN RIGHT AND : PENNSYLVANIA MARY ANN LEIDIGH AND RONALD : T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs V. No. 2007-1169 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED PETITION FOR APPROVAL OF MINOR'S SETTLEMENT FOR ALEXANDRA LEIDIGH AND NOW, comes the Petitioner, Mary Ann Leidigh, as the Parent and Natural Guardian of Alexandra Leidigh, a minor, and respectfully sets forth as follows: 1. The Petitioner, Mary Ann Leidigh is the Parent and Natural Guardian of Alexandra Leidigh, currently residing at 601 Belvedere Street, Carlisle, Cumberland County, Pennsylvania. 2. The Petitioner's daughter, Alexandra Leidigh, is a minor, date-of-birth February 25, 1998, who resides with her mother, Mary Ann Leidigh, and father, Ronald T. Leidigh, Jr., at the above-mentioned address. 3. On April 13, 2005, Alexandra Leidigh was a passenger in her mother's car on Interstate 81 in South Middleton Township, Cumberland County, Pennsylvania. 4. Ms. Mary Ann Leidigh had stopped the vehicle in the right lane of Northbound Interstate 81 because the traffic in front of her had been stopped due to a blasting project. 5. Defendant, Mr. Miller, was traveling in the left lane of Northbound Interstate 81, moved to the right lane and struck Ms. Mary Ann Leidigh's vehicle in the rear as it sat stopped in the right lane. 6. Alexandra Leidigh was treated at the scene of the accident by Carlisle Community Ambulance. She experienced neck pain immediately following the accident. She was taken to the Carlisle Regional Medical Center where she was examined and released. (See Carlisle Community Ambulance Records attached as Exhibit "A" and Carlisle Regional Medical Center Records attached as Exhibit "B") 7. On April 19, 2005, Alexandra Leidigh followed up with Dr. Pion at the Graham Medical Clinic. She complained of head pain, abdominal tenderness and neck tenderness and was diagnosed with mild cervical strain. (See Graham Medical Clinic Records attached as Exhibit "C"). 8. On May 5, 2005, Alexandra Leidigh returned to the Graham Medical Clinic due to persistent pain in her lower abdomen. Dr. Pion noted that Alexandra likely suffered a muscle injury in the accident. (See Graham Medical Clinic Records attached as Exhibit "C"). 9. Alexandra Leidigh had been having anxiety and depression since the accident and had attended joint therapy sessions with her sister who was also in the accident. After the psychologist determined that Alexandra would benefit more from individual sessions, Alexandra had an individual evaluation at Franco Psychological Associates on May 12, 2005. She was diagnosed with acute reactions to stress and adjustment disorder with mixed anxiety and depressed mood. Alexandra's condition was functionally impairing the family and social areas of her life at a moderate level. She was scheduled to attend additional therapy sessions which would include play therapy. Alexandra attended 6 therapy sessions through the end of June 2005. (See Franco Psychological Associates Records attached as Exhibit "D"). 10. Alexandra Leidigh was seen by Dr. Pion on November 2, 2005 due to abdominal pain. He noted general tenderness in her abdomen and ordered a CT scan. Alexandra Leidigh returned on November 14, 2005 with epigastric discomfort. Dr. Pion felt that her stomach symptoms may be functional and encouraged Ms. Mary Ann Leidigh to talk to Alexandra about her emotional issues. (See Graham Medical Clinic Records attached as Exhibit "C"). 11. She had no additional complaints or treatment. 12. All medical expenses have been paid by the Leidigh's insurer, State Farm Insurance Company. There are no outstanding medical bills. 13. The Petitioner has reached a compromise with Erie Insurance Company regarding the claim for injuries sustained by Alexandra Leidigh, in the form of a lump sum payment of Four Thousand Dollars ($4,000.00) in return for a general release. (See Parents Release and Indemnity Agreement attached as Exhibit "E") 14. (a) The Petitioner, Mary Ann Leidigh, is satisfied that the offer of settlement is just and reasonable and is willing to accept the offer, if approved by the Court. (b) Ronald T. Leidigh, Jr., Alexandra Leidigh's father, also believes the offer to be reasonable and joins in the petition. 15. In pursuing the claim, the Petitioner engaged the law firm of Schmidt Kramer PC under a Contingency Fee Agreement that provides that Schmidt Kramer PC should be paid a fee of 25% of any settlement or award. (See Contingency Fee Agreement attached as Exhibit "F"). 16. Schmidt Kramer PC has incurred costs of $249.50 relative to obtaining copies of medical records and costs associated with the investigation of this matter. (See Summary of Attorney Costs and Expenses attached as Exhibit "G"). 17. The Petitioner requests that the Court distribute the present payment of Four Thousand Dollars ($4,000.00) as follows: Schmidt Kramer PC - Attorney Fees 25% $ 1,000.00 Schmidt Kramer PC - Costs to Date $ 249.50 Invested for Alexandra Leidi h, a minor $ 2,750.50 Total Settlement $ 4,000.00 18. The Petitioner requests that an account be authorized without the formal appointment of a guardian of estate of the minor, or the entry of security, as permitted by Pennsylvania Rule of Civil Procedure 2039(b)(2), with the Petitioner, Mary Ann Leidigh, being authorized and directed to invest funds belonging to Alexandra Leidigh, a minor, as follows: a. to invest the funds in Certificates of Deposit to the extent possible, not to exceed such sums as are fully insured by F.D.I.C.; and b. to invest the balance of said sums which cannot be invested in Certificates of Deposit, if any, in a Savings Account, not to exceed such sums as are fully insured with F.D.I.C. Each account on behalf of Alexandra Leidigh shall be marked as follows: This money shall be held in trust not to be redeemed, withdrawn, negotiated, or in any way alienated, except for the renewal in its entirety, before February 25, 2016, except by Order of this Court. 19. The Petitioner and her counsel shall promptly file proof of the deposit of the sum of $2,750.50. 20. There are no outstanding debts owed by Alexandra Leidigh. WHEREFORE, Petitioner, Mary Ann Leidigh, requests that this Honorable Court enter an Order approving the foregoing compromised settlement, permitting the Petitioner to execute the Release, and directing the distribution of proceeds as set forth herein. Dated: 0? « D Respectfully Submitted, SCHMIDT KRAMER PC By: Ge and C. Kramer ttorney at Law ,r Attorney I.D. #44715 209 State Street f Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs VERIFICATION I, Petitioner, Mary Ann Leidigh, mother of Alexandra Leidigh, a minor, have reviewed the contents of the Petition for Approval of Minor's Settlement and hereby verify that the statements set forth herein are true and correct to the best of my knowledge, information, and belief. I am satisfied that the offer of settlement, referred to in this Petition, for my daughter, Alexandra Leidigh's injuries, is just and reasonable and I am willing to accept that offer. I understand that any intentional false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsifications made to authorities. Date: ary Ann rtfp Parent nd Natural Guardian of Alexandra Leidigh, a Minor - I-JOINDER I, Ronald T. Leidigh, Jr., am the father of Alexandra Leidigh, a minor, and hereby state that I have read the foregoing Petition for Approval of Minor's Settlement and that I understand, agree, and approve the contents thereof and join in the Petition. Date. 4a,? A Ronald T. Leidigh, Jr. i EC'-06- ;i(_7 11 :;a8 C'UMB. G_)1.-)F)W1L:L FIFE FE;='. 7172436482 F. U33 Cumberland Goodwill Fire Rescue EMS M,CU 4? Patient Services Charge Form - PCR: 0501147 Trip Number: 0501147 Patient Name: Patient Number: Address: City/State/Zip: Phone: Member: Transported From: Transported To: 601 Belvedere Street Carlisle, PA 17013 (717) 258-9762 No 18 1 North near York Rd exit Carlisle Regional Medical Center Service/Type Charges Call Type: Prehospital Waiting Time: 0 Minutes Medicare Checks ? Moved by Stretcher ? Hemorrhaging ? Bed Confined Before Chief Complaint: Reason for Transport: Other: ICD-9 Code 1: Other - Not listed insurance information Alexandra Leidigh Date of Birth: Age. SSN: Sex: Crew 1: Crew 2: Crew 3: Crew 4: Loaded Mileage: Origin Zip Code: Date: 04/13/2005 02/25/1998 07 Years 167-78-4940 Female Page, Stephwttrcr Katona, Ed 3 Miles 17013 ? Bed Confined After ? Unconscious/Shock Present ICD-9 Code 2: 0 Prima Comp aB NAIC Group # ID # Other Information Auto Accident- Specify none 7069187B State Farm Auto 3138P Other- Specify 2861600 ZAH15954 PBSHM 378 PPO 4952 Guarantor Information - Self Stock Charges Item Product # Alt. Prod. # Quantity _ Response r Resp Resp I Billing Notes: H1PAA given Printed On: 04/14/2005 16:39 EMStat Reporting(c) 1998-2005, Med-Media, Inc. All Rights Rescrved Page: 1 of 1 DE'-06- 00DWiLL FIRE RE,':-'. Pennsylvania ELVIS Report 7172435482 P.ii;tF Service Name Cumberland Goodwill Fire Rescue EMS Unit No. 2100224 PCR No. 0501147 PSAP Incid. No. 050043210 Date 04/13/2005 Iacident Location 181 North near York Rd exit MCD 21926 Receiving Agency Carlisle Re ional Medical Center Patient Name Alexandra Leidi Phone No. 717 258-9762 Age 07 Years Date of Birth 02/25/1998 Social Sec. No. 167-78-4940 Sex Female a Street Address Crew Times 00 601 Belvedere Street AN] Page, Stephanie E 141984 911 i, Q City Carlisle State Zip PA 17013 A#2 A R3 Katona, Edward P 063110 Dispatch Enroute 14:14 14:26 .20 Patient Number Membership A k4 Arrive Scene 14:30 'fi't No Contact 14:31 co g Private Phy"sn Out On-Scene Deal. In Depart Scene 14:55 o I Pion. Joseph MD 0 16901 16904 0 Arrive Facility 15:06 Transportiag Assist Units OS Time Medksr Command Phyeician MCC Available In Quarters 15:15 Chief Complaint: no complaints voi ced Current Meds: none All lea meds : none Narrative PMHx: none Ambulance 240/Medic 283 dispatched and responding with immediate response, class 2 to Interstate 81 North near the York Road exit via Cumberland County 911 for an MVA with injuries. Prior to arrival ambulance 240/medic 283 are advised that there are 2 vehicles. There are to be 2 injuries. One injured is a 10 year old complaining of lower back pain and a 50 year old with chest pain from the air bag. Upon arrival ambulance 240/Medic 283 finds 2 vehicles with one sitting on the interstate with the second sitting off the side of the road. The vehicle sitting on the interstate rear-ended the first vehicle. There is front-end damage to the vehicle on the interstate and rear end damage to the vehicle on the side of the road. Patient is a 7-year-old female conscious, alert and oriented still sitting in a child safety seat. Patient is restrained. Patient has no complaints of pain anywhere. Patient's mother states that the patient initially complained of neck pain. Patient states that she is fine. Patient's neck is palpated and there are no deformities noted. Patient's PE is otherwise unremarkable. Patient's mother would like her transported to be checked out. Patient has no past medical history, takes no medications and has no known drug allergies. Patient is assisted from her seat and walked to the ambulance. Patient is placed in the child safety in the back of the ambulance and secured. Once in the back of the ambulance, patient is reassessed and PE is found unremarkable. Patient's vital signs are assessed and are as follows: blood pressure-118/72; pulse-84; respiration-16. Patient has no complaints during transport. Patient is transported to Carlisle Regional Medical Center. Patient care is transferred to Carlisle Regional Medical Center Emergency Room nursing staff upon being placed in room 1. Patient's mother is given the notice of privacy practices and signs the form understanding what she signed. 0 N i•+ J N N ti0 41 04 Provider EMStat Reporting(c) 1998-2005, Med-Media, Inc. All Rights Reserved Page: 1 of 2 HC-06-2007 11:40 C'UMB. G=OODWILL FIRE RES. 1724 35 62 r Pennsylvania EMS Report Unit No. PCR No. Date Service !Name 2100224 0501147 =?] 04/13/2003 Cumberland Goodwill Fire Rescue EMS Patient Name Date of Birth Social Security Number MCC Medical Command Physician Alexandra Lcidigh 02/2511998 167-78-4940 Ambulance 240/Medic 283 goes available and returns to quarters. Stephanie Page, EMT 141984 Provider R orrtmems Time Time 1 P. X Ox Gias Rh Treatment di etched in 14:26 14:3 on sceru enroute to CRMC 14:55 14:55 W16 4/5/6 Al initial VS at CRMC 15:06 1515 FHE II I / available EMStat Reporting(c) 1998-2005, Med-Media, Inc. All Rights Reserved O O M-+ Fr+ J N N ?O 00 0AV'11Uw-A m H1494 Provider Page: 2 of 2 DE:i-'_!h-2h i 1 1 "tiME . 1aCiODW I .L FIRE nE;= . CARLISLE REGIONAL MEDICAL CTR 04/14/2005 11:17:56 F A X ?A To: NONSTAFF. FAMILY PHY PROMED SYSTEM (ER) From: CRMC 717 43546 P.03 PAGE: 2 OF 3 Patient AdIgit el Time AMR No PIT EC Me / 9308376 04/1312085 1540 0000 E 1 F 7 02 25/1998 F CA SS 88808 9188 Address Patient Nape A SS Number Patient Employer Phone Number , LEIDIGH. ALEXANDRA C 167-78-4940 CHILD 601 BELVEDERE STREET Phone Number coun y CARLISLE PA 17613 717-258-9762 Responsible party& Add r 55 AMORE, Responsible Party m olr_r Phone Number LEIDIGH, RONALD JR - 159-54-4952 STATE POLICE 717-249-2121 601 BELVEDERE STREET Phone Nmber COMMERCE AVE CARLISLE PA 17013 717-258-9762 CARLISLE PA 170 13 Other Responsible Party SS Number Other Employer Phone Number 060-00-0000 Phone Nober Pajor Name Insured Group No - Pol j cy No 1. STATE FARM AUTO LEIDIGH, RONALD OR NONE 7069187B3138P Pre-Cert Number: Insured Sex: F Rel ation: PARENT HAS P 0 BOX 14007 YORK PA 17404- PH. 717-2412341 2. PBSHM 378 PPO LEIDIGH? RONALD OR 2861600 ZAH159544952 Pre-Cert Number: Insured Sex: M Rel ation: PARENT HAS PO BOX 890173 CAMP HILL PA 17089-0173 PH. 866-8033708 3. Next Of Kin Be], phone Address-City.St.. Zi o York Phone WILLARD. DINA GMOTH 717-249-3663 Attending Physician r Physicia n LASEK, ROBERT W MD PION, JOSEPH A Diagnosis Accide nt Acciaent-Date / Description MVA--MINOR INJURY NO FAULT 04/13/2005 INT 81 NORTH Prey. Admit Dt. Disch arge Date Discharge Time Discharge C ode 04/13/2005 15:40 Diagnosis Codes (Primaryl Ste. L1 LU 1U M L71 181 M Procedure Codes/Dates 1U End Of Page 7 1 "iIL:Wi;., F'iRE F'E_'. i Cumberland Goodwill Fare Rescue EMS West Shore EMS Assignment of Benefits Authorization, Responsibility for Payment and Acknowledgement of Receipt of Notice of Privacy Practices BILLING AUTHORIZATION, RESPONSIBILITY FOR PAYMENT AND RECEIPT OF NOTICE OF PRIVACY RIGHTS I understand that I am financially responsible for the services provided to me by Cumberland Goodwill Fire Rescue EMS/West Shore EMS regardless of insurance coverage. I request that payment of authorized Medicare or other insurance benefits be made on my behalf to Cumberland Goodwill Fire Rescue EMS/West Shore EMS for any services provided to me by Cumberland Goodwill Fire Rescue EMS/West Shore EMS. I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services and its carriers and agents, as well as to Cumberland Goodwill Fire Rescue EMS/West Shore EMS and its billing agents and any other payers or insurers, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by Cumberland Goodwill Fire Rescue EMS/West Shore EMS, now or in the future. I agree to immediately remit to Cumberland Goodwill Fire Rescue EMS/West Shore EMS any payments that I receive directly from any Cumberland Goodwill Fire Rescue EMS/West Shore EMS source for the services provided to me and I assign all rights to such payments to. I also acknowledge that I have received a copy of the Cumberland Goodwill Fire Rescue EMS/West Shore EMS Notice of Privacy Practices. I understand that I should read it carefully. I am aware that the notice may be changed at any time. I may obtain a revised copy of the Notice by requesting a one at the Cumberland Goodwill Fire Rescue EMS/West Shore EMS office or on the website at www.cumberiandgoodwill.org or at www.hsh.org. A copy pf this form is as valid as the original. Date: i1-1 Patient Sign t Patient Representative's Signature Patient unable to sign because: MC W Relationship to Patient Cumberland Goodwill Fire, Rescue, EMS Inc. 102 W. Ridge St. Carlisle, PA 17013 717-249-0012 www.cumberland og odwill.org P. 0',44 ?t ? ?? . `"T?.. fi ??'fl I o '?"" "? , r};, vo? ADMISSION RECORD K?K)NAL .tet c r lk MEDICAL RECORDS est e c4 ? 9308376 7 1 0000829168 2?6 Pukcr St Culirle, PA 17013 Ph:717.2?9.1212 ` - ..". . -:.' ... . ADMI DATE !TIME R M ND P FC AGE DATE OF BIRTH EX RA to LOCATION PROGRAM p 04/13/2005 15:40 0000 E1 F 7 02/25/1998 F 1 S A I ArMN DRF' ??- P LEIDIGH, ALEXANDRA C R P V 167-78-4940 CHILD ER PHO E N E 601 BELVEDERE STREET NTr N CARLISLE PA 17013.. . (7N17)258-9762 T US G LEIDIGH, RONALD JR 601 BELVEDERE STREET STATE POLICE COMMERCE 159-54-4952 AVE (717)249-2121 U PA 17013 ARLISLE C E .ION HP P TI M A R CARLISLE PA 17013 PHONE NUM (717)258-9762 FATHER RESP EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE EMERGENCY CONTACT RELATIONSHIP TO PATIENT WILLARD, DINA (717) 249-3663 GMOTHER M , K V IVA AD MI . C N O Y QQN Y ? N KAS PRIVACY PAYER 825: AT.O POLICYNLI ER ,,70b9187B31.38P FARM AYU 0 N D 7 GH , RONALD JR P O BOX 14007 N YORK PA 17404 NONE (717)241-2341 ALITHONZATIDN S ; PA A12/07/1`965:: Z 200 U A PBSHM 378 PPO LEIDIGH, RONALD JR R PO BOX 890173 -GRMP NUMBER R AME CAMP HILL PA 17089 2861600 PA STATE POL (866)603-3706 Au N A PAYE MAN DATE IR H N U C -GROUP Nom"A GROUP N E . A I / A MV IN AMILV / PRimAAY CAPE DR. M I LASEK, ROBERT W MD PION, JOSEPH A S C MVA- -MINOR INJURY NO FAULT 04/13/2005 PRI NC PAL DIAGNOSIS IT Its condition esiammm,ed Sher n v to be ChipOY r9eports?hle to occssioning the sdmi"ion of me pe(jent to the HOSPITAL IC/ cue). COMPLICATIONS COMORBIDITVRESI PRINCIPAL PROCEDURE IIII IAN n ?ry ?p q_DIA p?IpII p i iu'Y '!'' mgpl' ?I n? 10 ?010062N9p1'p6'8 II??I?I111?I??IINVII1n I?IIAII?UIII?III?IWIIIN MEDICAL RECORDS COPY IUI?UIIINIIIUN?fllul??u??lill?lllV .- RE ?vAI. AlF ?ICwt CtN iF.R EMERGENCY DEPARTMENT Date ?? f f r g ?{ lift >'l ?LF,tfl,ir?r? was inc wadtated fromo;! work! physical education due to illness t injury from 4. 1 r ?rto and including Other comments Staff Signature ER 0510 (096) Carlisle Regional Medical Center ` (Incthirlinna• rirrta n 6tvv _ h?rkclnch nannfiva nrnuirfa aMitinnnl noninam ;M-C- 1 NAME: LEIDIGH, ALEXANDRA C Pto-. 9308376 DATE OF SERVICE: 4113t2005 08: 2,2511998 Aga: 7 Yrs 0 Mos 0 Wks MRM. 0000829188 Pros Time: 15AD Sex: F VW' 23.E KG Ht: Trtage Time: 15AQ Chief Complaint: MVA-MINOR INJURY T: 99.2 PO Medicines: NONE P:96 Regular R:16 Unlabored Allergies: NONE BP: 117/079 Sa02: 99 % Normal / Hypoxfa EDP: LASEK, ROBERT W MO PCP: PION. JOSEPH A Arrival Mode: BLS Pain Scale: 0 ff(S TO-Y OF PRESENT ILLNIESS Exam Time: Hx by: atient F EMS NH Translator Limited by: ALOC Intoxication Severity UnrelfaNe C I C / HPI: (Narrative): C-Collar TAY EMTALA Medical Screen: Emergent [] Non-Emergent(3 va's (P ? Timing: Sx started suddenly/ gradually min. I hr . 1 days t Wks, ago : continuous / lntermiltent Duration. Sx last min. I hrs. / days / wks. at a flme Present / absent Location of injury: head face neck chest back abd upper ext R / L lower ext R I L Quality: cannot describe fall / height It MVA crush injury punched kicked GSW stab wound Severity: mild moderate severe 1.10 scale life weatening Context: accident assaulted MVA child abuse found unresponsive Exacerbated by: nothing movement palpation Relieved by: nothing rest Ice OTC meets Assoc. Signs 8 Symptoms: none LOC G.P. abdominal pain bleeding deforndlies REVIEW OF SYSTEMS Limited Due To: ALOC Intoxication Severity Unreliable Constitutional: lever chills weakness diaphoresis Neurologlcal: HA seizures weakness confusion ENT: sore throat ear pain facial pain Psychological: anxious depressed Eyes: pain visual changes Endocrine: polyurla polydipsia Cardiovascular: C.P. palpitations DOE PND Integument: rashes pruritis lesions Respiratory: S.O.B. cough congestion Hematologic: anemia bleeding disorders transfusion GI: N I V diarrhea / constipation pain melena hematemesis Allergyllmm.: frequent infections allergies hives GU: flank pain d?jl ?tn "turia frequency Other Musculoskeletal: eck 1 back painext. pain ystems Reviewed And Are Negative Agree With Nursing Assessment MEDICAL AND SOCIAL HISTORY Mod. Hx: none ZOOM / ROOM asthma Reviewed Past Mod. ONE Mods: NE Reviewed Allergi NON viewed Sop. Hx: none Appy Tonsillectomy Family fix: negative R 1 L Handed Uves Alone: Y / N Social Hx: day care student occupation: Tobacco: Packs/Day _ Years ETOH: Y / N OMksfft. Drugs: Y IN Immunizations: Up-to-date' Y I N Tetanua' Reproductive Hx: LMP: G P AS Pro-MED Maximus Pediatric - Trauma - Page 1 of 2 Qrpy„„ N zw t ae++cv c,.<r s, .. a .? Rti wa,e. trdt nSIC rw91V1131 1YIOUJGal t,t3rIJVF Instructions: circle positive -barkslash ne ative rovide additional ettinenl information. NAME; LEIDIGH, ALEXANDRA C Pw.- 9308376 PHYSICAL EXAM MR#: 0000829188 GENERAL: odele lsevere distress VITAL SIGNS: T99.2 P96 R16 8A 117/079 HEEN ERR ? EOMt - CV: R MI NL m Rnurg 16 sys / dys 7 P ru s Clicks gallop S3/S4 Location/Description of Symptoms: lequal bilateral resp, etto NL Is s RESP: tun QrJe4 r rales wheezes ,0n r?chl s NL r ABN GI: soft flat l d bowel sou r e n -tender guarding riglty MS: O M N • u 'ng cyar Is a ma !i SKIN: - diaphoretic rashes NEURO: 2 Intact DTRs ual I sy metric f( l1 Y 0 X3 la ul I o rig for age PS CH: p yf Pr P LYMPH: a opatn?- j i. t d I I t ?= .r ? GU: NL tleferred i Other: t I MEDICAL DECISION MAKING LABS AND STUDIES ED COURSE AND TX ? Labs reviewed and we negathre x4uy: C-spine: MEDS: CXR: -- - NF: NI- I ABN NL / ABN pelvic DIFF FOLEY: S C.T. head / abd / pelvis B EKG: NSR? no acute disease NG: UA: SG Prot RBCs INBCS Pulse Ox: % NL I hypoxia RE-EVAL: Time: UCG: * / - Other; ABG: pH 02 C02 Improved Sam• Worse DOX: concussion cervical strain Fx laceration hemaloma skull Fx Critical Care: 30-74 / 75-00191-104 / 103.120 pneumothorax shock spleen injury contusion child abuse other. 121.134111&164 Minutes 0 Exci. billabt• proc. CLINICAL IMPRESSION(S) DISCHARGE INSTRUCTIONS 1. Discharged to: Home Nursing Home Family 2• Y ?' t V' \ Follow-up with Patients Dr. In days. 3, ! Other Instructions: 4. S. CONSULTATION DISPOSITION Discussed with Dr. Discharge Time Out: Admit Admit: 08S ICU PCU Floor Tale. OR Prescriptions Given: Follow-up In Office Transfer: Old Records Reviewed Y / N AMA: Reviewed D/W Radlotogist Y [N DOA: l Case D/W Patient I Family Y I N Condition: Improved Stable Dec ed RETURN TO ER IF CONDITION WORSENS. See ro ure form attached Slgnatures: PAIARNP .4 1 Record Complet Pro-MED Maximus Pediatr c -Trauma • Page 2 2 CCQ"M fool PrCMEO0"" SY-w . L L C. RN. GVMM ORDER PROCEDURE FORM ORTHOPEDIC EMERGENCIES Date in: 411312005 Time: Carlisle Regional Medical Center Name: LEIDIGH, ALEXANDRA C Pt#.9308376 Age: 7YRS DOB:02l2511998 Sex: F MRM0000829188 EDP: LASEK. ROBERT W MD PCP: PION. JOSEPH A Laboratory Testa Other Diagnostic Tests Order Time - Order Son Order Time Radiology Order Sent By CBC X P lAT - Portable) 8MP CMP Sed Rate _ C-Spine (X-table) (Complete Uric Acid RA FaGor Drug screen (serum), (urine} !?"? _ ETOH Type 8 creep w Cross # Units Cardiopulmonary _ EKG A _ eta HCG 02 LPM -' ? Misc. Orders 1,111I Necessity Information: Prevlo)js Medical Records Physical Therapy - Eval 8 Tx Weight: Ibs: 52 kgs: 23.6 Allergies: NONE Order Time Medication I Dosage I Route VO Read Bads Adm time Adm by Site Time Reassessment Palo initials p Improved p Worse ? Unchanged O C Improved 0 Worse ? Unchanged ' D 0Improved C3 Worse p Unchanged Q 0 Improved Q Worse O Unchanged 0 ? improved p Worse o Unchanged Order Time IV/ Solution I Added Medication StartTime Device I S ize Loca tion # AttemptsAmount Start by DIC Time Amt Infused IC by O KVO Device: ? IV r1uld: Procedures I Nursing Assistance p Cardiac Monitor Rate- Rhythm T? ? Splint Application ? (Local), (Regional) Arn-Ohesia Q NIBP Monitor Pulse Oximetry Q Ace Bandage Application p Conscious Sedation p (Cold), (Heat) Application ? Sling Application p Laceration Repair ? Wound Irrigation A ? C-Spine Immobilization Q Cast Application ? Dressings p Foreign Body Removal O Fracture Care (open), (closed) Discharge Instructions Initials/Signature: IniualslSignature: Initials/Signature: InibalsfSignature: PAIARNP: Physician's Signa e : i lt,/ EMERGENCY DEPARTMENT ONGOING NURSING ASSESSMENT Date: 4/13/2005 Carlisle Regional Medical Center Name:LE{DIGH, ALEXANDRA C Pt#'9308376 Age: 7YRS DOB:021251199B Sex: F MRM 0090829188 EDP: IASEK, ROBERT W MD PCP: PION, JOSEPH A NURSING DIAGNOSIS (Number in order of priority. Each patient must have at least one seteoted.) Airway Clearance, Ineffective Communication Impaired Infection, Potential Self Care Deficit "Anxiety `Coping, Ineffective -lnjyry; Potential -Skin Integrity impairment Breathing Patterns, Ineffective fluid Volume, Alteration In nowted9e Deflclt -''Thought Processes, Impaired -Cardiac Output, Decreased Gas Exchange, Impaired _tviobifity Impaired _Thought Processes, Alteration in ^Comturt, Alteration in -Hyperthermis (Fever) `Non Compliance Tissue Pertusion, Alteration in -Other - other The GOAL I PLAN for this atient is to assist in meeting identified needs and initiate Interventions for I to'. Not Not Not MN MN tnl NtM Met lm Met- Mot a FB REMOVAL 13 IMMOBILIZATION i PROPER ALIGNMENT O IMPROVEMENT OF BREATHING Int Cl BLEEDING CONTROL 0 DECREASE I PREVENT SWELLING 0STABILIZE PATIENT INOISTRESS G PAIN CONTROL 0 MAINTAIN STABLE. HOMEOSTASIS O meet ENVIRONMENTAL NEEDS O ALLEVIATE NN 0 MAINTAIN SKIN I TISSUE INTEGRITY t7 meet PSYCHOSOCIAL NEEDS E] FEVER CONTROL D PREVENT FURTHER INJURY p i SELF CARE ABILITY NEEDS q DECREASE ANXIETY 0 MAINTAIN I IMPROVE CIRCULATION ,10 meet EDUCATIONAL NEEDS D SAFETY IN THE ED O oYFECTiON CONTROL a Other Int: N s documentation in nurses notes, other'codos6 per Hospital Policy, Throe Nunes Progress Notes 8 Reassessment Signature Time T P R BP 02 Sat NG / Emesl Cardiac Monitor Urine GCS Pain 1 IVY7 I6,ig 1? (1- Itk All I (j tj 01spositfon Discharged in re of: t3'firtib R WIC O Stret p Carried - - Discharge ins"ctlons given oV!?Oalized understanding Admit: Room ft': to Dr. Ready for Room Time: Report called at and given to Transfered to o Transfer Verified Report called at and given to q Left wftlhout treatment pLeh Against Medical Advise diti tri Di C 5r on on at ed: D0jp1 s oved OStabie ?Serious G1Expired Pain Scale: Pain Location: Worse Patient reports that pain is: Oimproved DeK. an10 P i R L BP 7 tJ OZ Disposition Vitals: 1 - 4- 37 Time- Disposition Date: 0? Nurse: V R V- VAN](W ;EMERGENCY DEPARTMENT ,PEDIATRIC NURSING ASSESSMENT Date tn:4/13/2005 Time: Carlisle Regional Medical Center Name:t_EIj3)GH, ALEXANDRA C Pt#: 9308376 Age: 7YRS DOB:02/25il998 Sex: F MR#:0000829188 EDP: LASEK. ROBERT W MD PCP: PION, JOSEPH A Subjective Notes: -? Pain op nt denies pain Location: Duality: OSharp ODull []Cramping OBuming OAching O Rating Scale: Mode of Onset: O Sudden G Gradual O Intermittent WONG/BAKER FACES RATING SCALE Onset: Date: Time: Duration: ' _ Onset > 24 hrs. medical attention was sou9nt? ?No OYes Dale: lJ ?? Radiating. QNo oYes tsoer:ry> 0 2 4 6 t) 10 Psychosocial Caregiver: rents t7Mother OFather OOther. Envlronment: ONo steps IOFew steps OMany steps Accompanied by: ' v _ Nutritional status: J¢Alormal OCachetic Lt Obese Appearance: pUnkempt ?Other- E Religious 1 Cultural preference: ONone upeay) Activity level: OPlayful files / Laughs m Best learn by: (pt/ caregiver) OVerbal OWritten ORetum demo 001her Learning Barriers. Neurological Gastrointestinal Ll Not Assessed wake OZF*nted operative OCrying DLethargic Abdomen: oft OFlat 0Rigld 0Distended ORestiess ODiscriented ?Unresponsive -Mon Tender OTend (Area) Pupils sire and reaction: Bowel Sound Present 00ecreased OAbsent Cardlovascul• r Ellmination: O Normal OConstipation ODlanriea # of Stools: Skin: vvarm ODry OCool ?Moist ODiaphoretle GenitourInary: O ssed Color, nk ? Pals O Ashen o Flushed OCyanotic o Jaundiced Volding: OContinent Olncontinenl ODiaper OPotty trained Capillary Refill: ? <2 Secs (Normal) O>2 Secs (Delayed) p0ysuna OFrequency Color: Turgor: c Normal O Decreased Other findings: Pulses: L Radial:[] Present p Absent R Radial: C1 Present p Absent _ t P nt R P l Prese Ab L P t l Ab d nt - resen 0 se : C3 n se eda e a : 0 O Respiratory Musculoskefetal O Not Assessed Airway: Clear 1701her _ Lacerations / Abrasions / Contusions Effort: O U?bored O labored O Mildly 13 Severely Location: O Retractions D Stride O Nasal Flaring Size: Cough: O None Ci Productive O Non-Productive Bleeding: 0 Absent 0 Present O Scant O Moderate ? Heavy O Pulsating Lung Sounds: ROM. O WNL O Decreased OAbsent OClear U Wheezes ORhonchl ?Crackles 0Diminished OAbsent Edema: C Absent p 1+ O 2+ O2+ DelonratyO Yes ? No OR OL OR OL ?R OL OR OL OR OIL OR OL Scars: ?Yes 13 No Distai pulses, OAbsenl OPresent Growth and Deve opment Weight: KG. Heigh R In Head Circumference: Cm ONEW BORN Age e - t Month OINFANT I.12 month Language: OCries Often OSmllas ?Coos / Gurgles ?Babbles Bom at Terma7Yes []No Delivery: ?Vaginal ?C-Section Diet: O Breast Feed [!Formula type: Uses: OBotue ?Spoort LICup Elimination: D 3. B stools a day Other: Activity: Lifts Head OYes ONo Sits up: ?with help O without help Crawls: O Yes O No Teething: O Yes U No Observation of interaction with caregiver Is OAppropriate ?See Nursing Assessment OTODDLER Ag. t•: v.,,s ? Pre-Schooi Age s • s vears language: OFew Words DSentences D Easily Understood Diet: ?Finger Foods OReguiar Diet CFeeds Self Uses: OBottie DCup Teething: OYes DNo Elimination: I31 - 2 Stools per day ODiapers OToilet trained 13Wets bed: D Rarely OOccasionally DFrequently Activity: Walks: O Yes O No OWalks with assistance 17Walks Independently Ob atlon of interaction with Caregiver is O Appropriate OSee Nursktg Assessment SCHOOL AGE 1, ttYeam OADOLESCENT Ag.tl - teveep Reached Puberty: 0Yes DNo Learning disability: 0 Yes School grade: Diet: g ats'3 meals/day OEabng disorder, (specify) Wears Braces UYes 13No Elimination: Na problem reported ? Wets bed: ORarely/ OOcCasionally DFrequently U/ses Abcohol: Social Habits: Smokes O Yes C?1 a Yes 01 Uses Drugs: C Yes ONo _ Observation of interaction with caregiver Is t;?Appropriate OSee Nursing Assessment Vital Signs: 15:40 T: 99.2 P: 96 Regular R: 16 BP: 1171079 Nurse Signature: 4?ad t,( J / U Rev. 03I05s 0.t INITIAL ASSESSMEN'TFORM Carlisle Regional Medical Center PRIORITY: 4 r,at ent LEIDIGH. ALEXANDRA C Pw 9308376 Non-Urgent DOB: 0212 5/1 998 AGE: 7YRS Sex: F MR#: 0000829188 EDP: LASEK, ROBERT W MD womers Comp: DATE: 04113/2005 PCP: PION. JOSEPH A Emp. Referred Preseniatron Time. 15:40 Triage Time: 15:40 Arrival Mode: BLS Height: Weight. 52.0 tbs. 23.6 I<gs. LMt : Last Tetanus: Ace By: Chief MVA--MINOR INJURY Vital Signs Complaint: IT: 99.2 PO Brief PT WAS THE LEFT REAR PASSENGER IN A VEHICLE THAT WAS HIT IN THE REAR. PT WAS IN Assessment A CHILD BOOSTER SEAT. THE SEAT WAS BROKEN. PT INITIALLY HAD PAIN IN HER NECK. PT STATES SHE NOW FEELS FINE. MOTHER WANTS DAUGHTER EVALUATED. NIGHT SWEATS LINK HEMOPTYSIS UNK WEIGHT LOSS LINK FEVER UNK ANOREXIA UNK SAFETY UNK RESTRAINED YES DRIVER NO AIRBAG OEPLOYED NO P: 96 Regular R: 16 Unlabored s p: 117/079 02: 99 % RA Pain Intensity Scale: 0 110 Pain Location: Sudden Onset: Pre-Hospital PT WAS MONITORED AND TRANSPORTED Treatment: Pediatric G&D App, for Age - N/A, immunization UTD • NIA, Height It. In., Head Circ. - Grade - , with Assesment: Past Medical NONE History: Allergies: NONE Medicines'. NONE Rev 04112104 Nurse Signature: DMJ Addltlonat Notes: Carlisle Hospital -- Emergencv Department l.eldiah, Alexandra 246 Parker St. Carlisle, PA 17013 -- (717) 245-5500 4113105 4:15Dm 829188 DISPOSITION SUMMARY Patient: Leidich, Alexandra Ape/DOB: SS #: Current Ph: CURRENT Address: Medical Record: 829188 City, Zip: Arrival: 4113/05 4:15prn Disch: 4/13/05 4:18pm Disposition: MD ED: Robert Lasek MD PMD: i Res/PA/NP: PMD Ph: Dx #1: MVA (Unspecified) ICD-9 #1: E819,9 #1 Dx Enq): MOTORVA.ESIN #1 Dx Span: MOTORVA.SSW Follow-up: PION, JOSEPH A DO 100 SOUTH HIGH ST GMC I NEWVILLE, PA F/U MD Ph: 7177763114 I F/U D/T: if needed. Other Instr: I MY SIGNATURE BELOW INDICATES: > i have received and understood the oral instructions regarding my current medical problem. > I witi arrange follow-up care as instructed above. I > I acknowledge receipt ,?f the written instructions as outlined on this and nv pre io P I 'I ( d and review these instructions. X X I tien co) uardian)`Sig ature Staff (Witn s) Signatu e ti i I i I I i EMERGENCY SERVICES Point of Care Laboratory Testing Report Form LA13F 166-01 Issued-Date: 02-04 PATIENT NAAW; MED REC# FINANCIAL* Employee Name (Performing testing): MNE CSI;MSIM 7 PH Glucose{ Ketones Leukocytes"' , - Nitrite Protein a u-, Blood(Hgb "?- (Read all results at I minute, except j'Ladweyte pad lndicates a trace result, than it should be read again at 2 minutes,} Reference values: All results negative except for pH that is normally around 5.0 but may range from 5.0-8.0. IMM PREQNANOTEST Patient result is (circle one): Positive Negative Reference value is negative. 9H YAPERTESTING pH Result: Reference.Ralges; Eye: The pal of the eye is neutral, around 7.0. Vagina: Normal vaginal pH is 4.5-5.5 Amniotic fluid is 7.0 or greater. CRMC Laboratory, 246 Parker Street, Carlisle °A 17013 Filename: G-Labora tory- Procedure Manual-Forms -',ABF168-01 Page 1 of 1 246 Pater SL Carus,,, YA 37D13 Pb 1; 7-219-1212 CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME L£1DIGH, ALEXANDRA C ATTENDING PHYSICIAN LASER, ROBERT W MD ACCOUNT NO. 9306376 DATE 47IMEOFADMIS510N _04/13/2005.15.40 CONSENT TO HOSPITAL CARE AND TREATMENT I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCH CARE, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL STAFF, OR THEIR OESIGNECS. AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY' WELL BEING. 1 ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL, INCLUDING THE ATTENDING PHYSICIAN{S) NAMED ABOVE, AND RADIOLOGISTS, ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL fACIL%TLES FOR THE CARE AND TREATMENT OF THEIR PATIENTS. 1 AGREE TO ACCENT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL, I UNOEASTANO THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEmENt' FOR COMPCE7E MELrICAI CARE. CONSENT TO RELEASE INFORMATION I HEREBY AUTHORIZE THE HOSPI"AL TO DISCLGSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE FOR ALL OR )'ART OF THE HOSPITAL CHARGES. ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY i1NCLUDING ANY TREATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCE), TO OEYERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLA1161S FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RELEASE I CERTIFY THAT THE INFORMATION GIVEN ElY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVI11 AND TITLE XIX OF THE SOCIAL SECURITY ACT JS CORRECT. I AUTHORIZE ANY HOLOER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEOEO FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO T HE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT, PERSONAL EFFECTS AND VALUABLES I UNDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY, GLASSES, DENTURES, DOCUMENTS, C! OTHING, ETC.) UNLESS SUCH ITEMS ARE OF-POSITED IN TK HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE IN EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY KRSONAL EFFECTS OR VALUABLES QEPOSITEO WITHIN THE HOSPITAL SAFE. ABOUT YOUR BILL I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND FOR ANY SUPPLIES OR MEDICINES UTILIZED. I VALL ALSO RECEIVE A DILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR EXAMPLE, I MAY RECEIVE A SEPARATE BILL FROM ONE OA MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUT+40RQE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT )HEREINAFTER 'PHYSICIANS'), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF INSURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS. FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS MAY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE ANO SIGN ANY OTHER DOCUMENTS THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. S <TEMENT OF FINANCIAL RESPONSIBILITY I UNDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVEREQ IN FULL BY ANY THIRD PARTY. I FURTHER AGREE THAT SHOULD I NOT PAY THE BALANCE WI11-11N THIRTY 1301 DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I AGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND INTEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. FRAUD ANY PERSON WHO KNOWtN31-Y AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW. ADVANCE DIRECTIVE IFOA ADMISSION TO HOSPITAL ONLY) IF I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE BEEN GIVEN WA)TTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. I HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM 140T REQUIRED TO HAVE AN ADVANCE DIRECTIVE IN ORDtR TO RECEIVE MEDICAL TREATMENT AT TNJS HOSPITAL, I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL. FOLLOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. )INITIAL THE FOLLOWING OPTION THAT APPLIES) . I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. • I HAVE NOT E)(ECUTFO AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO S0. INIT. IMf. (FOCLOWUP DONE BY DATE • I WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. NWT I CERTIFY THAT I HAVE READ 0 "AVE BEEN READ) THE ABOVE CONSENTS AND CERTIF ONS AND L1ND TAND AND AGREE WITH THEM, a- 0 '11?' A444 DATE: // OMTH DAY YEAR kAT(/RE Of PATIEM OR LEGALLY AUTHORIZED MPRFSENTATNE _ _ ? 1?,.[[ l !Jn'am C ? L,?G t 4 f Gu WITNESS .? PRINT NAME Of PERSON ABOVE ^00016 9300316 0000624106 O 1 _ ?IfA1 f AI CtT. ft\ 246 Parker Si. cuiisk, rA 97013 Ph:?I7-14q.r2i2 HIPAA FORM 20 ACKNOWLEDGEMENT: RECEIPT OF PRIVACY NOTICE Purpose: This form is used to document (a) an individual's acknowledgement of receipt of our Privacy Practices Notice or (b) when we have not obtained this acknowledgement, our good faith effort to obtain the acknowledgement, Patient Name: LEIDIGH, ALEXANDRA C Medical Record Number; 0000829188 Social Security Number: 157-78-4940 Date of Admission: 04/13/2005 Notice Version (Date): 4/1412,Q03 Acknowledgement of receipt of Privacy Practices Notice 1, LEIDIGH, ALEXANDRA C , acknowledge that I have received a Privacy Practices Notice from: CARUSLE REGIONAL MEDICAL CTR Further, by signing below I provide my permission for this facility to use and disclose my medical information for the permitted purposes of treatment, payment and health care operations as discussed in the Notice of Privacy Practices. Patient Signature: _ pate; 04/13/2005 []Notice has previously been distributed by another location in our OHCA (except for physicians): List location that distributed the Joint Notice: If a personal representative on behalf of the ndividual sign% this authorization, complete the following: Personal Representative's Name• (r- Relationship to Individual: 1?4 j ?`?g IF NOT SIGNED:IGood faith effort to obtain acknowledgement of receipt) Describe your good faith effort to obtain the individual's signature on this form; Describe the reason why the individual would not sign this form: SIGNATURE: (Hospital Representative) 1 attest that the above information is correct. Signature: date: 0411312005 Print Name: Bethea, Kyuati - Admitting Title: - U. 0 Include this acknowledgement form in the Individual's records. Hospital Copy CONTINUATION LDDRESS mo- / ------- ? - ------- -? I u - - ---- -- ----- )v. L L U -- _-- Alexandra Leidigh S: Is here for a the •? ? p. This is her first visit with us. PMH is otherwise she has been fairly liealthv. positive for an episode of admission to the hospital for but O: Her exam reveals her to be in NAD_ Her ears no injection or bulging of the TM's her nose was positive for injected boggy turbinates her throat was without injection her neck is supple without nodes her chest is CTA heart RRR without M. her abdomen was nontender her skin was normal neuro exam normal. UA was negative. A., Normal three year old growth and development are stable and we will continue our present course of care at this time. Joseph A. Pion, D. O. WPM i MR r r? - I Alexandria Leidigh --- ------- ---- S: Alexandria is here for a checkup. No real complaints or problems. She has some low grad has some concern over. At this time. she is using Westcort on a very infrequent pm basise eczema that mom ------ O: On exam, she is happy, active and playful. Her growth and auscultation. Heart: RR without M. HEENT': Normal. Neck: d Supple w thoute odes. N ul o: Normal. t Skin: Normal. Extremities: Normal. n: A: Normal physical with nnld eczema. - P: Westcort on a prn basis. Follow up as needed. Cam' - -1 Joseph A. Pion. D.O. - -------- - ------- ----------------------------------------- ------------------------------------ --- - -------------- ------------- - r GIEa_-ter Alexandra Leidigh S: Alexandra is here for checkup. No complaints or problems. O: She is happy, active and playful. Ears: No injection or bulging of the TMs. Head: Normocephalic. Eyes: PERRLA. EOMI. Mouth: Normal. Throat.- Normal. Nose: Normal. Neck: Supple without nodes. Chest- Clear to auscultation. Heart: Regular rate and rhythm without murmurs. Abdomen: Nontender. No masses. No - hepatosplenomegaly. Bowel sounds were heard throughout. Extremities: Normal. Skin: Normal other than _ some patches of eczema which we will treat with Elidel on a prn basis. P: Go ahead with immunizations,at i time. She will follow up as needed. Joseph A. Pion. D.O. --- -- - r A161 - I?YT,117-1 /-11 A -7 ---------------- ------ ------------------------------ ----------------- - CON7INUATION ------ NAME r•- . ADDRESS - ' -- -- ?''? DATE 1 P ?I p LNFP -- - ----- --- ---- ALLERGIES Q 1-Id r LAA. ?.o y ar Sx -- _ _ ua Fm, l 2 vt ?n,u c (kO a j ?' /hit ? ? ? ? •?i TT i Alexandra Leidigh 03/13/03 S: Alexandra is a 5-year-old brought in for a three day history of nausea, vomiting and diarrhea. Symptoms are -- gradually improving but Mom and Dad are very concerned given her history of having a hospitalization in the past minimal appetite, and complains of occasional belly pain. - t virus when she was a toddler. She has had a for roo She has not had any vomiting in the last 48 hours. ? --- O: Afebrile. Alexandra is happy and alert Tympanic membranes are intact and clear bilaterally. Nasal and oropharynx: No injection or exudates. Mucous membranes are moist. Neck: Supple without adenopathy or _ Chest: Clear. Heart: Regular. Belly: Normal active bowel sounds throughout. No palpable abdominal masses . masses or tenderness. No hepatosplenomegal_: noted. Extremities: Within normal limits today. - - A: Resolving gastroenteritis. P: We are going to have Mom and Dad watch her closely. Go ahead with clear liquids, bland BRAT diet and slowly advanced as tolerated. Call is symptoms should worsen., Suzanne K. McCombie. P.A.-C I - Alexandra Leidigh 03/14/03 Phone Call Phone call from Mom. Alexandra had worsening diarrhea after she left our office. Therefore, we are going to have her pick up cultures for a stool culture and sensitivity, ova and parasites. Iardia and C. dill and await those - - findings. If symptoms should worsen over the weekend. I have asked the ),k'6 have Alexandra either evaluated in -- the emergency room or at the very least call the doctor on call. Suzanne K. McCombie, P.A.-C C BP HT d1IT_4_q-TEMP --i---,? __ ??I!L I T?' j -' -- 3 N T `T -1r f7H T. _ H r?!I JEhH IIFII t_1,' - IaiT ?1EI?HT .!E U NEI.HTI'. E i ?I Alexandra Leidigh 11/26/03 S: Alexandra is here with 3-3 days of urinary frequency. She denies any dysuria but she has been having a little bit of suprapubic abdominal pain. O: Afebrile. Heart/Lungs: Normal. Abdomen: Soft and nontender and nondistended. Back: Does not reveal any CVA tenderness. Genital: Normal. A/P: Probable UTI. Even though her urinalysis looks okay. We are going to go ahead and tre r ith Bactrim suspension 40/200 per 5 nil two teaspoons twice a day for 7 days. Jeffrey H. Harris. M.D. < -- - - -------- Qr1Pac, r, T rr. - - - - - - - - - - - - - ---- GL II NEGHTiLJE j'- ---- -- -- ---- ---- - E1L NEGHTiiaE Y,E'I t'aEGHTIIE i Vi t_1 2Ln NEGHTI!.IE r I't th , r PRO tdEGHTIUE URO A.2 E.U.:A L - !J1T NEGHTIUE I CONTINUATION ADDRESS `; 1\ ??TE ?T- AMP 7 PULSE j~ ALLERGIES r U, Alexandra Leidigh 12/04/03 S: Alexandra is here with the above mentioned svmptoms. Mom noted these svmptoms and explained them to me -4 last night as I was leaving from plaving basketball at the school where Alexandra was receiving CCD education. ?- She reports these svmptoms again today. O: At this time. Alexandra is in no apparent distress. Head: Norm - ? ocephatic. Eves: PERRLA. EOMI. Ears: No injection or bulging of the TM's. Nose and throat: Within normal limits. Neck: Supple without nodes. Chest: Clear to auscultation. Heart: Regular rate and rhythm without murmurs. Abdomen: Nontender. No masses. No hepatosplenomegaly. Bowel sounds were heard throughout. There is possibly-some discomfort over _ the suprapubic area. Genital: There was no erythema or edema of the labia. The hymen is?infact. The UA is negative. A: Urinary frequency, etiology is uncertain. P: We will send her urine for culture again. Go ahead with a consult to Dr. Hollowell. Joseph A. Pion. D.O. - 4 - I III - -_. . - I I I- -- -- _--.--__- ----._-_---.-_. _.- - -- _.-_---_ ---_?y :• I TEMP ---- ---------- - - - ------ -- -------- - - LMP- -- I I' Alexandra Leidigh structions. - S: Alexandra is here for a school PE. See school PE form. Patient unde J113-1 I? n Joseph A. Pion, D.O. - I I; r? 1 a ATE Lit-- I HT WT TEMP PULSE - - fcLMP -- -- - Y? - i ke7l Alexandra Levdigh 0--,A)4104 ?- S: Alexandra is here with a couple of davs of cough, sore throat and some mild belly pain. She was nauseated last night but did not throw up todav She feels much b 1 . etter. Dad is concerned because Strep in school. they have been exposed to O: Afebrile. Tympanic membranes are clear. Nasal turbinates are unremarkable. Oropharynx revealed a mild j erythema of the posterior oro har n b p y x ut no exudate. Neck is supple. There is no adenopathy. Lungs - Heart is regular. are clear. - -- A/P: Viral URI. Stsymp-to rep sere s negative. Recommended some Tylenol for the sore throat and plenty of fluids. Dad will call if her uld worsen Patie t' f h . n s at er understands instructions. Jeffrey H. Ham I Harris. M.D. --- - ----- ----- CONTINUATION ADDRESS DATE Ir r 3 C/ , CI t7 d ?.... ' Fn C-'O- -? i i v sew i Alexandra Neidigh 03/29/04 S: Four day history of an itchy rash on her chest, abdomen, extremities, back and face. No associated fever or any other associated symptoms. Alexandra has a history of significant allergies accordin Y been using Eli 1 to her de g cream to icall g mother. Mom has P Y. O: Afebrile. Happy and alert. Tympanic membranes: Intact and clear bilaterally. Nasal and oro Unremarkable. Neck: Supple without nodes or masses. Chest: Clear. Heart: Re P. barely noticeable at this time but they are several a ?m•• Skin: Very vague rash difficult to distin rythematous papules on her abdomen and back. Again, almost guish at this time. A: Possible contact dermatitis versus viral exanthem. P: We are going to go ahead with Zyrtec syrup one teaspoon daily given the complaints of itching. Mom may continue the Elidel cream or Hydrocortisone cream topically as needed Return if symptoms worsen or Patient understands instructions. persist. Suzanne K. McCombie, P.A. -C DATE HT ALLERGIES 04,EL2/04 F-- S: Herewith sore throat, and congestion. She vomited once this morning. O: HEENT: Ears appear normal. Nose is clear. Pharynx is red with no exudates. Neck: Supple. Negative adenopathy. H Regular. Lungs: Clear. Rapid Strep was negative. A: Viral URI. P: Rest. Push fl 'd:.. enol for pain and fever. Clear liquid diet today. Patient understands instructions. Carol K. Robison, .O. IT FM 074197A715/R111 r..()l WFI 1 1 AM 817 1 1.1!1 ra, t=)r- d s l,-tl c j00 Pace {'b .rwo,Rvw b l Q 1- ? Alexandra Leidigh 02/03/05 S: Here today with the above mentioned symptoms. O: Afebrile. Happy and alert. Tympanic membranes: Intact and clear bilaterally. Posterior pharynx: Clear with clear PND. Neck: Supple with mild anterior adenopathy. Chest: Clear. Heart: Regular. Rapid Strep screen was negative. A: Acute viral URI. P: Will treat symptomatically at this time. Hold back on anti Return if sympto worsen. Patient understands instructions. Suzanne E. Kelly, P.A. -C HT --- -- WT ---TEMP PULSE" --- __- LMP- -n %MtA N! aiwE CONTINUATION (ADDRESS DATE Alexandra Leydig S; motor vehicle accident. Mother was driving and she was in a car seat. Car seat was broken in the back. She I was sitting in the second seat, they were hit from behind by a car, apparently traveling at a rapid speed. She has - head pain, but this seems to be minimal. She had no compl pints at the time of the accident, and not put on a _ board. She does complain of low grade abdominal tenderness, and some questionable neck tenderness. No other neuro symptoms no loss of consciousness at the time of the accident. 0; in no apparent distress head is normocephalic , nontender. Eyes PERLA, EOMI ears no injection or bulging of the tms , nose and throat were wnl. Mouth was wnl. Neck supple, full range of motion is noted. There is no palpitory tenderness. Chest is clear, heart is regular without murmurs. Chest wall was nontender, Abdomen is nontender no masses or hepatosplenomegly bowel sounds were heard thruout PVIVIS IS SId.U1G, GXLLO1111110J 11V11ML14G1, 11V ?u?xna. uV -ElVa -A- I I think she may have some post mVA mild strain, cervical strain, and I don't think that ?anylhing more to r- offer for pain relief. PUI Joseph A. Pion, D.O. i I :. -,p 47 CAW fic)!2? 44Afn=:z S'- Alex Laidig S Somewhat persistent lower quadrant abdominal pain, Was in a motor vehicle accident. History is as noted above. - 0; in no apparent distress Chest is CTA Heart is regular without murmurs, abdomen was positive for tenderness with light palpation over her abdomen. Actually she had more tenderness with light palpation than with deep palpation over her abdomen. It was located in the lower quadrants, specifially left. Bowel sounds were heard thruout no masses or hepatosplenomegly A; Left lower quadrant abdominal pain, secondary to muscle injury to the accident where the seat belt would 1 cross her abdomen. P; Tylenol and Tincture of time and hopefully see some improvement. PUI Joseph A. Pion, D.O. c 1 ITEM 07-057621516111 COLWELL 1Ann 61711an ?CLX 1-41 U0 1_? 7-1 DAFE PULSE ALLERO S Alexandra Leidigh 08/26/05 - S: Alexandra is here today because she fell down about six steps at home and landed awkwardly on her right arm. Since that time, she has been having a lot of right elbow pain. _ O: On examination, she has good range of motion of her right shoulder and right hand and wrist. Palpation does not reveal any obvious shoulder tenderness or tenderness of hand and wrist but she gets very tender as you approach her elbow. She is especially tender immediately over her right medial supracondylar region and over her - right medial epicondyle. She did straighten her arm out for the elbow x-ray so I doubt that she has nurse maid's - elbow. X-ray revealed a possible supracondylar fracture near her medial epicondyle. _ A/P: Right elbow injury/possible supracondyl racture. I am going to try to get her in to ortho today for an opinion. If not, I am going to have to put her• elbow sling over the weekend. Patient understands I instructions. Jeffrey H. Harris, M.D. - f- - I r I - TEMr PuLSEU _ LMP T ALLERGIES 1\/&Utt ' ?- Cyr F i Alexandra Leidigh S; as above. ?- O; tenderness over the mid shaft of her humerus. There was tenderness with movement of her e w. Minimal tenderness with shoulder movement. Xray read by me seems to be neg. ??-_ will await official reading, they will call. PUI Joseph A. Pion, D. 0. 10 I I ?I BATE. EP In P 1 -- - - - ULSF LMP ALLERG6ES - Alexandra Leidigh 10/06/05 S: Alexandra is a 7-year-old here today with a week's worth of a sore throat and a little bit of a cough. The sore throat has lingered on and now that her sister has developed a sore throat, has not had any fever mom was concerned about Strep. She . O: Afebrile. Tympanic membranes: Clear. Oropharynx: Unremarkable. There is no tonsillar enlargement, exudate or erythema. Neck: Supple. No adenopathy. L s• Clear. Heart: Regular. Strep test is negative. A/P: Pharyngitis. This is likely viral. I recommende e of fluids and some Tylenol or Motrin. Patient understands instructions. Jeffrey H. Harris, M.D. -- i DATO e s 7 c /3 .'? G zd, i L CONTINUATION_ 1111E !ADDRESS DATE I I Alexandria Laidig S; here as above. O; in no apparent distress She is happy, active and playful, throat was without injection. Temp is 97.2 pulse is 88 weight is 65 and up since the last visit. Head is normocephalic Chest is CTA heart is regular without murmurs ; abdomen was without rebound or guarding, generalized abdominal tenderness In the epigastrium and some tenderness in the lower quadrants bilaterally. No masses or hepatosplenomegly bowel sounds were heard thruout . She has some tenderness right over the wound, I received the report of her appendectomy and she did have inflammatory condition of the appendix. P; ct of the abdomen and labs, regarding her chronic abdominal pain, etiology of this is uncertain, and I am concerned that this may be functional, but in light of her recent surgery, this is con ruing and we will await this result. PIA Joseph A. Pion, D.O. _- g{ R --- ---TEMP CLARITY: -------------- AMP COLOu• LT. YELLOW ILA . 0"- M. ULT I GLU NEGATIVE - BIL NEGATIVE / KET NEGATIVE C f ? /' 11 It -L?WV I 1bMiVJ ??1U/Y IGYLYU-lU Wdll -- Alex Llaidig 11-14-05 S: as above. O; in no apparent distress Heent benign, chest is CTA heart is regular without murm abdomen is positive for epigastric discomfort, bowel sounds were heard thruout urs , no masses or hepatosplenomegly, UA is neg etiology of her symptoms is uncertain, and i explained to mom that I am concerned that these ma e _i functional and that having a talk with her about emotional issues may be helpful. They will ween off the qnc, and have this conversation, and see if we can't settle her, down a little emotionally. PUI Joseph A. Pion, t HT TfMr COLOR. _T. l l?.v h1!IL7iSTI: GLl1 NEFjAT i UE N E i; A T I E Z 81L KET NE6NT ME _- - i C/ 1 t9 i Alex Lleidig S; as above. O; happy, active and playful ears no injection or bulging of the tms, nose was positive for minimal injection. Throat was positive for marked injection of the pillars in the posterior pharynx neck was supple with anterior i? cervical adenopathy Chest is CTA heart isregular without murmurs, abdomen is nontender no masses or hepatosplenomegly A;. Strep screen was neg. P; uRI with vaginal monilial infection, Treat that with Lotrimin, alovert delsym, follow p s needed. Pui Joseph A. Pion, D.O. ?lva ss3aoad 3Wb'N NOi-LvnNl-LNOO --- P-- - PU1.;E ALLERGI ----- I ?' ? ------ 467 r. 1 ? -n' _T. YELLOW' TISTTX 1E^ L4 vi s V Gci u w? t7/?ti W E-t l7 ??- r i `) G L U N E G A T I l! E BIL NEGATIVE KET NEGATIVE '.;G 1.020 -:LO NEGATIVE r? H 7.0 PRO NEGATIVE UR0 0.2 E.U./dL rs E!IT NEGATIVE LEU-* SMALL - -- Alexandra Leidigh 02/15/06 S: Here today with some vaginal burning with urination noted. Mom has noticed some white vaginal discharge. _ No history of fever, nausea or vomiting. She has had some urinary frequency so mom was concerned about the possibility of a UTI. O: Afebrile. 'Vital signs are as above. HEENT: Unremarkable. Lungs: Clear. Heart: Regular. Back: Negative CVA tenderness. Neck: Supple without nodes or masses. Abdomen: Benign. Nontender. No masses. A/P: Urine dipstick revealed a small amount of leukocytes. We will send this for culture and sensitivity before we initiate antibiotic treatment. I think this is more likely to be some monilial vaginitis. We will have mom continue to use Nystatin for those symptoms. Will follow up as instructions. Suzanne K. Glossner, F.A.-C r need.Qd? Patient's mother understands UU1'4 111'4 uH i ivrv in DATE ADGRESS EEL Y , _ EfT "_ P1.°U+•M. ALLERGIES C ?- - 7 C A 1 I L? L? l ®Q Cw ? Alexandria Leidigh 04/11/06 S: Here today with. right ankle pain for three days. She has been limping. No associated injury or trauma. She complains of pain in her right heel. This all started after she began wearing her soccer cleats more routinely. O: On exam, no acute swelling or deformity noted. She does have some tenderness directly over the Achilles tendon on the right. No pain at the heel. She has normal range of motion of the foot and ankle. A/P: At this point, I am recommending Advil as needed. Rest. Ice. Elevation and having her not wear her cleats for several days. I think she may have an Achilles tendinitis. They are to let us know if this persis s or worsen. We may consider an orthopedic consult if necessary. Patient understands instructions. -- Suzanne K. Glossner, P.A.-C C3 -SQ \C? * e?. lo?3o?cT1 Nuyc?rhS pare __ LMP ALLER,GEES Leidigh, Alexandra 01/08/2007 -- S: Alexandra is here today because she was playing basketball and she got her left middle finger bent back awkwardly. It has been a bit sore since then, especially at her MCP and PIP joints. -- O: She has a little bit of swelling around her PIP joint and she is tender there. Range of motion is decreased. There is no -- gross deformity to her finger. No bruising or ecchymosis. X-ray did not reveal any obvious fracture. _- A/P: Hyperextension of her left middle finger. o vious fracture. I recommended another day of ice and then some warm moist heat and some range of motion e i s. She can return to activity as normal. -- Jeffrey H. Harris, M.D. 13012 -- ITEM 07-057621S/81 11 t DATE SP HT ?' TEMP Leidigh, Alexandra 02/05/2007 - S: Alexandra is an 8-year-old here today with a couple of days' of sore throat, cough and runny nose. Mom is _ not at all that concerned about her symptoms, but her sister is sicker, so mom was just worried that Alexandra had strep throat. No fever, chills, vomiting or diarrhea. - 0: Blood pressure is 110/56. She is afebrile. Tympanic membranes are clear. Oropharynx is normal. Her - neck is supple. Lungs are clear. Heart is regular. A/P: Viral URI. I recommended my of fluids and antihistamine. I reassured mom that her symptoms - should improve over the next w or so. Jeffrey H. Harris, M.D. _LMP_ --? mac.: V 11012U - 13JUN0 JUN09 ------------ t 96)O< 01 IIIbC) II 610006-404"1 I I'I Prohet from fight stvron 7.1'C IJ&K'Fl. UG NOT F#EEZ E. SgAR luar WELL gFPoIIF UtlNf. ? i.tr.rwe.l.,?y - rtrr.? © YlrriwY lRw Leidigh, Alexandra 03/02/2007 - S: Alexandra is here for a routine checkup with no complaints. Past medical history is negative. - 0: On exam, Alexandra is happy, active and playful. Her head was normocephalic. Eyes: PERRLA. EOMI. - Ears: No injection or bulging of the TMs. Nose and throat were without injection or exudate. Neck is supple without nodes or goiter. No neck vein distention. No bruits. No thyromegaly. Chest is CTA. Heart was at a - regular rate and rhythm without murmurs, and abdomen was nontender. No masse No hepatosplenomegaly. _ Extremities were without any edema. Skin is normal. Neuro exam is normal. A/P: Impression is normal physical. She will follow up as needed. Gardisol was start at this time. Joseph Pion, D.O. Aviv n NAME -?'----- ADDRESS --- DATE t N___ t Leidigh, Alexander 04/25/2007 S: This 9-year-old girl fell on the playground today on an outstretched h pain, a neighbor friend, who is a doctor, stated she needs an x-ray. and and now she has significant right wri; O: Vitals in the chart. Examination of the right wrist revealed no erythema or deformity. ecchymosis of the medial aspect of the wrist. She did have some point tenderness to the distal but no snuffbox tenderness. She was neurovascularly intact in the hand. She does have som %?/P: Right wrist pain status post fall. We will obtain an aspect of the ulna Michael Van Grouw, P.A.-C, a oday, call report otherwise followu TK/spp/sb/10427 p p.r.n. r -') o ? ?? L?sadd a at an r/ _ 2? Papillonudros m' yyj?'(7 IiYPn i H, fg 1/) L Q W =i ? .111 i? BMDAgMMYaccinel O ?c I NT Leidigh, Alexandra 08/20/2007 S: Alexandra is in today complaining of s veral things. Firstly, she had an episode of vomiting that lasted a few times in the 24-hour period last week. It disappeared and then she developed a fever, sore throat, runny nose, some congestion in her chest and cough as well. Mother notes that she could hear her wheezing. She also developed a cough that began this morning. Mother is concerning that with school is starting in a week, she may be developing something. Her fevers were never more than 100 degrees. Mother has been using Tylenol to treat that and she has been getting plenty of rest and fluids. O: She is afebrile. Tympanic membranes are clear. Oropharynx is slightly erythematous. Neck is supple with posterior cervical chain adenopathy on the left side. Lungs are clear. Heart is regular. Rapid strep was done in the office and was negative. A/P: Viral URI. The patient was told to c tinue with plenty of fluids and rest and to try some Dimetapp Cold and Cough over-the-counter. Mother was r ssured that her symptoms should improve by the time school starts next week. Kerry Edwards, PA-Student TK/sud/sb/ 10031 - 3 71: M L ci 'n o a ? ,iii e =bieeiit Vaccine] BARUASIN © U 5 Gp U Nn ! R..* - . he 3 q4 - r c2A CONTINUATION t M E )DRESS DATE _ - -- Leidigh, Alexandra 09/18/2007 S: She presents because two days ago she was doing a flip and hit her right foot on a desk. It has been painful since with difficulty with ambulation, although somewhat improved from two days ago. O: Vitals are in the chart. No acute distress. Examination of the right foot reveals ecchymosis and tenderness at the proximal fifth metatarsal, but no angulation or deformity of the foot noted. X-ray was performed, appears fairly unremarkable, just a little calcification at the tendon insertion of the fifth metatarsal, but an x-ray was done of the other foot and she had the same calcification. We will wait final radiology report. A/P: Right foot contusion. Advil is to be used as needed. Reassured father that there do not a epe to be any acute fractures at this time. Michael Van Grouw, P.A.-C. TK/sud/sb/ 10008 Flu Vax 0.5cc IM Melt. Lot# AFLLA052AA exp.# 08/2008 (GSK) i Quest Diagnostics Q ? 0 v QUEST DIAGNOSTICS INCORPC:RATED -_L! ENT SERVICE -?15.957.4370 SPECIMEN INFORMATION SPECIMEN: NE9937331.V RE?;JISI'T_'10N : 002932? ? B REF N0: COLLECTED: 02/15/2006 14:19 RECEIVED: 02/15/2006 07 REPORTED: 02116/2`.;06 1843 Test Name Quest on Demand"',, PATIENT INFORMATIN REPORT STATUS Final LEIDIGH,ALEXANDRA C ORDERING PHYSICIAN DOB: 02/25/1998 Age: ? GLOSSNER,SUZANNE K GENDER: F CLIENT INFORMATION ID: 167-78-4940 17241001 SHONE: 7:1.'0589762 GRAHAM MECICaL CENTER 10:0 S HIGr vT NEWVILLE, PR 1.7241-1409 Lab CULTURE, JRINE, R U:iNE MHO SOURCE: URINE S TATUS : FI .z; RESULT: 0 GROWTH ------------------------------------------- -- ----------- -- --C ---,- -- ------------------ Performing Laboratory Information: F0 tF. S - 7_? 1 F._... .CR-:'.Pd9 PA .?1149 ,[, F'NL?I. uEIDIGH,ALE:ANDRA .? - NE?93?31V Page 1 - End c= Repor*_ C<.?'rL:i:3i:_• h;i???1i?'il::il Medical ..(?'i) .G•'.i Laboratory, 246 1-'a'r'•ke t-. I:?uck.I..y't Chang, N.D., Medical Director Carlisle, {=A 17013 un Y. Kim, N. D.. , PatI-,i: lon:i. -1 FINAL REPORT MRN:: 000082+188 L..oi_ationwHO'SPI-LAi._ DRAW SIT•E-fldm:it;t,ed:::1:1. 0;3;'t+ DOB:02/25/1998 i--i rl r r Physicians PION, j0SEPH Ovderho 59030184 FINAL Date&Tim Ordered n 11/03/05 0808 Requested 1_,.y:: PION, JOSEPH Copy not PION, jOSEPPd HEMATOLOGY TEST-NAME RESULT AB REF-RANGE U1,110, t.l_ L_L_E:CfED 1.:1.:'ist;:,.?i?i5 0`:?;;itq RECEIVED ! 11/03/05 BLOOD C ELL COUNT ICIBC:: 9.+, X 1!±^3 I-: B C . '_? .i. I-1 3.4@-5.30 , 10 _i " r::; { I •it.7.(: h. 1.4.. S 1.3..0--•1°:5 ? q/t:1l III C:H -a .4. ? L.. 26.0-24.0 p!1 M C H [.- 1.1...5 31.0-36.0 g ..' ;:! !. R 1? ICJ 11. 11.0-16.0 ? 1-'L_ ( 438 I-1 140-400 x 10' -3 AUTOMATED DIFFERENTIAL I'•keut% 4 4.. -4 16.0-76.0 Lyre ph% 38.4 18. 0-58.0 Mono% 10.8 H 1.0--8,.0 .a Eois ? 5.3 0.0-6.0 B a <::_ ire °S. 0.7 0.0-2.0 :L h•f e+_C t-. # 3. `:? ` 1.20-8.80 x 1 j%} '• LymphO 3.4'1-1 1.00-4.20 .103 17C no*i J. 9i H 0. 00-0.60 : 10 Eos # 0.52 H 0.00-0.40 10' ... WSW 0.0(--, 0.00-0.20 X 10 continued on next page Ki::1% for Idbnr:?rfital Column '..L:::L ow I-I::::i-1ighl A.Br::j..i(:) trii`fiial C::::(.:r:;.1::ic:)..1. 1:::"1oxiC:_? LEIDICH, ALEXANDRA f--: HOSPITAL DRAW10-: 1 of 2. 2 of 3 PP;INTED i1i04/2995 0115 Pages 1 F 2 Carlisle Regional Medical Cent r I._ bo•r•atory, 246 Parker St. Duckkyu Chang, M.D., Medical Director Carlisle, PA 1701,''k Sun Y. Kim, M.D., Pathologist FINAL REPORT* LEIDIGH, ALEXANDRA C' M1=NN 0000829:188 L_ocat:i.on ; HO` PITAL DRAW.: I TL"-Admitted ::L 1 ;'03/(l5 2, 2 1_• r r f Agew7 Physician: PION, JOSEPH OrderNN 5903018A FINAL Date &Time Orderedw 11/03/05 08:38 Requested by: PION, JOSEPH Copy to; PION, JOSEPI--I continued CHEMISTRY TEST-NAME: RESULT AB REF-RANGE UNITS COLLECTED 11/03/05 09:08 F:I_CI_IVI_:lD 11I03/05 O'? e 15 ROUTINE CHEMISTRY B U I-,I I "]'.C Sodiurfl 13'.) Potassium 4. Chloride 10-'3 Carbon Dioxide 27.8 I° B S 8-17 Fasting Glucose Interpretation;: Normal fasting glucose: Impaired fasting glucose: (Patient may benefit from Diagnostic for diabetes: Calcium 10.2 Creatinine 0.6 Protein, Total 7.3 Alkaline F'hosphatase 265 A T 37 AI bum in 4.. 7 ' A I._T J V5 Bilirubin, Total 0.4 7-it1 mg/d:!. 136-145 rl i 111 o f J. 3.4-5.3 mmol/1- 21.0-32.0 mmol:'L. 60-100 mg/d], 70-100 1'11--:125 a 2hr Glucose Tolerance Test) : •=lL'c"" I.a HMYIaSe 00 J-Li pase 18 E21 (? 0.3-0.8 6.4-8.2 H 50-136 15 3 '1 3.4-5.0 30---65 L.0-1.0 25-115 114-286 mg/dl mg/dl g.'d1. 1_I /L g d3. mg/dl. I_i / I_. U / 1._ Key for Abnormal Column (L-='I_oof i1-Higit AB::=Ab;.l+._i''ma.I- C:::Cy'.t;ical i==if...:ic) L..I:::I:'c.>:I:GH„ ALEXANDRA C'' HOSPITAL {?R,;W 17i: of " 3 of 3 PRINTED 11/04/2005 0 1 0 P a l o : of 12 Quest Diagnostics - Philadelphia _ tlnical Laboratory RepOr4' 900 Business Center Drive PAGE# 1 1 Horsham PA 19044 215-957-9300 Complete Report ] LEIDIGH, ALEXANDRA C. 12/04/2003 01:49pm 12/04/2003 12/04/2003 Patient Native Date Dawn Time Drawn Date Received Date of Report F 02/25/1998 5 GRAHAM MEDICAL CENTER 17241001 Sex D.O.B. Age 100 SOUTH HIGH STREET Hospital/ID #' Account Number 167-78-4940 hP176276U Patient I.D.ISoc. Sec. Number 1V EWVILLE, PA 17241 Specimen Number PION, JOSEPH ? Ordering Physician ?A 01?3 B02652 # (717) 258-9762 Patient Home!# Patient Work# J - R ` Comments Test Name Results Units Reference Range Site 395 CULTURE, URINE, ROUTINE SOURCE: SEE NOTE CHO :TRINE STATUS: FINAL CHo RESULT: LISTEC BELOW QF10 QUEST DIAGNCSTICS-RCRSHAM 900 BUSINESS CENTER DRIVE HORSHAM, PA 19044 Medical Direc_or: HERMAN HURWITZ, MD, FCAP b *** END OF REPORT *** Legend ? ! High I Low L*! Abnormal © Corrected ?T] Incomplete k Preliminary Printed on 1 2108 /2003 at 1109:44 Site# 802652 AutoPrint GRAHAM MEDICAL CENTER WAL- --T BOTTOM RADIOLOGY Belvede:-e lkledical Cenwr?- 850 Walnut Bottom Road. Carlisle, PA 17013 Phone 71.7 245-0071 Fax 717 245-0180 DAVID R. ROYAL., M.D. KEITIi S. PUMROY, INi.D. Leidigh. Alexandra (02-25-987 601 Belvedere Street Carlisle, PA 1701 CT OF THE ABDOMEN AND PELVIS - WITH ORAL CONTRAST P2373 11-03-05 Dr. Pion OPEN A COMPUTED TOMOGRAP ULTRASONOGRAP DOPPLER SONOGRAP hIAMMOGRAP DEIA BONE DENSM ANALY.` DIAGNOS11C IUDIOLO; The CT examination of the abdomen and pelvis was performed with oral contrast only. There is mild soft tissue edema in the anterior abdominal wall consistent with a recent previous appendectomy. There is no evidence of fluid collection or abscess within the abdomen or pelvis. There is no free intraperitoneal fluid. The appearance of the abdomen and pelvis is unremarkable. IMPRESSION: Essentially normal CT examination of the abdomen and pelvis. There is minimal edema within the subcutaneous soft tissues in the abdominal right lower quadrant consistent with recent previous appendectomy. There is no evidence of abscess or postoperative fluid collection within the abdomen or pelvis. The examination is unremarkable. Keith S. Pumroy, M.D. KSP/eah T: 11/03/05 Thank you for referring your patient to Walnut Bottom Radiology. n 'Ile J I II I V 1lammograph} Accredited b-, the FDA & SCR NTRI, L Itrasound mid Vascular Sonography Accredited by the ACR Franco Psychological Associates 26 State Avenue, Carlisle, Permsylvania 17013 Initial Evaluation and Treatment Plan Client's Name: Evaluation Date: - Primary Diagnosis: ? `. `/, '3V, ,1 fU 7 (Client's Date of Birth: Problem Area/Symptoms (Circle All That Apply): Depression Anxiety Panic Attack Somatization Relationship Problem Poor Impulse Control Conduct Problems ADD or ADHD Eating Disorder 4- Other:- Client's Presenting oncern:l Client's Desired Outcomes of Therapy Primarv Clinical 1. Current Mental Status Evaluation (Should Correlate with DSM-IV Diagnosis/Diagnoses: (Circle each description applicable) Appearance: Well-Groomed Disheveled Bizarre Inappropriate Casuall G oomed/Dressed Older/Younger Attitude: Co_?erative Guarded Suspicious Uncooperative Belligerent Motor Activity: Calm Hyperactive Agitated Tremors/Tics Muscle Spasm Affect: Appropriate Labile Expansive Constricted Blunted Flat Tense Mood: Flat Depressed Anxious Euphoric Angry/Irritable Speech: Normal-- Delayed Soft Loud Slurred Excessive Pressured Perseverating Incoherent Thought Process: Inta(A_ Circumstantial Loosening of Association Tangential Flight of Ideas Thought Content: Hallucinations: Not Present Present: Auditory Visual Olfactory Delusions: Not Present Present: Persecutory Being Controlled Grandiose Thought Insertion/Deletion Bizarre *Suicidal Ideation Present: Yes No *Homicidal Ideation Present: Yes No *Comments: Self-Perception: No Impairment Depersonalization Derealization Body Image Distortion Orientation: Fullv ^^?^*°a Disoriented: Always Sometimes Time Place Person Memory: )fit Impaired Cognitive Function: General Knowledge Intact: Yes No Judgment: Intact Impaired Insight: Intact Impaired -------------------------------------------------------------------------------------------------- 2. Central Life Role Function Assessment (Document/rate current level of severity of functional impairment using specific example(s) to illustrate nature of client's deficits in everyday functioning. a. Occupation None Mild Moderate Severe Describe: b. Education None Mild Moderate Severe Describe: C. MaritalJFamily None Mild Moderate Severe Describe: ?- d. Interpersonal/Social None Mild Moderate Severe Describe: e. Self-Maintenance None Mild Moderate Severe Describe: Global Central Life Function Impairment Assessment: Mild Moderate Severe Franco Psychological Associates Initial Evaluation and Treatment Plan Page 2 Relevant Psychological Social History: g i r L t. n -'?L.C ,?'?.(c-ti.??L( F ?L? ?x ???...?.-'? .?V?.. /?1?E.iY'?l.:.?r.?'?'wi>?J Vii., -c_i a? < <, r ?(, si do 't.4,7 -?-?' , ?'1'l-?','W/Lk-?? c? L`i„C z._!?-- C?4°:/? ? -?TF- ??`-?f?'C.c?/? ? r?? f1r??ti ? l.G??..??t. C?-E;.Z...L f qq ???.'•4,'L'?-C llJ L'L: `-` . ? Franco Psychological Associates Initial Evaluation and Treatment Plan Page 3 I Psychological History (Including Family Members) (For Initial Treatment Plan) Identify significant mental health history including alcohol/ substance abuse, prior mental health and/or alcohol/substance abuse treatment; and relevant medical history including lab-test results, if any, and name of treating physician. Also include past psychot:ropic medications: Clinical Formulation: (working hypothesis of the nature and etiology of client's problems): Treatment Goals & Plan: Measurable,Behavioral Goal S GLet-i,- ?1/1___I' Method(s) for Achieving Goal Target Date for Achieving Goal Measurable,Behavioral Goal 2. Method(s) for Achieving /7/V`-Z) Target Date for .Achieving Goal Treatment Goals & Plan reviewed and understood by client Date -? l 5 Franco Psychological Associates Initial Evaluation and Treatment Plan Page 4 Substance Abuse Information: Current Substances: Quantities Frequency Date of Last Use r Current Medication Information: (circle those that apply) Psychotropic Medical No Information Specify type: Prescribed by: Family Physician: Telephone No.: Does client follow medication regime? No Yes Does client need a Psychiatric Medication Evaluation? No Yes Medication Allergies- Dia2nosis Information: AXIS I - Primary DSM-IV Code: AXIS II - Developmental Disorders or Personality Disorders: Yes --7 1 1 ? I AXIS IV - Severity of Psychosocial Stressors Scaje: (circle one) 1 2 3 4(?:fi AXIS I - Secondary DSM-IV Code (if applicable) 4 1 7? lc j AXIS III - Physical Disorders & Conditions No (Describe if yes): AXIS V/GAF Current: Sr Therapist Signature Date: ?.?:? s. ?? s F ti ?. f. r ? i GENERAL RELEASE For the consideration of Four Thousand Dollars ($4,000.00), receipt of which is hereby acknowledged, I/we release and discharge, and for myself/ourselves my/our heirs, representatives, executors, administrators, successors and assigns, do hereby remise, release and forever discharge Charles E. Miller, Sr. and Carol G. Miller hereinafter referred to as the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns, and any and all other persons, firms, corporations, associations, of and from any and all causes of action, suits, judgments, claims and demands of whatsoever kind, in law or in equity, known and unknown, which I/we now have or may hereafter have, and/or which the minor Alexandra Leidigh now has or may hereafter have, especially the claimed legal liability of releasee(s), which liability releasee(s) expressly deny(ies), arising from or by reason of any and all bodily or personal injury and/or property damage known and unknown, foreseen and unforeseen which heretofore has/have been or which hereafter may be sustained by me/us or the minor aforementioned arising out of the accident on or about April 13, 2005, at or near Interstate 81, Carlisle, in the County of Cumberland, in the State of Pennsylvania, in which the minor aforementioned sustained personal injuries and/or property damage. I/We agree that the consideration set forth above is specifically applicable to and paid to me/us with respect to any and all damage to any property, either real or personal, of mine/ours or the minor aforementioned, and with respect to any and all personal or bodily injury of mine/ours or the minor aforementioned, whether presently known or unknown, foreseen or unforeseen or which may subsequently develop and the consequences thereof, all as arising from the aforementioned accident. I/We further agree that the consideration set forth above is specifically applicable to and paid to me/us with respect to any right of contribution the I/we or the minor aforementioned may have against the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns relative to claims of others that may be brought against me/us or the minor aforementioned by reason of said accident. I/We further agree that the consideration set forth above is specifically applicable to my/our agreement that I/we or the minor aforementioned will not join nor attempt to join the releasee(s), his/her/their/its executors, administrators, insurers, successors and assigns in any capacity, in any action that may be brought against me/us or the minor aforementioned arising out of said accident. In consideration of the aforesaid payment, I/we for myself/ourselves and my/our heirs, representatives, executors, administrators, successors, and assigns do hereby: (1) agree to indemnify and hold forever harmless the releasee(s) and his/her/its/their representatives, administrators, or assigns, against loss from any and all further claims, demands or actions that may hereafter be made at any time or brought against the releasee(s) by me/us or the minor aforementioned, or by anyone in our behalf for the purpose of enforcing a further claim, for which this release is given; REL3 Initia s: Pa 1 1796438 2. DOC GENERAL RELEASE (2) warrant that I/we have received no money or other valuable consideration from any other person or persons by reason of any causes of action, suits, covenants, agreements, judgments, claims and demands of whatsoever kind, which I/we now have or may hereafter have, for injuries to person or property arising out of the aforementioned accident or for the other matters for which this release is given. Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this of day NOTICE: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties." WITNESS (Seal) Father-Guardian (Seal) other Minor Claim #010170804445 Catherine L. Marshall : klh (Seal) Ini i REL.3 JPo f 2 1796438 2.DOC r 0 CONTINGENT FEE AGREEMENT 4'ti THIS .AGREEMENT entered into the AL day of 2007, by and between SCHMIDT KRAMER PC and MARY ANN LEIDIGH AS PARENT AND NATURAL GUARDIAN OF ALEXANDRA C. LEIDIGH, A MINOR AND ABIGAIL M. LEIDIGH, A. MINOR, of 601 Belvedere Street, Carlisle, Pennsylvania 17013, hereinafter referred to as "Client." WITNESSETH: The law firm of SCHMIDT KRAMER PC, will act as Client's attorney in negotiating for a settlement, and in bringing a claim against CHARLES E. MILLER, SR., arising out of an accident which occurred on April 13, 2005, on Interstate 81 North, Carlisle, Cumberland County, Pennsylvania. In addition, SCHMIDT KRAMER PC, will pursue all claims for underinsured or uninsured motorist benefits to which the Client may be entitled under his/her insurance policy. In return, the Client will: 1. Promptly supply accurate information, as requested by SCHMIDT KRAMER PC, and cooperate fully, including making ourselves available for meetings with attorneys and for legal proceedings. Client promises all information supplied will be truthful and accurate. 2. (a) In any claim brought on Client's behalf, to pay to SCHMIDT KRAMER PC, for its services an amount equal to twenty-five (25%) of any recovery. (b) Client agrees not to settle or negotiate the above claim or any proceedings based thereon. (c) If Client terminates this Agreement before recovery, Client agrees that SCHMIDT KRAMER PC, shall be entitled to a fee based upon work done and benefit conferred. (d) Client agrees to read and follow SCHMIDT KRAMER PC's "Client Instruction Manual". 3. Client agrees to reimburse SCHMIDT KRAMER PC, out of any recovery, in addition to attorneys' fees, all costs and expenses incurred on Client's behalf in order to make the claim. All such costs and expenses will be advanced by SCHMIDT KRAMER PC as they are incurred. Such costs and expenses include, but are not limited to, filing fees, cost of medical records, copying costs, fax costs, long distance telephone costs, expert witness fees and sheriffs service costs. In the event there is no recovery, the Client will not be responsible for any costs or interest charges. Costs will be repaid to SCHMIDT KRAMER PC, out of any funds or property collected either by settlement or judgment. 4. Claims for first party medical benefits and income loss benefits are separate items. SCHMIDT KRAMER PC, will help you process these claims. A separate agreement will have to be entered into for fees if a major dispute occurs requiring the filing of suit for these benefits. The Client has read and does understand this Agreement. Signed. the day and year set forth above. WITNESS: iL7x Client: r ?,?' ?l •'? 1 ?.. MARY AiQf L &IGii, PARE T AND NATURAL GUARDIAN OF ALEXANDRA C. LEIDIGH AND ABIGAIL M. LEIDIGH, MINORS Approved: SCHMIDT KRAMER PC By I have received a copy of this Contingent Fee Agreement. 441 Initials D o N C) _V n ? A C V ai fl7 N N 1 O D 0 r r _m °-? -I O. (-)(-)0N r o _ zr ::r s wfQ m m m m ? Q CL n) n n n A N N n ? CD D x (D d x v a a ? N N ? N N A ? O O O co O O eo co m O N m j Z X wood C 2) 3 CL (D (D a 2) C/) _ a ?0C) r-_ O O O D :1 :3 D M ? 0 S . n n n c = Q iZ ? T a 3 > > n n n 13 m ? J TT d W cD D o ?. 3 N a a a C C C .? c < c O O CD N N N i ? ? ? Cn Cn u) A A A .' A p ? D w A 3 fD cn (D rn o CZ) i I iD j o N I N N i (D (D N C) O 0 p o cp I I 1 A s O U FILED--j,:F;CE OF THE PP; , 7-1,I)N TA,RY 2009 JUL 20 PH 12: 56 PBN SYLVAN SCHMIDT KRAMER PC BY: Gerard C. Kramer Attorney at Law Attorney ID No.: 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Fax ('717) 232-6467 gkrame t;schmidtkramer.com Attorney for Plaintiff MARY ANN LEIDIGH AND RONALD : IN THE COURT OF COMMON T. LEIDIGH, JR., INDIVIDUALLY : PLEAS AND IN THEIR OWN RIGHT AND CUMBERLAND COUNTY COUNTY, MARY ANN LEIDIGH AND RONALD PENNSYLVANIA T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs V. No. 2007-1169 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED PETITION FOR APPROVAL OF MINOR'S SETTLEMENT FOR ABIGAIL LEIDIGH AND NOW, comes the Petitioner, Mary Ann Leidigh, as the Parent and Natural Guardian of Abigail Leidigh, a minor, and respectfully sets forth as follows: 1. The Petitioner, Mary Ann Leidigh is the Parent and Natural Guardian of Abigail Leidigh, currently residing at 601 Belvedere Street, Carlisle, Cumberland County, Pennsylvania. 2. The Petitioner's daughter, Abigail Leidigh, is a minor, date-of-birth February 27, 1995, who resides with her mother, Mary Ann Leidigh, and father, Ronald T. Leidigh, Jr., at the above-mentioned address. 3. On April 13, 2005, Abigail Leidigh was a passenger in her mother's car on Interstate 81 in South Middleton Township, Cumberland County, Pennsylvania. 4. Ms. Mary Ann Leidigh had stopped the vehicle in the right lane of Northbound Interstate 81 because the traffic in front of her had been stopped due to a blasting project. 5. Defendant, Mr. Miller, was traveling in the left lane of Northbound Interstate 81, moved to the right lane and struck Ms. Mary Ann Leidigh's vehicle in the rear as it sat stopped in the right lane. 6. Abigail Leidigh was treated at the scene of the accident by Carlisle Community Ambulance. She had pain in her low back, right hip and pelvis. The right side of her pelvis was notably higher than the left side. Abigail was taken to Carlisle Regional Medical Center where she was examined and diagnosed with a back contusion. (See Carlisle Community Ambulance Records attached as Exhibit "A" and Carlisle Regional Medical Center Records attached as Exhibit "B"). 7. On April 19, 2005, Abigail followed up with Dr. Pion at the Graham Medical Clinic. She had head, abdominal, pelvic, low back and right knee pain. Dr. Pion diagnosed her with a cervical strain. He referred her for physical therapy. (See Graham Medical Clinic Records attached as Exhibit "C"). 8. Abigail had her teeth and jaw examined at Conner-Apicella Orthodontic Associates on April 19, 2005. The examination revealed no clicking or popping. (See Conner-Apicella Orthodontic Records attached as Exhibit "D"). 9. Abigail had an initial evaluation at Alexander Spring Rehab on April 29, 2005. She was having periodic shoulder, tailbone and right leg pain. The therapist rioted pain in her right thigh and hip with extension and tenderness in her spine and soreness in her upper trapezius. After 15 therapy sessions, she was discharged on June 16, 2005. Her pain had decreased by over 75%. (See Alexander Spring Rehab Records attached as Exhibit "E"). 10. Abigail also attended sessions at Franco Psychological Associates for treatment related to the accident. 11. She had no additional complaints or treatment. 12. All medical expenses have been paid by the Leidigh's insurer, State Farm Insurance Company. There are no outstanding medical bills. 13. The Petitioner has reached a compromise with Erie Insurance Company regarding the claim for injuries sustained by Abigail Leidigh, in the form of a lump sum payment of Five Thousand Dollars ($5,000.00) in return for a general release. (See Parents Release and Indemnity Agreement attached as Exhibit "F"). 14. (a) The Petitioner, Mary Ann Leidigh, is satisfied that the offer of settlement is just and reasonable and is willing to accept the offer, if approved by the Court. (b) Ronald T. Leidigh, Jr., Abigail Leidigh's father, also believes the offer to be reasonable and joins in the petition. 15. In pursuing the claim, the Petitioner engaged the law firm of Schmidt Kramer PC under a Contingency Fee Agreement that provides that Schmidt Kramer PC should be paid a fee of 25% of any settlement or award. (See Contingency Fee Agreement attached as Exhibit "G"). 16. Schmidt Kramer PC has incurred costs of $350.01 relative to obtaining copies of medical records and costs associated with the investigation of this matter. (See Summary of Attorney Costs and Expenses attached as Exhibit "H"). 17. The Petitioner requests that the Court distribute the present payment of Five Thousand Dollars ($5,000.00). as follows: Schmidt Kramer PC - Attorney Fees 25% $ 1,250.00 Schmidt Kramer PC - Costs to Date $ 350.01 Invested for Abigail Leidi h, a minor $ 3,399.99 Total Settlement $ 5,000.00 18. The Petitioner requests that an account be authorized without the formal appointment of a guardian of estate of the minor, or the entry of security, as permitted by Pennsylvania Rule of Civil Procedure 2039(b)(2), with the Petitioner, Mary Ann Leidigh, being authorized and directed to invest funds belonging to Abigail Leidigh, a minor, as follows: a. to invest the funds in Certificates of Deposit to the extent possible, not to exceed such sums as are fully insured by F.D.I.C.; and b. to invest the balance of said sums which cannot be invested in Certificates of Deposit, if any, in a Savings Account, not to exceed such sums as are fully insured with F.D.I.C. Each account on behalf of Abigail Leidigh shall be marked as follows: This money shall be held in trust not to be redeemed, withdrawn, negotiated, or in any way alienated, except for the renewal in its entirety, before February 27, 2013, except by Order of this Court. 19. The Petitioner and her counsel shall promptly file proof of the deposit of the sum of $3,399.99. 20. There are no outstanding debts owed by Abigail Leidigh. WHEREFORE, Petitioner, Mary Ann Leidigh, requests that this Honorable Court enter an Order approving the foregoing compromised settlement, permitting the Petitioner to execute the Release, and directing the distribution of proceeds as set forth herein. Dated: Respectfully Submitted, SCHMIDT KRAMER PC By: ?rerard C. Kramer Attorney at Law Attorney I.D. #44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs VERIFICATION I, Petitioner, Mary Ann Leidigh, mother of Abigail Leidigh, a minor, have reviewed the contents of the Petition for Approval of Minor's Settlement and hereby verify that the statements set forth herein are true and correct to the best of my knowledge, information, and belief. I am satisfied that the offer of settlement, referred to in this Petition, for my daughter, Abigail Leidigh's injuries, is just and reasonable and I am willing to accept that offer. I understand that any intentional false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904 relating to unsworn falsifications made to authorities. Date: 0-711 El Qg Mary A Leidigh, Parent nd Natural Guardian of Abigail Leidigh, a Minor JOINDER I, Ronald T. Leidigh, Jr., am the father of Abigail Leidigh, a minor, and hereby state that I have read the foregoing Petition for Approval of Minor's Settlement and that I understand, agree, and approve the contents thereof and join in the Petition. Date: ice.. Ronald T. Leidigh, Jr. LE!= (- 1 )C-'L,(-107 11 '3 ICU IF, i i=GLW:LL FIRE RE.=;. Trip Number: Patient Number: Address: City/Statemp: Phone: Member: Transported From: Transported To: 71724''546'z F1.020 Cumberland Goodwill Fire Rescue EMS U 40 Patient Services Charge Form - PCR: 0501146?Ci 0501146 Patient Name: Abigail Leidigh Date: 04/13/2005 601 Belvedere Street Carlisle, PA 17013 (717) 258-9762 No 181 North near York Rd Exit Carlisle Regional Medical Center Serviceffype Charges Call Type: Prehospital Waiting Time: 0 Minutes Medicare Checks ? Moved by Stretcher ? Hemorrhaging ? Bed Confined Before Chief Complaint: MVA Reason for Transport: Other: ICD-9 Code 1: Multiple Injury 959.8 Insurance Information Date of Birth: 02/27/1995 Age: 10 Years SSN: 169-76-2598 Sex: Female Crew 1: Page, Stephanie Crew 2: Katona, Edward Crew 3: Crew 4: Loaded Mileage: 3 Miles Origin Zip Code: 17013 ? Bed Confined After ? Unconscloas/Shock Present ICD-9 Code 2: Prima Com an NAIL Group # ID # Other Information / Auto Accident- Specify None 70691878 State Farm Auto 3139P Other- Specify 02861600 ZAH15954 PBSHM 378 Classic IND 4952 Guarantor Information - Self Stock Charges Item Product # Alt. Prod. # Quantity Cervical Collar stif 13.95 1 Lo Sine Board LSB 1 LSB2 1 Response Res Res 1 Pharmacy Charges Item Product # Alt. Prod. # Quantity Billing Notes: HIPAA given Printed On: 04/14/2005 15:57 EMStat Reporting(c) 1998-2005, Med-Media, Inc. All Rights Reserved Page: 1 of I DEi__"-i.ii;- i ;07 11 "UMB. GOODWILL FIRE RES. CARLISLE REGIONAL MEDICAL CTR 04/14/2005 11,17:56 * * F A X %A r I? 7!72435482 F. i?21 PAGE: 1 OF 3 To: NONSTAFF. FAMILY PHY PROMED SYSTEM (ER) From: CRMC Patient Admit Date/Time Roan No M fG Agg Birth Date SM RE MS 5K OgdRect 9308375 04/13/2005 1533 0000 E 1 F 10 02/27/1995 F CA S 0000793299 Patient Name A Address r Patient Employer Phone Number LEIDIGH. ABIGAIL M 169-76-2598 STUDENT 601 BELVEDERE STREET Phone Number Con CARLISLE PA 17013 717-258-9762 CUM ERLAND . Responsible Party r SS Nk aber Responsib14 Party Emalyr Ph ng gr LEI IGH. RONALD 159-54-4952 STATE POLICE 717-249-2121 601 BELVEDERE STREET Mont?_ COMMERCE AVE CARLISLE PA 17013 717-258-9762 CARLISLE PA 17013 Other Responsible Party r Other EmplOyer Phone Number LEIDIGH. MARY ANN M 159-52-6434 NOT EMP 601 BELVEDERE STREET Phone_Maber_ CARLISLE PA 17013 717-258-9762 Payor Name insured Group No - Policy 1W 1. STATE FARM AUTO LEIDIGH, RONALD JR NONE 706 187B3138P Pre-Cart Number: Insured Sex: F Relation: PARENT HAS P 0 BOX 14007 YORK PA 17404- PH. 717-2412341 2. PBSHM 378 CLASSIC IND LEIDIGH, RONALD JR 02861600 ZAH159544952 Pre-Cert Number; Insured Sex: M Relation: PARENT HAS PO BOX 890173 CAMP HILL PA 17089-0173 PH. 866-8033708 3. Next Of Kin Rel. Phone Address-City.St..Zia Mork Phone WILLARD. DINA GRAND 717-249-3663 Attending Physici an Other Phy=sician LASEK. ROBERT W MD PION, JOSEPH A Diagnosis Accident Accident Date / Description MVA NO FAULT 04/13/2005 INT 81 NORTH Prey. Admit Ot. DiAchlrge Date Discharge Time Discharge Code 04/1312005 15:33 Diagnosis Codes (Pri Mary) M . 5? iu in M M Procedure Codes/Dates 1U Lu J41 151 lu End Of Page DEC'-06-2007 11::2,3 CUME. Cris, LWILL FIRE RES. l`?JV 1 717?4.ar•482) Cumberland Goodwill Fire Rescue EMS West Shore EMS Assignment of Benefits Authorization, Responsibility for Payment and Acknowledgement of Receipt of Notice of Privacy Practices BILLING AUTHORIZATION, RESPONSIBILITY FOR PAYMENT AND RECEIPT OF NOTICE OF PRIVACY RIGHTS I understand that I am financially responsible for the services provided to me by Cumberland Goodwill Fire Rescue EMS/West Shore EMS regardless of insurance coverage. I request that payment of authorized Medicare or other insurance benefits be made on my behalf to Cumberland Goodwill Fire Rescue EMS/West Shore EMS for any services provided to me by Cumberland Goodwill Fire Rescue EMS/West Shore EMS. I authorize and direct any holder of medical information or documentation about me to release to the Centers for Medicare and Medicaid Services and its carriers and agents, as well as to Cumberland Goodwill Fire Rescue EMS/West Shore EMS and its billing agents and any other payers or insurers, any information or documentation needed to determine these benefits or benefits payable for any services provided to me by Cumberland Goodwill Fire Rescue EMS/West Shore EMS, now or in the future. I agree to immediately remit to Cumberland Goodwill Fire Rescue EMS/West Shore EMS any payments that I receive directly from any Cumberland Goodwill Fire Rescue EMS/West Shore EMS source for the services provided to me and I assign all rights to such payments to. I also acknowledge that I have received a copy of the Cumberland Goodwill Fire Rescue EMS/West Shore EMS Notice of Privacy Practices. I understand that I should read it carefully. I am aware that the notice may be changed at any time. I may obtain a revised copy of the Notice by requesting a one at the Cumberland Goodwill Fire Rescue EMS/West Shore EMS office or on the website at www.cumberlandgoodwill.org or at www.hsh.org. A copy of this form is as valid as the original. Date:-QJ? 3 Patient Sig t Patient Representative's Signature Patient unable to sign because: Relationship to Patient Cumberland Goodwill Fire, Rescue, EMS Inc. 102 W. Ridge St. Carlisle, PA 17013 717-249-0012 www.c urnberlandizoodwill. ors r-.oz'23 DES: 0C-200 19';;4 C= ,Mi3. i_c_ir_iliWILL FIRE REi Pennsylvania EMS Report 717243F?482 F'.0143 Unit No. PCR No. PSAP Ineid. No. Date Service Name Cumberland Goodwill Fite Rescue EMS 2100224 0501146 05(1043210 04113/2005 Incident Location MCD Receiving Aaeacy 181 North near York Rd Exit 21926 Carlisle Regional Medical Center Patient Name Phone No. Age Date or Birth Social Sec. No. Sex Abigail Leidi h 1 2 717 258.9762 1 D Years 02/27/1995 169-76-2598 Female 4 4 Street Address Crew Times a 911 H 601 Belvedere Street A N Stephanie E 141984 it City state Zip A N a, Edward EKaton, P 063110 Dispatch 14:24 Carlisle PA 17013 A N Enronte 14:26 ? Patient Number Membership A N Arrive Scene 14:30 . ? No Contact 14:31 P vate hysician Out On-Scene Dest. in Depart Sane 14:55 A4 0 16901 16904 0 Arrive Facility 15:06 I PPion, Joseph MD 15 15 Transporting Assist Units OS Time Medical Command Physician MCC Available In Quarters : Chief Complaint. MVA--lower bac k pain, right hi in Current Meds: all a Allergies coeds : sulfa Narrative PMHx: none Ambulance 240/Medic 283 dispatched and responding with immediate response, class 2 to interstate 81 North near the York Road exit via Cumberland County 911 for an MVA with injuries. Prior to arrival ambulance 240/medic 283 are advised that there are 2 vehicles. There are to be 2 injuries. One injured is a 10 year old complaining of lower back pain and a 50 year old with chest pain from the air bag. Upon arrival ambulance 240/Medic 283 finds 2 vehicles with one sitting on the interstate with the second sitting off the side of the road. The vehicle sitting on the interstate rear-ended the first vehicle. There is front-end damage to the vehicle on the interstate and rear end damage to the vehicle on the side of the road. The patient is a 10-year-old female conscious, alert and oriented. Patient is seated the rear on the passenger side of the vehicle. Patient was restrained. Patient is complaining of lower back pain and right hip pain. Patient denies no loss of consciousness, trouble breathing or chest pain. Patient states that she remembers the accident. Patient's c-spine is held and a cervical collar is put in place. There were no deformities felt upon palpation in the patient's neck. Patient's back is palpated and there were no deformities noted. Patient has no deformities, contusions, abrasions, punctures, and bums, swelling or lacerations. Patient does have tenderness upon palpation at her right hip. Patient is tumed and laid on a tong spinal board. Patient is slid onto the board and secured. CIDs are put in place. Patient is placed on the litter and secured. Patient is taken and placed in the back of the ambulance. Patient has no past medical history. Patient takes the following medications: aliegra. Patient is allergic to sulfa drugs. 0 0 •A CIN J N N A .p J Once in the back of the ambulance, patient's vital signs are assessed and are as follows: blood pressure--122/82; pulse--80; respiration--18. Patient's pelvic is palpated and the right side is higher then the left side. Patient has tenderness upon palpation. Patient's P is o hermse unre able. Yn ?ul°lS Provider EMStat Reporting(c) 1998-2005, Mod-Media, Inc. All Rights Reserved Page: I of 2 DEC- OG-2r?n 11:;?4 'Ul?B. C?-:OD n^ RES, 17"24'5)482 P.(_'''4 Pennsylvania EINIS Report Service Name Unit No. PCR Na Dote Cumberland Goodwill Fire Rescue EMS 2100224 0501146 04/13/2005 Patient Name Date of Birth Social Security Number MCC Medical Command Physician Abigail Leidigh 02127/1995 169-76-2598 Patient is transported to Carlisle Regional Medical Center. Patient care is transferred to Carlisle Regional Medical Center upon being placed in room 1A. Patient's mother is given the notice of privacy practices and signs the form understanding what she signed. Ambulance 240/Medic 283 goes available and returns to quarters. Stephanie Page, EMT 141984 Time P R H. P. %Ox Glasgow Treatment Provider Res Cornnu i 14:24 dispatched 14:26 t responding 14:30 on scene 14:55 minute to CRMC 14:55 s0 18 122182 4/516 Al Initial VS 15:06 at CRMC 15:15 available d C11 D Q1 -4 N J "I. N M7 HIJ Provider EMStat Rgwrting(c) 1998-2005, Med-Media, Inc. All Rights Reserved Page: 2 of 2 ADMISSION RECORD YIO TCAL?? A 246 Parker St. Carlis1e, PA ) 7013 Ph:7 0.249.1212 ;9.10,8.3 ;7 5 0 0 0 0 7 9 3 2 9 __A? ADMIT DA YE 1 TIME ROOM NO. PT I_FC AG DATE OF mFt X S LOCATION PROGRAM p 04/13/2005 15:33 0000 El F 10 02/27/1995 F 1 S A T PATIENT NA 'PATIENT l PL NE N 1 LEIDIGH, ABIGAIL M 169-76-2598 STUDENT E 601 BELVEDERE STREET N CARLISLE PA 170.13 (717)258-9762 T U5 CUMBERLAND LEIDIGH, RONALD T STATE POLICE G 601 BELVEDERE STREET 159-54-4952 COMMERCE AVE (717)249-2121 A PHONE ND CARLISLE PA 17013 R CARLISLE PA 17013 RELATIONSHIP TO P U5 (717)258-9762 FATHER RESP EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE EMERG Y ONTACT RELATIONSHIP 0 PATIENT WILLARD, DINA (717)249-3663 GRANDMTHER COMMEtirs M PRIVACY- ADMIT-gq . D y (NN o r Qp N Y KAB rar[n 825 rl,wn/ . ATO.. S ATE FA AU O P O BOX 14007 N YORK PA 17404 (717)241-2342 S U 2 INSUIUME Co NAME 1 PAVER 200 gS3'* . . Amm"T, PBSHM 378 CLASSIC IND R PO BOX 890173 CAMP HILL PA 17089 A (866)803-3708 N 3 PAYER ' - ? pATE OF BIRTH -. ?'+? 8313BP;° 12/0:7/19.65. RONALD JR DATE OF BIRTH / C E M 1 LASEK, ROBERT W MD 5 C MVA PION, JOSEPH A ACCIDENT NO FAULT 04/13/2005 4NCC1PAL DIAGNOSIS (The concinion aatab4ohe0 afar ctuOy-to be :CamorYno the bdrnisWn Of the gallant to the HOSPITAL for care). COMPLICATIONS COMO RBIOIT Y(7ES) PRINCIPAL PROCEDURE AD001 A W9275 D00079)Zso ?AfIM??NGrMI1?Ni ??81ti?slttlBIN1M?Yd MEDICAL RECORDS COPY ?I?lIIIN?YIB?YNfiA?A?tNYNA6 PHYSICIAN DOCUMENTATION FORM Date IW4/1312005 Carlisle Regional Medical Center Name:LEIDIG'H, ABIGAIL M Age: 10 Yrs 0 Mo. 0 Wks Sex: F MR#007 3299 Pty en9308375 Chief Complaint: MVA Triage m:15: 3 Allergies: PEANUTS, STRAWBERRIES, SULFA T. 98,8 Medicines: ALLEGRA 1() MG DAY, XXXXXXX P. 89 History: Alcohol_ Tobacco Wt: 45.5 KG Ht: Head rmu:r°IUN, J05EPH A Phys Notified: cc Pf: ROS PH FH SH j Exam: Appearance: HEENT: Chest: Heart: Abdomen: Extremities: Neurological: Pelvic: Re-Exam Time Medical Decision Making: Discharge Instructions: Diagnosis: Staff 510hature l R: 20 ALLERGIES BP: 1211078 Sa02: 99% LMP: LDT: Imm. Status: VA: OD OS: EDP: LASEK, ROBERT W MD Time Diagnostic Studies Exam Time: Ordered Test Interpret T?ABG: CBC t3MP/CMP r'wc CLNTER EMERGENCY DEPARTMENT Date ?i LL Ai'l(-7r}IL was incapacitated fro E_i work; physical education due to illness / injury from 4114 ! (•) ,) to and including Other comments me: Ime: Test with ER 0510 (4196) COURSE IN ED PROCEDURES Disposition: DIC Admit _ Trans Time: LWOT AMA Acuity of D/C: Stable Expired DOA Coroner Autopsy Referred to 0r. _ Patient Request Colaborating EDP:_ - ----------- On Calr Mo I I I I I i i i Carlisle Regional Medical Center Instructions: circle positive - backslash negative, provide additional ertinent information. NAME; LEIDIGH, ABIGAIL M p": 9308375 DATE OF SERVICE: 4113/2005 DOB: 22711995 Age: 10 Yrs 0 Mos 0 Wks MRS: 0000793299 Pros Time: 15:33 Sex: F Wt: 45.5 KG ?it: Triage Time. 15:33 Chief Complaint: MVA T: 98.8 PO Medicines: ALLEGRA 10 MG DAY, XXXXXXX P; 99 Regular :20 Unlabored Allergies: PEANUTS, STRAWBERRIES, SULFA R BP; 1211078 Sa02.,99 % Normal I Hypoxla EDP: LASEK, ROBERT W MD PCP: PION, JOSEPH A Arrival mode, BLS Pain Scale: 4 •• • Exam Time: H Patient Family EMS NH Trarrsia;V Lim!= Cy- AEW Intoxlr:alion Severity Unreliable C I C I HPI: (News ve): G-collar PT40N EMTALA Medical Screen: Emergent [] Non-Emergent[] AVA L41V 4-a fA- 16, Timing: Sx started suddenly !gradually min. / his. l days /wks. ago :Continuous /Intermittent /J Duration: Sx fast min. / his. I days / wks, at a Time : present / absent A?-- Location of Injury: tread face neck chest back abd upper ext R / L lower ext R / L Quallty: cannot describe fall r height ft MVA crush mjury punched kicked GSW slab wound Severity: mild moderate sever 1-10 scale Me Ihresterrng Context: accident assaulted MVA child abuse found unresponsive Exacerbated by: nothing movem n palpallorn Relleved by: nothing rest Ice OTC coeds Assoc. Signs 3 Symptoms: none LOC C.R abdominal pain bleeding deformities REVIEW OP SYSTEMS Limited Due To: ALOC Intoxication Severity Unreliable Constitutional: fever chills weakness diaphoresis Neurological: HA seizures weakness confusion ENT: sore throat ear pain facial pain Psychological; anxious depressed Eyes: pain visual changes Endocrine: pdyuria polydipsla Cardiovascular: C.P. palpitations DOE PND latagurnent: rashes prurilis lesions Respiratory: S.O.B. cough congestion Hematologic: anemia bleeding disorders transfusion GI: N / V diarrhea / constipation pain melena hematernesis Allergy/lmm.: frequent Infections allergies hives GU; flank pain dysurta ?fnemaatu ' Requency Other; Musculoskeletad: Joint 14&5^ "' ext. pain Other Systems Reviewed And Are Negative Agree With Nursing Assessment MEDICAL AND SOCIAL HISTORY Med. Hx: none ID 1 NIDDVI asthma eviewed Past Med. Hx: AELRGS Mods: ALLEGRA f0 MG DAY, XXXXXXX _-===_ /? Reviewed Allergies,. PEANUTS, STRAWBERRIES, SULFA Surg. Hx: none Appy Tonsillectomy Reviewed Family Hx: negative R / L Handed Lives Alone: Y / N Social Hx: day care ent occupation: Tobacco.fi / N Packs/Day _ Years ETON: Y 1 N DrinkslM. Drugs: Y IN Immunizations: Up-to-dale: Y / N Tetanus: Reproductive Hx: LMP: G P AS Pro-MED Maximus craryrgftr+mor Pediatric - Trauma - Page / of 2 r+v.MEOG+ntrsnrma.??c. rt« oaf Carlisle RRninnal MAAicml r1^mFnr - - - ------ +13:.s+c?dtts cuc+e OSAIVe - Damsiasn negative, provide adtlitionel eminent informalion. NAME: LEIDIGH, ABIGAIL M PHY Ptll: 9308375 MRS: 0000713299 SICAL EXAM GENERAL: NAD- mil / oderato 1 severe distress HZEFE N N. T e EOMI _ VITAL SIGN: T98.8 99 R20 OP 1211078 l C RRR PA NL eaLrnXi;s /6 sys / dys rubs (ca- 9a' o s -S31 S4 ww ` LocatloniVosatption of Symptoms: RESP: lungs ear tlaleral resP.0 NL 4iep;?, ' rates r onch! wheezes '? • y. t} )/ fla . Istended bowel sounds NL 1 ABN tender / n er guarding rebound rigidity US ?m ? ( SKIN?-WSRh?Ory? dlapi o%W- mshe -' NEURO: 2 12 in t OTRs equal r symmetric - {{i1 l ?tjj 1 _ PSYCH AAO'X -pl y ,ul l propriate age L Y P { ? + ? (t ? M H: adencPathy GU: N deferr - f `,?r V I t v f pw= r ; Other: ? { r MEDICAL i od G DECISION MAKING LABS AND STUDIES EO COUR5E ANO T% Labs reviewed and are negative X•Ray. C-spine: MEDS: ? CXR: lvf; NL / ABN NL I ABN PUNIC DIFF FOLEY: S C.T.: head / abd / pelvis _ l - a EKG: NSR no acute disease No- UA: SG Prot RBCs WBCs Pulse Ox: %NL / hypoxla RE•EYAL: Time: UCG: + r - Other: ABG: pH 02 C02 Improved Same Worse DOX: concussion cervical strain Fx laceration hernstoma skull Fx Critical Care: 30-74175.90 191-1041105-120 pneumothorax shock spleen injury contusion child abuse other: 121-11341 '135-164 Minutes [] ExcJ. billable pros. CL?NICAL e DISCHARGE (NSTRUCI(ONS 1 • 1 Discharged to: Home Nursing Home family 2. L Follow-up with Patient's or. In days. 3. Other Instructions: 4. 5. CONSULTATION DISPO SITION Discussed with Dr. Discharge Time Out: Admit Admit: OBS ICU PCU Floor Tole. OR Prescriptions en: Follow-up In Off ce Transfer: Otd Records Reviewed Y 1 N AMA: Reviewed 01W Radiologist Y I N DOA: Case D/W Patient / Family Y f N Condition: Improved Stable Deceased RETURN fF CONDfT10N WORSENS. See procedure form attached Q Slgnalur•s: PA/ARNP MD/DO Record Complete F] Pro-MED Maximus Pediatric - Trauma - Page 2 of 2 acxvr.nn{ &V1 .roMrO CMw s?swn.. ?? ' . Ate. OMM4, ORDER PROCEDURE FORM TRAUMA EMERGENCIES Date In: 411312005 Time: Carlisle Regional Medical Center Raw- IDiGH, ABIGAIL M Pttf 9308375 Age: 10YRS 009:02/2717995 Sex: F MRq:0000793299 EDP: LASEK, ROBERT W MD PCP: PION, JOSEPH A laboratory Testa Other Diagnostic Tests Order Time Order Sen er Tim Radiology Order Sent By CBC X P T • Po BMP CMP Am lase Li ass C- pine ( -table) (Complete) Drug screen (serum), (urine) CT Head eTOH Cardiac Profile PT/PTT en or, rocs kl-Uni Cardla mona ' UA " ee A8Q 02 LPM Misc. Orders i Medical Necessity kdonnittom Previous RAedical Records PhyslCal Therapy- Eval & Tx Weight: )bs: 700 kgs: 45.5 Allergies: PEANUTS, STRAWBERRIES, SULFA Order Time Medication I Dosage I Route VO Read Bade dm U Adrn by Sits Time Reassess"" Pain Initial 0 improved p worse ? Unchanged 0 ? Improved Q Worse C3 Unchanged ? ? InnDmyed ? Worse C3 Unchanged C7 D Improved 0 Worse O Unchanged Improved 0 Worse 0 tlntthanged Order Time IV I Solulion / Added Medication SlartTlme Device / Size Location Attempts Amount Stan by D/C Time Amt Inlueecl tNC b OKVO Device: 0 IV Fluid: Procedures I Homing Assistance 0 Cardiac Monitor Rate Rhythm 0 Laceradon Repair ? 8loW Product Administration D NIBP Monitor 0 Cast / Splint ? Urinary Catheter Insertion p Fr. C3 Pulse Oximetry ? Central Line Placement ? NGT Insertion Fr. {] Endolracheal Inlubation ? SucUoning 0 CPR ? Chest Tube Insertion p Cardioversion 0 Wound Dressings p Diagnostic Peritoneal Lavage ? Periccardiocentesis Disch4rge Instructions fniU I S atu nitlalslS tur PA/ARNP: Physician' S lure v V v y Kev. v9r14ro4 EMERGE ONGOINI Date: 4113120 NURSING DIAGNOSIS (NurnliiWr in order of prio*. EWA PsWnt mutt have at least one seleded.) Airway Clea rance. Ineffective Communication impaired Infection. Potentlai Saff Care Deficit - Anxiety _-TopIng. IneffectiYe --Injury. Potential -Skin Integrity InVairment -'Breath_ing P; ????ac Output, Decreawd ---Pas Exchange, Impaired /COmfort, Alt `Other Tha GOAL 1 PLAN for this PstiOnt Is to assist in M15641ing identifft needs and initiate interventions for I to-, k4l, met int Not MCI D FB REM( p 8 EOIN ;VAIN CONTROL 0 STABILIZE PATIENT IN OtSTRESS 0 MAINTAIN STABLE KOME06YASIs 0 mwi ENVIRONMENTAL NEEDS to ALLEVIATE O FEVER CONTROL * DECREASE Q SAFETY Time, Numas Progress Notes 02 NO/ I Cardiac ipain 1 IInn lo?l LJ1 ff IAr°SG?1' ? k" ELI Dispooklion Discharged in care of: !P, OStrelOCaffliad * Admit: Room *-to Dr.- Ready for Roorn T wne:_ Report called at and given to Reporl Called at and given to c3 Left vAthout treaurient t3left Against Medical Advise Pain Scale: a r(O Pain Location: Patient reports that pain is: BimproveC OrU,nchangeo ?Worse Dlsposulon Vitals: T 8. P I Y R la BP D'rsposluon Date: E Rime: 70V Nurse: KO-10105-M4 EMERGENCY DEPARTMENT PEDIATRIC NURSING ASSESSMENT Date ?n:4113/2005 Time: Carlisle Regional Medical Center Name:LEINGH, ABIGAIL M Pt#:8308375 Age: 10YRS 008.0212711995 Sex F MR#: D000793299 EDP: IASEK, ROBERT W MD PCP: PION, JOSEPH A Subjective Notes: A 0. Pain Dpatient denies pain Location: v ?'C]tiaiity:DSharp ?Dull OCramping DBuming 0.4chtng 0 Rating Scale: la Mode of Onset: t] ud en D Gradual D intermittent WONG/BAKER FACES RATING SCAL Onset: Date: Time: Duration: r r . Onset ;, 24 hrs. medical attention was sopght] DNo pYes Date: Radiating: RNo ONes IW'aN 0 2 4 6 8 10 Psychmoclat Caregiver. arents []Mother ?Father QOther. Environment: ?No steps 4Few steps 0Many steps A=Mpamed by-Aa 714-v Nutridonal status: p fypcrnat 0 Cachew E3 Obese Appearance: pGean DUnkempt DOVwt _ Religious /Cultural preference: DNone (sp"i ` Activity level: t sake RPlaytuiles /Laughs Best team by: (pt / caregiver) DVerbal 4Wntlen DRetum demo p0ther Learning Barriers: Nourologicai Gatrtrair?bostlnal D Not Assessed ake OOry,ated ?ra$,. OCry?ng DLethargic Abdomen: DHM ?Flat 0Rigid 0Distended DResiless ODisoriented DUnresponsiva on-Tender ?Tendar(Area) Pupils size and reaction: Bowel Sounds: 31ts sent O Decreased D Absent Cardlovaacular E6minabon:.1Qormal OConstlpation oDiarrhea # of Stools: Skin arm D Dry D Cool D Moist r3Dlaphorelic Genitourtnsry; .2KO Assessed Color: 04rink OPale DAshen DFlushed DCyanotk; ?Jaundiced Voiding: oConlinent olnconfinent tlDlaper ?Pottytrained Capillary Refill: ? <2 Secs (Normal) ?>2 Secs (Delayed) C?Dysuria ?Frequency Color: Turgor: D Normal O Decreased Other findings: Pulses: L Radial; E) Present p Absent R Radial: 0 Present C] Absent LPedal: ?PresentClAbserit RPedal: C3 Present ?Absent Respiratory musculosketetal 0 Not Assessed Airway: tear D Other Lacerations I Abrasions / Contusions r Effort: elfitlabored p Labored D Mildly 0 Severely Location: U Retractions, O Stridor D Nasal Flaring Size: Cough: •O None - O Productive D Non-Productive Bleeding: Abs ent D Present O Scant ? Moderate o IieavyO Pulsating ' f ROM: ? ?WNL ? Decreased DAbsent Lung Sounds: pCTear DWheezes DRhonchi oCrackles DDiminished DAbsent Edema:.--dAAbsenl a 1+ (32* 02+ Deftmrnity?Yes a ll<- Oft Dt-'17R t7L OR (31. QR DL QR Dt ?R ?L ? Scars: El Yes 2 0 Dlstaipulses: 4Absent Present Growth and Development Weight: KG. Height: R In Head Circumference: cm 13NEW BORN Aw o • i Montn OINFANT i • u Month• Language: OChes Often ?Smiles EDCoos / Gurgies DBabbles Sorn at Term:13Yes 3No Delivery-, OVaginal OC-Section Dist: (38reastFeed ita type: Uses: 08ottle ?Spoon OCup Other. Sits up: Owith help O without help Crawls: Q Yes O No Teething: O Yen ? NO Observaltion of Inleraclilon with caregiver Is D Appropriate OSee Nursing Assessment 13TODDLER Ago 1- 2 YON" vl A4.3 • s YWy Language: OFew Words OSentences D Easily Understood Diet: DFInger Foods ular Diet OFeeds Self Uses: Oaotde O Cup Teething. 13Yes ONo Elimination: [11 - 2 Stools per day ?Dlapers Moiilel trained OWels bed: El Rarely 0 Occasiarwlly DFrequently OWalks with assistance OWaiks independently ObnZation of Interaction with caregiver is ClAppropriate C1See Nursing Assessment ;ENT Aoo rt . is rears Reached Puberty: 0 Yes DNo Learning disabalty: O Yes Sthoot grade: Eatlng disorder. (specify) Wears Braces OYes DNo 50s 3 me EftinaUen: CTNo problem reported - O Wets bed: ClRarely 00ccasionally OFrequently I "- ?? Uses.Aloohot: C Yes QMd Uses Drugs: ? Yes ONo Social Habits: Smokes 0 Yes Observation of Interaction with caregIver Is opriate OSee Nursing Assessment Vital Signs: 15:33 T: gg.9 P: 'f Regular R: 20 9P: 1211078 Nurse Signature: 0 V .2V. ujar51e4 INITIAL ASSESSMENT FORM Carlisle Regional Medical Center PRIORITY: 3 Patient: LEIDIGH, ABIGAIL M Pw 9308375 Urgent Doe: 0212711995 AGE: 10YRS Sex: F MR#: 0000793Z99 EDP: LASEK, ROBERT W MD Worker's Comp: DATE: 04/1312D05 PCP: PION, JOSEPH A EnW, Referred: Presentation Time: 15:33 Triage Time: 15:33 Amval Mode: 81.5 Height: . Weight: too.0 tbs. 45.5 k9s, LMP: Last Tetanus: AGC By: Father Chief MVA Complaint: Brief PT WAS THE RIGHT REAR RESTRAINED PASSENGER IN A VEHICLE THAT WAS HIT IN THE Assessment: REAR. PT IS COMPLAINING OF LEFT BACK PAIN AND RIGHT HIP PAIN. PT WA$ NOT OUT OF THE VEHICLE. NIGHT SWEATS UNK HEMOPTYSIS UNK WEIGHT LOSS UNK FEVER LINK ANOREXIA LINK SAFETY UNK RESTRAINED YES DRIVER NO AIRBAG DEPLOYED NO C-SPINE TENDERNESS LINK NEURO MOTOR DEFICIT NO EJECTED NO HEADTRAUMA NO LOSS OF CONSCIEMTIOUSNEENO AMNESIA OF EVENT NO Sudden Onset: Pre-Hospital PT WAS FULLY IMMOBILIZED Treatment: VITALS WERE MONITORED Pediatric G&D App. for Age - NIA. Immunization UTD - N/A, Height It. In., Head Cira. - Grade -, with Father Assesment: Past Medical ALLERGIES History: Allergies: PEANUTS, STRAWBERRIES, SULFA Medicines: ALLEGRA 10 MG DAY, XXXXXXX Vital ins T: 98.8 PO P: 99 Regular R: 20 Unlabored BP: 121/078 02: 99 % RA Pain Intensity Scale: 4 110 Pain Location: Hip Nurse Signature: DMJ Additional Notes- Rev 04/12/04 Carlisle Hoseital - Emerqencv Department Leidiah, Abigail 246 Parker St. Car(f sfe. PR 17013-0171245-5500 4113105 4:26am 793299 i DISPOSITION SUMMARY ? Patient: Leidigh, Abigail Aqe/DOB: SS #: Current Ph: CURRENT Address: Medical Record: 793299 City: Zip: Arrival: 4/13105 4:26pm Disch: 4113105 4:28pm Disposition: MD ED: Robert Lasek MD PMD: Res/PA/NP: PMD Ph: Dx #1: MVA (Unspecified) ICD-9 #1: Ea 19.9 #1 Ox Engl: MOTORVA.ESW #1 Dx Span: MOTORVA.SSW Ox 42: Contusion, Back 1CD-9 #2:922.3 #2 Dx Engl: CONTUS.ESW #2 Dx Span: CONTUS.SSW Med Inst: Ibuprofen Med #1 Engl: IBUPROFE.EDP Follow-up: PION, JOSEPH A DO 100 SOUTH HIGH ST GMC NEWVILLE, PA F/U MD Ph: 7177763114 F/U D/T; It needed Other Insir: MY SIGNATURE BELOW INDICATES: > 1 have received and understood the oral instructions regarding my current medical problem. > I will arrange follow-up care as instructed above. > l acknowledge receipt of the written instructions as outlined on this and any revious pages . i will read and review these instructions. x x Pat n (or L rdia igna re Staff tWit4ess) Siq afore Eh"RGENCY SERVICES Point of Care Laboratory Testing Report Form LABF 168-01 lmued Date: 02-04 PATIENT NAME: Ag rGA 1L-DA1'ElTime: tp, 1og ] &at MED REU (O0D `* Nz!n FINANCIAL,# Employee Name (Performing testing): URINE CHEMSTRrP 7 PH Glucose Ketones Leukocytes' ??- Nitrite Protein, Blood/Hgb / (Read aft result ae I minute, ezeept f Leukoeyle pad indicates a trace result, than it should be read again at Z mbuaaa.) Reference values: Al results negative except, for pH that is norma}ly around 6.0 but may raugc from 5.0-8.D. . URINE PREGI?tANCY TEST Patient result is (circle one): Positive. Negative Reference value is negative. , H, PAPERS TES'TIN pH Result: Reference. Ranges: Bye: The pH of the eye is neutral, around 7.0. i Vagina: NOtmul vaginal pH is 4.5-5.5 Amniotic fluid is 7.0 or greater. CRMC Laboratory, 246 Parker street, Carlisle PA 17013 I Filename: G-Labora tory- Procedure Manual -Forms -LABF'I68-01 Page i of i CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: LEIDIGH ABIGAIL M X-RAY#: 793 MED REC #: 793299 299 EXAM DATE: 4/13/2005 ACCOUNT #: 9308375 D.O.B.: 02/27/1995 ORDERING: ROBERT W LASEK,MD 245-5500 ROOM: 02 I ATTENDING: CONSULTING: JOSEPH A PION,DO 776-3114 HISTORY: MVA MVA i LUMBAR SPINE; PELVIS HISTORY. Pain following motor vehicle accident. An AP view of the pelvis and five views of the lumbosacral spine were obtained on 04/13/05. Normal curvature and alignment of the vertebral bodies is noted. No fracture is evident. The sacroiliac joints and hip joints are intact. VIE D S JAY ROSENBLUM, M.D. INTERPRETING PHYSICIAN DATE DICTATED: 4/14/2005 DATE TRANSCRIBED: 4/14/2005 11:02 DATE SIGNED: 4/14/2005 11:19:41 TRANSCRIPTIONIST: JND 6144896 E.R. PELVIS I VIEW SPINE LUAfHAR COMP W108LIQ PAGE 1 OF 1 , c - ? - I ?0\ r-bR < 246 Parker St. Carhilc, PA 17013 Ph:717.249-1212 CONDITIONS OF TREATMENT AND ADMISSION PATIENT'S NAME LEIDIGH, ABIGAIL M ATTENDING PHYSICIAN LASEK, ROBERT W MD ACCOUNT NO, 4 3 0 8 3 7 5 DATE & TIME OF ADMISSION _ 04/13/2005 1S-.33 CONSENT TO HOSPITAL CARE AND TREATMENT I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND 1 VOLUNTARILY CONSENT TO THE RENDERING OF SUCH CARE. INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT. BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL STAFF, OR THEIR DESIGNEES. AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY Ok BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL, INCLUDING THE ATTENDING PHYSICIAN(S) NAMED ABOVE. AND RADIOLOGISTS, ANESTHESIOLOGISTS. PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILECE OF USING THE HOSPITAL FACILITIES FOR THE CARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL. I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO RELEASE INFORMATION 7 NEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO AMS(JRANCF COMPANIES, MCLUDINO WORMERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY TREATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCE), TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH CARE SERVICES PROVIDED. MEDICARE CERTIFICATION RELEASE I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVIII AND TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT. I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS DR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT. PERSONAL EFFECTS AND VALUABLES I UNDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY, GLASSES, DENTURES, DOCUMENTS. CLOTHING, ETC.) UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE IN EXCESS OF i50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE. ABOVT YOUR BILL I UNDERSTAND THAT I WALL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EOUIPMENT, AND FOR ANY SUPPLIES OR MEDICINES UIILIZEO. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO ME. FOR EXAMPLE, I MAY RECEIVE A SEPARATE BILL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER SPECIALIST. INSURANCE ASSIGNMENT I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE OURING THIS PERIOD OF ILLNESS OR TREATMENT (HEREINAFTER 'PHYSICIANS'), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT OANTATIONS, TO ENSURE THAT ANY INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF INSURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS MAY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. 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I HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. 1 UNDERSTAND THAT I AM NOT REOUIRED TO HAVE AN ADVANCE DIRECTIVE 114 ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW )HE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. I (INITIAL THE FOLLOWING OPTICAI THAT APPLIES) • I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME, • I "AVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO. (NIT' INR- (FOLLOW-VP GONE BY DA TE . 1 WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. INIT. } CERTIFY THAT 1H READ t0i HAVE BEEN READ) THE ABOVE CONSENTS AHD_CERT TONS ANDTANO AND AGREE WITH THEM. DATE: 95 (jJ` : n I MONT YEAR SIGNATURE OF ATIENT OR LEGALLY RUTH ZEOIkU%ESENTATIVE WITNESS PRINT NAME OF PERSON ABOVE ADWIf 030 375 0000793299 CONTINUATION a. c D R S s -- ----- - -- I I EN I -i?itT?-- ^-- sy a _ --- -- ?/ ?/// --- --- -- ? I Lti L Abby Leidig S; recently in a motor vehicle accident. She sitting in the second seat, belted and she was hit from behind, by a - r ? rapidly moving vehicle. According to mom and dads history. The seat was pushed forward, and she had no loss - of consciousness. She was taken to the e.r. on a back board and xravs were done. She has periodic h ead and neck pain, abdominal pains, and pelvic pain. Minimal left lower bac k pain, and rt knee pain. J - O: in no apparent distress Head is normocephalic Eyes PERLA, EOMI Ears no injection or bulging of r the tms . -J Nose and throat were without injection or e xduate, neck was supple without nodes , There was tenderness with ----j - side bending bilaterally She had full range of motion with side bending noted and she had full range of motion with flexion and extension and with rotation. right and left. Chest is CTA Heart is regular without murmurs . Nontender, abdomen is nontender no masses or hepatosplenomegly . Pelvis is normal. Extremities nontender, although there was tenderness and erythema around the left knee She . ran in a track meet yesterday, She s tates that she was somewhat sore after this. Left knee has full range of motion, and there is minimal PalPitory tenderness. - I think she has a mild cervical strain and mild left knee pain. Get pt eval. And treat ibupro n. moist heat to the neck and follow up as needed PUI Jose h A Pion D O . p . , . . TFI.A 17-%-2' . • ! CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: X-RAY#: EXAM DATE: ORDERING: ATTENDING: CONSULTING. HISTORY: MVA MVA LEIDIGH ABIGAIL M 793299 - 4/13/2005 ROBERT W LASEK,MD 245-5500 JOSEPH A PION,DO 776-3114 MED REC #: 793299 ACCOUNT #: 9308375 D.O.B.: 02/27/1995 ROOM: ER LUMBAR SPINE; PELVIS HISTORY: Pain following motor vehicle accident. An AP view of the pelvis and five views of the lumbosacral spine were obtained on 04/13/05. Normal curvature and alignment of the vertebral bodies is noted. No fracture is evident. The sacroiliac joints and hip joints are intact. ?I REVIEWED AND SIGNED JAY ROSENBLL;M, M.D. INTERPRETING PHYSICIAN DATE DICTATED: 4/14/2005 DATE TRANSCRIBED: 4/14/2005 11:02 DATE SIGNED: 4/14/2005 11:19:41 TRANSCRIPTIONIST: JND 6144896 CONSULTING PAGE 1 OF 1 PELVIS 1 VIEW SPINE LUMBAR CONIP W/OBLIQ aa Address _?QU 1 `"j ?) e Sullidam: 's Stsspvac+'Dk__ BB?'w g P-y -4 los-o "'4 U No I Spoute/Father's Name lather's Occupation L 'spousdMotWr'x N _ rtothea's OcSC?p?anion/?r-? 1 Z Dentist k.? t K+17V ^ Nhom May We Thank Par Refcnal. huUm's & Sistr's Names a Ages. MED ALERT _ CG 33) Case a referred Nanx ?_ ?1 u t A P b "no Elam Date ! L) Ago 2 f ?-- ate' i :?1 J1?' Address Phone Wbee Fasploycd 1? but, Phone 9 - 1 a r Address Phone %cro F.roployed S L) Bus. Phone PL Physician " PANORAMIC RADIOGRAPHS ??7 p?u x FACIAL, DENTAL, MODEL ANALYSIS / 4id Face WNLW Protrusile O Recessive U Class: I @IQ Div: ?p 2 SuMliv: R L Fseudo .ower Face WNL Cr Protrusive O Recwsive O Space Maxilla ? Adequate O Crowd Mificess Sp J BiawAlary Facial Proausion Space Mandible 0'Ad uaae a Crowd O F.sccss Sp 1 Obvious Menudia O Lip Strain YeTWW Bite Relation: U WNL I Other QTW Overbite 6C Eroib I Misaligna U Prue Visible Q Anterior Open Site UIBLrcca! Open Bic(P L rGingivitis Appatrnt QG*.Recession O'ovotjet 3-- I bbdtutc Dis. Q"Dlasu= 1,5"- Cl Dental Pratuswp Apparent o t ? l I Enamel MAdli[u:s Cl Dent Az& Courtrictiun Q MwAtla a Mend. V 1} Q X-Bttes 1t L :EPHAL0Mk''1WC Date DO ;NA 80;76~84 . ............... Occl. Plane (9; 15-141 .......... ;NB 78: 75-Si ................. b„ orincLW (13S; 00-1.5% ....... ....................... And Plane 22; 17._28 ........... Ut-AP Wm (23; 1+5) ........... Fkf TE3i ..................... UI Ell Otn) ................... [v--WA 30 ... ............... Ll-AP (23) ...................... LI-AP - (-2+3) ............. . FMIA(65) .................... 1 WA (901) ................... . TH SKELETAL SUMMARY C PH DENTAL SUMMARY CI= Deco T- ;nuA,f+ ;' LtC n AGNQSnCSLSMMA.RY !? A P SIC?L,S1=- tk1kc A.A? ivj C,_6 LZtQ?_A J?ATMENT Q8JWrrrEY CLASS I CUSPID GUIDANCE L .' rrL c f C( m IDEAL Ovwu & ovEurm tty hi IDEAL ALIGNMENT OF TFX7W GOOD MAXUI.A & MANDIBULAR RELATIONSHIP FACIAL SOFT 77SSUE BALANCE GOOD PhlUODONTAL HMALTH &ATM Vr PLAN, .? X4 ? jL,r6eS ?'? Q Apparent TM Abnurmabry Cl Aganeva O Missing Tcztb U Prob. Impacted Teeth U Supetnumomy Teuh O CyststAbscesses O Ptbb" Caries D Shat Roots O Rm Resorption Qlero le ANcylosia -- ^? ? Uoderdevelo a 'Ibnh O Transposed Teeth ? Bridgesitrowns . U Eclopic ErupUan Q Crowding Bone Level Q W&NL O Lo* Condition of I's j4O Condition of 8'a L$ 6QVjr For Discussion: L rz vt :r L ?s?3??Ck c? y fb -fUvc . t (?' i IS ? (l r n tt?.Jl i- '1??2.L tL OS-f\ a i, r a a a WU a MM x 1010CM re , , aarn s xr o s s y? .a., Lan 1- W J Q J Q U n W a l` I V V ? o pa L i U? -- - - - - -- -- - - - - - -- J ? 1 ? f \, ti l V y v' a ? P y KIN J - J ? v V V a rr.? _ a O o x i ? f ? 3 a ? W V ; U W C1 ac A T O - 0° n V? 1 Z 01 j ? i. 1 Y 3 1 i V e z 1? (f P c ? 3 a f 1 J j ? Z v ( ? rS J U / ? ? s l F ? ? v V L ? f t ? ? ? Z 3 v ;r o CC o r a o Q• s y ? u a 0 f ?r _? ?--- I, d Y 3 _z 4 a N 3 4 ? y ^ V ? ` 1 ' ? ` ?? C h < J ? { n J ? ? 0 ? ? ? ? w ? ? ? ? t J -_ h m N ? ? y V V, M { 4 0 el a ? ? - - v ? V ? ? ?^ } } ? 7 i. ? V ?? ? w 3 ? ^? s e ti , N U C7 Q o ` ' \ ? ? O d a_' . T ? t (((L V` T -T j r- - r- f r f ` 3 II J ? ? ? ? ?? ; I J e x I+ ll` ? 4 II r -°J ? I? y a lL n 4 r w ? -? I ? ?`?,lY r S v o I ? ? 11]] U \t ` ? ? f * V al h 3 G O ? } f Y Y - a ? ? E o A r l , ti Q P 1 S? d L ti f d 1 ,I l ?I J I IT! I Q 1 i c7 T r p r I C a a0 ?7 w Alexander Spring Rehab, Inc- 1 Tyler Court Carlisle, PA 17013 (717) 245-2341 Fax: (717) 245-9672 Physical Therapy Initial Evaluation & Plan of Care Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age. 10 Date Initiated: 04/29/05 Physician: Joseph A. Pion, D.O. Period Covered: 04/29/05 - 05/27/05 Diagnosis: Cervical,thoracic and lumbar sprain/strain after MVA 04/13/05 Chief Complaint: This 10 year old female was involved in a high speed MVA on April 13, 2005. She was a back seat belted passenger in a vehicle that was hit from behind. she reports some -bilateral shoulder pain, "tailbone" pain, and R leg pain that is periodic in nature. Sitting increases tailbone pain and walking sometimes hurts her R leg. Her mother noted no bruising after the accident. Heat and cold do help symptoms. Functional Limitations: Minimal limitation, but complaint of pain after activity. Patient's Goals: Decrease soreness. Pain Rating: 4-6/10. Medical History: Unremarkable. Allergies: Sulfa drugs, peanut allergy. Medications/Supplements: Allegra, vitamin, stool softener, fiber capsule. Social History: Patient lives at home with family. Patient is a student. Patient is a nonsmoker and does not drink alcohol. Diagnostic Tests: Lumbar, leg/pelvis x-ray negative, per parent. EXAMINATION- Posture: Poor postural habits. Girth/Edema: None. AROM: Bilateral hip ROM WNL, but pain with full R hip flexion. Cervical AROM WNL. Pain with R and L side bend, and R rotation and extension. Lumbar ROM V7NL except flexion 80%. Strength: Bilateral LE's grossly 4+/5 with complaint of R thigh pain with testing. Neurological Scan: Light touch WNL. .Joint Mobility: Not tested. Palpation: Tender lumbar spine, cervical and thoracic spine, mild upper trapezius soreness, tender R thigh anteriorly and posteriorly. L rotated L1-L4, L rotated T7-10. Transfers: Independent. Gait: WNL. Special Tests: Cervical: Negative quadrant test. Lumbar/Sacroiliac: Negative straight leg raise, negative slump test. Treatment Today: The treatment plan and options were discussed with this patient, who is in agreement with the plan as outlined and wishes to proceed. Treatment included the evaluation, followed by joint mobilization to thoracolumbar spine with muscle energy technique, instruction in neck and back flexibility exercises, and hot pack to back for 10 minutes. Diagnosis/Assessment: Cervical, thoracic and lumbar sprain/strain after MVA. Interventions: 2 times/week for 4 weeks. Expected duration of treatment: 4 weeks. Treatment plan includes: A. Body mechanics instruction/ergonomic training to improve spine and joint protection, ensure ergonomic soundness of school desk. S. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pain.. C. Manual therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. D. Patient/caregiver education to assure independence with self-care/home program. E. Physical agents/mechanical modalities to decrease pain, increase tissue extensibility/compliance, decrease muscle guarding/spasm, increase tolerance to exercise. Prognosis/Rehab Potential: Good Please see reverse RE: Abigail M. Leidigh PT Initial. Evaluation & Plan of Care 04%29/05 Page 2 Short Term Goals: 3 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 3 weeks. 2. Patient will report decreased sleep disturbance/interrupted sleep in 3 weeks. 3. Patient will demonstrate increased ROM to facilitate improved ADLs/IADLs in 3 weeks. 4. Patient will demonstrate increased strength to facilitate improved ADLs/IADLs in 3 weeks. - -5. Patient will consistently demonstrate appropriate body mechanics with functional activities in 3 weeks. 6. Patient will be independent with home program in 3 weeks. Long Term Goals: by discharge 1. Patient will be able to perform ADLs/IADLs with less than 0-2/10 pain and minimal substitution. 2. Patient will consistently utilize proper body mechanics/joint protection techniques with functional activities. 3. Patient will be compliancewith home program to maintain gains and current status. Therapist: Step'hany S P.T., PT-011837-L; DAPT-000681 Date: 04/29/05 I- SS/md I certify that I have examined the patient, have read the initial evaluation, and have reviewed the interventions and goals as provided by the therapist. I certify that rehab services are necessary and will be provided while the patient is under my care. The plan of treatment will be reviewed at a t every 60 days or as the patient's condition warrants. This patient does not require ial needs assessment. _ cc ..- Physician: _ Date: Physician Comments and/or R strictions: Alexander Spzi.ng Rehab, Inc. Ccn.rt Carlin- PA 17013 (717) 245-2341 Physical Therapy Interim Plan of Treatment: 1 Name. Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age: 10 Date Initiated: 04/29/05 Physician: Joseph A. Pion, D.O. Period Covered: 05/27/05 - 06/17/05 Diagnosis: Cervical, thoracic and lumbar sprain/strain after MVA 04/13/05 8 Change Impairments: (N/T; Better; Unchanged; Decline in Status; <25%; 25-50%; 50-758; >75%) 1. Joint integrity & mobility: 25-508 better 2. Pain: Greater than 75% better (lumbar and legs); 25-508 better (cervical) 3. Posture: 25-508 better 4. Range of motion: Greater than 758 better (pain with cervical flexion/extension) Functional Limitations: A. Activities of Daily Living: 50-758 better (ADLS) Especially: Patient with decreasing pain and improved postural habits allowing performance off school, play activities with decreased complaints. Assessment: Primary area of therapy now C-spine with therapy focusing on improving spinal alignment and decreasing comfort with ROM of C-spine. Interventions: 2 times/week for 3 weeks. Treatment plan includes: A. Body mechanics instruction/ergonomic training to improve spine and joint protection. B. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pain. C. Manual therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. D. Patient /caregiver education to assure independence with self-care/home program. E. Physical agents/mechanical modalities to decrease pain, increase tissue extensibility/compliance, decrease muscle guarding/spasm, increase tolerance to exercise. Prognosis/Rehab Potential: Good Short Texan Goals: 2 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 2 weeks. 2. Patient to demonstrate increased ROM to facilitate improved ADLs/IADLs in 2 weeks. 3. Patient will consistently demonstrate appropriate body mechanics with functional activities in 2 weeks. 4. Patient will be independent with home program in 2 weeks. Long Term Goals: by discharge 1. Patient be able to perform ADLs/IADLs with less than 2/10 pain and minimal substitution. 2. Patient will consistently utilize proper body mechanics/joint protection techniques with functional activities. 3. Patient will be compliant with home program to maintain goals and current status. Therapist: SS/md Date: 05/27/05 I certify that I have examined the patient, have read the initial evaluation, and have reviewed the interventions and goals as provided by the -therapist. I certify that rehab services are necessary and wil a provided while the patient is under my care. The plan of treatment will be reviewed east every 60 days or as the patient's condition warrants. This patient does not requir social needs assessment. Physician: Date: Q? Physician Comments and/or'Restrictions: Alexander Spring Rehab, Inc. JUN 2 2 2005 `I'yl ?' urt Carlisle, PA 17013 (717) 245-2341 Physical Therapy Discharge Summary This information is for your records Tame: Abigail M. Leidigh ID#: 12624 Tate of Birth: 02/27/95 Age: 10 Date Initiated: 04/29/05 Ihysician: Joseph A. Pion, D.O. Date of Discharge: 06/16/05 Liagnosis: Cervical, thoracic, and lumbar sprain/strain after MVA on 04/13/05 % Change Impairments: (N/T; Better; Unchanged; Decline in Status; <25$; 25-50%; 50-75%; >75%) 1.--- Joint integrity-& mobility: 50-75% better 2. Muscle length: 50-75$ better Pain: Greater than 75* better 4. Posture: 25-50% better S. Range of motion: Greater than 75% better 6. Strength: Greater than 75W better Functional Limitations: A. Activities of Daily Living: Greater than 75% better (ADLs) Especially: Play activities WNL. B. Instrumental Activities of Daily Living: 50-75% better (IADLs:) Especially: School work was aggravating factor to neck, although significantly improved. Interventions: Patient was seen 15 visits in 7.55 weeks. Treatment included: A. Body mechanics instruction/ergonomic training B. Exercise C. Manual therapy techniques D. Patient/caregiver education E. Physical agents/mechanical modalities Discharge/Rome Program: Patient has been instructed in a home program of flexibility, postural, strengthening, and cervical isometrics exercises, as well as improved postures and body mechanics and independent use of moist heat. Reason for Discharge: A. X Goals achieved B._ Patient achieved goals and was progressing in remaining goals C.? Patient failed to progress - number of goals met: 0.? Patient declined to continue PT E._ Patient failed to schedule additional visits F._ Patient did not comply with plan of care G._ Physician discontinued therapy H.? Conversion to Phase III/community program I. Therapist: r Date: 06/16/05 Stephany Sloan,/ P.T., PT-011837-L; DAPT-000681 SS/md 4] zA L3 0? f ?3y Yv`°r S/s 330 I ril '7i ALEXANDER SPRING REHAB, INC. PATIENT: _ u a ( Let "?? ; a L, j -4 I' ". C/!/fLf i * I'H / C r?1 F' C, -ty G W'C G?.. S fw r l _1604 L e 6-- ti r r a 1, ,L P/- d7?2?.C .r /7a Q doh QlJ o ??c? . ?D ?3 l ° 4- ,•r. ?a l..a-Q p ?. ?.c t? d,-c -? t F-t- fL..b ?? o7 tr. 1. - ?, J, 4? Lok r?--? a 4c, t.:-+ Z f C P? ?4 oQ ,? (ca ,. t 1 t , L- P? P`' f • / ? m ? ? r 1 ?? /t.t -t S l?LJL aw t?.? f ?f? Cl f o ?c..tir -I- YYt r'!6, ( G l-)-7 £ &cA f 7-- .S G / vim' L.( I /-VV ? P, ?-•h.?- n; - ,?.?? a y ?e? sue., ?, ? ?- v _ o n kA -ter .Q. - r. ?? ?•-? .. ? , ASR 001 -PI 02/03 ALEXANDER SPRING REHAB, INC. S r. y l d-,.-5v 3?3 0 V ?'- 04 PATIENT: a i_?11?? y - ? n e?- AEC , i't G y? v i 71. - If r A, C-16- m r z. 7? S' . 5 ?C K'L I U -1 ALEXANDER SPRING REHAB, INC. a I0.c mkt, • --- - __. _ _ ? tit alp ?? r.i n?!?.. . ,4-n.Q - ? ?L?eh TT S t•.-? fol. T GS 1' fo a-tce < < 1,?c h - --- - - - - r LC LA ---_ _.____--.__ Wry l r?-St>rvc??.c'.t„4 , ._. ?. 7' &t _ ___ _..-_.,_ _ ?. _- 1 "? ?'?^'1 ? 1-?, [Q/1N(` + S?j?NQ'?yy ? G I GVdQ_?el,.?. a ./v mU,,,., ,. ASR 001-PI 02/03 S d r + PATIENT: A ? ? ALEXANDER SPRING REHAB, INC. Ja r ? ?. E? + ? ? Q? 4- A, 4 i t? ,a a,._ r ? _c. w sms- MA X14 1111 -2- G 'br A/ Q IL 4A , esa _4 •. '?? :._ ,.t ? g ?p•------- ? S's?-,n- tam-? -ft t +.. + ?) -a ? f C` ... iC ? ? C?1,.5SC? ?M_,_=-.i ?l.,Ji1 L\a?"'?sy, l? PC S •r•? @ C ti 4 \ ` . ,? v \ r tir ?? G i s Alexander Spring Rehab, Inc. 1 Tyler Court Carlisle, PA 17013 (717) 245-2341 Fax: (717) 245-9672 Name: Date of Birth: Physician: Diagnosis: Physical Therapy Initial Evaluation & Plan of Care Abigail M. Leidigh 02/27/95 Age: 10 Joseph A. Pion, D.O. Abdominal pain ID#: 12624 Date Initiated: 12/21/05 Period Covered: 12/22/05 - 02/01/06 Chief Complaint: Patient has had a long term chronic abdominal and rectal problem, approximately 18 months. She is being seen by Dr. Pion and Dr. Field/Dr. Dillon at HMC. Functional Limitations: Sleep disturbance secondary to chronic abdominal pain. Patient's Goals: Decrease pain. Pain Rating: Sometimes 9110 at rest, 10/10 with activity. Medical History: Cyst in perineal area. Family History: Cholesterol problem, high blood pressure, diabetes. Allergies: Food: all nuts and strawberries; sulfa drugs. Medications/Supplements: Multivitamin, Ailegra. Social History: Patient lives in a one story home with family. Patient is a 5th grader. Diagnostic Tests: Colonoscopy June 2005. Exam under anesthesia (rectal /vaginal) in July 2005. 2nd examination under anesthesia in August 2005. Botox injection (rectal/perianal) September 2005. MRI in October 2005. Lactose tolerance test December 2005. SYSTEMS REVIEW: Musculoskeletal impaired. EXAMINATION: Posture: Elevated R hemipelvis. T12 prominent posteriorly. AROM: Lumbar: Forward bend WFL with mild decreased L5 motion. Back bend 70% normal, decreased T12 motion, Side bend R 70$ with decreased L3-5. Side bend L 50% with decreased L3-5. Rotation R WFL, L 50%. Strength: Not tested. Neurological Scan: Denies LE radiating symptoms. Palpation: Bilateral T12-10 paraspinals tender with increased tone L greater than R. Severe fascial compression of respiratory and pelvic diaphragms. Tender over cardiac and pyloric sphincters, sphincter of Odi, and DJ junction. Special Tests: Lumbar/Sacroiliac: R LE short, R ASIS elevated, R pube descended, R ischial tuberosity decreased and tender. R PSIS elevated, both PSIS tender. Treatment Today: The treatment plan and options were discussed with this patient, who is in agreement with the. plan as outlined and wishes to proceed. Treatment included the evaluation, followed by manual PT to pelvic, respiratory, thoracic and cranial diaphragms. Diagnosis/Assessment: 1. Abdominal pain. 2. Impaired joint mobility, and range of motion associated with connective tissue dysfunction. Interventions: 17. times/week for 4-6 weeks (6 treatments total). Treatment plan includes: A. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pain. B. Manual therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. C. Patient/caregiver education to assure independence with self-care/home program, prevent recurrence. Prognosis/Rehab Potential: Fair/good. Intervening Factors Which May Modify Frequency and/or Duration of Care: Chronicity. Short Term Goals: 2-3 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 2-3 weeks. 2. Patient will report decreased sleep disturbance/interrupted sleep in 2-3 weeks. 3. Patient will demonstrate increased ROM to facilitate improved ADLs/IAOLs in 2-3 weeks. 4. Patient will be independent with home program in 2-3 weeks. Please see reverse PE ;d)iuai_l M. Leidigh PT ln,:t.ial Evaluation & Plan of Care 12/ 2'-/ 05 Page Long Term Goals: 4-6 weeks 1. Patient will be able to perform ADLs/IADLs with less than 2-4/10 pain and minimal substitution. 2. Patient will consistently utilize proper body mechanics/joint protection techniques with functional activities. 3. Patient will be compliant with home program to maintain gains and current status. Therapist: _ A -- Date: 12/21/05 She ley D. Bi er, P.T., - 0SM q; DAPT-00080'7 SDB/md I certify that I have fexa ed the pati ent, have read the initial evaluation, and have reviewed the interventd goals as provided by the therapist. I certify that rehab services are necessary 1 be provided while the patient is under my care. The plan of treatment will be revi least every 60 days or as the patient's condition warrants. This patient does not a social needs assessment. I? Physician: Date: Physician Comments and/or Restrictions: Alexander Spring Rehab, Inc. 1. Tyler Court Carlisle, PA 17013 (717) 245-2341 Physical Therapy Interim Plan of Treatment: 1 Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age: 10 Date Initiated: 12/21/05 Physician: Joseph A. Pion, D.O. Period Covered: 02/01/06 - 02/28/06 Diagnosis: Abdominal pain Change Impairments: (N/T; Better; Unchanged; Decline in Status; <25t; 25-50%; 50-75%; >75%) Joint integrity & mobility: 25-50% better (pelvic.alignment) 2. Pain: 25-50% better (abdominal pain) 3. Range of motion: 25-50W better (lumbar side bend and rotation) Functional Limitations: A. Activities of Daily Living: 25-50t better (ADLs) Especially: B. Instrumental Activities of Daily Living: 25-50% better (IADLs:) Especially: Assessment: Patient's parents were reporting a moderate decrease in nighttime and daytime abdominal pain. Pain increased with stress re: upcoming toe surgery. Improvements: 1. Fncreased mobility and symmetry in pelvis, respiratory and pelvic diaphragms. 2. Increased L trunk rotation and side bend to 70% normal. Continued problems: 1. T12 is prominent posteriorly with tenderness in T10-12 area. Patient still has moderate fascial restrictions and mild pelvic asymmetries. Treatment has focused on a variety of gentle manual therapies in the trunk, abdomen and pelvis. 2. Patient unable to sit erect secondary to pain in T12 area. Interventions: 2 times/week for 4 weeks. Treatment plan includes: A. Body mechanics instruction/ergonomic training to improve spine and joint protection. B. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pain. C. Manual therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. D. Patient /caregiver education to assure independence with self-care/home program. Prognosis/Rehab Potential: Good. Intervening Factors Which May Modify Frequency and/or Duration of care: Chronicity of symptoms, stress. Short Term Goals: 2 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 2 weeks. 2. Patient will report decreased sleep disturbance/interrupted sleep in 2 weeks. 3. Patient to demonstrate increased ROM to facilitate improved ADLs/T_ADLs in 2 weeks. 4. Patient will be independent with home program in 2 weeks. Long Term Goals: 3-4 weeks 1. Patient will be able to perform ADLs/IADLs with less than 3-4/10 pain and minimal substitution. 2. Patient will be compliant with home program to maintain goals and current status. Please see reverse Ak ig< i M. Leidigh zt=x: Lvalua?.on & Plan of Care I ht!rapist Date: 02/01/06 S:B/md Shelley D. BAtner, P.-TF,::` I'-005267-L; DAPT-000807 I certify that I have examined the patient, have read the initial evaluation, and have r>uiewed the interventions and goals as provided by the therapist. I certify that rehab a,:rvices are necessary and will be provided while the patient is under my care. The plan of i::-eatment will be reviewed at least every 60 days or as the patient's condition warrants. TI Lis ;patient does not require a social needs assessment. 1111;(sician: Date: Physician Comments and/or Restrictions: Alexander Spring Rehab, Inc. acx .rt. Carlisle, PA 17013 (717) 245-2341 Physical Therapy Interim Plan of Treatment: 3 Narrt:: Date, :f 21: i r-h D13 Abigail M. Leidigh 021127/95 Age: 11 Joseph A. Pion, D.O. Abdominal pain ID#: 12624 Date Initiated: 12/21/05 Period Covered: 02/28/06 - 03/28/06 4; Change Irm).ii.r,nit (N/T; Better; Unchanged; Decline in Status; <25t; 25-50V; 50-75%; >75%) L. Joint integrity & mobility: 50-75% better (improved pelvic alignment) Pain 25-50% better (abdominal and thoracolumbar pain) Posture: 25-50% better Range of motion: 25-50% better (ankle dorsiflexion) `uricti in, I ::,imitations: ?. Activities of Daily Living: 25-50t better (ADLs) Especially: Decreased sleep disturbance secondary to abdominal pain. Still has thoracolumbar pain with sitting erect. iisse: snerl:: Lumbar ROM: Grossly 70% normal to WFL, except rotation 50-70* normal. Chief complaint is pain at thoracolumbar ;unction, pain at T12 area 4- 5/10, with occasional 8-9/10 pain. Stomach pain is a lot better, per patient report. Patient has consistently complained of bilateral LE aching with treatment, L dorsiflexion -5° pre-treatment, 0-5° after treatment. R dorsiflexion to neutral actively, 5° passively. 171tC1Ve:1t.i.01 113 t::m!s,`w(tuk for 2__4 weeks. Treatment plan includes: A i':ody mechanics instruction/ergonomic training to improve spine and joint ::rotection. 8 :',:xercise to increase ROM/flexibility, increase strength/stabilization, decrease pain. _ Vanual therapy techniques to improve soft tissue extensibility, improve joint -ability/function, decrease pain. 1). Patient/caregiver education to assure independence with self-care/home program, :irevent recurrence. i`s. PI?ysical agents/mechanical modalities to decrease pain. Vr agnc s i s:/Reh ab Potential : Good. Ir.::ervenincl p;actors Which May Modify Frequency and/or Duration of Care: Multiple complaints, ch --onici :y. Short 1'e: •m GcNals : 2 weeks L. Patient will report decreased pain to improve ADLs/IADLs in 2 weeks. ?. ;Patient to demonstrate increased low back and ankle ROM to facilitate improved i%I:Ls/IADLs in 2 weeks. Pa,t:ient will consistently demonstrate appropriate body mechanics with functional activities in 2 weeks. 4. Patient will be independent with home program in 2 weeks. Long Tt am Goal s : 4 weeks 1. Patient will be able to perform ADLs/IADLs with less than 1-4/10 pain and minimal substitution. 2. Patient will consistently utilize proper body mechanics/joint protection techniques with functional activities. 3. Patient will be compliant with home program to maintain goals and current status. Please see reverse RE: kbigail M. Leidigh Interim Plan of Treatment 62/28/06 Page 2 Therapist: ??itn., PT-005267-L; RAPT-000807 Date. 02/26/06 Shelley D. _ SDB/md. I certify that I have examined the patient, have read the initial evaluation, and have reviewed the interventions and goals as provided by the therapist. I certify that rehab services are necessary and will be provided while the patient is under my care. The plan of treatment will be review at least every 60 days or as the patient's condition warrants. This patient does not re a social needs assessment. Physician: _ Date) Physician Comments and/or Re ions: { ALEXANDER SPRING REHAB, INC. PATI ENT: R • te : , ` ?_ ?, . `e , ?? M A 11 92 Li ? C Ci D C .r te !` - ` ? ?. ?-4.? .-...ter -.f?•? `s 0. ? ? r 1? ?rr ?• --?.. ? j C U? G'r ?il' ?u `' ALEXANDER SPRING REHAB, INC. P ALEXANDER SPRING REHAB, INC. PAT IENT: el L ' A? 1Y Q.. l _ t ',S o n e `? . ? . b _ may.. Y Q l f Zia _ oa /A in ? y L7 es, - - ?< J, ALEXANDER SPRING REHAB, INC. P)i 1 A i ."1 -I A?llc- ALEXANDER SPRING REHAB, INC. r- J-' d ?.J 1 16 1 : 4 - . ?Sul .._. -S'_.??_ L.,..4^- ?'Tt5 c n ry ?..?z ? ?._ cT-2s 4 `•-??"?, +y-.s??.,,?, . er ? ..?' ,r•e? ?-?. sL c. ? r ?t l ?: t+ r? ?. .._ -,. .? ?? . \ ? p _\ _• ?--.._.fa. `i?4:_ . ?- h .\ --• ??, ?t mss it C? '?+1 -t1^a ?ee?'G:,___ - ? ? l 'y'-- .rY_ e c^?"--a (??' 1?--ta e? ?- ? ? _y_3 ? •- S r tit ? b ..._?.-?.L?'?.a?'?1.0.-.?a- Vr`y,e ?s e 4 L s .?„?1.? .e-r. 0 ?" -----?r'?k (? ?, r ?.. ? ?„ f' - C. _ ??i r?i4 ?.?.r al's ? ?.. -?- `? 1" ?,-' ? .l ti?•", 0 .: /1. --- - ?i .t s ? c: y- i ALEXANDER SPRING REHAB, INC. PATIENT: cr _ n\ r `?? Zl c-? d a? C.. cue , C "'? =? c- ___-• ? \ _NL l F. 1 ALEXANDER SPRING REHAB, INC. MTIENT: J ALEXANDER SPRING REHAB, INC. ?? (s ??o r; I 1 ?'ArIENT. .\ c,-,- -c) c 4L ._ _ ? a?-c?•,?-?s s- ?r W `Li- l ' r' ? ? n 4 n c^c \ G ? v-?F c \ ? _ y --- - ?. s \ le i- c c- A- 4 C? J-* pe Ott c- f- 777>z: -Nm ..?_ 7.1 i`'- ALEXANDER SPRING REHAB, INC. ;PikTIENT: CM -4 Olt- 417, N 1 ?'V a ?? _- c._ -, ? -c+-? _T ? .? ? ?-•.,_ _y\c - ?. ?? ? -. F? ra 't-?? y ck, r 1 'feel i?a ? .. _ ?.?_...._? rt1? y' ?--c..,.._ _ ?? .ate ? ?T"t.+ rrc ? ? ) •.c? . -5 -?- '?1 - -- ?-?. ?,- n e _AAl VS- 8 -- Qc_ , ALEXANDER SPRING REHAB, INC. Alexander Spring Rehab, 1 Tyler Court Carlisle, PA 17013 (717) 245-2341 Fax: (717) 245-9672 Physical Therapy Initial Evaluation & Plan of Care Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 . Age: 10 Date Initiated: 04/29j05 Physician: Joseph A. Pion, D.O. Period Covered: 04/29/05 - 05/27/05 Diagnosis: Cervical thoracic and lumbar sprain/strain after MVA 04/13/05 Chief Complaint: This 10 year old female was involved in a high speed MVA on April 13, 2005. She was a back seat belted passenger in a vehicle that was hit from behind. She reports some bilateral shoulder pain, "tailbone" pain, and R leg pain that is periodic in nature. Sitting increases tailbone pain and walking sometimes hurts her R leg. Her mother noted no bruising after the accident. Heat and cold do help symptoms. Functional Limitations: Minimal limitation, but complaint of pain after activity. Patient's Goals: Decrease soreness. Pain Rating: 4-6/10- Medical History: Unremarkable. Allergies: Sulfa drugs, peanut allergy. Medications/Supplements: Allegra, vitamin, stool softener, fiber capsule. Social History: Patient lives at home with family. Patient is a student. Patient is a nonsmoker and does not drink alcohol. Diagnostic Tests: Lumbar, leg/pelvis x-ray negative, per parent. EXAMINATION: Posture: Poor postural habits. Girth/Edema: None. AROM: Bilateral hip ROM WNL, but pain with full R hip flexion. Cervical ARCM WNL. Pair: with R and L side bend, and R rotation and extension. Lumbar ROM WNL except flexion 80%. Strength: Bilateral LE's grossly 4+/5 with complaint of R thigh pain with testing. Neurological Scan: Light touch WNL. Joint Mobility: Not tested. Palpation: Tender lumbar spine, cervical and thoracic spine, mild upper trapezius soreness, tender R thigh anteriorly and posteriorly. L rotated L1-L4, L rotated T7-10. Transfers: Independent. Gait: WNL. Special Tests: Cervical: Negative quadrant test. Lumbar/Sacroiliac: Negative straight leg raise, negative slump test. Treatment Today: The treatment plan and options were discussed with this patient, who is in agreement with the plan as outlined and wishes to proceed. Treatment included the evaluation, followed by joint mobilization to thoracolumbar spine with muscle energy technicrue, instri,.ction in neck and back flexibility exercises, and hot pack to back for 10 minutes. Diagnosis/Assessment: Cervical, thoracic and lu<< ar sprain/strain after MVA. Interventions: 2 times/week for 4 weeks. Expected duration of treatment: 4 weeks. Treatment plan includes: A. Body mechanics instruction/ergonomic training to improve spine and joint protection, ensure ergonomic soundness of school desk. B. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pain. C. Manual, therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. D. Patient/caregiver education to assure independence with self-care./home program. E. Physical agents/mechanical modalities to decrease pain, increase tissue extensibility/compliance, decrease muscle guarding/spasm, increase tolerance to exercise. Prognosis/Rehab Potential: Good Please see reverse I Tyler Court Alexander Spring Rehab, Inc. Carlisle, PA 17013 - (717) 245-2341 Physical Therapy Interim Plan of Treatment: 3 Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 _ Age: 11 Date Initiated: 12/21/05 Physician: Joseph A. Pion, D.O. Period Covered: 02/28/06 - 03/28jC6 Diagnosis: Abdominal pain % Change Impairments: (N/T; Better; Unchanged; Decline in Status; <25%; 25-50%; 50-75%; >75%) 1. Joint integrity & mobility: 50-75% better (improved pelvic alignment) 2 Patin: 25-50% better (abdominal and thoracclumbar pain) 3. Posture: 25-5096 better 4. Range of motion: 25-50% better (ankle do rS4 flexion) Functional Limitations: A. Activities of Daily Living: 25-50% better (ADLs) Especially: Decreased sleep disturbance secondary to abdominal pain. Still has thoracolumbar pain with sitting erect. Assessment: Lumbar ROM: Grossly 70% normal to WFL, except rotation 50-70% normal. Chief complaint is pain at thoracolumbar junction, pain at T12 area 4- 5/10, with occasional 8-9110 pain. Stomach pain is a lot better, per patient report. Patient has consistently complained of bilateral LE aching with treatment, L dorsiflexion -5° pre-treatment, 0-5° after_ treatment. R dorsiflexion to neutral actively, 5° passively. Interventions: 2 times/week for 33=4 weeks. Treatment plan includes: A. Body mechanics instruction/ergonomic training to improve spine and -oint protection. B. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pair. C. Manual therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. D. Patient/caregiver education to assure independence with self-care/home program, prevent recurrence. E. Physical agents/mechanical modalities to decrease pain. Prognosis/Rehab .Potential: Good. Intervening Factors Which May Modify Frequency and/or Duration of Care: Multiple complaints, chronicity. Short Term Goals: 2 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 2 weeks. 2. Patient to demonstrate increased low back and ankle ROM to facilitate improved ADLs/IADLs in 2 weeks. 3. Patient will consistently demonstrate appropriate body mechanics with functional activities in 2 weeks. 4. Patient will be independent with home program in 2 weeks. Long Term Goals: 4 weeks 1. Patient will be able to perform ADLs/IADLs with less than 1-4/10 pain and minimal substitution, 2. Patient will consistently utilize proper body mechanics/joint protection techniques with functional activities. 3. Patient will be compliant with home program to maintain goals and current status. Please see reverse #19620 LEIDIGH, ABIGAIL IVL DOB: 2/27/95, 601 Belvedere St., Carlisle, PA 17013 ??? ?i G S/ Pt. presents today with cc. and for oval. of her R great toe. She reports minimal discomforts at this point in time. 0/ The neurovascular status is grossly intact to the R foot. The R great toenail area appears to be almost completely resolved from its previous procedure, with no signs of infection or reoccurrence. A/ Status post matrixectomies of the involved toenail borders of the R foot. P/ 1. Discuss with the pt. that she may soak this on an as-needed basis. ?. Recom. leaving this open to the air at night, but a Band Aid while in shoes for the next wk. or so. 3. Recom. pt. RTO prn. MSG:ps CC: Joseph A. Pion, . - COMPUTER COPY - Pinker & Associates Mark E. Pinker, D.P.M. Mark S. Golec, D.P.M. 47 Brookwood Avenue Carlisle, PA 17013 C9 00 ?.1.:02a ASR 7172159672 p.2 `Alexander Spring Rehab, Inc. 1 Tyler Court Carlisle, PA 17013 (717) 245-2341 Physical Therapy Interim Plan of Treatment: 1 Name: Abigail-M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age: 10 Date Initiated: 12/21/05 Physician: Joseph A. Pion, D.O. Period Covered: 02/01/06 - 02/28/06 Diagnosis: Abdominal pain Change Impairments: (N/T; Better; Unchanged; Decline in Status; <25%; 25-50%; 50-75%; >75%) 1. Joint integrity & mobility: 25-50% better (pelvic alignment) 2. Pain: 25-506 better (abdominal pain) 3. F'.ange of motion: 25-50% better (lumbar side bend and rotation) Functional Limitations: A. Activities of Daily Living: 25-50% better (ADLs) Especially: B. Instrumental Activities of Daily Living: 25-50% better (IADLs:) Especially: Assessment: Patient's parents were reporting a moderate decrease in night-.ime and daytime abdominal pain. Pain increased with stress re: upcoming toe surgery. Improvements: i. increased mobility and symmetry in pelvis, respiratory and pelvic diaphragms. 2. Increased L trunk rotaticn and side bend to 70% normal. Continued problems: 1. T1.2 is prcminent posteriorly with tenderness in T10-12 area. Patient still has moderate fascial restrictions and mild pelvic asymmetries. Treatment has focused on a variety of gentle manual therapies in the trunk, abdomen and pelvis. 2. Patient unable to sit erect secondary to pain in T12 area. Interventions: 2 times/week for 4 weeks. Treatment plan includes: A. Body mechanics instruction/ergonomic training to improve spine and joint protection. B. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pain. C. Manual therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. D. Patient/caregiver education to assure independence with self-care/home program. Prognosis/Rehab Potential: Good. Intervening Factors Which May Modify Frequency and/or Duration of Care: Chronicity of symptoms, stress. Short Term Goals: 2 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 2 weeks. 2. Patient will report decreased sleep disturbance/ interrupted sleep in 2 weeks. 3. Patient to demonstrate increased ROM to facilitate improved ADLs/IADLs in 2 weeks. 4. Patient will be independent with home program in 2 weeks. Long Term Goals: 3-4 weeks Patient will be able to perform ADLs/IADLs with less than 3-4/10 pain and minimal substitution. 2. Patient will be compliant with home program to maintain goals and current status. Please see reverse r"~ ??1 Feb 09 06 11:02a ASR 7172,458672 RE. Abigail M. Leidigh PT Initial. Evaluaticn & Plan or Care 02 /01106 Page 2 Therapist: SDB/ aaeiie D. Y tner, P. ? -005267-L; RAPT-000807 Date: 02;01/06 md I certify that I have examined the patient, have read the initial luaon, reviewed the interventions and goals as provided by the therapist- Ievacertiftiy that rehab services are necessa and have treatment wiil be r,vie i writ.1 leastreveryd60 while ays the as 1 ' This patient does not re ire a social needs assessment- care- The plan of the patients condition warrants. Physician: Date .? Physician Comments and/or Restrictions: ?,L?? C C„.. ,?,, ;G'ti1.. 1J.1 U?li uJ1U4.J ..??..L I', .?fi? 'a`ir ?i l?i?????ILi J VL le Pediatric Authorization Form DATE: January 23, 2006 DO& 02-07-06 PCP FAX: 776-6003 Dear Dr. Pion: Dr. Golec has scheduled Abigail Leidigh for a Avulsion nail partial or complete at the Carlisle Regional Surgery Center. Per the PA Department of Health Rules and Regulations for Ambulatory Care Facilities (Chapter 15), documentation in the medical records is required that you have been notified in advance of the performance of a procedure in an Ambulatory Surgery Center and that your opinion was sought regarding the appropriateness of the use of the facility for the proposed procedure. Please Complete the following information and return it by FAX to 245-5121 as soon as possible, so that we may meet this requirement. Thank you for your timely response. Ambulatory Surgery Center is appropriate for the proposed procedure for this patient. Comments: i 'n Ambulatory Surgery Center is NOT appropriate for the proposed procedure for this patient. Physician's Signature 1 r7 \? L Date PINKER & ASSOCIATES 47 BROOKWOOD AVENUE PODIATRIC MEDICINE AND FOOT SURGERY CARLISLE, PENNSYLVANIA 17013 MARK E. PINKER, D.P.M. TELEPHONE 717-243-2236 FELLOW AMERICAN COLLEGE OF FOOT AND ANKLE SURGEONS FAX 717-243-6536 DIPLOMATE, AMERICAN 130ARD OF PODIATRIC SURGEONS MARK S. GOLEC, D.P.M. DIPLOMATE, AMERICAN 130ARD OF PODIATRIC SURGEONS Januarv 17. 2006 Joseph A. Pion, D. O. Graham Medical Clinic 100 S. High Street Newville, PA 17241 Re: Abigail M. Leidigh DOB: 02/27/95. 601 Belvedere Street, Carlisle, PA 17013 Dear Dr. Pion: This letter is to inform you about plans for our mutual patient, Abigail Leidigh. As you know, Abigail is a 10-year-old individual who presented to my office originally on January 17, 2006, with a chief concern of a longstanding incurvated right great toenail border laterally. She reported the fact that she has been on a course of antibiotics prescribed by her grandfather consisting of Zithromax for a week. Although the nail area has improved it has not fully healed. The nail itself is incu vated and painful on palpation but shows no signs of clinical bacterial infection. She does have the classic appearing "ingrown" toenail/onychocryptosis. There appears to be significant apprehension on the part of Abigail to undergo this procedure to rectify this condition in the office here under straight local anesthesia. We have then suggested to Abigail's father to have this performed under local anesthesia and IV sedation as an outpatient at Carlisle Regional Medical Center's outpatient surgical center. All are in agreement and we will schedule her accordingly. Should you have any questions or concerns regarding this procedure, please feel free to contact me although I expect no complications from this and an excellent result. Sincerely, i, G Mark S. olec!D.P..\4. MSG:mjg C? 4TE/TIME FAXEDIL,_ 1 MED REC Nd. HOSP ONLY NANCIAL # PAT NANCIAL #E SLWtG Jmit Date 3tients Name _ atiertra Address 'lLITY LOC: SURGE=RY CEN?FA HOSPITAL. Burg/Proc Deft c --] - 0 (p PAT Datlen•im e ACCOMM %TION: Y OUTPATIENT SURGERY SAMEDAY (ADMISSION) INPATIENT J04NT CAMP No PAT RequirodK_ Birth Date a -7 ?S Sex r- RAO Only _ SS* bona Numbers: (H) S Jy 7 L z _ ( (Call) i nme g * to caii roc. Length j h`am' r Anes: ? Gwwai ? spinal ? MAG ? Epidural ? 111 Reg C1 AI4ck ? Mod. Sed r--"I local ? Chalce lagnoses: Q Tr li Gr s ?o ?r I? ?1 Q n f7?-R CO(?B :20 Q rocedure. _ f y !/I s # . a"- j 0/' ?d _ node I / 7 30 hysic>w fll - -: Ip Iht 1 O PS 11 ? PS 111 ? PS IV selt3t. Surgeon Radiologist is #1 Pre-Cart ? N ? Y, N umber _ is #2 Pre-Cart 0 N ? Y, Number and Copies of 8fudy Anoulb To- :ommenVEquiPMwtt Needed: Was Rep WOW: O Yw ? No Name of Rep: Telephone Number: 'anent: O Is Ok beft (] to Hypertensive 0 Takes Antlco Quisnts 0 Pre-Op Antibiotic REQUIRED: LWt ALL ICD-o DIAGNOSIS CODE(S) THAT SUPPORT STUDIES ORDERED ABORATORY: FASTING: ? YES ? NO *w.dlo.ra zs?tea? BLOOD BANK: I MP C] CBC* In the past 3 months has the patient: ? L.ytss (K, Ct, NA, 002) 0 HRH' Received a blood transfusion 0 Yes 7 No 0 BUN C PT* Been Pregnant O Yes Q No D Greaftne* C3 APTT• ? CROSSMATCH UNITS © GILxx*9* O UA ROUTINE 0 TYPE AND SCREEN 3 OTHER TESTS ? UA CULTIIRE* D AUTOLOGOUS ? YES UNITS IN10- 61K or GUMT FORM REQUIRED L3 YES 0 NO LWr ALL tC" DIAGNOSIS CODE(S) THAT SUPPORT STUDIES ORDERED ] EKG, TO BE READ W. IF UNDER 40 YRS OF AGE ICD-A CODE REQUIRED PFf SCREEN I - j O INCENTIVE SPtROMETPIY ? ABG ] FULL PULMONFUNCC-nO?N (I1114 RESPIRATORY) kM% LIST ALL iCOA DIAGNOSIS C ODE($) THAT SUPPORT STUDIES ORDERED :]CHEST I -?T-? _ REPORTS COMING (Pain Clinic Only) :1 OTHER - r- . -1 PIVS All ] PRE-OP INSTRUCTIONS (TNS) 0 REVIEW OF PCST OPERATIVE EXERCISES AND PROTOCOLS ? OTHER CommULT D ANESTHESIA Q CASE MANAGEMENT D VISITING NURSE O INPATIENT REHAB (5TH FLOOR) ORIENTATION r?i ,.k s ?d(f c- ? PHY81GMP8 SIQNATtM PHYBtClAFI'A NAME FMiONE NUM9ER PARENT IDENTIFICATION r[Decw? c?Nrsa PRIE-WMlSjMON TESTING ORDERS ?PSV * surgery Center only n _ PCP" 2nd Opinion Q N ? Y, Number 2nd Opinion 0 N ? Y, Number /0, " /--a ,')y 1/, -14 , 1D rs r 1 r - 24 65- 0 PAGE 62 PINKER & ASSOCIATr- 4" EIROOKW000 AVENUE FooiAMIC MEDICINE AND FwT SURGERY CARLISLE. PENN5YLVANiA 17013 TELEPHONE 7 .2o3-2236 MARK E. PINKER, D.P.M. FAX ?17.2as-36 FELLOW .AMERICAN COLLEGE OF FOOT AND ANKLE SURGEONS DiPLOmATE. AMERICAN BOARD OF P0019MIC SURGEONS MARK S. GOLEC, D.P.M. OPIOWTE. AMERICAN BOARD OF PODIATRIC SURGEONS DEAR PHYSICIAN, YOUR PATIENT IS SCHEDULED FOR A SURGICAL PROCEDURE THAT REQUIRES A PRE-OPERATIVE HISTORY AND PHYSICAL. YOU WILL FIND ATTACHED AN "AMBULATORY CARE RECORED" (GOLD FORM) THAT THE CARLISLE REGIONAL MEDICAL. CENTER REQUIRES TO BE COMPLETED BY THE PHYSICIAN WITH A DATE AND SIGNATURE W1THIN **7 DAYS** OF TFM SURGERY DATE. *PLEASE FAX A COPY OF THIS TO * 243-6536, AND PLACE THE ORIGINAL BACK IN THE SURGICAL FOLDER PLEASE REVIEW THE PREADMISSION TESTING ORDER. FORM FOR ANY TEST THAT YOUR OFFICE PREFERS TO PERFORM. (place a copy in folder or fax to 245-5130 "pat office") ALL OTHER TEST CAN BE PERFORMED AT CARLISLE HOSPITAL. 02/2D/1994 00:1L 1 -2436536 DR MARK E PINKER PAGE 02 PINKER & ASWCIATES 47 BROOKWOOD AVENUE F)ODATRIC ENE AND FQQT SURGEW CARLISLE. PENNSYLVANIA 17013 MARK E POMM D.M. TELEPHONE 717-243-2236 FAX 717-243-$$35 FEilOYtl AMEiIr31iW iSOLt.6C3E OF FOOT AND ANKLE SURGEONS DlPLOMoKM AhAEi41CM BOARD OF POMMIC SURGEONS MAIM & QCIAr„ D.P.M. DiPLOMRTE. AMMAN BOARD OF PODWTRIC SURGEONS January 17, 2006 Joseph A- Pion, D. U, Crraham Medigd C hnic 100 S. F60 SMW Newville, PA 17241 Re: Abigail M. Leidigh DOB: 02!27/95, 601 Belvedere Street, Carlisle, PA 17013 Dear Dr. Pipe: This ldter is to idform you about plans for our mutual patient, Abigail Leidigh. As you know. Abigail is a l0-year-old individual who presented to my office originally on January 17, 2006, with a chief concern of a longstanding incurvated right great wenail border laterally. She reported the fact that she has been on a course of antibiotics prescribed by her grandfxt:ber consdsting of Zithromax for a week. Although the nail area has improved it has not fully hcalcd. The nail itself is incw-mtcd and painful on palpation but shows no signs of clinical bacterial infection. She does have the classic appearing "ingsrown" toenail/onychocryptosis. There appears to be significant apprehension on the part of Abigail to undergo this procedure to rectify this condition in the office here under straight local anesthesia. We have then suggested to Abigail's father to have this performed under local anesthesia and IV sedation as an outpatient at Carrlislc ftional Medical Center's outpatient surgca[ center, All are in agreement and we wiU schedule her accordingly. Should you have any questions or concerns regarding this procedure, please feel free to contact me although I expect no compheations fixim this and an excellent result. Sincerely, r Mark S. ?DP. M. MSG:mjg -- Alexander Spring Rehab, Inc. 1 Tyler Court Carlisle, PA 17013 (717) 245-2341 Fax: ('717) 245-9672 Physical Therapy Initial Evaluation & Plan of Care Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age: 10 Date Initiated: 12/21/C5 Physician: Joseph A. Pion, D.O. Period Covered: 12/21/05 - 02/01/06 Diagnosis: Abdominal pain Chief Complaint: Patient has had a long term chronic abdominal and rectal problem, approximately 18 months. She is being seen by Dr. Pion and Dr. Field/Dr. Dillon at HMC. Functional Limitations: Sleep disturbance secondary to chronic abdominal pain. Patient's Goals: Decrease pain. Pain Rating: Sometimes 9110 at rest, 10/10 with activity. Medical History: Cyst in perineal area. Family History: Cholesterol problem, high blood pressure, diabetes. Allergies: Focd: all nuts and strawberries; sulfa drugs. Medications/Supplements: Multivitamin, Allegra. Social History: Patient lives in a one story home with family. Patient is a 5th grader. Diagnostic Tests: Colonoscopy June 2005. Exam under anesthesia (rectal/vaginal) in July 2005. 2nd examination under anesthesia in August 2005. Botox injection (rectal/perianal) September 2005. MRI in October 2005. Lactose tolerance test December 2005. SYSTEMS REVIEW: Musculoskeletai impaired. EXAMINATION: Q/ Posture: Elevated R hemipelvis. T12 prominent posteriorly. V AROM: Lumbar: Forward bend WFL with mild decreased L5 motion. Back bend 70% normal, decreased T12 motion. Side bend R 70% with decreased L3-5. Side bend L 50% with decreased L3-5. Rotation R WFL, L 50%. Strength: Not tested. Neurological Scan: Denies LE radiating symptoms. Palpation: Bilateral T12-10 paraspinals tender with increased tone L greater than R. Severe fascial compression of respiratory and pelvic diaphragms. Tender over cardiac and pyloric sphincters, sphincter of Odi, and DJ junction. Special Tests: Lumbar/Sacroiliac: R LE short, R ASIS elevated, R pube descended, R ischial tuberosity decreased and tender. R PSIS elevated, both PSIS tender. Treatment Today: The treatment plan and options were discussed with this patient, who is in agreement with the plan as outlined and wishes to proceed. Treatment included the evaluation, followed by manual PT to pelvic, respiratory, thoracic and cranial diaphragms. Diagnosis/Assessment: 1. Abd<minal pain. 2. Impaired joint mobility, and range of motion associated with connective tissue dysfunction. Interventions: 11=2 times/week for 44=6 weeks (6 tr A. Exercise to increase ROM/flexibility, pain. B. Manual therapy techniques to improve mobility/function, dccrcasc pain. C. Patient/caregiver education to assure prevent recurrence. eatments total). Treatment plan includes: increase strength/stabilization, decrease soft tissue extensibility, improve joint. independence with self-care/home program, Prognosis/Rehab Potential: Fair/good. Intervening Factors Which May Modify Frequency and/or Duration of Care: Chronicity. Short Term Goals: 2-3 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 2-3 weeks. 2. Patient will report decreased sleep disturbance/ interrupted sleep in 2-3 weeks. 3. Patient will demonstrate increased ROM to facilitate improved ADLs/IADLs in 2-3 weeks. 4. Patient will be independent with home program in 2-3 weeks. Please see reverse I Tyler Court Alexander Spring Rehab, Inc. JUN 2 Z 2005 Carlisle, PA 17013 (717) 245-2341 Physical Therapy Discharge Summary This information is for your records Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age: 10 Date Initiated: 04/29/05 Physician: Joseph A. Pion, D.O. Date of Discharge: 06/16/05 Diagnosis: Cervical, thoracic, and lumbar sprain/strain after MVA on 04/13/05 16 Change Impairments: (N/T; Better; Unchanged; Decline in Status; <25%; 25-50%; 50-75%; >75%) 1. Joint integrity & mobility: 50-75% better 2. Muscle length: 50-75% better 3. Patin: Greater than 75% better 4. Posture: 25-50% better 5. Range of motion: Greater than 75% better 6. Strength: Greater than 75% better Functional Lim=itations: A. Activities of Daily Living. Greater than 75% better (ADLs) Especially: Play activities WNL. B. Instrumental Activities of Daily Living: 50-75% better (IADLs:) Especially: School work was aggravating factor to neck, although significantl,,r improved. Interventions: Patient was seen 15 visits in 7.5 weeks. Treatment included: A. Body mechanics instruction/ergonomic training B. Exercise C. Manual therapy techniques D. Patient/caregiver education E. Physical agents/mechanical modalities Discharge/Home Program: Patient has been instructed in a home program of flexibility, postural, strengthening, and cervical isometrics exercises, as well as improved postures and body mechanics and independent use of moist heat. Reason for Discharge: A. X Goals achieved B._ Patient achieved goals and was progressing in remaining goals C._ Patient failed to progress - number of goals met: D._ Patient declined to continue PT E._ Patient failed to schedule additional visits F._ Patient did not comply with plan of care G._ Physician discontinued therapy H._ Conversion to Phase III/community program I. Therapist: ? Date: 06/16/05 Stephany S oan, P.T., PT-011837-L; DAPT-000681 SS/md ?(f14 cU/ I4 S5 C. (a; 1, ALEXANDER SPRING REHAB, INC. PATIENT: Q r Q y I cc cCe - . (I.f, lv, ,? M?r4 n?t ???? G -o 3s . ha 10 T. "/V IA( Y?9-c? 5 Q/? Cl? A !V b f? y? L'LL ? QYE !? in? i coo-,, W / /? ®? ?`ti''? W A4 e C / O4VI C? f n u lY(ti? !? v r?C T G / ( ?i? ! - 2?% ?i r?- f? N i i fy (I? i e?? a tP.v?rC GS - _ JJAA4 p - ?li ASR 001-PI 02103 62 2 ALEXANDER SPRING REHAB, INC. 6(k PATIENT: OS 5 t laC c?-?-t l? S c? _ I y l /4?t,L 2 i iAAOCK "Ad J h?? c - - L sa.- C r ? ?? c-+;EP- . ?? Gl) t\ t'\M ?.. "? ? l • ? ?e\L(? n r L ? nl ?. "f? A P L1 _? O ? J?Cif - ?fL? \? h ?? ?-? C\ ?? LS . __ nn C- 1? I, 'X-41 e 5! - ?, ?L, ?- _?ta_. `•75.x_ 7S -+?L' ? t(1C "1?SL ?d` C ? ? ? GS ? l4. aa.( L 3`? n101- `C _,--A-? k -V6? ? #O / -IT J I ? fAA?y 2 3c" -Z? C" PATIENT: sIZ1 K5? ?? KZ q`33 io:? ALEXANDER SPRING REHAB, INC. , J .. , ! n 4--j\- c"+, - k J aC tL .mac - S ic r_ - d a Vic, ?l H4 4r, n T ? - 2-x x r _ 42:2 r- 4- 44-- ?nn nb 1. r e i.t o f LA -r S & ST -k, `- ? ? ?-?N?l ?1? t -y t?i!/?! ? _?-°?JL i S?Y?r.O `?l'7 ? c I ? -c-? ?j c?li•'?° Wry ? Q_ _ Q s' ^ Let 44- - P_. IVO man wI-n uc;uo ALEXANDER SPRING REHAB, INC. ?, ra l 3y 0 PATIENT: --__-- L ? r- ? ?y 6 - 1vrv-?4f. - Or Pte: pte -'4e? C -7- - L-? 40 /J n tom' / ,, ?1 , J / /) 0 A / I O? v v lv- _ - 4"'k- AaZ, -v a, -t- l :?ctcc Lf? c ue ref ?_ - G s GiAr- Wit` S ?- l c?y,? r o ?~e-, ?u - --- n C A-\ 41-,-A to 60-1`3 "v l(- O'l IL3 3-? i5 s/spa '? ; Q: . i t? f? ALEXANDER SPRING REHAB, INC. All, PATIENT: t-' U, G a 1--2 ?` ;atom- __ ' U ? _.!??/l ,,? mac, ? ! ? car ? ? s ?S ?? ? ?, ?/ 9- ?- ?? . ? /t ; 1-4 1 -r- u 7- Y'? 74 X17= c K x Z ` T - :2 G S' !sue/?/ t ?/ ?L? Gl ll?.f J (?? l? ? ? _ `, ' ??-7 v vl' L'Y ` -? v ?`" ?? r`w.`-' ?" ? t !????. -(-. I i r` / _ 7 ?/?d w ?-L?_.??? Cpl- =;J l? trLk c.-ICV? Sc?. ?v ke S ? ??? M a^- ? ? ? ti 41 J !i - it ?1'?i r? Srko?uC '? 20? LA_ I v r?{-c? sy .? h S S u 1L _ 4c, l "f + I T? 3 4 cAL O I Pi r S' i? yy r? J Ci/o `s 4 4 '(1- 7z - r l--) ne 1- y 7-:7 r -- >t m a 6r (- c 1? cf T- 14 j-,L c Ar- J ? ? \s rr T _ c - V>Y.1 c \ J Cervical Isometric Exercises CERVICAL SPINE - 7 Strengthening: Isometric Flexion (in neutral) Using light pressure .E with finger tips at forehead, resist bending head forward. Hold ? times. Repeat S times. Do ? sessions per day. Copyright VHI 1990 CERVICAL SPINE - 5 Strengthening: Isometric Lateral Bending (in neutral) Using light pressure from finger tips, press into side of head above ear. Resist v bending head sideways. Hotd?seconds. Repeat--!5--times, both directions. Do sessions per day. Copyright VH11990 CERVICAL SPINE - 8 Strengthening: Isometric Extension (in neutral) Using light pressure with finger tips at back of head, resist backward bending ?' of head. ` Hold _times- Repeat--1,- times. F)n-l -(zpc6nn q-nnr-data Copyright VHI 1990 CERVICAL SPINE - 6 Strengthening: Isometric Rotation Cin neutral) *. S0- Using light pressure from finger tips, press into temple/forehead area. Resist turning head. Hold times. Repeat---'J-times, both directions. Do--/ sessions per day. Alexander Spring Rehab; Inc. • I Tyler Court • Carlisle, PA 17013 • 717-245-2341 • Fax: 717-245-9672 • vmwalexanderspring.c rn CERVICAL SPINE -14 Strengthening: Isometric flexion (out of neutral) Bend head forward, apply light pressure to forehead with finger tips. Resist bending head forward further. Repeat times. Do times per Copyright VH11990 I CERVICAL SPINE -13 Strengthening Isometric Rotation (out of neutral) CERVICAL SPINE -15 Strengthening: Isometric Extension (out of neutral) Bend head backward, apply light pressure to back of head with finger tips. Resist bending head backward further. Repeat times. Copyright VHI 1990 CERVICAL SPINE -12 Strengthening Isometric Lateral Flexion (out of neutral) Turn head to side, apply light pressure to area just in front of Tilt head toward shoulder. Apply light pressure to side of temple, resist turning head further. Turn head to other side head just above ear and resist tilting head down further. and repeat. Re Repeat times, both directions. Do times per day. Repeat times. Do__timeS per day. Copyright VH11990 Copyright VH1 1990 Alexander Spring Rehab, Inc. Physical Therapy Patient History 2? cZ Name:G Date of Birth: 02-1 1. When were you injured (when did your problem begin)? Or, if not injured, when did a chronic condition recently cause more problems? h L-? i 1':? 7 c- 1,. 1 r i o C>1 1 How were you injured? At work: -Auto Accident:)(_ Home: _ Other: v ' 2. Have you ever been treated for this condition before? Yes: No: _ You were treated by. Physical Therapy: Occupational Therapy: Speech/Language Therapy: _ Chiropractor: _ Alternative Health Care Provider: 3. Please list any related tests or surgeries. x C O j j Please list any other surgeries: Functional Status/Activity Level (check all that apply) Difficulty with locomotion/movement y'm r ?? 1 d? bG 7? l t??(Y?t? _ Bed mobility _ Transfers (i.e. moving from bed to chair, from bed to commode) _ Gait (walking): On level: _ On stairs: _ On ramps: _ On uneven terrain: _ _ Difficulty with self-care (such as bathing, dressing, eating, toileting) _ Difficulty with home management (such as household chores, shopping, driving/transportation, care of dependents Difficulty with community and work activities/integration Work/school Recreation or play activity 3ro(L C?`}`*V\ Jeep disturbance? Please describe: _?u{hp y? c? ??„ + '&-t-4j.z 4. Please check all of the following that apply to: You Parent Sibling Grandparent Asthma/emphysema/COPD Heart attack/heart problems Stroke High blood pressure Diabetes (blood sugar problem) Arthritis Seizure disorder Cancer Circulatory problems Osteoporosis Cholesterol problem Problems with your eyesight (other than corrective lenses) Dizziness, fainting spells Hearing aid Metal implants Radioactive implants Pacemaker or implanted defibrillator Thyroid problem Fractures Other: -C4 iii ?0 r .gyn. L c? 5 -x- - 4":) 6 r-o4 C) c vx rn I&A Spnr YA" A L K ..n0 .i 1 Indicate your symptoms on the body diagram, using: xxx for pain symptoms; ooo for numbness symptoms, /// for tingling 00) . -C k,vou,T bones K - Please rate your pain on a scale of 0-10, with 0 being no pain and 10 being the worst pain imaginable (such that you would go to the emergency room): At rest: A--/10 With activity: -1?1/10 6. Pain is worse at what time of day? Early a.m. Late a.m. Early p.m. Late p.m. Nighttime Page 1 of 2 Physical Therapy Pt. History Form - Page 2 of 2 7. Are you allergic to anything? Yes: No: If so, please list." 8. Please list all medications, supplements, and ove he- ounter medicines you are currently taking an the reasons p??nc,??r you are taking them: _ y" X -- - " ru c,Gr,? -j? i1i 1 k d?t'd' r? b?/r 9. If female, is there a possibility that you P-0 may be pregnant? Yes: No:_ ?Y Living Environment: One-story - Two-story Lives alone ??++ Lives with caregi?,,-w Kxr*? _ Stairs, no railing V -? Stairs, with railing -{? b(n? Ramps Elevator _ Uneven terrain Assistive devices (e.g. bathroom): _ Any obstacles: - Other Do You Use: Cane _ Walker or rollator _ Manual wheelchair Mot 'zed wheelchair lasses, earing aids ther: n C 10. Where do you work and what are your main job duties? ( =ak-o 11 Do you smoke? Yes.-- No: x If yes, how often? Previous smoking amount/length & quit date (if you smoked more than 20 years before quitting): 12. Do you drink alcohol? Yes: No: /_ If yes, how often? Clinical Tests: Within the past year, have you had any of the following tests? Check all that apply. ` Angiogram - Mammogram - Arthroscopy _ MRI Biopsy _ Myelogram -XBlood tests - NCV (nerve conduction velocity) - Bone scan _ Pap smear - Bronchoscopy J _ Pulmonary function test - CT scan - Spinal tap - Doppler ultrasound _ Stool tests _ Echocardiogram _ Stress test (e.g. treadmill, cycle)EEG (electroencephalogram) ?_ Urine tests Spn? 10,E LkAA'"? EKG (electrocardiogram) Ow, -CU G? U'?^ X-rays Svv r r,-4A OLI oq kdos- _ EMG (electromyogram) ?J S) -N okhe c- - Other: Cbv ?? MV-A Signature: Date: (patient o (person completing form Revised 09/02/04 il?4 \. Cat 'l,(i(/BACK - 20 , 91 Mid-Back Stretch Push chest toward floor, reaching forward as far as possible. Hold seconds. Repeat _ times per set. Do sets per session. Do sessions per day. © 200 VHI (ORTH) CERVICAL SPINE - 23 Flexibility: Upper Trapeziu ' Gently grasp RIGHT / LEFT side of he while reaching behind bac with other hand. Tilt head away until a gentle stretch is felt. Hold seconds. Repeat times per set. Do sets per session. Do sessions per day. 41 InP.TH) Alexander Spring Rehab, Inc. 1 Tyler. Court Carli.*;* PA 1.7013 (717) 245-2341 Physical Therapy Interim Plan of Treatment: 1 Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age: 10 Date Initiated: 04/29/05 Physician: Joseph A. Pion, D.O. Period Covered: 05/27/05 - 06/17/05 Diagnosis: Cervical, thoracic and lumbar sprain/strain after MVA 04/13/05 % Change Impairments: (N/T; Better; Unchanged; Decline in Status; <25%; 25-50%; 50-75%; >75%) 1. Joint integrity & mobility: 25-50% better 2. Pain: Greater than 75% better (lumbar and legs); 25-50% better (cervical) 3. Posture: 25-50% better 4. Range of motion: Greater than 75% better (pain with cervical flexion/extension) Functional Limitations: A. Activities of Daily Living: 50-75% better (ADLs) Especially: Patient with decreasing pain and improved postural habits allowing performance off school, play activities with decreased complaints. Assessment: Primary area of therapy now C-spine with therapy focusing on improving spinal =.lignment and decreasing comfort with ROM of C-spine. Interventions: 2 times/week for 3 weeks. Treatment plan includes: A. Body mechanics instruction/ergonomic training to improve spine and joint protection. B. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pain. C. Manual therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. D. Patient/caregiver education to assure independence with self-care/home program. E. Physical agents/mechanical modalities to decrease pain, increase tissue extensibility/compliance, decrease muscle guarding/spasm, increase tolerance to exercise. Prognosis/Rehab Potential: Good Short Term Goals: 2 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 2 weeks. 2. Patient to demonstrate increased ROM to facilitate improved ADLs/IADLs in 2 weeks. 3. Patient will consistently demonstrate appropriate body mechanics with functional activities in 2 weeks. 4. Patient will be independent with home program in 2 weeks. Long Term Goals: by discharge L"-a?..1``.?°nt 1 be abi__P to perform ADLs/IADLs with less than 2/10 pain and minimal substitution. 2. Patient will consistently utilize proper body mechanics/joint protection techniques with functional activities. 3. Pat:_ent will be compliant with home program to maintain goals and current status. Therapist: SS/md Date: 05/27/05 I certify that I have examined the patient, have read the initial evaluation, and have reviewed the interventions and goals as provided by the therapist. I certify that rehab services are necessary and wil be provided while the patient is under my care. The plan of treatment will be reviewed at/least every 60 days or as the patient's condition warrants. This patient does not requirle? social needs assessment. Physician: of Date: Physician Comments and/or Restrictions: j Alexander Spring Rehab, Inc. 1 Tyler Court Carlisle, PA 17013 (717) 245-2341 Fax: (717) 245-9672 Physical Therapy Initial Evaluation & Plan of Care Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age: 10 Date Initiated: 04/29/05 Physician: Joseph A. Pion, D.O. Period Covered: 04/29/05 - 05/27/05 Diagnosis: Cervicalythoracic and lumbar sprain/strain after MVA 04/13/05 Chief Complaint: This 10 year old female was involved in a high speed MVA on April 13, 2005. She was a back seat belted passenger in a vehicle that was hit from behind. She reports some bilateral shoulder pain, "tailbone" pain, and R leg pain that is periodic in nature. Sitting increases tailbone pain and walking sometimes hurts her R leg. Her mother noted no bruising after the accident. Heat and cold do help symptoms. Functional Limitations: Minimal limitation, but complaint of pain after activity. Patient's Goals: Decrease soreness. Pain Rating: 4-6/10. Medical History: Unremarkable. Allergies: Su-fa drugs, peanut allergy. Medications/Supplements: Allegra, vitamin, stool softener; fiber capsule. Social History:: Patient lives at home with family. Patient is a student. Patient is a nonsmoker and does not drink alcohol. Diagnostic Test=s: Lumbar, leg/pelvis x-ray negative, per parent. EXAMINATION: Posture: Poor postural habits. Girth/Edema: None. AROM: Bilateral hip ROM WNL, but pain with full R hip flexion. Cervical AROM WNL. Pain with R and L side bend, and R rotation and extension. Lumbar ROM WNL except flexion 80%, Strength: Bilateral LE's grossly 4+/5 with complaint of R thigh pain with testing. Neurological Scan: Light touch WNL. Joint Mobility: Not tested. Palpation: Tender lumbar spine, cervical and thoracic spine, mild upper trapezius soreness, tender R thigh anteriorly and posteriorly. L rotated L1-L4, L rotated T7-10. Transfers: Independent. Gait: WNL. Special Tests: Cervical: Negative quadrant test. Lumbar/Sacroiliac: Negative straight leg raise, negative slump test. Treatment Today: The treatment plan and options were discussed with this patient, who is in agreement with the plan as outlined and wishes to proceed. Treatment included the evaluation, fo_lowed by joint mobilization to thoracolumbar spine with muscle energy technique, instruction in neck and back flexibility exercises, and hot pack to back for 10 minutes. Diagnosis/Assessment: Cervical, thoracic and lumbar sprain/strain after MVA. Interventions: 2 times/week for 4 weeks. Expected duration of treatment: 4 weeks. Treatment plan includes: A. Bod,r mechanics instruction/ergonomic training to improve spine and joint protection, ensure ergonomic soundness of school desk. B. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease pain. C. Manual therapy techniques to improve soft tissue extensibility, improve joint mobility/function, decrease pain. D. Patient/caregiver education to assure independence with self-care/home program. E. Physical agents/mechanical modalities to decrease pain, increase tissue extensibility/compliance, decrease muscle guarding/spasm, increase tolerance to exercise. Prognosis/Rehab Potential: Good Please see reverse t RE: Abigail M. Leidigh PT Initial Evaluation L Plan of Care 04/29/05 Page 2 Short Term Goals: 3 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 3 weeks. 2. Patient will report decreased sleep disturbance/interrupted sleep in 3 weeks. 3. Patient will demonstrate increased ROM to facilitate improved ADLs/IADLs in 3 weeks. 4. Patient will demonstrate increased strength to facilitate improved ADLs/IADLs in 3 weeks. 5. Patient .,7ill consistently demonstrate appropriate body mechanics with functional activities in 3 weeks. 6. Patient will be independent with home program; in 3 weeks. Long Term Goals:: by discharge 1. Patient will be able to perform ADLs/IADLs with less than 0-2/10 pain and minimal substitution. 2. Patient will consistently utilize proper body mechanics/joint protection techniques with functional activities. 3. Patient will be complia with home program to maintain gains and current status. Therapist: Stephany S1 P.T., PT-011837-L; DAPT-000681 Date: 04/29/05 SS/md I certify that I have examined the patient, have read the initial evaluation, and have reviewed the interventions and goals as provided by the therapist. I certify that rehab services are necessary and will be provided while the patient is under my care. The plan of treatment will be reviewed at ast every 60 days or as the patient's condition warrants. This patient does not require/a cial needs assessment. Physician: { Date: ?J Physician Comments and/or R4strictions: ? GRAHAM MEDICAL CLINIC, P.C. I JR? A. TOWNSEND, M D. . j. 100 SOUTH HIGH STREET DEA REG. NO. JOS4PH A PIO Llc. No. MOD 1 1 NEWVILLE, PENNSYLVANIA 17241 039E DEA REG. No. CAROL D. TELEPHONE 776-31 14 D O . RCe31SON LIC. NO. OS0071 I OE,.. , . . JEFFREY H. HARRIS, M.D. DEA REG. NO. DEA REG NO EG SUZANNE MCCOMBIE,'F.A.C. . . LIC. No. O S00571(1. LIC. No. MW66172L DEA REG. NO. CERT. 11 MA002720L c NAME AGE ADDRESS DATE i 7-? LABEL REFILL TIMES SUBSTITUTION PERMISSIBLE DR. IN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED THE PRESCRIBER MU , WRITE "BRAND NECESSARY"- OR "BRAND MEDICALLY NECESSARY" IN THE ST HAND- SPACE BELOW. Alexander Spring Rehab, Inc. 1 Tyler Court Carlisle, PA 17013 (717) 245-2341 Physical Therapy Discharge Summary This information is for your records Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 - Age: 10 Date Initiated: 04/29/05 Physician: Joseph A. Pion, D.O. Date of Discharge: 06/16;05 Diagnosis: Cervical, thoracic, and lumbar sprain/strain after MVA on 04/13/05 % Change Impairments: (N/T; Better; Unchanged; Decline in Status; <2516; 25-50%; 50-75%; >75%) 1. Joint integrity & mobility: 50-75% better 2. Muscle length: 50-75% better 3. Pain: Greater than 75% better 4. Pos-ure: 25-50% better 5. Range of motion: Greater than 75% better 6. Strength: Greater than 75% better Functional Limitations: A. Activities of Daily Living: Greater than 75% better (ADI,s) Especially: Play activities WNL. B. Instrumental Activities of Daily Living: 50-75% better (IADLs:) Especially: School work was aggravating factor to neck, although significantly improved. Interventions: Patient was seer.. 15 visits in 7.5 weeks. Treatment included: A. Body mechanics instruction/ergonomic training 3. Exercise C. Manual therapy techniques D. Patient/caregiver education E. Physical agents/mechanical modalities Discharge/Home Program: Patient has been instructed in a home program of flexibility, postural, strengthening, and cervical isometrics exercises, as well as improved postures and body mechanics and independent use of moist heat. Reason for Discharge: A. _x Goals achieved B._ Patient achieved goals and was progressing in remaining goals C._ Patient failed to progress - number of goals met: n, D__ Patient declined to continue PT is E__ Patient failed to schedule additional visits F Patient did not comply with plan of care i'j G. - Phvs__cian discontinued therapy H._ Conversion to Phase III/community program I. Therapist: Date: 06/16/05 Stepha.ny S oan, P.T., PT-011837-L; DAPT-000681 SS/md Alexander Spring Rehab, Inc- I Tyler Court Carlisle, PA 17013;; _ ?''??? i? ! ? ` `?•, ;' (717) 245-2361 r-- r Physical Therapy Interim Plan of Treatment: 1 -- Name: Abigail M. Leidigh ID#: 12624 Date of Birth: 02/27/95 Age: 10 Date Initiated: 04/29;'05 Physician: Joseph A. Pion, D.O. Period Covered: 05/27/05 - 06,/17/05 Diagnosis: Cervical,- thoracic and lumbar sprain/strain after MVA 04/13/05 % Change Impairments: (N/T; Better; Unchanged; Decline in Status; <2596; 25-50%; 50-75%; >75%) 1_ Joint integrity & mobility: 25-50% better Pain: Greater than 75% better (lumbar and legs); 25-50% better. (cervical) 3. Posture: 25-50% better 4. Range of motion: Greater than 75% better (pain with cervical flexion/extension) Functional Limitations: A. Activities of Daily Living: 50-75% better (ADLs) Especially: Patient with decreasing pain and improved postural habits allowing performance off school, play activities with decreased complaints. Assessment: Primary area of therapy now C-spine with therapy focusing on improving spinal alignment and decreasing comfort with ROM of C-spine. Interventions: 2 times/week for 3 weeks. Treatment plan includes: A. Bodv mechanics instruction/ergonomic training to improve spine and joint: protection. B. Exercise to increase ROM/flexibility, increase strength/stabilization, decrease: pain. C_ Manual therapy techniques to improve soft tissue extensibility, improve joint: mobility/function, decrease pain. D. Patient/caregiver education to assure independence with self--care/home program. E. Physical agents/mechanical modalities to decrease pain, increase tissue extensibility/compliance, decrease muscle guarding/spasm, increase tolerance to exercise. Prognosis/Rehab Potential: Good Short Term Goals: 2 weeks 1. Patient will report decreased pain to improve ADLs/IADLs in 2 weeks. 2. Pat-ent to demonstrate increased ROM to facilitate improved ADLs/IADLs in 2 weeks. 3. Patient will consistently demonstrate appropriate body mechanics with functional activities in 2 weeks. 4. Patient will be independent with home program in 2 weeks. Long Term Goals: by discharge 1. Patient will be able to perform ADLs/iAuLs with less titan 2/10 pain and minimal substitution. 2. Patient will consistently utilize proper body mechanics/joint protection techniques with functional activities. 3- Patient will be compliant with home program to maintain goals and current status. Therapist: d ",\ , Date: 05/27/05 Stepha y S , P.T., PT-011837-L SS/md I certify that have examined the F- °tienr a__ have read th° i nkt, al °<r Illation, and have ?° reviewed the interventions and goals as provided by the therapist. I certify that rehab services are necessary and will be provided while the patient is under my care. The plan of treatment will be reviewed at least every 60 days or as the patient's condition warrants. This patient does not require a social needs assessment. Physician: Date: Physician Comments and/or Restrictions: ??? ?, y?, . GENERAL RELEASE For the consideration of Five Thousand Dollars ($5,000.00), receipt of which is hereby acknowledged, I/we release and discharge, and for myself/ourselves my/our heirs, representatives, executors, administrators, successors and assigns, do hereby remise, release and forever discharge Charles E. Miller, Sr. and Carol G. Miller hereinafter referred to as the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns, and any and all other persons, firms, corporations, associations, of and from any and all causes of action, suits, judgments, claims and demands of whatsoever kind, in law or in equity, known and unknown, which I; we now have or may hereafter have, and/or which the minor Abigail Leidigh now has or may hereafter have, especially the claimed legal liability of releasee(s), which liability releasee(s) expressly deny(ies), arising from or by reason of any and all bodily or personal injury and/or property damage known and unknown, foreseen and unforeseen which heretofore has/have been or which hereafter may be sustained by me/us or the minor aforementioned arising out of the accident on or about April 13, 2005, at or near Interstate 81, Carlisle, in the County of Cumberland, in the State of Pennsylvania, in which the minor aforementioned sustained personal injuries and/or property damage. I/We agree that the consideration set forth above is specifically applicable to and paid to me/us with respect to any and all damage to any property, either real or personal, of mine/ours or the minor aforementioned, and with respect to any and all personal or bodily injury of mine/ours or the minor aforementioned, whether presently known or unknown, foreseen or unforeseen or which may subsequently develop and the consequences thereof, all as arising from the aforementioned accident. I/We further agree that the consideration set forth above is specifically applicable to and paid to me/us with respect to any right of contribution the I/we or the minor aforementioned may have against the releasee(s), his/her/their/its heirs, executors, administrators, insurers, successors and assigns relative to claims of others that may be brought against me/us or the minor aforementioned by reason of said accident. I/We further agree that the consideration set forth above is specifically applicable to my/our agreement that I/we or the minor aforementioned will not join nor attempt to join the releasee(s), his/her/their/its executors, administrators, insurers, successors and assigns in any capacity, in any action that may be brought against me/us or the minor aforementioned arising out of said accident. In consideration of the aforesaid payment, I/we for myself/ourselves and my/our heirs, representatives, executors, administrators, successors, and assigns do hereby: (1) agree to indemnify and hold forever harmless the releasee(s) and his/her/its/their representatives, administrators, or assigns, against loss from any and all further claims, demands or actions that may hereafter be made at any time or brought against the releasee(s) by me/us or the minor aforementioned, or by anyone in our behalf for the purpose of enforcing a further claim, for which this release is given, REL3 Initials:`?+ Page 1 of 2 17964381 DOC GENERAL RELEASE (2) warrant that I/we have received no money or other valuable consideration from any other perst,n or persons by reason of any causes of action, suits, covenants, agreements, judgments, claims and demands of whatsoever kind, which I/we now have or may hereafter have, for injuries to person or property arising out of the aforementioned accident or for the other matters for which this release is given. Intending to be legally bound thereby, WITNESS my/our hand(s) and seal(s) this of , day NOTICE: "Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties." WITNESS (Seal) F r-Guardian (Seal) er Minor Claim #010170804445 Catherine L. Marshall : klh (Seal) Initi S REL3 Page 2 of 2 1796438_1.DOC CONTINGENT FEE AGREEMENT THIS AGREEMENT entered into the day of 2007, by and between SCHMIDT KRAMER PC and MARY ANN LEIDIGH AS PARENT AND NATURAL GUARDIAN OF ALEXANDRA C. LEIDIGH, A MINOR AND ABIGAIL M. LEIDIGH, A MINOR, of 601 Belvedere Street, Carlisle, Pennsylvania 17013, hereinafter referred to as "Client." WITNESSETH: The law firm of SCHMIDT KRAMER PC, will act as Client's attorney in negotiating for a settlement, and in bringing a claim against CHARLES E. MILLER, SR., arising out of an accident which occurred on April 13, 2005, on Interstate 81 North, Carlisle, Cumberland County, Pennsylvania. In addition, SCHMIDT KRAMER PC, will pursue all claims for underinsured or uninsured motorist benefits to which the Client may be entitled under his/her insurance policy. In return, the Client will: 1. Promptly supply accurate information, as requested by SCHMIDT KRAMER PC, and cooperate fully, including making ourselves available for meetings with attorneys and for legal proceedings. Client promises all information supplied will be truthful and accurate. 2. (a) In any claim brought on Client's behalf, to pay to SCHMIDT KRAMER PC, for its services an amount equal to twenty-five (25%) of any recovery. (b) Client agrees not to settle or negotiate the above claim or any proceedings based thereon. (c) If Client terminates this Agreement before recovery, Client agrees that SCHMIDT KRAMER PC, shall be entitled to a fee based upon work done and benefit conferred. (d) Client agrees to read and follow SCHMIDT KRAMER PC's "Client Instruction Manual". 3. Client agrees to reimburse SCHMIDT KRAMER PC, out of any recovery, in addition to attorneys' fees, all costs and expenses incurred on Client's behalf in order to make the claim. All such costs and expenses will be advanced by SCHMIDT KRAMER PC as they are incurred. Such costs and expenses include, but are not limited to, filing fees, cost of medical records, copying costs, fax costs, long distance telephone costs, expert witness fees and sheriffs service costs. In the event there is no recovery, the Client will not be responsible for any costs or interest charges. Costs will be repaid to SCHMIDT KRAMER PC, out of any funds or property collected either by settlement or judgment. 4. Claims for first party medical benefits and income loss benefits are separate items. SCHMIDT KRAMER PC, will help you process these claims. A separate agreement will have to be entered into for fees if a major dispute occurs requiring the filing of suit for these benefits. The Client has read and does understand this Agreement. Signed the day and year set forth above. WITNESS: Client: r * 461 rrr ? rkARY A LEI IG , PARE T AND NATURAL GUARDIAN OF ALEXANDRA C. LEIDIGH AND ABIGAIL M. LEIDIGH, MINORS Approved: SCHMIDT KRAMER PC By I have received a copy of this Contingent Fee Agreement. Initials D O N n V O L71 C V 63 O ? LD W LU N fl10 1 D O (p r d -I 0 C) n N a ro N ro m m W =. d 0 N C) nr A T 3 ?? fn G ? ? i D v rn Q CD D y 6 _ N I N co N N A O O N N 0 0 O Ol co O O LD 00 co co J V O Lo co Z W N Ch N V CD i iZ K i?: (D (D (D _L _Q 9- (') () (7 0 0 0 73 73 :3 :D 7 7 (D (D (D c) n c) :D Z) D ro ro m L2 as m ro ro C C C C) CD <D O O O N N N C7t (T CT C/) cn C/) D U T A A A CD A A a v W W L" N A LO O CD W CO a W i i i i !w I tr Cn O 1 C '1 O O [O C'J L7 N -+ O O O A O A Lo Un v Dn O Z m CD i (D O ? D 13 0 c D _V CD =r v N W CD 0 5 = m ?n ? I CD y CD ro OF THE Pp! 'T C-17 CTAPY 2009 JUL 20 P,11 3-. 41 cv4BF,-H Y L_"ti rJ RiJi PENN SYLVAN [A L MARY ANN LEIDIGH AND RONALD : IN THE COURT OF COMMON PLEAS T. LEIDIGH, JR., INDIVIDUALLY : CUMBERLAND COUNTY COUNTY, AND IN THEIR OWN RIGHT AND : PENNSYLVANIA MARY ANN LEIDIGH AND RONALD : T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs V. No. 2007-1169 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED AMENDMENT TO PETITION FOR APPROVAL OF MINOR'S SETTLEMENT FOR ALEXANDRA LEIDIGH 21. No judge has been assigned to this issue or related matter. 22. There is no opposing council of records. The defendant is insured by Erie Insurance Exchange. The Erie representative has been provided with a copy of the petition and concurs in the petition and order. Dated: 1A3161 Respectfully Submitted, SCHMIDT KRAMER PC By: Qer rd C. Kramer ,'Attorney at Law r' Attorney I.D. #44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs } SCHMIDT KRAMER, P.C. BN : Gerard C. Kramer, Esquire Attorney at L.ax% Attorney I.D. #44715 209 State Street Harrisburg. PA 17101 (717) 232-6300 Attomeys for Plaintiff MARY ANN LEIDIGH AND RONALD T. : IN THE COURT OF COMMON PLEAS LEIDIGH, JR., INDIVIDUALLY AND IN : CUMBERLAND COUNTY COUNTY, THEIR OWN RIGHT AND MARY ANN : PENNSYLVANIA LEIDIGH AND RONALD T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs No. 2007-1169 V. CIVIL ACTION - LAW CHARLES E. MILLER, SR., I Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE AND NOW, this 23rd day of July 2009, I hereby certify that I have, this day, caused a copy of the foregoing Plaintiffs Petition for Approval of Minor's Settlement for Alexandra Leidigh with Amendment to Petition for Approval of Minor's Settlement for Alexandra Leidigh to be served by deposit in the United States mail, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Catherine L. Marshall, Adjuster Erie Insurance Group 4901 Louise Drive P.O. Box 2013 Mechanicsburg, PA 17055 SCHMIDT KR.AMER PC By: e/15erard C. Kramer, Esquire Attorney I.D.# 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 gkramer@schmidtkramer.com Attorney for Plaintiffs ,,)F THE 2009.lj'L 24 M 1: _;? MARY ANN LEIDIGH AND RONALD : IN THE COURT OF COMMON PLEAS T. LEIDIGH, JR., INDIVIDUALLY : CUMBERLAND COUNTY COUNTY, AND IN THEIR OWN RIGHT AND : PENNSYLVANIA MARY ANN LEIDIGH AND RONALD : T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, '. j ni Plaintiffs U F =' } V. No. 2007-1169 ?c s- --3 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED AMENDMENT TO PETITION FOR APPROVAL OF MINOR'S SETTLEMENT FOR ABIGAIL LEIDIGH 21.No judge has been assigned to this issue or related matter. 22.There is no opposing council of records. The defendant is insured by Erie Insurance Exchange. The Erie representative has been provided with a copy of the petition and concurs in the petition and order. Respectfully Submitted, SCHMIDT KRAMER PC 01 a? cq ".? Dated: By: .,'? rard C. Kramer Attorney at Law / Attorney I.D. #44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs SCHMIDT KRAMER, P.C. By Gerard C. Kramer; Esquire Attorney at Law Attorney I.D. #44715 209 State Street Harrisburg. PA 17101 (717) 232-6300 Attorneys for Plaintiff MARY ANN LEIDIGH AND RONALD T. : IN THE COURT OF COMMON PLEAS LEIDIGH, JR., INDIVIDUALLY AND IN : CUMBERLAND COUNTY COUNTY, THEIR OWN RIGHT AND MARY ANN PENNSYLVANIA LEIDIGH AND RONALD T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs No. 2007-1169 V. CIVIL ACTION - LAW CHARLES E. MILLER, SR., Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE AND NOW, this 23rd day of July 2009, I hereby certify that I have, this day, caused a copy of the foregoing Plaintiffs Petition for Approval of Minor's Settlement for Abigail Leidigh with Amendment to Petition for Approval of Minor's Settlement for Abigail Leidigh to be served by deposit in the United States mail, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Catherine L. Marshall, Adjuster Erie Insurance Group 4901 Louise Drive P.O. Box 2013 Mechanicsburg, PA 17055 SCHMIDT KRWR PC By: z P16'rard C. Kramer, Esquire Attorney I.D.# 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 gkramer@schmidtkramer.com Attorney for Plaintiffs SCHMIDT KRAMER PC BY: Gerard C. Kramer Attorney at Law Attorney ID No.: 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Fax (717) 232-6467 gkramerCaschmid tkramer. com Attorney for Plaintiff JUL 212009 MARY ANN LEIDIGH AND RONALD T. LEIDIGH, JR., INDIVIDUALLY AND IN THEIR OWN RIGHT AND MARY ANN LEIDIGH AND RONALD : : IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY COUNTY, PENNSYLVANIA T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF . ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs . V. No. 2007-1169 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED ORDER AND NOW, this -A ay of - VU/ , 2009, it is hereby ORDERED and DECREED as follows: 1. The settlement terms as set forth in the Petition for Approval of Minor's Settlement of the claim of Abigail Leidigh, are hereby approved. 2. The Court specifically approves the settlement offer in the amount of Five Thousand Dollars ($5,000.00). This payment is to be distributed in accordance with Pa. R.C.P. 2039 as follows: Schmidt Kramer PC - Attorney Fees 25% $ 1,250.00 Schmidt Kramer PC - Costs to Date $ 350.01 Invested for Abigail Leidi h, a minor $ 3,399.99 Total Settlement $ 5,000.00 3. The funds shall be invested by Petitioner, Mary Ann I.eidigh, on behalf of Abigail Leidigh, a minor, as follows: a. in Certificates of Deposit to the extent possible, not to exceed such sums as are fully insured by F.D.I.C.; and b. the balance which cannot be invested in Certificates of Deposit, if any, in a Savings Account, not to exceed such sums as are fully insured with F.D.I.C. Each account on behalf of Abigail Leidigh shall be marked as follows: This money shall be held in trust not to be redeemed, withdrawn, negotiated, or in any way alienated, except for the renewal in its entirety, before February 27, 2013, except by Order of this Court. 4. The law firm of Schmidt Kramer PC, shall oversee that the directives set forth in the preceding paragraph are carried out. 5. The Petitioner is directed to execute the Parents Release and Indemnity Agreement attached to the Petition as Exhibit "F." BY THE COURT: i? /j J. OF TH2 ,t 2009 JUL 29 All "-'. 19 Clt P y cof I cq-? 3 SCHMIDT KRAMER PC BY: Gerard C. Kramer Attorney at Law Attorney ID No.: 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Fax (717) 232-6467 gkramer(u-_schmidtkramer. com Attorney for Plaintiff MARY ANN LEIDIGH AND RONALD : IN THE COURT OF COMMON PLEAS T. LEIDIGH, JR., INDIVIDUALLY : CUMBERLAND COUNTY COUNTY, AND IN THEIR OWN RIGHT AND : PENNSYLVANIA MARY ANN LEIDIGH AND RONALD : T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs V. No. 2007-1169 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED ORDER ) 2009, it is hereby AND NOW, this ? day of LJIJ ORDERED and DECREED as follows: 1. The settlement terms as set forth in the Petition for Approval of Minor's Settlement of the claim of Alexandra Leidigh, are hereby approved. 2. The Court specifically approves the settlement offer in the amount of Four Thousand Dollars ($4,000.00). This payment is to be distributed in accordance with Pa. R.C.P. 2039 as follows: Schmidt Kramer PC - Attorney Fees 25% $ 1,000.00 Schmidt Kramer PC - Costs to Date $ 249.50 Invested for Alexandra Leidi h, a minor $ 2,750.50 Total Settlement $ 1 4,000.00 3. The funds shall be invested by Petitioner, Mary Ann Leidigh, on behalf of Alexandra Leidigh, a minor, as follows: a. in Certificates of Deposit to the extent possible, not to exceed such sums as are fully insured by F.D.I.C.; and b. the balance which cannot be invested in Certificates of Deposit, if any, in a Savings Account, not to exceed such sums as are fully insured with F.D.I.C. Each account on behalf of Alexandra Leidigh shall be marked as follows: This money shall be held in trust not to be redeemed, withdrawn, negotiated, or in any way alienated, except for the renewal in its entirety, before February 25, 2016, except by Order of this Court. 4. The law firm of Schmidt Kramer PC, shall oversee that the directives set forth in the preceding paragraph are carried out. 5. The Petitioner is directed to execute the Parents Release and Indemnity Agreement attached to the Petition as Exhibit "E." BY THE COURT• J. THr. or- 2009 JJ! 29 AN 9, 19 CUr°/' '•j y ?''1 e. ?i??LL Ad?e.4? MARY ANN LEIDIGH AND RONALD : IN THE COURT OF COMMON PLEAS T. LEIDIGH, JR., INDIVIDUALLY : CUMBERLAND COUNTY COUNTY, AND IN THEIR OWN RIGHT AND : PENNSYLVANIA MARY ANN LEIDIGH AND RONALD : T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs V. No. 2007-1169 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED PROOF OF COMPLIANCE WITH COURT ORDER AND NOW, this :2-j day of , 2009, attached for filing is the Certificate Disclosure verifying that a restricted account has been opened for Alexandra Leidigh, a minor, in accordance with the Order signed by Edward E. Guido, Judge on July 29, 2009. Respectfully submitted, SCHMIDT KRAMER PC BY 941'rard C. Kramer Attorney at Law Attorney I.D. No. 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 d St MEMBERS 1st FEDERAL CREDIT UNION SCHMIDT KRAMER 209 STATE STREET HARRISBURG, PA 17101 Dear GERARD C. KRAMER : Re: ALEXANDRA LEIDIGH 8/31/09 Members 1" Federal Credit Union has established an account for ALEXANDRA LEIDIGH. The funds in the account have been placed in a Certificate of Deposit and frozen until FEBRUARY 25, 2016. The enclosed document shows the account name and the restriction placed on those funds. Please contact us for any additional assistance. Any questions or further communications should be directed to Gregory P. Schank, VP of Branch Operations at 1-800-283-2328, extension 6003. Respectfully, enclosure MEG BEASTON Member Service Representative REV. 6/30/08 Share and Loan List Account 0000366237 Account Type: Court Ordered Member ALEXANDRA C LEIDIGH 601 BELVEDERE STREET CARLISLE, PA 17013 Share Description Soo REGULAR SAVINGS S40 60 MONTH CERT Page 1 of 1 Alexandra C Leidigh Member Type Birthdate SSN Home Phone Primary 02/25/1998 167-78-4940 717-258-9762 :Maturity Date 02/25/2016 Available -8,251.50 -8,751.50 Balance 5.00 2,745.50 file:HC:\Program Files\Symitar\SFW\HTML\HTMLView 5539924.htm 8/31/2009 St MEMBERS 111 PH1»xA'1,CRF1J1T UNl!?N Walnut Bottom 1166 Walnut Bottom Road Carlisle PA 17013 Inquiries Call: 717-249-4666 Acct XXXXXXX237 LEIDIGH,ALEXANDR Eff: 08/31/09 Date: 08/31/09 Tlr: 0171 Time: 4:52pm Deposit to REGULAR SAVINGS 00 Prev Bal: 0.00 Amount: 5.00 New Bal: 5.00 Seq: #425312 Deposit to 60 MONTH CERT 40 Prev Bal: 0.00 Maturity date: 08/30/14 Amount: 2,745.50 New Bal: 2,745.50 Seq: #425314 Chk hld rls 09/02/09 2,745.50 Check Received 2,750.50 Authorized by ID Source: 7 Drv Lic SigCard L, Known Other Got bills? Need cash fast? Signature Loan Special: Rates as low as 8.90?s APR with terms up to 60 months! ALEXANDRA C LEIDIGH r SCHMIDT KRAMER, P.C. By: Gerard C. Kramer, Esquire Attorney at Law Attorney I.D. #44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff MARY ANN LEIDIGH AND RONALD T. : IN THE COURT OF COMMON PLEAS LEIDIGH, JR., INDIVIDUALLY AND IN : CUMBERLAND COUNTY COUNTY, THEIR OWN RIGHT AND MARY ANN PENNSYLVANIA LEIDIGH AND RONALD T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs No. 2007-1169 V. CIVIL ACTION - LAW CHARLES E. MILLER, SR., I Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE AND NOW, this day of S291?w\ 2009, I hereby certify that I have, this day, served a copy of the foregoing Proof of Compiance to be served by deposit in the United States mail, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Catherine L. Marshall, Adjuster Erie Insurance Group 4901 Louise Drive P.O. Box 2013 Mechanicsburg, PA 17055 SCHMIDT K13 MER PCB By: ,derard C. Kramer, Esquire Attorney I.D. # 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 gkramer@schmidtkramer.com Attorney for Plaintiffs OF THE PRAT HIONOTAAY 2009 SEP -4 PM 1: 51 PENNSYLVANIA MARY ANN LEIDIGH AND RONALD : IN THE COURT OF COMMON PLEAS T. LEIDIGH, JR., INDIVIDUALLY : CUMBERLAND COUNTY COUNTY, AND IN THEIR OWN RIGHT AND : PENNSYLVANIA MARY ANN LEIDIGH AND RONALD : T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs V. No. 2007-1169 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED PROOF OF COMPLIANCE WITH COURT ORDER AND NOW, this day of , 2009, attached for filing is the Certificate Disclosure verifying that a restricted account has been opened for Abigail Leidigh, a minor, in accordance with the Order signed by Edward E. Guido, Judge on July 29, 2009. Respectfully submitted, SCHMIDT KRAMER PC BY Gerard C. Kramer Attorney at Law Attorney I.D. No. 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 V/ St MEMBERS 1St FEDERAL CREDIT UNION SCHMIDT KRAMER 209 STATE STREET HARRISBURG, PA 17101 Dear GERARD C. KRAMER : Re: ABIGAIL LEIDIGH 8/31/09 Members 151 Federal Credit Union has established an account for ABIGAIL LEIDIGH. The funds in the account have been placed in a Certificate of Deposit and frozen until FEBRUARY 27, 2013. The enclosed document shows the account name and the restriction placed on those funds. Please contact us for any additional assistance. Any questions or further communications should be directed to Gregory P. Schank, VP of Branch Operations at 1-800-283-2328, extension 6003. Respectfully enclosure MEG Member Service Representative REV. 6/30/08 Share and Loan List 8/31/2009 Account 0000366238 Account Type: Court Ordered Member ABIGAIL M LEIDIGH 601 BELVEDERE STREET CARLISLE, PA 17013 Page 1 of I Abigail M Leidigh Member 'T'ype Birthdate SSN Home Phone Primary 02/27/1995 169-76-2598 717-258-9762 Share Description Maturity Date Available Balance Soo REGULAR SAVINGS -10,199.97 5.00 S40 36 MONTH CERT 02/27/2013 -10,699.97 3,394.99 file://C:\Program Files\Symitar\SFW\HTML\HTMLView 0342474.htm St IV, I MEMBERS lot loll?NRAW,(,kEtwl` UNI N Walnut Bottom 1166 Walnut Bottom Road Carlisle PA 17013 Inquiries Call: 717-249-4666 Acct XXXXXXX238 LEIDIGH,ABIGAIL Eff: 08/31/09 Date: 08/31/09 Tlr: 0171 Time: 4:59pm Deposit to REGULAR SAVINGS 00 Prev Bal: 0.00 Amount: 5.00 New Bal: 5.00 Seq: #428116 Deposit to 36 MONTH CERT 40 Prev Bal: 0.00 Maturity date: 08/30/12 Amount: 3,394.99 New Bal: 3,394.99 Seq' #428118 ' Chk hld rls 09/02/09 3,394.99 Check Received 3,399.99 Authorized by ID Source: Drv Lic SigCard ? Known ? Other Got bills? Need cash fast? S ignature Loan Special: Rates as low a s 8.908s APR with terms up to 60 months! ABIGAIL M LEIDIGH SCHMIDT KRAMER, P.C. By: Gerard C. Kramer, Esquire Attorney at Law Attorney I.D. #44715 209 State Street Harrisburg, PA 17101 (717)232-6300 Attorneys for Plaintiff MARY ANN LEIDIGH AND RONALD T. : IN THE COURT OF COMMON PLEAS LEIDIGH, JR., INDIVIDUALLY AND IN : CUMBERLAND COUNTY COUNTY, THEIR OWN RIGHT AND MARY ANN PENNSYLVANIA LEIDIGH AND RONALD T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiffs No. 2007-1169 V. ' CIVIL. ACTION - LAW CHARLES E. MILLER, SR., I Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE e- / AND NOW, this C 1 day of 2009, I hereby certify that I have, this day, served a copy of the foregoing Proof of Compiance to be served by deposit in the United States mail, postage prepaid, at Harrisburg, Pennsylvania, addressed as follows: Catherine L. Marshall, Adjuster Erie Insurance Group 4901 Louise Drive P.O. Box 2013 Mechanicsburg, PA 17055 SCHMIDT KR.AMER PC By: erard C. Kramer, Esquire Attorney I.D.# 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 gkramer@schmidtkramer.com Attorney for Plaintiffs F THE 2909 SEP -4 PM 1: 50 CLUBE ;rt ti V V X.-UI aW PENINSYLVANA SCHMIDT KRAMER PC BY: Gerard C. Kramer, ESQUIRE I.D. # 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorneys for Plaintiff(s) gkramer(@schmidtkramer.com MARY ANN LEIDIGH AND : IN THE COURT OF COMMON PLEAS RONALD T. LEIDIGH, JR., : CUMBERLAND COUNTY COUNTY, INDIVIDUALLY AND IN THEIR : PENNSYLVANIA OWN RIGHT AND MARY ANN LEIDIGH AND RONALD T. LEIDIGH, JR., AS PARENTS AND NATURAL GUARDIANS OF ABIGAIL LEIDIGH, A MINOR AND ALEXANDRA LEIDIGH, A MINOR, Plaintiff V. No. 2007-1169 CHARLES E. MILLER, SR., CIVIL ACTION - LAW Defendant JURY TRIAL DEMANDED PRAECIPE TO SETTLE, DISCONTINUE AND END TO THE PROTHONOTARY: Please mark the above-captioned action settled, discontinued and ended with prejudice. Respectfully submitted, SCHMIDT KRAMER PC B Gerard C. Kramer, Esquire Date: l? 1 `0 C? Attorney for Plaintiff(s) IL'U ,.. CU Q, 0 EC ""2 f'j":1 2: .f