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Home My WebLink About98-00479 POINT FOR CHARGE NO. 2 In civil cases such as this one, the Plaintiff has the burden of proving those contentions which entitle him/her to relief. When a party has the burden of proof on a particular issue, his contention on that issue must be established by a fair i ! preponderance of the evidence. The evidence establishes a contention by a fair preponderance of the evidence if you are persuaded that it is more probably accurate and true than not. To put it another way, think, if you will, of an ordinary balance scale, with a pan on each side. Onto one side of the scale, place all of the evidence favorable to the Plaintiff; onto the other, place all of the evidence favorable to the Defendant. If, after considering the comparable weight of the evidence, you feel that the scales tip, ever so slightly or to the slightest degree, in favor of the Plaintiff, your verdict must be for the Plaintiff. If the scales tip in favor of the Defendant, or are equally balanced, your verdict must be for the Defendant. In this case, the Plaintiff has the burden of proving the following propositions: that the Defendant was negligent, and that that negligence was a substantial factor in bringing about the accident. If, after considering all of the evidence, you feel persuaded that these propositions are more probably true than not true, your verdict must be for the Plaintiff. Otherwise, your verdict should be for the Defendant. Pa. SSJI (Civ) 5.50; sisk v. Duffv, 201 Pa. Super. 213, 192 A.2d 251 (1963); Reist v. Manwiller, 231 Pa. Super. 444, 332 A.2d 518 (1974) . ( , "C\ ',j POINT FOR CHARGE NO. 5 If you find that the Defendant is liable to the Plaintiff, you must then find an amount of money damages which you believe will fairly and adequately compensate the Plaintiff for all the physical and financial injury he/she has sustained as a result of the accident. The amount which you award today must compensate the Plaintiff completely for damage sustained in the past, as well as damage the Plaintiff will sustain in the future. Pa. SSJI (Civ) 6.00; Miller v. Weller, 288 F.2d 438 (3d Cir. 1961); Frankel v. United States, 321 F. Supp. 1331 (E.D. Pa. 1970), aff'd, 466 F.2d 1226 (3d Cir. 1972). ( I (' [;"", ."'0'- t r ' f ,~., POINT FOR CHARGE NO. 8 The Plaintiff is entitled to be fairly and adequately compensated for such physical pain, mental anguish, discomfort, inconvenience and distress as you find he/she has endured, from the time of the accident until today. Pa. SSJI (Civ) 6.01E; Niederman v. Brodskv, 436 Pa. 401, 261 A.2d 84 (1970); Boaaavaraou v. Ponist, 518 Pa. 162, 542 A.2d 516 (1988). ~ , ~~ G~ 1 ~ , I ! \ i I t J' I ll'~ ~'~ il~ it'-.. " i.l. I L_-' I ~. ~ POINT FOR CHARGE NO. 9 In evaluating the amount to be awarded for pain and sUffering, you should consider that the infliction of pain means taking from a person what is his/her own to possess and retain __ namely health and well-being -- and that the law allows for compensation of this loss to the extent that loss may be calculated in money damages. Corcoran v. McNeal, 400 Pa. 14, 161 A.2d Iannuzzi, 403 Pa. 329, 169 A,2d 777 Rockcraft Stone Products Co., 424 Pa. 77, 367 (1960); Thompson v. (1961); DiChiacchio v. 225 A.2d 913 (1967), , ~ Q Q/<1. \ --,V' \(v.-rvv., U (J o ,rp";:) ), ',\11 \-1" I I,' 1:,'1 11\ , POINT FOR CHARGE NO. 12 The Plaintiff is entitled to be fairly and adequately compensated for past, present and future loss of his/her ability to enjoy any of the pleasures of life as a result of his/her injuries. . Pa. SSJI (Civ) 6.011; Frankel v. United States, 321 F. Supp. 1331 (E.D. Pa. 1970), aff'd, 466 F.2d 1226 (3d Cir. 1972); Corcoran v. McNeal, 400 Pa. 14, 161 A.2d 367 (1960); Thompson v. Iannuzzi, 403 Pa. 329, 169 A.2d 777 (1961); DiChiacchio v. Rockcraft Stone Products co., 424 Pa. 77, 225 A.2d 913 (1967). "jl) ( "-' , ' Afi j(j POINT FOR CHARGE NO. 14 As you heard, Dr. Mira has testified that Plaintiff had a pre- existing condition which consisted of arthritis. Although Plaintiff had this pre-existing condition, this does not mean that she is not entitled to recover for those additional injuries which either activated a dormant condition or aggravated an active impairment and made it worse. If you find that Plaintiff's condition was aggravated or activated by this accident, you may award her such monetary damages as you feel are entitled to compensate her, The law has determined that a Defendant must take his victim as he finds her. Lebesco v. Southeastern Pennsvlvania Transp. Authoritv, 251 Pa. Super. 415, 380 A.2d 848 (1977); Freer v. Parker, 411 Pa. 346, 192 A.2d 348 (1963); Fretts v. Pavetti, 282 Pa. Super. 166, 422 A.2d 881 (1980); Gever v. Steinbronn, 351 Pa. Super. 536, 506 A.2d 901 (1986) . c ~)\ eff-- 98.()28 LAW OFFICES OF RUBINATE, JACOBS & SABA 214 Senate Avenue, Suite 503 Camp Hill, PA 17011 Telephone Number: (717) 731-0988 Attorneys for Defendant, Ronald L. Bowers VmGINIA L. BRANDT AND RICHARD BRANDT, HER IRJSBAND, PLAINTIFFS IN THE COURT OF COMMON PLEAs CUMBERLAND COUNTY, PENNSYLVANIA '. .\1 r it, t, 1/, ~; I ,- No. 98-479 CIVIL VS. .... RONALD L. BOWERS, DEFENDANT CIVIL AcnoN - LAW JURY TRIAL DEMANDED . ) PROPOSED PoINTS FOR CHARGE OF DEFENDANT, RONALD L. BOWERS ') ,\ , I J .' ., : '00' . 1. In civil cases such as this one, the Plaintiffs have the burden of proving those contentions which entitle them to relief. When a party has the burden of proof on a particular issue, their contention on that issue must be established by a fair preponderance of the evidence. The evidence establishes a contention by a fair preponderance of the evidence if you are persuaded that it is more probably accurate and true than not. To put it another way, think, if you will, of an ordinary balance scale, with a pan on each side. Onto one side of the scale, place all of the evidence favorable to the Plaintiffs; onto the other, place all of the evidence favorable to the Defendant. If, after considering the comparable weight of the evidence, you feel that the scales tip, ever so slightly or to the slightest degree, in favor of the Plaintiffs, your verdict must be for the Plaintiffs. If the scales tip in favor of the Defendant, or are equally balanced, your verdict must be for the Defendant. In this case, the Plaintiffs have the burden of proving the following propositions: that the Defendant was negligent, and that the negligence of the Defendant was a substantial factor in bringing about the accident of May 7, 1996, and the hann alleged by the Plaintiffs arising therefrom. In this case, the Defendant has admitted that he was negligent, and that such negligence was the sole and proximate cause of the motor vehicle accident of May 7, 1996. However, the Plaintiffs have the burden of proving that the injuries alleged by Plaintiff, Virginia L. Brandt, were caused by the motor vehicle accident of May 7, 1996. If, after considering all of the evidence, you feel persuaded that these propositions are more probably true than not true, your verdict must be for the Plaintiffs. Otherwise, your verdict should be for the Defendant. Pennsylvania Standard Jury Instructions (Civil) fi5.50 " ,~-,,^ C U'r ........... -' , , , I ~~ ,,\ ,i " i! I ! ..r, 2. In a negligence action such as this case, proof of damages is an essential element. When a plaintiff fails to establish damages in a negligence action, the defendant is entitled to a verdict even though the defendant was guilty of negligence. Troutman v. Tabb, 285 Pa.Super. 353, 427 A.2d 673 (1981) ') .1 , I ! Col--Y~ tt il.{ I'..' :,W \',i} (/{ i: I ' '.~ .,'.1 .j,! I.'. \ il;:' 1:\\ 3. The number of witnesses offered by onc side or the other does not, in itself, determine the weight of the evidence. It is a factor, but only one of many factors which you should consider. Whether the witnesses appear to be biased or unbiased, whcther they are interested or disinterested persons, are among the important factors which go to the reliability of the testimony of each witness. In short the test is not which side brings the greater number of witnesses or presents the greater quantity of evidence; but which witness or witnesses, and which evidence, you consider most worthy of belief. Even the testimony of one witness may outweigh that of many, if you have reason to believe his testimony in preference to theirs. Obviously, however, where the testimony of the witnesses appear to you to be of the same quality, the weight of numbers assumes particular significance. Pennsylvania Standard Jury Instructions (Civil) ~5.03 1;\; , ," ,I J& , l C~tN.f."!'\ ') I , I l ( \. I l " ~ I I! :,~ I. I,{I , \ 4. You may find inconsistencies in the evidence. Even actual contradictions in the testimony of witnesses do not necessarily mean that any witness has been wilfully false. Poor memory is not uncommon. Sometimes a witness forgets; sometimes he remembers incorrectly. It is also true that two persons witnessing an incident may see or hear it differently. If different parts of the testimony of any witness or witnesses appear to be inconsistent, you the jury should try to reconcile the conflicting statements, whether of the same or of different witnesses, and you should do so if it can be done fairly and satisfactorily. If, however, you decide that there is a genuine and irreconcilable conflict of testimony, it is your function and duty to detennine which, if any, or the contradictory statements you will believe. Pennsylvania Standard Jury Instructions (Civil) ~5.04 , ,,' I ,.. , ~ C>.j(>JV ') I , I J , , ,~ I , \ !" ).', I >~ ;:~ 7. Pain and suffering, like any other Item of damage, must be causally related to the accident In order 10 be recoverable. Pennsylvania Trial Guide (Civil), 2D REVISED edition, 1978 (037.21) / \ eJ)/k C6-( 8. The Plaintiffs have the burden of proving through expert testimony that the automobile accident in question was a substantial factor in bringing about the injuries and damages they have alleged. Kravinsky v. Glover, 263 Pa.Super. 8, 396 A.2d 1349 (1979). The Plaintiffs must sustain this burden by what is known as a preponderance of the evidence. This means that they must make it appear that it is more likely than not that the conduct of the Defendant was a substantial factor in bringing about the alleged harm. A mere possibility of such causation is not enough; when the matter remains one of pure speculation and conjecture, or the probabilities are at best evenly balanced, it becomes your duty to find for the Defendant. Hamil v. Bashline, 481 Pa. 256, n.9, 392 A.2d 1280, n.9 (1978); COMMENT (a) to Section 433B Restatement (Second) of Torts; Walsh v. Snyder, 295 Pa.Super. 94, 441 A.2d 365 (1981) Q~9/~ (.,', ['( _A -,....... LAW~r~ OF RUBINATE JACOBS & SABA By, ();u ) Donald R. Dorer, Esquire Attorney for Defendant, Ronald L. Bowers Identification No. 39126 Respectfully submitted, Date: Week of S~tember 14. 1998 \ J '~ # ';1 ';'. :i; ~i~' 'p 98~28 LAW OFFICES OF RUBINATE, JACOBS & SABA 214 Senate Avenue, Suite 503 Camp Hill, PA 17011 Telephone Number: (717) 731-0988 Attorneys for Defendant, Ronald L. Bowers VIRGINIA L. BRANDT AND RICHARD BRANDT, HER HUSBAND, PLAINTIFFS IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 98-479 CIVIL VS. RONALD L. BOWERS, DEFENDANT CIVIL ArnON - LAW JURY TRIAL DEMANDED CERTIFICATE OF SERVICE Donald R. Dorer, Esquire, hereby certifies that he is the attorney for the Defendant herein, and that he caused a true and correct copy of the attached Pro.POsed Points for ChaTl!e of Defendant. Ronald L. Bowers to be served by hand delivery upon: Michael E. Kosik, Esquire Angino & Rovner, p.e. 4503 North Front Street Harrisburg, PA 17110 Date: Week (If S~tember 14. 1998 nald R. Dorer, Esq Attorney for Defendant '~~-~'-:~l:;;;'" . ',1i',~VOU ARE HE,REBY NOTIFIEO TO FilE rlf,':A;WRITTEH ',RESPONSE TO THE !ol:' ENCLOSED, " ," l<i'WITHIN TWENTY (20) DAYS ,FROM .\t SERVICE HEREOF OR A JUDGEMENT 1))1.~~~E,~~TERED A?AINST YOU ""'-'BY".(:,,';I<.,::"',. "., .,':I;,.:..~t.,;:" ',"',', AnoRNEY' - - - -. ~'I.~'I~'" " " ' 1':~~Z-~':;~::'." . .-: . I.A W OFfICf.~ RUIIINAn:, JACOIIS & SAUA 214 Sf.NAn: AVf.NUf. SUITf. 503 CAMP HII.L, PA 17011 (7t7) 731-0988 FAX: (717)'7::~7 WE DO HEREBY CERTIFY THAT THE WITHIN ISA TRUE AND CORRECT COPV' OF THE ORIGINAL FilED IN THIS ACnON. ' .' .........-'1. ATTORNEY VmGINIA L. BRANDT AND RICHARD BRANDT, HER HUSBAND, PLAINTIFFS IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 98-479 CIVIL VS. RONALD L. BOWERS, DEFENDANT CIVIL ArnON - LAW JURY TRIAL DEMANDED PROPOSED VERDICT SLIP 1. We, the members of the jury, find that the Defendant, Ronald L. Bowers, was negligent in the occurrence of the motor vehicle accident of May 7, 1996. 2. Do you find that the negligence of the Defendant, Ronald L. Bowers, was a substantial factor in bringing about the Plaintiffs' harm'! YES NO If you answered Question No.2 as "No", do not answer any other questions and return to the Courtroom. Otherwise, please proceed to Question No.3. 3. State the amount of damages you fmd that the Plaintiffs have suffered as a result of the negligence of the Defendant in the motor vehicle accident of May 7, 1996. Plaintiff, Virginia L. Brandt $ Plaintiff, Richard Brandt, Sr. $ TOTAL $ (Dale) Foreperson "'. 33 Hoffer VIRGINIA L. BRANDT and RICHARD BRANDT, her husband, plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY/ PENNSYLVANIA V. CIVIL ACTION - LAW RONALD L. BOWERS, Defendant NO. 98-479 CIVIL IN RE: PRETRIAL CONFERENCE A pretrial conference was held before the Honorable George E. Hoffer, President Judge, on Wednesday, August 26, 1998. In this auto accident case, Michael E. Kosik, Esquire, represents the plaintiff, and Donald R. Dorer, Esquire, represents the defendant. It is a rear-end collision at an intersection at which the defendant admits liability. The extent of plaintiff's soft tissue injuries, however, are seriously in question, as is the extent of her prior existing health condition. Neither party raises an objection about any witness or exhibit contained in the other party's pretrial memorandum, and the videotape deposition of the plaintiff's medical expert is already prepared for trial. The Court estimates this is a one day jury trial case with four challenges each. the Court, G Michael E. Kosik, Esquire 4503 North Front Street Harrisburg, Pa. 17110 Donald R. Dorer, Esquire 214 Senate Ave., suite 503 camp Hill, Pa. 17011 Prothonotary Court Administrator :mtf . I . I ' J\! ! \ , '/ , ' " I /: Exhibit A lll"Alt'l"'" ."/.'1<t'>,,' 11'" MU'"IJ @ " "; Aug-11-9B 03:53P AN"'-"1O & ROVN"R PC P.02 71; 85610 A.Ll.AN J. MlllA.. P. C. Medical Art, BuUdJ.ar SWle 208 220 WIlIcm. StIret, CIrUlle, PA 17013 ORTHOPEDIC SURGERY ALLAN J. MmA.M,D. Phone (711) 249.1400 August 10. 1998 ~ich.el E. Kaeik. E.~uire Angina' Rovner, P.C. 4503 Na~th Front Street H'r~isburl, PA 17110-1708 RE: VlralnlL Brandt SSN: 179-12-4434 DOB: S/24/23 D/A: 5/7/96 Dur hr. Kosik: The following ~.dic.l report is subm.tted in re~pon.e to ~our reques. ~or information concerning the above-nlmed pAtient in your lecter of June 30. 1998, ! f~r.t Gal' M... Brandt in the offiCI on Juna 4, 1996. At thet time. she presentad as a 72-yo"x---old female "ith the thhf COlllplRint of neck pain. She seid that ahe WA' rear-endad in her motor vehicle On May 7, 1996. She expu:ianced a jolting strain and thell latlr that Ivening alot of neck paln. She hod radiltion of neck pAin into the .houlder blldeo. She also complained of 0 quick shot of pain down to her lower beck area and SOml atiffness or cramping of the flnsers when spreading tho fingers in her right upper extremity. She had aun ,Dr. Townsend, "ho is her primary care phYSician, a eoupl.. deys .fte~ th.. accident. \/h,on she presented to tho ofUca, she had persistent neck and shoulder blade area discomfort wh1ch hsd improved somewhat aine. the :l.niUsl accident. Mr.. Brandt told me thllt OVer the hot year che had mild neck aymptoma and she we. aware of sOmO Arthrltis there and eleewhere but aha 'had not boen di..bled by it. My impression after .ee1n~ Hre. Brandt was that .he had suotained a~ acute cerv1cal spralr. secondary to the motor vehicle accldent of Hay 7. 1996. My ~"collllllendatlon for tr~atmeot at that ell'\l! was hOllle range or motion exerci.e.'and antl-lnflsnnatory m~dic.tia". Since thllt time, I had aeen HrG. Brandt on 4 oubsequent viaits. tht last being Ootober 16. 1996. Aug-ll-~B 03:G3P ANr,.TJ:"o & ROVNER PC 71; B6610 P.03 Brandt, Virginia Paga 2 ' AuSuat 10, 1995 As of Ootober 16. 1996. the pat hnt 1I1d. had An EMG, ImI, bone ocan and flexion/extension cervical spine films. She was having "tinging in har neele into the trapezius muucloa bilatarally. Sha had numbness of the radial d1ait8 of the right band .which uhe add wer-. present dnce the occid..nt. She h~d otin8ing 1MO cha radie! aspect of tha right thumb. Her ImX hAd shown de8enerative di.c at C4-S. ~-6 and 6-7 innerspaces which had proaressed slnce aarlior HRl of Harch 1985. Hor EMG showod only minimal depre38ion of conduction through the right, carpal tunnel and no neurogenic abnonlllll1tie... Her booa acen v.. ne8attvQ fox- infloftMatory ,chans.. which might havo aUlsested a fractur.. At that point in tlm.. I sugg60tad that the patient had options of giVing h.r condition t1mo with cons.rvativa tnat....nt. consultation with 'the Pain Cllnlc for po..ibla injections in the carvical spine or to aea Dr. Berry Moore, nauroeurgaon" whom Dhe hAd DOan in the pest for t.arpal tunnel surgery, to evaluate her for possibla surgical nerve root decompression. At that point in tiDe, .he IIa.. opting to cek. .h. eona..rvariv. meaoure". Her medieationl ineluded Clinoril and Advil occlSionally. She WAS going to be in Florida for ebDut 6 month.. I havs not aeon her .inee that tlme. Slne~ I have not had a r~cent follow-up with this pat1ent, L cannot make accurate cOIIIlllents about tha patient's curranc pxognoais or future trell:lllent thae .ay be requircd. He~ prosnoll. at rhn tlm. that I laGt Ga~ her was, ln lleneral, flilr in that I do think that with the condition it may have been posoible to continue with conserVAtive treatment, albeit she mAY hava had eo~. permanent mild to moderate sym~tom.. It i. my opinion with 0 reaoonable degree of m.dical certAinty that thia patleat's SympC01ll6 a"d conditiona as desc~ibed above we1:''' aggravated by the motor vehlcle accident of MAy 7, 1996. A.JM/kao 98-02S LAW OFFICES OF RUBINATE, JACOBS & SABA 214 Senate Avenue, Suite 503 Camp Hili, PA 17011 Telephone Number: (717) 731-0988 Attorneys for Defendant, Ronald L. Bowers VIRGINIA L. BRANDT AND RICHARD BRANDT, IlER HUSBAND, PLAINTIFFS IN Tim COUR1' 0.' COMMON PLEAS CUMBERLAND CoUNfY, PENNSYLVANIA No. 98-479 CIVIL VS. RONALD L. BOWERS, DEFENDANT CIVIL AC110N - LAW JURY TRIAL DEMANDED CERTIFICATE OF SERVICE Donald R. Dorer, Esquire, hereby certifies that he is the attorney for the Defendant herein, and that he caused a true and correct copy of the attached Memorandum for Pre- Trial Conference of Defendant. Ronald L. Bowers to be served by regular first class mail upon: Michael E. Kosik, Esquire Angino & Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110 Date: AUl!Ust 20. 1998 nald R. Dorer, Esquire Attorney for Defendant VIRGINIA L. BRANDT and RICHARD BRANDT, her husband, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA v. CIVIL ACTION - LAW NO . q .f - L/ 7 1 CA-;':,-t.' JURY TRIAL DEMANDED -- I .,,~<.....-- RONALD L. BOWERS, Defendant COM P L A I N T 1. Plaintiffs Virginia L. Brandt and Richard S. Brandt, citizens of the Commonwealth of Pennsylvania, are husband and wife, adult individuals who reside at 698 Brandy Run Road, Newville, Cumberland County, Pennsylvania. 2. Defendant Ronald L. Bowers is an adult individual and .\ , I citizen of the Commonwealth of Pennsylvania who resides at 1532 Terrace Avenue, Carlisle, Cumberland County, Pennsylvania. 3. The facts and occurrences hereinafter related took place on or about May 7, 1996 at approximately 4:30 p.m. on Allen Road near its intersection with U.S. 11, Cumberland County, Pennsylvania. 4. At that time and place, Plaintiff Virginia L. Brandt was operating her car a 1990 Oldsmobile 88 Royale, and was stopped in a line of traffic facing north on Allen Road (Route 465) waiting for the red traffic signal at the intersection of Route 11. 5. At that time and place, Steve Johnson stopped directly behind Plaintiff Virginia L. Brandt. 6. At that time and place, Defendant Ronald L. Bowers was , J I I ~ . " I , , I ~ I'...,; I '.:- operating a Ford Escort station wagon and was travelling north on Allen Road directly behind Steve Johnson at an excessive rate of speed. 7. At that time and place, the front portion of Defendant Ronald L. Bowers' vehicle violently collided with the rear portion Steve Johnsons' vehicle, thus pushing the Johnson vehicle into the rear of Plaintiff Virginia L. Brandt's vehicle. 8. The foregoing accident and all of the injuries and damages set forth hereinafter sustained by Plaintiffs Virginia L. Brandt and Richard S. Brandt are the direct and proximate result of the negligent, careless, wanton and reckless manner in which J .\ , I Defendant Ronald L. Bowers operated his motor vehicle as follows: (a) failure to have to be able to distance ahead; his vehicle under such control as stop within the assured clear (b) failure to keep alert and maintain a proper watch for the presence of other motor vehicles on the highway; I I t '1'1 , I H \ (i, I (c) failure to apply his brakes in sufficient time to avoid striking the rear of the Johnson vehicle which was pushed into the rear of Plaintiffs' vehicle (d) failure to travel at a safe speed; (e) failure to keep a proper watch for traffic on the highway; (f) failure to drive his vehicle with due regard for the highway and traffic conditions which were existing and of which he was or should have been aware; 2 ,\ forced to incur similar expenses in the future, and claim is made therefor. 13. As a result of the aforementioned injuries, Plaintiff Virginia L. Brandt has undergone and in the future will undergo great physical and mental suffering, great inconvenience in carrying out her daily activities, loss of life's pleasures and enjoyment, and claim is made therefor. 14. As a result of the aforesaid injuries, Plaintiff Virginia L. Brandt has been and in the future will be subject to great humiliation and embarrassment, and claim is made therefor. 15. Plaintiff Virginia L. Brandt continues to be plagued by persistent pain and limitation and, therefore, avers that her injuries may be of a permanent nature, causing residual problems for the remainder of her lifetime, and claim is made therefor. CLAIM II Richard S, Brandt V. Ronald L. Bowers 16. Paragraphs 1 through 15 of the Complaint are incorporated herein by reference. 17. As a result of the aforementioned injuries sustained by his wife, Plaintiff Virginia L. Brandt, Plaintiff Richard S. Brandt has been and may in the future be deprived of the care, companionship, consortium, and society of his wife, all of which will be to his great detriment, and claim is made therefor. 4 ~ Cl 0.-; --- ~L C':a f=: 1-- l.uQ .. .'~' N :".') \.2'{-; .~ ~~l~.:!; I::~ ';f' .,- 'f"' 11_ 0.'-' 9'~' :.::'~ ('J " r-- \.iJ~. N ,-' ,),J fi~1 ' 1 . .~ ~ :...: '0-'.. .~~ r': .' ;:i.1L;2 .. IJ.. 0:-; -' ~) ..J c,"' U ~ \~ 'J'~' I~ ~ ..:::::s- -~ ~ !' ~ '""- ~ ...... \S"-- ~ en 'rb ~~' m r<\' '" ~ ~ ......... .~. ~ ~T11 OF p~V1INIA COONl"i OF aJMBERU\ND VIRGINIA L. BRANDT & RICHARD BRANDTIH!H 98-479 CIVIL File No. VS RONALD L. BOWERS SUBPOENA TO PR()()I.X:E ()()O.J'1!;NTS OR 1l-I1 NGS FOR DISCOVERY PURSUANT TO RULE 4009.22 CUSTODIAN OF RECORDS FOR; ALLAN J. MIRA. M.D. (Ncrne of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to ~roduce the following documents or things: SEE ATTACHED MCS GROUP INC. 1601 MARKET STREET SU!TE 800 PHILADELPHIA PA 19103 (Address) You may deliver or mail legible copies of the documents or produce things requested by this subpoena, together with the certificate of carpliance, to the party making this request at the address 1 i sted above. You have the right to seek in advance the reasonab 1 e cost of preparing the copies or producing the things sought. If you fail to produce the documents or things required by this subpoen~ within twenty (20) days after its service, the party serving this subpoena rray seek a court order c:aT\';lel1ing you to =rply with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF "THE FOLLONING PERSON: NAME: DONALD R. DORER, ESQUIRE ADDRESS: 214 SENATE AVENUE, SUITE 503 CAMP HILL PA 17011 TELEPHONE: (215) 246-0900 SU'REl'E OJURT I D II AlTORNEY FOR: DEFENDANT DATE: g BY 1l-IE COJRT: ~+~ f2.. 1 MlO_ Prothon<>t~y/Ch"'. cIY;! D~'.Sion \. I.J)O D If'f\~n u y (Eff. 7/97) '- <.', i;: f.~ ~ cv .. 4<' IJJq ;:-: ~~:, ,-1.-;' .'~ ~~;:j-. C.U I..!--J '".'C di..~ ("', 0'" \0 '':/'1 ::1'. ('oJ .!:::: e",' :- .,I.lt'iJ r,L :-~ .. '...-.:;,,- -'- " u. (7:1 ::) 0 c." U .\ "I , the provisions of the Pennsylvania Motor Vehicle Financial Responsibility law. To the contrary, it is averred that Plaintiffs may recover damages which they set forth in their Complaint. WHEREFORE, Plaintiffs respectfully request that this Honorable Court enter judgment in favor of Plaintiffs and against Defendant. Respectfully submitted, ANGINO & ROVNER, P.C. ~sqUi~ LD. No. 36513 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791 Counsel for Plaintiffs DATED: 4/9/98 VERIFICATION I, VIRGINIA L. BRANDT, plaintiff, have read the foregoing Reply to New Matter and do hereby swear or affirm that the facts set forth in the foregoing are true and correct to the best of my knowledge, information and belief. I understand that this Verification is made subject to the penalties of 18 Pa.C.S.A. Section 4904, relating to unsworn falsification to authorities. WITNESS: (--:!Irk .',) /; " , ,/ ., I--! 2-<"t.!-,..(&- lj, ./"j .. ., . , ~...J; ,-/1 '-'{/",t.:J. " I.' n J ....i t"'7n Jr,. VIRrfNIA L. BRANDT' 71542/PJM CERTIFICATE OF SERVICE AND NOW, thls 9th day of April, 1998 I, Michelle M. prucnal, an employee of Angino & Rovner, P.C., do hereby certify that I have served a true and correct copy of the PLAINTIFFS' REPLY TO DEFENDANTS' NEW MATTER in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Donald R. Dorer, Esquire RUBINATE, JACOBS & SABAQ 214 Senate Avenue, Ste. 503 Camp Hill, PA 17011 (717) 731-0988 Attorney for Defendant $hLLdh7J1,Pw~ Michelle M. Prucnal Defendant's vehicle collided with the rear portion of Steve Johnsons' vehicle, thus pushing the Johnson vehicle into the rear of the vehicle opcrnted by the Plaintiff, Virginia L. Brnndt. All olher allegations deemed factual in nature are denied genernlly pursuant to Pa.R.C.P. ~ 1029(c). 8. Admitted in part and denied in part. It is admitted genernlly by the Defendant that he was negligent in the occurrence of the subject motor vehicle accident as described in Plaintiffs' Complaint. All other factual allegations set forth in Parngrnph 8, including subparngrnphs thereof, deemed factual in nature are genernlly denied pursuant to Pa.R.C.P. U029(e). 9. Parngrnph 9 is an incOIporation by reference parngrnph to which no response is required. 10.-15. Denied. These parngrnphs are genernlly denied pursuant to Pa.R.C.P. ~I029(e). 16. Parngrnph 16 is an incotpOration by reference parngrnph as to which no response is required from the Defendant. 17. Denied. This parngrnph is genernlly denied pursuant to Pa.R.C.P. ~I029(e). WHEREFORE, the Defendant respectfully prnys this Honornble Court to dismiss Plaintiffs' Complaint, and to enter judgment against the Plaintiffs and in favor of the Defendant. NEW MATI'ER 18. Parngraphs I through 17 are incotpOrnted herein by reference, and made a part hereof as if set forth in full. ...~ \1 \ 19. Plaintiffs' claims are barred in whole or in part by the provisions of the Pennsylvania No-Fault Motor Vehicle Insurance Act and/or the Pennsylvania Motor Vehicle Financial Responsibility Law. ,I WHEREFORE, the Defendant respectfully prays this Honorable Court to dismiss Plaintiffs' Complaint, and to enter judgment against the Plaintiffs and in favor of the Defendant. , ~ r I I " 'ta . i I B}\: I~/m, JACOBS & SABA L----- onal 'R. Dorer, Esquire Attorney for Defendant Identification No. 39126 , l Respectfully submitted, J Date: March 20. 1998 ') \ , I :\ ; :1. } , ; l' r ,~ :1 li' "( I: " i: , 'i: !.I 1996 in which she related problems she was having as a result of the accident. Her family physician at the Graham Medical Center referred her to Dr. Allan Mira where she was first evaluated on June 4, 1996. At that time, she had complaints of pain in her neck radiating into her shoulders with occasional pain radiating into the low back. At that time, she did admit that she had some minor pain in her neck prior to the accident as a result of arthritis but nothing which was disabling. At that time, Dr. Mira diagnosed an acute cervical strain secondary to the motor vehicle accident and recommended a home exercise program. When she was seen in follow up in July, she was not feeling any better and the pain was shooting across her upper back and into her upper arms. Dr. Mira placed her on medications and recommended physical therapy at the Alexander Spring Rehab facility. Mrs. Brandt received physical therapy for approximately a month, and when she was re-evaluated by Dr. Mira in August was told to discontinue physical therapy and attempt conservative treatment. He continued her on Clinoril for her symptoms. Mrs. Brandt had two follow up visits in October of 1996 with Dr. Mira, and although he referred her for an evaluation with Dr. Barry Moore, a neurosurgeon, she did not follow up or seek any additional treatment. Based upon her condition at that time, Dr. Mira indicated that he believed that she will continue to have mild to moderate symptoms. Plaintiffs took the videotaped deposition of Dr. Mira on Friday, August 14, 1998 to preserve his testimony for use at trial. At the time of the accident, Virginia Brandt was retired, although she did volunteer work, however, she has no loss of earnings. All medical expenses have been covered by her first party medical coverage, and therefore, there are no specials to be submitted to the jury. Plaintiff Virginia Brandt seeks to recover for pain and suffering and loss of enjoyment of life as a result of the physical injuries she sustained. Mrs. Brandt's husband, Richard Brandt, seeks to recover for loss of consortium. III. Principle Issues of Liabilitv of Damaqes: 1. Negligence has been admitted. 2. It is anticipated Defendants will seek to request that the issue as to whether Plaintiff Virginia Brandt's physical injuries are directly related to the accident. 3. The nature and extent of Plaintiff's damages. IV. Summary of Leqal Issues: None anticipated. V. Witnesses: Plaintiff Virginia Brandt - Damages 698 Brandy Run Road, Newville, PA 1724] Plaintiff Richard Brandt - Damages 698 ndy Run Road, Newville, PA 17241 ~. ", eposition of Dr. Allan Mira - Damages treet, Ste. 206, Carlisle, PA 17013 Plaintiffs are contemplating a short deposition for Dr. Townsend, Plaintiff's treating physician. Plaintiff reserves the right to call another family member or friend to testify of the impact which the injuries have had on Plaintiff's life. ~ ': VI. Exhibits: Plaintiff's medical records. Transcript of Dr. Mira's deposition. VII. Current status of settlement neqotiations: Defendant has made an offer of $1500 on Monday, August 10, 1998. Plaintiff, Virginia Brandt, has indicated that she would accept $25,000 in settlement of her claim. No further settlement negotiations have taken place. VIII. Schedulinq Conflicts: Plaintiffs' counsel is currently scheduled for an arbitration on Monday, September 14, 1998, in Perry County. This matter has been scheduled for arbitration since June of 1998 and can hopefully be concluded prior to 1:00 p.m. on September 14, 1998. IX. Estimated Lenqth of Trial: One day, including jury selection. Respectfully submitted, ichael E. Kosi , Esquire 1.0. No. 36513 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791 Counsel for Plaintiffs DATED: 8/17/98 ~ CERTIFICATE OF SERVICE AND NOW, this 17th day of August, 1998 I, Michelle M. prucnal, an employee of Angino & Rovner, P.C., do hereby certify that I have served a true and correct copy of the PLAINTIFFS' PRETRIAL MEMORANDUM in the United States mail, postage prepaid at Harrisburg, Pennsylvania, addressed as follows: Donald R. Dorer, Esquire RUBINATE, JACOBS & SABAQ 214 Senate Avenue, Ste. 503 Camp Hill, PA 17011 (717) 731-0988 Attorney for Defendant ~1YI.~J Michelle M. P~ , Plio No.: 98-028 ~ECU~_E_FOJJ_LJS.TIlSG CASE. FOR '(ln~L (Must be typewritten and submitted In duplicate.) TO mB PROmONOTARY OF CUMBBRLAND COUNTY: Please list the following case (check one): ( x) for JURY trial at the next tenn of civil court. ( ) for trial without a jury. CAPTION OF CASB: (Entire Caption Must Be Stated In Full) (Check One) ( ) Assumpsit Virginia L. Brandt and Richard Brandt, her husband, ( ) Trespass ( x) Trespass (Motor Vehicle) (Plaintiffs) ( ) vs. (Oth,,) Ronald L. Bowers, (Defendant) The triallisl will be called on Au.usl 18. 1999 Trials commence on Seolember 14. 1995 Pre-lrials will be held on AUI/usI26. 1999 (Brief. are due S day. before p~lri.II.) (The party lilting thi, cue for trill.h.1I provide forthwith. copy of the praecipe to all counael, pUrluant to local Rule 214.1.) No. 98-479 Civil 19 98 Indicate the attorney who will try case for the party who files this praecipe: Donald R. Dorer. Esquire. Attorney for Defendant. 214 Senate Avenue. Suite 503. Camo Hill. Pennsylvania. 17011: (717) 731-0988. Indicate trial counsel for other parties if known: Michael B. Kosik. EsQuire. Attorney for Plaintiffs. An~ino & Rovner. P.C.. 4503 North Front Street. Harrisbur~. PA 17110: (717) 238-6791. This case is ready for trial. "g'''' ()f} Print Name: Donald R. Do Attorney for: Defendant Date: July 27. 1998 0 .n (1 (- _J " \ r.: , " - ,n \ CERTIFICATE I l , ' , \ PREREQUISITE TO SERVICE OF A SUBPOENA , ;] ) f.") ';11 PURSUANT TO RULE 4009.22 ' , .~ ... :7.1 :..J .<. ..;" P-<r~ IN THE MATTER OF: COURT OF COMMON PLEAS VIRGINIA L. BRANDT AND RICHARD BRANDT TERM. 0000 -VS- CASE NO: 98-479 CIVIL RONALD L. BOWERS As a prerequisite to service of a subpoena for documents and things pursuant tll Rule 4009.22 MCS on behalf of DONALD R. DORER. ESQUIRE defendant certifies that (1) A notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena is sought to be served, (2) A copy of the notice of intent. including the proposed subpoena. is attached to the certificate. (3) No objection to the subpoena has been received, and (4) The subpoena which will be served is identical to the subpoena which is attached to the notice of intent to serve the subpoena. DATE: 6/26/98 /)~.tP ,@61.9<.-- DONALD R. DORER. ESQUIRE Attorney for DEFENDANT DEll-04S7S3 56702-L02 CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 IN THE MATTER OF: COURT OF COMMON PLEAS VIRGINIA L. BRANDT AND RICHARD BRANDT TERM, 0000 -VS- CASE NO: 98-479 CIVIL RONALD L. BOWERS As a prerequisite to service of a subpoena for documents and things pursuant to Rule 4009.22 MCS on behalf of DONALD R. DORER, ESQUIRE defendant certifies that (1) A notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena is sought to be served I (2) A copy of the notice of intent, including the proposed subpoena, is attached to the certificate, (3) No objection to the subpoena has been received, and (4) The subpoena which will be served is identical to the subpoena which is attached to the notice of intent to serve the subpoena. DATE: 6/26/98 DONALD R. DORER, ESQUIRE Attorney for DEFENDANT DEll-048784 56702-L03 ~T11 OF PEmlSYINNIIA CXXJmY OF aJMBmLAND VIRGINIA L. BRANDT AND RIClUU{D BRANDT HER HUSBAND VS. File No. 98-479 CIVIL ROANLD L. BOWERS SUBPOENA TO PBOCllX:E DOa.M:NTS OR TH I NGS FOR 0 I SCX>VERY PURSUANT TO RULE 4009. 22 TO: CUSTODIAN OF RECORDS FOR: GRAHAH MEDICAL CLINIC (Nane of Person or Entity) Within twenty (20) days after service of this subpoena, you are ordered by the court to produce the following docunents or things: SEE ATTAC\IED at ~ vr~ r-Rnl~. TNC.. 1601HARKET STREET SUITE 800 PllILADLEPHIA, PA,.19103 (Address) You may deliver or mail legible copies of the doctments or produce things requested by this subpoena, together with the certificate of carpliance, to the party making this request at the address listed above. You have the right to seek in adv~ the reasonable cost of preparing the copies or producing the things sought. If you fail to produce the doctments or things required by this SUbPOel13 within twenty (20) days after its service, the party serving this subpoena rray seek a court order carPe I ling you to carp ly with it. THIS SUBPOENA WAS ISSUED AT THE REQUEST OF THE FOLLo.rilNG PERSON: NAtE: DOANLD R. DORER,ESQUIRE ADDRESS: 214 SENATE AVENUE SUITE 503, CAMP HILL,PA. 17011 TELEPHONE: (215) 246-0900 SU'RE:1'E exulT ID II ATTORNEY FOR: DEFENDANT DATE: JUI'Ul ;)4~ J /qq8 Sea I of the Court BY THE COURT: C UAt I'J) Q ~\la. Prothonotary/Clerk. Civi l-lllivis ion \.~ D(\~I\Y3 Deputy (Eff. 7/97) EXPLANATION OF REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: GRAHAM MEDICAL CLINIC JOO SOUTH HIGH STREET NEWVILLE, PA 17241 RE: 56702 VIRGINIA BRANDT INCLUDING REPORTS Any and all records, correspondence, files and memorandoms, handwrillen notes, billing and payment records, relating to any examination, consultation, care or treatment. Dates Requested: up to and including the present. Subject: VIRGINIA BRANDT 698 BRANDY RUN RD., NEWVILLE, PA 17241 Social Security H: 179-1.2-4434 Date of Birth: 08-24.23 'I :\ , I SUIO-145410 5670.2-L03 EXPLANA1l0N OF REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: NEUROLOGY CENTER, INC. 890 POPLAR CHURCH RD. SUITE 107 CAMP HILL, PA 17011 RE: 56702 VIRGINIA BRANDT INCLUDING REPORTS. Any and all records, correspondence, files and memorandums, handwritten notes, billing and payment records. relating to any examination, consultation, care or treatment. Dates Requested: up to and including the present. Subject: VIRGINIA BRANDT 698 BRANDY RUN RD., NEWVILLE, PA 17241 Social Security #: 179.12.4434 Date of Birth: 08.24.23 5U10-145412 56702 -LO 4 COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND IN THE MATTER OF. COURT OF COMMON PLEAS VIRGINIA L. BRANDT & RICHARD BRANDT -MVA TERM, 0000 -VS- CASE NO. 98-479 RONALD L. BOWERS -R. & B. BOWERS NOTICE OF INTENT TO SERVE A SUBPOENA TO PRODUCE DOCUMENTS NEUROLOGY CENTER, INC. GRAHAM MEDICAL CLINIC MEDICAL MEDICAL TO. MICHAEL E. KOSIK, ESQUIRE MCS on behalf of DONALD R. DORER, ESQUIRE intends to serve a subpoena identical to the one that is attached to this notice. You have twenty (20) days from the date listed below in which to file of record and serve upon the undersigned an objection to the subpoena. If no objection is made the subpoena may be served pursuant to the applicable Pennsylvania Rules of Civil Procedure 4009.24. Complete copies of any reproduced records may be ordered at your expense by completing the attached counsel card and returning same to MCS or by contacting our local MCS office. DATE. 7/03/98 MCS on behalf of DONALD R. DORER, ESQUIRE Attorney for DEFENDANT CC: DONALD R. DORER, ESQUIRE KATHY MARTINO - 98-028 - 5837A7645505796 Any questions regarding this matter, contact THE MCS GROUP, INC. 1601 MARKET STREET ~800 PHILADELPHIA PA 19103 (215) 246-0900 DE02-068290 62625-C02 CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 IN THE MATTER OF. COURT OF COMMON PLEAS VIRGINIA L. BRANDT & RICHARD BRANDT -MVA TERM, 0000 -VS- CASE NO. 98-479 RONALD L. BOWERS -R.& B.BOWERS As a prerequisite to service of a subpoena for documents and things pursuant to Rule 4009.22 MCS on behalf of DONALD R. DORER, ESQUIRE defendant certifies that (1) A notice of intent to serve the subpoena with a copy of the subpoena attached thereto was mailed or delivered to each party at least twenty days prior to the date on which the subpoena is sought to be served, (2) A copy of the notice of intent. including the proposed subpoena, is attached to the certificate, (3) No objection to the subpoena has been received, and (4) The subpoena which will be served is identical to the subpoena which is attached to the notice of intent to serve the subpoena. DATE. 7/23/98 DONALD R. DORER, ESQUIRE Attorney for DEFENDANT DEll-049S1S 6262S-L02 ~ ro. ~ ~ N tiP .. ;s.". N ,..)-, ...6 ~ 0;': jEi a.. c.Js:! .- :?;CI) tt N ::~ ;?: llt -. f.!:ifj "5' F:: => ~~ -, ~ lS. Cl:l ::> en (.) ! Mm: '=L::&:9.'L d CASE t<<>. ~g~ m P-l 1l.1I .Idl- 1I 18.11 p..~ f-'1 I I 1.11 ; , ! 22.11 i ! i 23.11 I I 24.11 I 25.11 I \ 26.11 n ii 27.11 !;\ C'aAflccfcls.v+ ~ ' '" ~,:f\'..... , /\ , , ,_f'r,~ \, . i{! L \ . I, I ~ V: . I i , i I ", t .b ...~ - \ , .~' , "~; , , 1:1.... . '" , , :, I 'I ! ,01" c , ; ,I. .) ) " '1 , I " I I , ! \ ! I I r \1 i ;1 ~ ~ " I{ , I 1 ! '~"'~'"~4''' ',' _ ...........-l._~...'I' ...~. "'I" ~ . "f... . .1 ~. , " , " ",' .. ,,~:: ~ ; , > ' '. . \' r:. .~; ;. ,,:\ , ~" " , i<,', 4,' ..~ ~ os. ,. , . ,.t . . ". .;... ; 'J ,.... . l' ". " 1 ib . .. ~ .' J 'j .JI4, (~!... .- .'" " ,,.: " '.t'- ," .'.- " ~......., "'t. . , J 98~28 VmGINIA L. BRANDT AND RICHARD BRANDT, HER HUSBAND, PLAINTIFFS IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 98-479 CML VS. RONALD L. BOWERS, DEFENDANT CIVIL ArnoN - LAW JURY TRIAL DEMANDED PRAECIPE TO SETrLE, DISCONTINUE AND END TO TIlE PROTHONOTARY: Please mark the above-captioned case settled, discontinued and ended. , \ , i BY~ Michael B. Kosik, Esquire Angino & Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110 Attorney 1.0.# 36513 Attorney for Plaintiffs l , Date: October 8, 1998 98'()28 LAW OFFICES OF RUBINATE, JACOBS & SABA 214 Senate Avenue, Suite 503 Camp Hili, PA 17011 Telephone Number: (717) 731-0988 Attorneys for Defendant, Ronald L. Bowers VIRGINIA L. BRANDT AND RICHARD BRANDT, HER HUSBAND, PLAINTIFFS IN TilE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA No. 98-479 CIVIL VS. RONALD L. BOWERS, DEFENDANT CIVIL ACTION - LAW JURY TRIAL DEMANDED CERTIFICATE OF SERVICE Donald R. Dorer, Esquire, hereby certifies that he is the attorney for the Defendant herein, and that he caused a true and correct copy of the attached Pmecipe to Settle. Discontinue and End to be served by regular first class mail upon: Michael E. Kosik, Esquire Angino & Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110 Date: October 8. 1998 ? /2 i12- Donald R. Dorer, Esquire Attorney for Defendant ...... - , ' " " cP,tf\ .,~ '0.. '" ,~ ~'-'..; I, ! i\. ~, t..~ ': i' I... , . ! . i#.;.1 . I 'r', .~ I ( , , , .' . '~JI! , i' \ '/ 1 \1\\ . " i~'< , f .# j 1 \ , I .,.. .. . ''''-?~...,-...,,~ ";" ....-.....:;J,,~_~~ I J \ I I t, r I II. '1-- \t., :( , , I! , , , :~: .. . ':'\. .:,.....4 '~:.. ~ J ~ ,,' , ;.~.. ': . ,rr. '~1 :\ .' . ~ . , .'; ..:~' . .~.,.,.... .' ..,. PLAINTIFF'S. . EXHIBIT' ~ I ''Ii'''' .,. "',; . " . . ..' .. . .;\:J' l'. ", :;".. ~. " " '. . , ., '~ . . ,,,-.....' ) ~, \', ' ',t)o " . ',' II: ,. I , I .' ~ , I ' , ! . ~ - f I,:J.;". "'}.' ... ,\ ., .'j,- 4.~..,...' '"' " . " ,~:'_'-( ".'_' i "._,:', ;:: il:~~, ; , ,:.it~ /)/PEO \ DEfo r/71JJ IF: rn~. rn/f(!l j If 1-L-1I1tJ :). ,CA-SE IV ~{fle - f3 /(IJ riD / Unlii) ~ /1'1/91 / II ;e -d.!:'~ , f/l I fI/ S' I ,i . ':J"~i"";" \' ",j)~ . ..!.:.. .,., ,,' .., ,,,.-;,. .... , ';:oJ .... ,.. ',' ;', ',_.1','_ ~h' , ., t:\~,..;~::;;':/;i;~D f{ . .' ,..,:.,~.::<:;\;..:\;r)Atii>'~ iii', "'~ .:~ <., ::.~ ,. .;>/...."t~'_:..:~';.,};-:L..~:;.j~l~i'd~;;';'...;.. /j}j' , , ".?;i~'<':,;'~::I;}'):~,~iJrMJflt};' .~ ':>,.$ '. '; 'lb ~ l' .. "'). r > :,! ',,' :i .' 'j '\ ,,,..,: '~:-., ,.:( ...... \ ! , ' ,,: " ~ , " ~ .,' , {' ." .~.: " ~..'.,~ .. 'I. ~ ~.....' ORI.GINAL IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA VIRGINIA L. BRANDT and RICHARD BRANDT, her husband, PLAINTIFFS V CIVIL ACTION - LAW NO. 98-479 CIVIL RONALD L. BOWERS, DEFENDANT VIDEO DEPOSITION OF: ALLAN J. MIRA, M.D. TAKEN BY: PLAINTIFFS BEFORE: CHRISTINE F. HAAG, RPR NOTARY PUBLIC DATE: AUGUST 14, 1998, 3:02 P.M. PLACE: OFFICES OF ALLAN J. MIRA, M.D. 220 WILSON STREET CARLISLE, PENNSYLVANIA APPEARANCES: ANGINO & ROVNER, P.C. BY: MICHAEL E. KOSIK, ESQUIRE FOR - PLAINTIFFS RUB I NATE , JACOBS & SABA BY: DONALD DORER, ESQUIRE FOR - DEFENDANT PLAINTIFF'S EXHIBIT l 2000 Ling\eslOwn Road · Suite 302 · Harrisburg, PA 171 717.540.0220 . Fax 717.540.0221 · Lancaster 717.393.51 , 2 ,., 1 WITNESSES 2 ~ DIRECT CROSS REDIRECT RECROSS 3 ALLAN J. MIRA, M.D. 4 BY: MR. KOSIK 4 40 5 BY: MR. DORER 21 6 7 8 9 10 11 12 EXHIBITS . 13 14 PLAINTIFF'S DEPOSITION EXHIBIT PRODUCED AND MARKED 15 l. CURRICULUM VITAE 3 16 2. MEDICAL RECORDS OF DR. MIRA 3 17 18 DEFENDANT'S DEPOSITION EXHIBIT PRODUCED AND MARKED 19 1. NOT MARKED 20 2. MRI REPORT 46 21 3. GRAHAM MEDICAL CLINIC RECORDS 46 22 23 24 . 25 . 1 2 3 4 5 6 7 8 9 10 11 12 . 13 14 15 16 17 18 19 20 21 22 23 24 . 25 3 VIDEOGRAPHER: My name is Arkie Simmers. I am a paralegal with Angino and Rovner. Our offices are located at 4503 North Front Street in Harrisburg, and I am operating the video equipment for today's deposition. The date is August 14th, 1998/ and it is 3:02 p.m. We are here to take the deposition of Allan J. Mira, M.D., at 220 Wilson Street, Carlisle, PA. Dr. Mira will be testifying on behalf of the Plaintiffs in this case, Virginia L. Brandt and Richard Brandt, her husband, versus Ronald L. Bowers in the Court of Common Pleas, Cumberland County, Pennsylvania, Case No. 98-479. Attorney Michael E. Kosik of Angino and Rovner is counsel for the Plaintiffs Virginia and Richard Brandt. Also in attendance is Attorney Donald Dorer of Rubinate, Jacobs and Saba, counsel for Defendant Ronald Bowers. The court reporter will now swear in the witness. (Curriculum vitae produced and marked as Plaintiff's Deposition Exhibit No.1.) (Medical records of Allan J. Mira, M.D., produced and marked as Plaintiff's Deposition Exhibit No.2.) ALLAN J. MIRA, M.D., called as a witness, duly sworn, testified as follows: DIRECT EXAMINATION BY MR. KOSIK: ~ . I 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 . 4 o Dr. Mira, could you state your full name for the jury and the record, please? A Allan J. Mira, M.D. o And where are your professional offices located, Doctor? A 220 Wilson Street, Carlisle, Pennsylvania, Medical Arts Building. o And for the jury could you explain what type of medicine that you practice? A Orthopedic surgery. It involves treatment of bone and joint problems and injuri.es, including the spine and extremities. o For the jury again could you summarize for them your medical educational background, where you went to school and trained to be an orthopedic physician? A I did undergraduate work at the University of Iowa, and then I did four years of medical school at Craig University at Omaha, Nebraska, followed by one year internship in Omaha, Nebraska, followed by four years of orthopedic surgery at Hershey Medical Center in Hershey. o That's where you did your orthopedic residency? A That's right. o Beyond your school and training do you have any certifications in the field of orthopedics? A Certified by the American Board of Orthopedic . . . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Surgery, a member of the Academy of Orthopedic Surgeons and some other state and local societies. Q For members of the jury that may not be familiar with certification within the field of orthopedics, what's involved in getting your certification? A Completing a residency and a year later taking written and oral examination about the specialty. Q Essentially, is that testing by other orthopedic physicians? A Yes. Q And is that over and above the licensing requirements for the State of Pennsylvania? A Yes. Q And are you licensed in Pennsylvania? A Yes. Q Doctor, you have been kind enough to provide us with your resume, and I have marked as Exhibit 1 for the record. At this time we would offer Dr. Mira as an expert in the field of orthopedic surgery. MR. DORER: I'm so agreed. BY MR. KOSIK: Q Doctor, the purpose for taking your deposition today is to have you explain to the jury the injuries that Mrs. Brandt suffered in a motor vehicle accident on May 7th of 1996 and the treatment that you provided to her. I see 5 ~ ~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 . . 6 you have her chart in front of you, and I have marked for the record a copy of your records as Exhibit 2. If you need to in the course of the deposition answer any questions, feel free to refer to the record. Okay? A Okay. Q Can you explain to the jury when you first saw Mrs. Brandt, and what was the circumstances, how she came into your office? A I first saw Mrs. Brandt in the office on June 4th, 1996. At that time she presented as a 72-year-old female with a chief complaint of neck pain. She told me that she was in a motor vehicle that was rear-ended on May 7th, 1996, that she later that evening experienced a lot of neck pain, earlier felt a jolting strain in her neck. Pain shot down between her shoulder blades, and she also noted that it seemed to shoot down into her lower back with a feeling of stiffness and cramping sensation, was spreading in her fingers on her right hand. She told me she had seen Dr. Townsend, her family doctor, for evaluation a couple of days after the accident and that she had been evaluated at the Carlisle Hospital Emergency Room at the time of the accident. When she presented at the office she told me that she had persistent pain in her neck and shoulder blade area which improved somewhat since the initial accident but ... 1 continued to be present. She told me that over the past year 2 she's had some neck symptoms and was aware it's arthritis. 3 But she had not been disabled by it and it wasn't this severe 4 until since the accident. 5 Q Were you aware that she had been referred over to 6 see you by her family physician, Dr. Townsend? 7 A Yes. 8 Q When you saw her and you developed that history 9 was that based upon some questioning that you had of her 10 especially concerning her past medical history? 11 A Yes. 12 Q So at that time you were aware that she had prior . 13 arthritic changes in her neck and some complaints referable 14 to that? 15 A Yes. 16 Q Did you conduct an examination? 17 A Yes. 18 Q What were the significant findings? 19 A She had motion of the neck about 80 percent of 20 normal, symmetrically in all directions. With tipping her 21 head back or extension, she felt some gritting and pulling 22 sensation in the upper part of the upper back where it meets 23 the neck right directly behind the -- right directly behind 24 the base of the head. . 25 She had a limitation of rotation to either side 70 ....."" 7 '(1 r: ., I) .;. ~ I l . . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 . 8 percent of normal, side bending of about 60 percent of normal. Leaning to the right elicited pain in the right shoulder blade area. The reflexes were within normal limits and not remarkable, testing the knee jerk as you commonly know and some others in the upper extremity. And X rays were viewed of the neck and it showed some arthritis. No obvious new fracture or dislocation. And that essentially is the examination. Q The X rays that you referred to, were those X rays that were taken by your office or that she had brought in with her? A We saw the initial ones from the hospital emergency room, and in addition to that we ordered some new ones with bending. So my record here I see the report of the ones on June 6th. And, yeah, but I don't see the original ones from the hospital. I'm only assuming that they did one at the hospital, but I don't have a report on the chart. Q Okay. As a result of the tests you reviewed, the X rays, in your examination of Mrs. Brandt, did you develop an initial diagnosis of what you thought that you were dealing with? A Yes. My diagnosis was acute cervical sprain caused by the motor vehicle accident of May 7th, 1996, and that it had improved since the accident somewhat and that she had some underlying arthritis of the neck. ~ . . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 9 o Were the complaints that she had when she came in to see you consistent with the type of accident that she had described that she was involved in on May 7th? A Yes. Very much so. o I didn't ask you this before, Doctor. You said that you saw her first on June 4th. Had she been a patient in your office, she, herself. prior to this? A I have no recollection or record of that. o So it was the first time that you were seeing her? A Right. o Did you develop a plan for treatment as far as how you were going to care for her? A Yes. I suggested simple range of motion exercises, antiinflammatory medication. She had taken Clinoril in the past, and I like to keep them on something that they know they have some results with or tolerate. And then I wanted to see her back in six weeks. o You said range of motion of exercises. Were these exercises that she would do on her own at home or was this a formal program that she was supposed to start? A These are at-home exercises that we give them diagram sheets to guide them. They are very simple movements. Q Doctor, based upon your examination of her again and the tests results that you had as well as your training ~ . . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 with her pain and then over-the-counter drug called Vanquish. Q Did you perform a physical examination that day as well? A Yes. Q Was there any change in her condition? A No. She continued to have some 80 percent motion, which was symmetrical in all directions, and tenderness in the right side of the neck towards the shoulder blade to the right side. Q In light of the fact that there was no real change, did you make any changes as far as your plan for treatment? A Not essentially. I did order a bone scan test to evaluate for perhaps a focus in the neck, lower neck or the right side of the neck or shoulder blade to indicate possible fracture. So we ordered a bone scan. Q Okay. I know that probably was not completed until a little bit later. Was there anything that showed on the bone scan that became a problem? A No. There is nothing in and around the neck or shoulder consistent with an acute fracture. There is some minor changes in the shoulders and neck consistent with some problems of arthritis. Q There was no reason as a result of that then to change your initial diagnosis? 11 -- . . 12 1 A No. 2 Q In the notes for July lIth, there also appeared 3 you changed her medication from Clinoril to Naprosyn? 4 A Yes. 5 Q What was the reason for changing it? 6 A Hopefully to give her a little more improvement. 7 They are essentially equivalent, but they vary sometimes from 8 patient to patient in their effectiveness. So we would try 9 to get a little better result with Naprosyn. 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Q At that time it also appears that you had recommended some formal physical therapy? ts ~ fi i I , ~ A Yes. Q What was the reason for recommending physical therapy at that point? A Again, and I think that's contingent upon the fact , i , that the bone scan would be essentially unremarkable for i I I l \~ , , . I 1/ I' H l I I fracture, but that was again to get her at a little higher level of improvement. Q I believe in your notes you have copies of the records from Alexander Spring Rehab. She essentially went there for approximately a month. Can you explain to the jury what type of treatment that she would be receiving there and what the purpose of that treatment is? A I recommended modalities, that's heat and ultrasound and just sort of physical things of that nature, , I C.~" ~ . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 . 13 generally, heat and massage and hands-on therapy; assisted range of motion, that is upper range of motion that she did, but it would be hands-on to guide them, to teach her home exercise routine of a little bit more instruction anyway to get her to do that better; and cervical traction as tolerated is one of the modalities. And I don't recall if she had actually had that one. She was to do that one tolerance and left that decision up to the therapist. Q It appears you then saw her about four weeks later at the end of the physical therapy on August 8th? A That's right. Q Were the changes which you made in her treatment of any help? Did they improve her condition? A No. As a matter of fact, she was a little bit worse at that point in time. The physical therapy didn't seem to be effective in getting her more relief. In fact, the Naprosyn didn't seem to help as much as the Clinoril did, so we switched back to Clinoril after that visit. Q What complaints did she have, the same complaints as when she initially came in, or had they changed at all? A She continued to have pain in the upper back and lower neck junction toward the middle, and it would a throbbing pain that would fluctuate better or worse from time to time. And the only symptoms she had in her right hand was the stinging into the right thumb which she said had been ~ . . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 14 there since the accident. Q Again, you performed another physical examination? A Yes. Q Were there any significant differences from the prior two examinations? A No. Really, there is no significant change in her examination. Q It appeared from the percentages which you note in your examination findings that her ranges of motion were a little bit decreased from what they had been before? A Yes. But I would consider my assessment between the 60 and 80 percent of normal to be hard to distinguish a real difference. Q Did you recommend any other changes at that point as far as the treatment, or did you go back to your initial plan of treatment? A We stopped the physical therapy. And I usually ask her to continue the home exercises and again back to the Naprosyn and just a follow-up in another six to eight weeks. Q And it appears that she did come back in October, and actually earlier it said four additional visits. I think it was five. But it appears you saw her two times in October, October 3rd and October 16th. How was she doing in October of 1996? A On the 3rd she continued to have neck pain with .~~~ ~ . . 1 2 3 4 5 E 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 15 some radiation or shooting of pain toward the right shoulder blade and complained that it was a burning sensation. And she continued to have a stinging sensation in the right thumb. Q Those appear to be consistent complaints that she had from the beginning? A Yes. As far as the examination is concerned, movement of her arms overhead caused a little bit of increase in the sensation or stinging in the right thumb. There appeared to be some weakness in the upper part of her right arm that I might not have mentioned before. And there appeared to be some irritability of the media nerve in the right wrist. She told me that in the past she had seen Dr. Barrymore, a neurosurgeon, who did carpal tunnel surgery where the median nerve was irritable in the right wrist. And a band is cut to relieve pressure and symptoms in the hand from numbness. And that is kind of hard to distinguish between new and old as far as that's concerned. Q This was a new complaint as of October though? A I'm not sure that -- I tested the median nerve root irritability of the right wrist prior to this. This was the first time that she mentioned to me that she had carpal tunnel surgery, and we talked about that. So it's a little hard to relate the carpal tunnel to the new item. ~ " 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 . 16 Q And when you say relate it, you mean it's hard to relate that complaint as far as the wrist to the motor vehicle accident? A Yes. Q Because at this point it's almost five months after the accident and it doesn't appear that there's any significant improvement in her condition. Did you make any additional recommendations to her as far as trying to diagnose what's causing her problems? A Yes. I suggested a nerve test of the right upper extremity because I felt she had some nerve findings in addition to her separate problem of preexisting carpal tunnel. And I suggested an MRI scan of the neck and in fact suggested that she see Dr. Moore regarding these findings since it's part of his expertise as well. Q He's a neurosurgeon? A Yes. Q What were the results of the tests which you had recommended, the EMG and the MRI? Maybe when you explain the results of the tests for the members of the jury that are familiar with those tests just give the general idea of what's involved with that. A Okay. The EMG test is a nerve impulse testing in the arm. The nervous system sends signals to the muscles and sensory organs to function. And it can read those signals, " I 2 3 4 5 19 L' \ ' 1,1 ,.... " )j, :II , I I , than normal. And there is less tolerance in there or less room for the nerves when they get jolted around, so they are more susceptible to trauma and being jerked around. And I believe an arthritic joint just doesn't tolerate a beating, nor do 6 the nerves around as well as normal ones do. And I think 7 that she had a strain in her neck and movement from the 8 accident that caused increased symptoms. 9 Basically, it's a little hard to measure that when 10 we see it on the X ray, but by history we realize she had 11 been worse off afterwards than she had been before. . 12 13 Q As of your last visit on October 16th, did you discuss with Mrs. Brandt any additional options that she 14 would have other than the efforts of treatment which you 15 16 17 18 19 20 21 attempted? I , \ i I , r \~ n , , A I again mentioned to her that actually I saw no specific treatment that I normally perform. I didn't think that surgery in my hands was indicated or required. And basically it came down to several options: One is leaving it go and putting up with it; and another one is going to what we call a pain clinic where the anesthesiologists and doctors 22 do a lot of spinal injections for anesthesia and so forth for 23 if pain might inject steroid in the neck; and the third one was . 24 to discuss it and see what Dr. Moore's opinion was regarding 25 the neck and nerve roots in the spine since they are experts ~ M . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 20 in that area as well. Q That would be for a possible surgical option? A possible or you might say nothing we can do. See the pain clinic or just a confirmation. If not, maybe a new treatment modality but certainly another look. Q And since October of 1996 has Mrs. Brandt come back to see you for treatment? A No, she hasn't. Q As of the time you last saw her and based upon the treatment that you provided to her over that five-month period -- little over five month period did you have a prognosis as far as how you felt she might do in the future? A As of that period of time, it appeared that her condition was going to be essentially the same, probably not improving. Although I often tell people I often see with pleasure that some of these things do settle down after a year or two. And it seems as though she was in a relatively very slow improvement or maybe she would be plateaued where she is not improving. Q Doctor, again based upon the period of time that you provided treatment to Mrs. Brandt, the tests of which you performed, as well as your training in your field, is it your opinion to a reasonable degree of medical certainty that the conditions which you have described for the jury today and the diagnosis which you made to Mrs. Brandt's case directly ~ ~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 w 22 passing that some of these studies taken during the course of your care of Mrs. Brandt mentioned prior studies. So you were aware of the prior studies, but you had not had a chance to review any of the reportfl or the films from these prior studies directly yourself? A I had a chance to review -- oh I'm sorry -- I didn't have a report of the previous MRI. The only thing I had was a reference to a new report, so I didn't review any previous reports or films. Q Well, as far as the and if I could direct your attention to the initial visit on June 4th of '96 with Mrs. Brandt -- A Um-hmm. Q __ the description that she gave you that the past year she had mild neck symptoms and that she was aware of some arthritis there and elsewhere with symptoms that fluctuate but nothing disabling, that's essentially just her report to you? A That's right. Q Okay. Did she provide you with any assessment as to what treatment if any she may have been receiving for her neck pain or arthritis or arthritis elsewhere in her body as of that visit? A No. Q When she says nothing disabling or when you use -- ~~. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 w '-' 23 those words in summarizing a patient report what do you mean by that, Doctor? A Something that doesn't really interfere with her daily activities more than maybe a day or two, and then she goes on with her life. Q As far as your course of treatment of her, Dr. Mira, did you make any reference to changes in her daily activities or functions in contrast to the functions or activities she was capable of performing before the accident? A No. Q Either on June 4th, 1996, or after did you place any full medical restrictions upon her? A Any what kind of medical restrictions? Q Formal. A As of when? Q June 4th or any time thereafter? A No. Q Would you though, even though it's not noted, would you have given her general advice or instructions as to monitoring or I should say moderating activities, or would you have just left her essentially to her own judgment based upon her subjective symptoms? A I think we generally talk about moderation, but I think we probably have an understanding about that written down. ~ ~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 . 25 Q Is the long-term use of Clinoril consistent with a chronic arthritic condition? A Yes. In general. Q Dr. Mira, the physical findings that you summarized upon Attorney Kosik's questioning, could those findings in terms of the range of motion measurements have predated the accident given the history of arthritis? A Yes. Q I gather what it changed essentially was the worsening of the patient's subjective presentation to you compared to prior to the accident? A Yes. Q On 6/12/96, Doctor, there is a notation in your records, and I gather that this is a summary of a patient telephone conference with your office as opposed to an actual office visit with yourself? A Right. Q And it states the patient was called and told that her X rays looked okay, and she stated she was doing pretty well, and she'll be seen as scheduled. Do you see where I am referring to? A Yes. Q So apparently there was some subjective improvement and the follow-up visit was not changed? A I -- doing pretty well on June 12th. I have to ~ ~ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 w 27 any other neurosurgeon since you last saw her? A I don't know of any. Q Do you have the MRI report before you, Doctor? A Yes. Q I will mark this at the end of the deposition as Defense Exhibit 2. This report was prepared by Carlisle Imaging Associates. The date of the report is 10/8/96. In this particular case, did you look at the film to which the report pertains to? A I generally get them especially when they are here at Carlisle hospital, bring them to the office here and look at them. Q And you would assume you did so in this case? A Yes. Q And as I understand it, this found the degenerative changes at C4-5, C5-6 and C6-7 progress since 3/25/88 as you have testified to; is that correct? A Yes. Q As well as the central and peripheral spinal stenosis at the fourth, fifth and sixth cervical levels due to osteoarthritic ridges progressed since 2/25/88. Does that read correctly? A You've read that correctly. I suspect there's a typo there. Q Probably 3/25 or it's one. One of the two is ~ " 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 . 29 talking about as far as the spacing between the disks themselves, and then also there were arthritic changes as far as the openings in which the nerves were trying to exit out essentially and peripherally at the levels mentioned; is that correct, Doctor? A Yes. Q As far as the degenerative changes themselves are concerned as far as the bony structuring and the space narrowing is concerned as distinguished from the nerves and narrowed spaces being jostled about by trauma, would it be fair to say that the degenerative changes revealed in the 10/8/96 report as progressed from the 1988 study would have predated the motor vehicle accident of May 1996? A I think the degenerative changes themselves, the spurs, the bony architecture that was seen on October 8th, 1996, probably predated the accident because they tend -- they are very slow -- evolutionary changes. Q And your opinion is that the accident that resulted in some muscular strain with some associated jostling of the nerves superimposed upon the ongoing evolutionary degeneration of the bony spurs? A Yes. To reiterate that I think that the jostling of nerves and joints, ligaments is superimposed on arthritis. Q As far as the MRI study is concerned, the bone scan study or the EMG report that you discussed, did any of ~ t.. . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 30 thoul! provide! nny further understanding as to the right thumb uymptomu you wore discussing, or were the right thumbs eUDentially a clinical or subjective presentation? ^ I think the MRI with the narrowing and disk diucaue at C5-6 and 6-7 both those levels contribute to uymptoms around the thumb area. A majority of the findings where I believe to the right side somewhat. It's my interpretation of the MRI was -- especially I was impressed that the 4-5 disk level spurs were predominantly noted toward the right side, and that could have an impact on the region of the thumb, 4-5/ F-6 to 6-7. And so therefore it's my notion that the MRI is consistent that those nerve roots are compromised by the spurs and the jostling around that those nerve roots would be more vulnerable to be bruised if you will or stretched. Q Doctor, for the record -- did I give you a chance to finish? A Yeah. Q For the record, Doctor, we'll mark for identification at the end of the deposition office records from Graham Medical Clinic dating from 1973 to the present, consisting of some 18 pages. However, to the extent to which I will be using these records for today's purposes will be fairly limited I can assure you. I understand that YOU've not seen these records '*' -/;;1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 w 31 before today? A That's right. Q Bearing in mind that we are only going to go through a few passages at most, I just want to give you a chance off the record merely to acquaint yourself with the records. VIDEOGRAPHER: Off the video record. The time is 3:55 p.m. (Recess. ) VIDEOGRAPHER: Back on the video record. The time is 4:03 p.m. BY MR. DORER: Q Dr. Mira, is it fair to say we've taken a few minutes to give you a chance to briefly acquaint yourself with the Defense Exhibit 3, which I will represent to you appear to be handwritten, partially typewritten records from the Graham Medical Clinic concerning Virginia Brandt? A Yes. Q And albeit some concerns with format while we were off the record, is it fair to say that at least in general rough terms these appear to be records in the form of records that would be maintained by a typical general practitioner? A Yeah, very much so. Q And these would be records you would encounter and/or review in the course of your daily professional ~ f::::. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 ., ~. 32 practice? A Occasionally, yes. Q Doctor, is it fair to say in general terms that these records from 1973 to the present highlight and touch upon a number of miscellaneous and extraneous matters that one would typically see a general practitioner for as well as various musculoskeletal complaints presented by Mrs. Brandt over the years? A Yes. And the last note was October 8th, 1997. Q Thank you. I just want to go through a few passages briefly. On page 5 the date and there are page numbers on the top right part of the page..- on page 5/ on 11/24/80/ there is a reference to pain in upper shoulders and neck. Arms get numb especially at night. Onset off and on, months. And then there is a reference to objective neck and muscle spasms and assessment, torticollis. Do you see where I am referring to? A Yes. Q And I apologize I have to read a little bit so that I can form a predicate for a question. Did Mrs. Brandt ever give you history to that detailed extent as to that incident or that visit? A No. In reference to carpal tunnel later. Q Which was late '80s, early 1990s when she had the carpal tunnel with Dr. Moore? 35 ~ I 1 also complains of significant pain in both hands and 2 specifically in the wrist area. " 3 A Yes. That sounds like carpal tunnel more than 4 radiculopathy. 5 Q Well, now I can move to shortly after this 6 accident, 5/9/96, on page 15. 7 A Okay. 8 Q This is about the middle of the page. Does it 9 appear that she has just returned for her checkup after she 10 comes back from Florida for the winter? 11 A I'm sorry. Where? 12 Q I'm sorry. Middle of page 15. l""'\ !""'f:J 13 A Okay. 14 Q She has returned from her sojourn in Florida for 15 the wincer. 16 A Okay. 17 Q The first two paragraphs appear to be a routine 18 physical, but then on the third paragraph Dr. Townsend, whose 19 typing this is in, writes as follows: A second problem of 20 Virginia's today is that at 4:30 p.m. on 5/7/96 she was 21 coming Allen Road to stop at Route 11, traffic was stopped 22 because of a red light and there was a car behind her. 23 A third van apparently came up behind that car and 24 hit the car behind her which was pushed into her vehicle. ~ 25 She had slight forward jolt and had some mild neck pain \ ~ 1 notice that her neurological status is WNL or within normal 2 limits throughout; is that correct? 3 A Yes. 4 Q And I gather that essentially that physical 5 finding was consistent with your examination a month later? 6 A Yes. There were no localizing neurologic 7 deficits. 8 Q And what does that mean, Doctor? 9 A That you have a weakness of a muscle or a numb __ 10 clearly dead numb area. Sometimes you get the symptoms of 11 numbness or feeling numb but you can't really map them out. L.'...~. i~~ 12 We mean something rather overt here when we're saying that. 13 Q As far as the physical examination that was 14 conducted, neurologic and otherwise, by Dr. Townsend as of 15 May 9, '96, was that fairly consistent generally with your 16 examination on June 4, 1996? 17 A My examination -- her reflexes were hypoactive. 18 And what I mean by that is that a kid can hit his knee, kicks 19 you on the table. The older folks they get less brisk and 20 symmetrically have hypoactive or less brisk reflexes, and 21 they are generally nonspecific. It probably means something 22 is not right, neurologically you're not a kid anymore and all 23 that. ~ 24 You get some arthritis and you had some injury and 25 this and that and the other, Nonspecific, nonlocalizing 37 ~ ( .'} _.'; 39 1 Q And then there were references -- three 2 references -- in the fall of '97. Do you recall generally 3 seeing those notations at the end of the records? 4 A I see those areas of the copy of the record that 5 you're talking about. 6 Q And in those further visits is there any further 7 reference to neck or upper extremity symptoms or treatment 8 for same? 9 A Yeah. Through that last note of 10/8/97, from 10 10/24/96 at least, I don't see any reference to neck or upper 11 extremity complaints. 12 Q And other than your brief review of those 13 additional notes I just referred or referenced for you, you 14 have no direct knowledge as to her current status; is that 15 correct? 16 A That's correct. 17 Q Doctor, would you look finally going back to your 18 last visit on 10/16/96? 19 A Okay. 20 Q And this is the last visit where she was planning 21 on leaving shortly thereafter for her wintering in Florida 22 that year; is that correct? 23 A Yes. 24 Q As far as her traveling was concerned she wasn't ~ 25 restricted from doing that, was she? ") C:') \~,.J 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Q And I think he asked you a lot of questions about that note. In those records is it clear that Dr. Townsend made a referral of Mrs. Brandt to your office in fact the day after that office visit on May 10th of 1996? A Can you tell me which page that's on? MR. DORER: Fifteen. BY MR. KOSIK: Q Fifteen. A Fifteen. Okay. I believe that note was the typed note of Dr. Townsend, examined May 9th, 1996. And a notation was made on May 10th, 1996, per Dr. Townsend: Okay to send to Dr. Mira. Q And it appears that his office made an appointment with yours for June 4th when you indicated Mrs. Brandt initially came in to see you? A Yes. It appears that way. Q So at that point at least either Mrs. Brandt felt or Dr. Townsend felt that additional follow-up would have been appropriate, and that was the reason for the referral to you? A Yes. Q Now, Doctor, I'm not going to go over those records that you have in front of you extensively, but essentially I think Mr. Dorer pointed you to three dates or three areas of treatment, the last one being 12/7/90. I 41 .') 42 1 think you indicated from your review of that office note from 2 Dr. Grant or Dr. Townsend that that appeared to be a carpal 3 tunnel complaint, the one involving the arms and swelling of 4 the breast bone and wrists. I believe that is page 10. 5 A Yes. I see it. It appears to be a good initial 6 symptom for a work-up of carpal tunnel. 7 Q 8 to this motor vehicle accident? 9 A 10 Q Okay. We've already decided that is not related That's correct. And I think the next date of treatment that he had 11 referred you to was on the page prior to that, page 9, which ,'''it. I",.., 12 was January of 1988? 13 A 14 Q Yes. And at that time Mrs. Brandt came in and had 15 complaints referable to osteoarthritis? 16 A 17 Q Yes. And would you agree that that was in fact over 18 eight years prior to this motor vehicle accident from your 19 review of the records? 20 A 21 Q 22 her treatment for osteoarthritis I think in fact was in the 23 1980 24 A ~~ Yes, it was. And then the only other prior record concerning 1981 time period? Yes. April of 1981 multiple joint complaints and 25 1980, November 24th, pain in the upper shoulders, neck and ~ " ( ") w 44 1 call about the results of the X rays? 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 A Yes. Q That was I think in June of 1996? A Yes. Q In fact, when you saw her the following time in July where you actually had an office visit on July 11th, she seemed to be doing better at that point as well? A Yes. Q But even at that point you still recommended physical therapy she start an actual formal physical therapy program? A Yes. Q So at least even as of that point you didn't feel her condition had resolved or totally improved to the point that she didn't need treatment? A That's correct. Q And then Mr. Dorer asked you about whether you had specifically limited her as far as activities of daily living. You would have received reports back from the physical therapist wouldn't you as far as the progress and what they had planned to do for Mrs. Brandt? A Yes. Periodically. Q One of the forms that you received would be the Physical Discharge Summary from the physical therapy? It was dated 8/8/96. ~ (') ..,..,.J 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 45 A I don't see that here in my chart. Do you have such a document? Q Yes. I will give you a copy of it. Refer you to the bottom of the summary of the discharge. At that time did the physical therapist make note as far as any difficulties she was having with activities of daily living? A Yes. It said that the patient was continuing to note intermittent discomfort. Pain was reduced following last treatment, tends to be re-aggravated by simple activities the following day. If the patient is diligent with her home program I expect gradual reduction of discomfort and improvement and function. Q That was as of August 8th? A Correct. 1996. Q And, Doctor, I think we've already gone over this. But the arthritis that Mrs. Brandt had, would that underlying condition which we agree is not caused by the accident make her more susceptible to suffering and injury in this type of accident? A Yes. Q Is that the reason why you made a diagnosis that her symptoms were more on an aggravation, that was the basis for relating your treatment to the motor vehicle accident? A Yes. I think the soft tissues are more susceptible to a jolt -- abnormal movement from their ..... !~- .. .~., ....f . .....",.,. ~ 46 1 previously restricted -- somewhat causes soft tissue to nerve 2 tissue injury. 3 MR. KOSIK: Thank you, Doctor. I have nothing 4 further. 5 MR. DORER: Thank you, Doctor. 6 (MRI report produced and marked as Defendant's 7 Deposition Exhibit No.2.) 8 (Graham Medical Clinic records produced and marked 9 as Defendant's Deposition Exhibit No.3.) 10 VIDEOGRAPHER: This concludes the deposition. The 11 time is 4:27 p,m. ~~" 12 U 13 14 15 16 17 18 19 20 21 22 23 o 24 25 . w o R D I N D E X .' , ' lj \':, " 1 '~' .... ':I, I 'f' I " ~ /' \" 'I,",;' j , , ' . /,-, I I ;j , ' . . e I I \ \1' i ~. \ I.. , i~\~ j,l.',: j ',ii ",.I"'" .,' ,r~ ... \, . 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MIRA, M.D. Multi-Poge'M assumlDg (21 8:16 bony PI 2'1:S 2'1:15 ccntrurll( 27: I 'I eomplalDts 1101 7:13 43:5 29:21 certainfll IH:17 9:1 1ll:2 13:19 assure III 30:24 bottom III 45:4 certainly 121 20:5 13:1'1 15:5 32:7 at-home (II 9:21 Bowers PI 1:4 3:10 21:9 3'1: II 42:15 42:24 attempted (II 19:15 3:(5 certainty 121 1ll:2 completed III 11:17 attendance III 3:14 brain III 34:1 20:23 Completing II) 5:6 attention 121 22:11 Brondt 1"1 1:1 certification 121 5:4 compromised (II 30:13 40:22 1:1 3:9 3:9 5:5 concerned 1111 15:7 attorney (51 3:12 3:13 5:24 6:7 certifications II) 4:24 15:19 29:8 29:9 3:)4 25:5 47:16 6:9 8:19 10:10 Certificd (II 4:25 29:24 36:25 38:19 47:17 19:13 20:6 20:21 39:24 43:15 43:20 August 1611:12 21:10 21:12 21:19 certify 151 47:6 47:8 43:22 3:4 22:2 22:12 26:11 47:13 47:15 47:19 concerning 16) 7:10 13:10 26:6 45:13 31:17 32:7 32:20 cervical 141 47:23 8:22 21:12 21:19 31:17 authorized III 3H:20 3S:21 40:23 13:5 27:20 34:7 38:19 42:21 47:4 41:3 41:14 41:17 chancel81 21:11 21:15 available II) 40:6 42:14 43:2 43:24 21:18 22:3 22:6 concerns III 31:19 aware (9) 7:2 7:5 44:21 45:16 30:16 31:5 31:14 conclude III 3H:18 7:12 22:3 22:15 Brandt's 12) 18:7 changeJ71 10:15 11:5 concludes II) 46:10 24:12 26:22 36:10 20:25 11:11 11:25 14:6 condition (III 10:3 36:13 breust (II 42:4 IH:6 24:19 10:15 11:5 13:)3 away (II 38:10 brief 12) 38:20 39:12 changcd 14) 12:3 16:7 18:13 20:)4 briefly PI 28:8 31:14 13:20 25:9 25:24 24:11 25:2 44:14 -B- 32:11 changes (Ill 7:)3 45:17 background (II bring (II 27:11 11:11 11:22 13:12 conditions (2) 18:8 4:14 brisk 121 14:14 23:7 27:16 20:24 band(l) 15:17 37:19 37:20 29:2 29:7 29:11 conduct (II 7:16 Barrymore (II 15:15 brought 121 8:10 29:14 29:17 33:10 eonduetcd III 37:14 bUSell) 7:24 40:22 chunging (II 12:5 conduction III bruised 11130:15 )7:6 based 151 7:9 9:24 bruits P) 33:20 33:20 chart 131 6:1 8:17 conference II) 25:15 20:9 20:20 23:21 45:1 eonfinnation II) 20:4 basis (I) 45:22 33:22 checkup III Building (II 4:7 35:9 consider II) 14:11 bearing 12)31:3 38:20 burning III 15:2 chiefll) 6:11 consistent 112) 9:2 beating (II 19:5 Christine (31 1:10 11:21 11:22 15:5 beC8IDC(I) 11:19 47:4 47:24 17:7 25:1 26:5 beginning (II 15:6 -C- chronic 11125:2 30:13 33:17 36:6 behalf II J 3:8 C4-5 (2) 17:23 27:16 circulation II) 34:1 37:5 37:15 behind (5) 7:23 7:23 C5-612) 27:16 30:5 cireumstanccs (I) 6:7 consisting (I) 30:22 35:22 35:23 35:24 C6-7111 27:16 CIVILI21 1:3 1:4 constitutes (I) 47:20 below (4) 10:19 33:13 capablclll 23:9 clearJ21 17:16 41:2 consultation (I) 26:15 34:25 38:23 capital (I) 36:23 clearly (II 37: 10 consulted (I) 26:25 bending (21 8:1 eaptionll147:14 clinic (81 2:21 19:21 contingentllJ 12:15 8:14 carp) 35:22 35:23 20:4 21:16 30:21 continue (I) 14:18 best (1) 38:22 35:24 31:17 3H:19 46:8 continued IS) 7:1 better (8) 10:17 12:9 care (2) 9:12 22:2 clinical (I) 30:3 11:6 13:21 14:25 13:5 13:23 26:2 carefully (II 18:22 Clinoril (10) 9:15 15:3 40:11 43:25 44:7 Carlisle 161 10:25 12:3 13:17 continuing PI 10:25 betwccn (4) 6:15 1:14 13:18 24:13 24:15 34:4 45:7 3:7 4:6 6:21 14:11 15:19 29:1 27:6 27:11 24:19 24:23 25:1 contrast (21 23:8 beyond (2) 4:23 33:4 carotid (II 33:25 colon (I) 36:23 28:9 bit (7) 11:18 13:4 carpal(lS) 15:15 15:23 comfortable II) 24:6 contribute JII 30:5 13:14 14:10 15:8 15:25 16:12 17:7 coming II) 35:21 conversation 12) 24:1 26:1 32:(9 17:H 21:2 32:23 Common 121 1:1 33:4 blade 181 6:24 8:3 32:25 33:7 34:20 3:10 copies (I) 12:19 10:7 10:24 11:8 34:23 35:3 42:2 commonly III 8:4 copy 141 6:2 39:4 11:15 15:2 38:2 42:6 Commonwealth 121 47:3 40:6 45:3 blades (II 6:15 case (71 3:9 3:11 47:5 correct (III 27:17 blood (11 33:23 18:7 20:25 27:H compared PI 17:24 29:5 36:24 37:2 board 121 4:25 28:12 27:13 33:25 25:11 34:20 39:15 39:16 39:22 body (21 22:22 43:19 caused (41 8:23 15:8 complained III 15:2 40:14 42:9 44:16 19:8 45:17 45:14 bone (81 4:10 11:13 causes (I) 46:1 complains (II 35:1 correctly 121 27:22 11:16 11:19 12:16 complaint 151 28:18 29:24 42:4 causing (II 16:9 6:11 27:23 bones (II 28:23 Centerlll 4:20 15:20 16:2 34:19 counsel (4) 3:13 42:3 '-/' Index Page 2 HUGHES, ALBRIGHT, FOLTZ & NATALE 717-540-0220\717-393-5101 " .'.. " . Mulli-Page '" County - cxtensively ALLAN J. MIRA, M.D. I' l 3:)5 47:16 47:17 20:24 36:20 37:8 3H:IH BMG(61 16:19 16:23 County 131 1:1 3:11 description 121 22:14 39:17 40:7 411:2( 17:17 26:H 26:15 47:1 36:5 40:21 41:22 45:15 29:25 couple(.) 6:20 detailed 121 32:21 4(0:) 46:5 employce ('I 24:7 course (SI 6:3 10:12 3H:14 doctor's 121 36:11> 47:15 47:17 22:1 23:6 31:25 develop 121 8:19 36:17 cneounter 111 31:24 court PI 1:1 3:10 9:11 doctors (1119:21 endl41 13:10 27:5 3:15 developed 111 7:S documcnt III 45:2 30:20 39:3 crack 121 10:19 10:21 diagnose 1'1 16:9 docsn'tlsl16:6 19:5 equipment 111 3:4 cracking (I) 26:3 diagnosed (I) 10:3 23:3 26:16 33:16 equivalent (II 12:7 Craiglll 4:17 diagnosis(BI H:20 Donald J2II :20 3:14 especially (61 7:10 cramping (I) 6:17 H:22 11:25 18:6 done (61 17:2 17:22 27:10 30:H 32:14 CROSSIII 2:2 18:IH 20:25 34:7 17:25 26:11 26:15 33:15 34:5 45:21 2H:13 ESQUIRE (21 I:IH CROSS-EXAMINATION diagnostic 11) 21:19 Dorer 114) 1:20 2:5 1:20 (I) 21:6 diagram II) 3:14 5:20 21:7 essentially (161 5:H cryptic III 34:19 9:22 31:12 36:19 40:17 difference (II 14:13 H:H 11:13 12:7 Cumberland ('I 1:1 40:22 41:6 41:24 12:16 12:20 20:14 3:11 47:1 differences 111 14:4 43:23 44:17 46:5 22:17 23:21 25:9 currcnt(l) 39:14 different (21 26:17 dosagc 111 24:19 29:4 30:3 34:13 Curriculum (2) 2:15 2H:4 doubtll) 18:23 37:4 38:16 41:24 3:17 differentiatc 111 34:19 down ('21 6:15 6:16 evaluate (II 11:14 cut (I) )5:)7 difficulties (II 45:5 )7:2 18:24 19:19 evaluated (2) 6:21 diligent II) 45:10 20:16 23:25 2H:15 10:16 -0- direct (4) 2:2 3:24 33:13 34:25 34:25 evaluation (I) 6:)9 22:10 39:14 47:10 evening(lJ 6:)3 daily (SI 23:4 23:7 direction 11) 47:12 Drp61 2:16 3:H event (IJ 31:25 44:)H 45:6 4:1 5:IH 6:)9 33:11 date (6) ):12 3:4 directions 12) 7:20 7:6 15:15 16:14 evolutionary (21 29:)7 27:7 2H:3 32:11 11:7 17:4 IH:I 19:24 29:21 42:10 directly [61 7:23 21:16 23:7 25:4 exactly I1IIH:IH dated (II 44:25 7:23 10:4 20:25 26:9 26:10 26:15 examination (19) 3:24 dates I') 3H:22 22:5 47:IH 26:19 26:25 31:13 5:7 7:16 8:H 2H:3 disabled (II 32:25 35:IH 36:11 41:24 7:3 H:19 9:24 11:2 disabling 12) 22:17 37:14 3H:14 38:15 14:2 14:7 14:9 dating (II 30:21 22:25 38:22 40:23 41:2 15:7 34:2 37:5 days (21 6:20 40:24 discharge (2) 41:10 41:11 41:12 37:13 37:16 37:17 dead(IJ 37:10 44:24 41:IH 42:2 42:2 38:13 38:15 40:19 45:4 43:12 dealing (218:2) IH:7 discomfort 121 45:H drug [II 11:1 examinations (I) 14:5 decided (I) 42:7 45:12 examined (I) 41:10 dceision (I) )3:H discuss (2) 19: 13 19:24 due 12) IH:3 27:20 example (I) 21:25 duly (2) 3:22 47:9 deer<:ased (II 14:10 discussed 131 21:2 during (II 22: I exception (II 21:1 Defendant ('I ):5 26:20 29:25 exercise (II 13:4 1:21 3:)5 discussing (II 30:2 -E- exercises IS) 9:)4 Defendant's [31 2:IH discussion (I) 33:5 9:1H 9:19 9:21 46:6 46:9 disease (31 17:23 2H:25 Em 1:IH 3:12 14:18 Dcfense (21 27:6 30:5 early (I) 32:24 Exhibit (10) 2:14 31:15 disk 171 17:23 18:11 edueational(.) 4:14 2:1H 3:18 3:20 deficit (I) 36:3 2H:25 30:4 30:9 effect (I) 24:2 5:17 6:2 27:6 deficits (I) 37:7 3H:5 3H:9 31:15 46:7 46:9 cffective (II 13:16 EXHIBITS II) degeneration (I) 29:21 disks (31 17:24 28:20 effectiveness (II 2:12 29:) 12:H exit(l) 29:3 degenerative [71 17:23 dislocation (I) efforts 11) 19:14 expcct (II 45:11 IH:)5 27:16 2H:25 H:7 eight (2) 29:7 29:11 29:)4 distinguish (2) 14:12 14:19 42:1H expcrienced [II 6:13 degree []J 10:1 17:7 15:IH citheflS) 7:25 18:16 cxpert(l) 5:1H 20:23 distinguished II) 29:9 23:11 34:22 41:17 expcrtise (I) 16:15 denied (I) 10:17 doctor (]71 4:5 5:16 clbows 111 33: 14 experts [1119:25 deposition (17) ):H 5:22 6:19 9:5 cleetrodes 111 17:3 e:<plain (714:H 5:23 2:14 2:IH 3:4 9:24 10:10 17:16 elicited I1)H:2 6:6 12:21 16:19 3:6 3:IH 3:20 20:20 21:4 21:H elsewhere ISI 22:16 IH:IH 2H:8 5:22 6:3 27:5 21:10 23:2 24:9 22:22 43:4 43:6 explained (2) 30:20 46:7 46:9 25:13 26:4 26:7 43:7 10:3 46:10 47:9 47:13 26:14 27:3 2H:7 26:H 47:19 29:5 30:16 30:19 emergency 1'1 6:21 extension (I) 7:21 H:13 21:13 described [2) 9:3 32:3 33:20 36:IH extensively (I) 41:23 " .' 1 ,I HUGHES, ALBRIGHT, FOLTZ & NATALE 717-540-0220\717-393-5101 Index Page 3 cxtcnt - item ALLAN J. MIRA, M.D. Multi-Pagc'" extent (21 30:22 32:21 fustl'l 6:6 (1:9 gcnerally 1'1 13:1 hypoactive 121 37:17 extraneous (II 32:5 9:6 9:9 15:23 23:23 27: 10 33:17 37:20 extremities (II 4:12 21:10 35:17 43:3 37:15 37:21 3K:2 extremity 1'1 K:5 43:13 39:2 -1- 16:) I )7:5 17:6 fiVeI'I (4:22 16:5 given 14) 23:19 25:7 33:5 33:9 39:7 20:11 43:21 47:20 idea 11) 16:21 39:11 five-month II) 20:10 gocSII) 23:5 identification 11) 30:20 cyell) 2K:16 Florida 1101 26:12 gone(l) 45:15 image 111 2K:12 26:19 26:20 26:23 goodllJ 42:5 Imaging 11) 27:7 -F- 35:10 35:14 39:21 gradual 11145: II impllet(11 30:10 40:3 40:7 40:12 FI'I 1:10 47:4 fluctuate 121 13:23 Graham 161 2:21 impressed 11) 30:H 47:24 22:17 21:16 30:21 31:17 impression 111 43:10 F-6(11 30:11 focus (I) 11:14 3H:19 46:H improve II) 13:13 fact III) 11:10 12:15 folks (II 37:19 Grant 111 42:2 improved ('I 6:25 13:14 13:16 16:13 follow (2) 10:12 10:14 gritting (II 7:21 H:24 44:14 24:12 41:3 42:17 follow-up 141 14:19 guess(l) 43:25 improvement 16) 12:6 42:22 43:3 44:5 guide (2) 9:22 13:3 12:IH 16:7 20:IH fair(,) 29:11 31:13 25:24 40:21 41:IH 25:24 45:12 3):20 32:3 34:18 followed 121 4:IH -H- improving (21 20:15 4:19 fairly (2) 30:24 37:15 following I') 20:19 fall (I) 39:2 44:5 HaagI') 1:10 47:4 impulse 11) 16:23 45:H 45: I 0 47:24 familiar (31 5:3 follows (2) 3:23 hand (') 6:IH 10:8 incident (I) 32:22 16:21 IH:17 35:19 13:24 15:17 47:22 include 11) 33:5 family (41 6:19 7:6 foregoing 111 47:6 hands 1') 19:IH 34:20 including 111 4:11 IH:)7 3H:15 fonn 121 3(:21 35:1 increase (2) 10:6 fart"l 32:20 9:11 11:11 fonnal(4) 9:20 12:11 hands-on 121 13:1 15:H 14:)5 15:7 15:19 increased 111 16:2 16:H 18:6 23:14 44:10 13:3 19:H 20:)2 22:10 23:6 fonnat(l) 31:19 handwritten (II 31:16 indicate (II 11:15 26:9 26:22 26:25 fonnslll 44:23 hard 161 14:12 15:IH indicated (61 IH:12 29:1 29:2 29:7 forth 121 19:22 38:6 15:25 16:1 19:9 19:IH 40:6 41:14 29:H 29:24 33:6 forward (II 34:19 42:1 43:24 36:25 37:13 38:IH 35:25 Harrisburg 111 3:3 indicating (I) 3H:4 39:24 43:14 43:14 found (2) 17:5 27:(5 head 141 7:21 7:24 indirectly 11) 47:IH 44:18 44:20 45:5 fourtsl 4:17 4:19 (0:20 3H:1 inflammation 111 34:12 fccling 1'1 6: 17 37:11 10:10 13:9 14:21 heat 121 12:24 13:1 initiallBI 43:24 fourth 11) 27:20 6:25 H:12 fcels (2) 36:2 36:11 fracture ISI help", 10:25 13:)3 H:20 11:25 14:15 H:7 13:17 22:11 24:20 42:5 feltlBI 6:14 7:21 11:16 11:21 12:17 helping 11133:15 inject (11 19:23 10:19 16:11 20:12 IH:11 41:17 4):IH 43:16 frame 111 26:7 hereby 111 47:6 injections II) 19:22 femalc(l) 6:10 frank (21 18:9 18:11 hereof(l) 47:14 injuries (21 4:11 few I') 21:H 31:4 frccll) hereunto (11 47:22 5:23 6:4 injury 141 31:13 32:10 40:2) front (31 herself(11 9:7 36:14 37:24 field(,) 3:3 6:1 Hershcy (21 45:)H 46:2 4:24 5:4 41:23 4:20 institution (I) 5:)9 10:1 20:22 full 161 4:1 4:20 2H:6 Fiftccn 1') 41:6 23:12 highertl) instruction (I) 13:4 41:H 34:4 34:6 36:2 12:17 41:9 36:12 highlight (I) 32:4 instructions (I) 23:)9 fifth (II 27:20 fully (I) 40:11 history (71 7:8 7:10 interested (I) 47:18 film (2) 21:20 27:8 function 121 16:25 19:10 25:7 32:21 interfere (I I 23:3 fihns (41 21:19 22:4 45:12 43:14 43:20 intermittent (I) 45:8 22:9 2H:21 functions 121 23:H hit 121 35:24 37:IH internship II) 4:19 finallY(11 39:17 23:H home (4) 9:19 13:3 interpretation (I) 30:6 financially 111 47:17 future 11) 20:12 14:IH 45:11 investigate 11) 43:19 finding III 37:5 Hopefully 111 12:6 involved ('I 5:5 findings (II) 7:IH -G- hospital(,) 6:21 9:3 16:22 )4:9 16:11 )6:14 gardening 111 H:12 H:16 H:17 involves 111 4:10 17:17 17:17 21:2 24:3 27:) 1 25:4 25:6 30:6 gathert'l 24:1 25:9 hours 111 36:1 involving (I) 42:3 36:25 25:14 36:5 37:4 housework 111 Iowa 11) 4:17 fine 121 general (101 16:21 24:3 irritability (21 15:12 36:2 36:11 huge (II IH:12 fingers 11) 6:IH 23:19 25:3 2H:9 15:22 31:20 31:22 32:3 husband 12) 1:2 irritable III 15:16 finislt(l) 30:17 32:6 33:2 3:10 33:5 item 11) 15:25 Index Page 4 HUGHES, ALBRIGHT, FOLTZ & NATALE 717-540-0220\717-393-5101 j . 'I , i "-../ . , ", Mulli-Page'M itself - neck All AN J MIRA M 0 . , , . , . ItSiill" II I 26:4 LAWIII 1:3 22:21 210:7 29:13 210:25 32:25 Leaning III 8:2 37:15 41:4 41:10 Moore's III 19:24 -J- least 161 31:20 38:10 41:11 most(11 31:4 J I") 1:8 1:13 39:10 41:17 43:17 mean 151 16:1 23:1 motion 1111 7:19 2:3 3:7 3:19 44:13 37:8 37:12 37:IH 9:13 9:IH 11:6 3:22 4:3 47:7 leave (21 26: II 26:19 mcanslll 37:21 13:2 13:2 14:9 Jacobs 121 1:20 3:14 leaving 12119: 19 39:21 measurable III 3H:12 25:6 34:5 36:2 !anuary(l) 42:12 left 141 13:8 23:21 measure III 19:9 36:12 26:23 34:1> measurements III 25:6 motorl"l 5:24 6:12 erk(l) 8:-1 less (51 media(ll 8:23 10:4 10:8 jerkcd III 19:4 18:25 19:2 15:12 (6:2 17:IH 18:20 (9:2 37:19 37:20 mcdian('115:16 'ointpI 4:11 19:5 15:21 21:1 29:13 42:8 42:24 level 121 12:18 30:9 medical 1191 2:16 42:18 45:23 oints(.) )8:25 29:23 levels 14) 27:211 28:24 2:21 3:19 4:6 Motrin III 33:15 43:8 43:10 43:19 29:4 311:5 4:14 4:17 4:20 35:5 licensed III 7:10 10:2 20:23 mOVe(11 jolt 12) 35:25 45:25 5:14 licensing (I) 21:12 21:16 23:12 movement 1'1 15:8 jolted III 19:3 5:11 23:13 30:21 31:17 19:7 45:25 :olting(l) 6:14 life (II 23:5 38:19 43:14 46:8 movements III 9:23 ostled II) 29:10 ligaments III 29:23 medication (4) 9:)4 moving I') 10:21 26:6 . ostling (3) 29:20 light (21 11:10 35:22 10:25 12:3 24:10 33:)9 29:22 30:14 limitation III 7:25 medicine II) 4:9 MRI(181 2:20 16:13 judgment (II 23:21 limited ('I 30:24 43:17 mcctslll 7:22 16:19 17:21 17:22 July III 10:14 10:14 44:18 memberJll 5:1 18:21 21:211 21:23 limits 1'1 21:24 21:24 22:7 10:16 12:2 26:1 8:3 37:2 members (41 5:3 27:3 28:8 29:24 26:3 44:6 44:6 38:H 16:20 IH:16 18:17 311:4 30:8 30:12 . unction II) 13:22 living 121 44:19 45:6 mention [21 33:7 46:6 June (121 6:9 8:15 local 121 5:2 38:3 33:8 Mrs 1291 5:24 6:7 9:6 21:10 22:11 localizing (I) 37:6 mentioned 161 15:11 6:9 8:19 10:10 23:11 23:16 25:25 located 121 3:2 4:4 15:23 19:16 21:25 18:7 19:)3 20:6 33:3 37:16 41:14 locations II) 26:17 22:2 29:4 20:21 20:25 21:10 44:3 merelYJlI 31:5 21:12 21:19 22:2 Jurgensen (2) 17:4 long-tennll) 25:1 22:12 26:11 32:7 26:9 longer III 21:9 Michael I') 1:18 32:20 38:20 38:21 3:12 jury 1"1 4:2 4:8 look 171 18:22 20:5 middle 141 13:22 17:24 40:23 41:3 4):14 4:13 5:3 5:23 27:8 27:11 28:12 41:17 42:14 43:2 6:6 10:3 12:21 38:11 39:17 35:8 35:12 43:24 44:21 45:16 16:20 17:16 18:16 looked III 25:19 might 141 15:11 19:23 multipleJlI 42:24 20:24 28:8 looks 121 10:10 211:3 20:12 muscle 121 32: 16 37:9 10:13 mild PI 22:15 35:25 IOWIII 33:8 36:14 muSeleSJlI 16:24 -K- lowerp) 6:16 11:)4 mind 121 31:3 38:20 muscular II) 29:19 kccp(l) 9:15 13:22 mind's III 28:16 musculoskeletal (I] kicks III 37:18 minimalJlI 36:14 32:7 kidl2) 37:18 37:22 -M- minorJl) 11:22 kind I'] 5:16 15:18 M.DIRI 1:8 ):13 minutesJl) 31:14 -N- 18:23 23:13 38:10 2:3 3:7 3:19 Mira 1161 1:8 1:13 name P) 2:2 3:1 kncc (21 8:4 37:18 3:22 4:3 47:7 2:3 2:16 3:7 4:1 knccs 12) 33:14 43:9 magnitude II) 18:12 3:8 3:19 3:22 Naprosyn IS) 12:3 knowledge (I) 39:14 maintained (I) 31:22 4:1 4:3 5:18 12:9 13:17 14:19 Kosik 1"1 1:)8 2:4 majorJl) 2H:22 23:7 25:4 31:13 24:17 3:12 3:25 5:21 majority (II 311:6 41:12 47:7 narrow III 18:24 17:9 17:15 21:4 mapJl) 37:11 miscellaneous III 32:5 narrowed 121 29:10 21:9 36:16 40:20 MarchJlI 17:25 modalities 121 12:24 33:23 41:7 46:3 13:6 narrowing P) 18:2 Kosik's(l) 25:5 mark 121 27:5 311:19 modalitYJlI 20:5 29:9 30:4 marked 1101 2:14 moderating (I) 23:20 nature 1'1 12:25 18:12 -L- 2:18 2:19 3:17 moderation III 28:8 3:20 5:17 6:1 23:23 L14) 1:1 1:4 36:23 46:6 46:8 monitoring JlI 23:20 Nebraska 12J 4:18 4:19 3:9 3:10 massageJlI 13:1 month 151 12:21 20:11 necessarily JlI 43:8 last III) 19:12 20:9 matterJll 13:14 36:8 37:5 38:14 27:1 32:9 39:9 matters 11132:5 months 141 16:5 28:4 neck 1501 6:11 6:13 39:IH 39:20 40:10 32:15 40:11 6:14 6:24 7:2 40:12 41:25 45:9 may II>I 5:3 5:24 Moore J7I 7:13 7:19 7:23 6:12 8:23 9:3 16:14 IH:I 8:6 8:25 10:7 late II) 32:24 10:4 10:9 21:H 26:10 26:15 26:19 10:19 10:20 11:8 HUGHES, ALBRIGHT, FOLTZ & NATALE 717-540-0220\717-393-5101 Index Page 5 . . need - planning ALLAN J. MIRA, M.D. Multi-Page'" 11:14 11:14 11:15 notIce III 37:1 29:18 36:17 partIes III 47:16 11:20 11:22 13:22 noting (II 34:24 opportunity (II 38:20 pass (II 28:18 14:25 16:13 17:24 notion (I) 31l:12 opposed (I) 25:15 passage (II 34:24 18:2 18:14 18:24 19:7 19:23 19:25 November (II 42:25 option (II 21l:2 passages 121 31:4 21:23 22:15 22:22 now 1'1 3:16 35:5 options 12119: 13 19:19 32:11 2H:14 32:14 32:15 41:22 oral III 5:7 passing (I) 22: I 33:5 33:7 33:16 numb 1'1 32:14 37:9 order (I I 11:13 pastlSI 7:1 7:10 33:20 35:25 36:1 37:10 37:11 43:1 9:15 15:14 22:14 36:11 38:4 39:7 number 12117: I ordered 1'18: 13 11:16 patient 191 9:6 12:8 39:10 42:25 43:5 32:5 17:25 43:7 43:8 43:16 numbers III 32:12 organs III 16:25 12:8 23:1 24:2 25:14 25:18 45:7 ncedl2) 6:2 44:15 numbness 1') 15:18 original (21 H:15 45:10 needles 11117:3 34:5 37:11 26:10 patient's 1'1 10:6 nerve (15) 15:12 15:16 originally (I) 26:14 25:10 15:21 16:10 16:11 -0- orthopedic 181 4:10 Pennsylvania (8) 1:1 16:23 )8:9 18:10 oaths (I) 47:5 4:15 4:20 4:21 1:14 3:11 4:6 19:25 28:20 30:13 object (I) 36:16 4:25 5:1 5:8 5:12 5:14 47:3 30:14 34:12 38:6 5:19 47:6 46:1 objective (II 32:15 orthopedics 121 4:24 people 12) 20: 15 43:11 nerves 191 18:2 18:24 obtain (II 24:9 5:4 41:11 19:3 19:6 28:IH obvious (II 8:7 osteoarthritic (II 27:21 peql) 29:3 29:9 29:20 Occasionally (II 32:2 osteoarthritis (4) percent ('17:19 8:1 29:23 34:7 8:1 11:6 14:12 occasions (II 10:11 42:15 42:22 43:15 percentages (II 14:8 nervous (I) 16:24 occurred (II otherwise (II neurologic (2) 37:6 33:1 37:14 perfonn 12) 11:2 37:14 October (" I 14:20 outside (I) 28:6 19:17 neurological 1'1 14:23 14:23 14:23 over-too-counter (II performed (41 14:2 36:3 14:24 15:20 17:22 37:1 38:7 11:1 18:5 20:22 26:9 19:12 211:6 26:7 neurologically (I) 37:22 26:21 29:15 32:9 overhead (II 15:8 perfonning (II 23:9 neurosurgeon (4) 15:15 off 111 17:9 17:10 overt(11 37:12 perhaps (I) 11:14 16:16 26:10 27:1 19:11 31:5 31:7 own 121 9:19 23:21 period (') 20: II 20:11 new (7) 8:7 8:13 31:21l 32:14 20:13 20:20 42:23 15:19 15:20 15:25 offer (I I 5:18 -p- Periodically III 44:22 20:4 22:8 office (15) 6:8 6:9 P.C(l1 1:17 peripOOralll) 27:19 next (3) 34:15 38:24 6:23 8:10 9:7 p.m181 1:12 3:5 peripherally PI 29:4 42:10 25:15 25:16 27:11 night 121 30:20 41:3 41:4 17:11 17:14 31:8 persistent(l) 6:24 32:14 43:1 31:11 35:20 46:11 perspeeti ve (II nonloealizing (II 37:25 41:13 42:1 43:25 28:11 44:6 page (1'1 28:3 32:11 pertains III 27:9 nonspecific 1'1 34:22 offices (') 1:13 3:2 32:11 32:12 32:12 physical (191 11:2 37:21 37:25 4:4 33:19 34:15 34:15 12:11 12:13 12:25 nor III 19:5 often 12) 35:6 35:8 35:12 13:10 13:15 14:2 20:15 20:15 41:5 42:4 42:11 nonna1191 7:20 8:1 old161 15:19 21:20 42:11 14:17 25:4 35:18 8:2 8:3 14:12 36:25 37:4 37:13 19:1 19:6 37:1 21:20 21:23 21:23 pages II) 30:22 44:10 44:10 44:20 38:8 21:24 pain 1271 6:11 6:13 44:24 44:24 45:5 nonnally (I) 19:17 oldeq2) 37:19 43:11 6:15 6:24 8:2 physician 1'1 4:15 North (II 3:3 Omahaf21 4:18 4:19 10:18 10:23 10:24 7:6 38:16 NotaryI') ):11 47:4 One(181 4:18 8:16 11:1 13:21 13:23 physicians 121 5:9 47:25 )3:6 13:7 13:7 14:25 15:1 19:21 21:12 19:19 19:20 19:23 19:23 20:4 22:22 pictures (II notation (31 25:13 21:25 24:13 27:25 32:13 33:5 33:7 28:13 41:10 43:24 27:25 28:15 32:6 33:8 34:16 35:1 pinched III 3H:6 notations (I) 39:3 41:25 42:3 43:23 35:25 38:2 42:25 pinpoint III 38:5 note (141 )4:8 24:24 44:23 45:8 place 131 1:13 23:11 32:9 38:24 39:9 ones (6) 8:12 8:14 paragraph (I) 35:18 47:14 40:5 40:10 40:22 8:15 8:16 19:6 paragraphs [I) 35:17 Plaintiff's 1'1 2:14 41:2 41:9 41:10 28:22 paralegal [II 3:2 3:18 3:20 42:1 45:5 45:H ongoing (II 29:20 paralysis (II 18:10 Plaintiffs ['I 1:2 noted 1'1 6:16 23:)8 Onset(l) 32:14 part (4) 7:22 15:10 1:9 1:19 3:8 30:9 opening 121 18:2 16:15 32:12 3:13 notes (') 12:2 12:19 28:18 partially (II 31:16 plan 141 9:11 11:11 21:21 39:13 43:4 openings (I) 14:16 26:10 nothing (7) 11:20 29:3 partieulaq'l 27:8 operating III 3:3 28:24 33:10 plane 121 18:21 21:20 20:3 22:17 22:25 24:4 38:8 46:3 opinion [61 10:1 particularly 1'1 24:6 planned (I) 44:21 10:6 19:24 20:23 24:11 28:17 planning(11 39:20 Index Page 6 HUGHES, ALBRIGHT, FOLTZ & NATALE 717-540-0220\717-393-5101 ~') '--" ~ '. Multi-Page ,,, plans - Ronald ALLAN J MIRA M 0 . . , . plans(l) 411:11 purposes 111 30:23 17:13 311:16 311:19 8:17 21:23 22:7 plateaued II) 20:)8 pushed 111 35:24 31:5 31:7 31:1ll 22:H 22:18 23:1 plausible 12) 43:16 put 12) 17:23 2S:15 31:211 39:4 42:21 27:3 27:6 27:7 43:18 puttinGIII19:211 47:211 27:9 29:12 29:25 Pleas (21 1:1 3:11 records 1261 2:16 46:6 pleasure (II 20:16 2:21 3:19 6:2 reported 11) 36: III -Q- 12:211 21:12 21:14 reporter 12) 3:16 point (101 12:14 13:15 questioned (I) 33:3 21:16 25:14 30:20 47:12 14:14 16:5 41:17 questioninG PI 311:23 311:25 31:6 Reporter-Notary (II 43:21 44:7 44:9 7:9 31:16 31:21 31:21 44:13 44:14 25:5 3H:IS 31:24 32:4 3H:19 47:11 pointed (1)41:24 questions 16) 6:3 39:3 40:6 41:2 reports 141 22:4 22:9 possible PI 11:15 21:5 21:8 411:21 41:23 42:19 43:12 26:) 44:)9 20:2 20:3 41:1 47:9 46:8 represent III 31:15 practice (21 4:9 RECROSS 11) 2:2 required (II 19:18 32:) -R- redllJ 35:22 requirements (I) 5:12 practitioner (21 31:22 radiation (II 15:1 REDIRECT (21 2:2 residency (21 4:21 32:6 radiculitis 12) 34:8 40:19 5:6 predated J3I 25:7 34:11 reduced (2) 45:8 residual (I) 17:8 29:13 29:16 radiculopathy (41 34:13 47:11 resilient (II 18:25 predicate (I) 32:20 34:20 34:23 35:4 reduction (II 45:11 resolved (II 44:14 predominantly (I) 30:9 ranGe (8) 9:13 9:18 refeq'l 6:4 33:16 respect 111 24:11 preexisting 11) 16:12 13:2 13:2 25:6 45:3 restricted (2) 39:25 prepared (I) 27:6 34:5 36:2 36:12 referable (2) 7:13 46:1 present l') 7:) 30:21 ranges 111 14:9 42:15 restrictions (21 23:12 32:4 ratheql) 37:12 reference [121 22:8 23:13 presentation (2) 25:10 ray (3) 19:10 28:9 23:7 32:13 32:15 result (5) 8:18 11:24 32:23 33:14 33:19 30:3 28:22 34:4 34:16 34:19 12:9 18:5 18:19 presented l') 6:10 rays (91 8:6 8:9 39:7 39:10 resulted (I) 29:19 6:23 32:7 8:9 8:19 18:22 referenced (II 39:13 results (6) 9: 16 9:25 21:23 25:19 43:17 pressure (21 15:17 44:1 references 131 33:17 16:18 16:20 18:1 24:7 39:1 39:2 44:1 pretty 12) 25: 19 25:25 re-aggravated 11) 45:9 referral (2141 :3 resume 11) 5:17 previous (2) reaching III 1ll:23 41:19 22:7 referred 15) return [1) 40:15 22:9 read (5) 16:25 27:22 7:5 retumed 13) 8:9 2H:24 39:13 35:9 previously (I) 46:1 27:23 32:19 38:22 42:11 35:14 38:21 primarily (II 33:7 reads (I) 26:1 referring 161 25:21 revealed (2) 28:25 problem (41 11:19 real 121 11:10 14:13 32:17 34:8 36:3 29:11 )6:12 33:24 35:)9 realize (II 19:10 43:5 43:7 reversible (II 38:11 problems (41 4:11 really 16) 14:6 23:3 reflect (II 21:21 review (11)21:11 21:18 10:13 11:23 16:9 37:11 38:1 38:5 reflection (I) 18:25 22:4 22:6 22:8 produced (6) 2:14 38:12 reflexcs P) 8:3 3):25 38:21 39:12 2:18 3:17 3:)9 rear-ended (II 6:12 37:17 37:20 42:1 42:19 43:12 46:6 46:8 reason (5) 11:24 12:5 reGarding 121 16:14 reviewed (I) 8:18 professional (2) 4:4 12:13 41:19 45:21 19:24 Richard 13) ):1 31:25 reasonable (2) 10:1 region 12) 17:6 30:10 3:9 3:13 prognosis III 20:12 20:23 RehabJlI 12:20 ridges II) 27:21 proGram 13) 9:20 received PI 40:2 reiterate III 29:22 right 1451 4:22 6:18 44:11 45:11 44:19 44:23 relate 14) 7:23 7:23 8:2 27:16 receivinG 12) 12:22 15:25 16:1 8:2 9:10 10:8 progress (2) 22:21 16:2 21:1 10:24 11:8 11:9 44:20 related PI 10:4 progressed (3) 18:3 Recess 121 (7:12 31:9 42:7 11:15 13:11 13:24 43:8 13:25 15:1 15:3 27:21 29:12 recheck II) 40:11 relatinG 12) 17:17 15:9 )5:10 15:13 progression (I) 18:) recollection (II 9:8 45:23 15:16 15:22 16:10 provide ('I 5:16 recommend (I) 14:14 relative 12) 47:15 17:5 17:6 18:10 22:20 30:) recommendations (II 47:16 22:19 25:17 28:1 provided (3) 5:25 16:H relatively III 20:17 311:1 30:2 30:7 20:10 20:21 recommended (51 12:11 relief 121 30:10 31:2 32:12 10:22 13:16 33:14 34:6 36:10 Public (4) 1:11 47:4 12:24 16:19 26:18 relieve (II 15:17 36:24 37:22 38:1 47:11 47:25 44:9 pulling (117:21 recommending III remarkable 121 8:4 38:2 38:4 3H:9 12:13 38:S 411:23 purpose (41 5:22 record Jl81 4:2 5:18 rephrase (I) 36:20 Road III 35:21 12:23 24:15 28:8 6:2 6:4 8:14 Ronald P) 1:4 9:8 17:9 17:10 report (15) 2:20 8:14 3:10 HUGHES, ALBRIGHT, FOLTZ & NATALE 717-540-0220\717-393-5101 Index Page 7 . . room - testing ALLAN J. MIRA, M.D. Multi-Pagc '" 3:15 selllelll 20:11, spaec 111 2'1:8 suffering (II 45:IH room (41 6:21 8:D severo It I I 19:19 spaecs 121 18:24 2'1:10 suggested 141 9:13 19:2 2(:13 severe 111 7:3 spaeinglll 29:1 lidO 16:13 16:14 root (21 15:22 34:12 sharp (II W:17 spasms 111 32: 16 suggcsts (II 18:21 roots 14) 19:25 2H:20 sheet (I) 47:14 speak 11) 2H:13 summarize II) 4:13 30:13 30:14 sheets (I) 9:22 speaking III 3H:3 summari7.cd III 25:5 rotating 111 3H:1 shoot (II 6:11, specialty (II 5:7 summarizing II) 23:1 rotation 11) 7:25 shooting 121 W:IH specific 121 19:17 summary 1'1 25:14 rough (II 31:21 15:1 24:1 44:24 45:4 Route (I) 35:21 shortly 121 35:5 39:21 specifically 14) 17:4 superimposed (21 29:20 routine (21 13:4 35:17 shot (II 6:15 33:11, 35:2 44:18 29:23 Rovner ('I 1:17 3:2 shoulder 1121 6:15 specified III 47:14 supplying 11) 33:25 3:12 6:24 8:3 10:7 spced 111 17:1 supposed 111 9:20 RPR(2) 1:10 47:24 10:24 11:8 11:15 spinal 121 19:22 27:19 Surgeons 111 5:1 Rubinate 121 1:20 11:21 15:1 33:14 spinel21 4:11 19:25 surgery (714: 10 4:20 3:14 33:15 3H:2 sprain 111 5:1 5:19 15:15 rupture (1118: 11 shoulders 13) 11:22 H:22 15:24 19:IH ruptured (II 3H:5 32:13 42:25 spreading III 6:IH surgical III 20:2 showed 141H:6 11:IH Spring 111 12:20 susceptible I') 19:4 -s- 17:22 IH:I spurs (3) IH:23 29:15 45: IH 45:25 shows (II 2H:IO 29:21 30:9 30:14 Saba (2) 1:20 3:15 sidel'l 7:25 H:l SSIII 47:2 suspcet 11127:23 swear 11 I 3:16 saw(u) 6:6 6:9 II:H 11:9 11:15 standpoint (II 3H:15 swelling 111 42:3 7:H H:12 9:6 30:7 30:10 3H:2 start 121 9:20 44:10 10:10 13:9 14:22 signals 121 16:24 16:25 stateI'I 4:1 switched 11) 13:IH 19:16 20:9 21:10 5:2 3:23 47:9 significance (I) 26:4 5:12 SWOm('1 27:1 40:23 43:16 symIDCtriealll1 44:5 significant (31 7:IH stateIDCnt (II 3H:7 11:7 says 14) 22:25 24:24 14:4 14:6 16:7 states 111 25:IH symmetrically 121 7:20 35:1 37:20 2H:6 36:1 signs 11) status 1'1 24:10 37:1 symptom 12) IH:IO scan (61 11:13 11:16 3H:3 39:14 11:19 12:16 16:13 Similar(1124:17 stenographically (I) 42:6 29:25 SimIDCrs II) 3:1 47:10 symptoms 1191 7:2 schedule (II 26:22 simple (41 9:13 9:22 stenosis 111 10:7 10:7 13:24 27:20 15:17 IH:19 19:8 scheduled 111 25:20 2H:9 45:9 steroid(l) 19:23 22:15 22:16 23:22 school 1') 4:14 4:17 simultaneously 11) 26:17 stiffness 111 6:17 30:2 30:6 33:6 4:23 situation II) 24:7 still 1'1 10:18 IH:13 33:9 36:15 37:10 second (21 24:24 35:19 six(41 9:17 10:14 44:9 3H:3 39:7 45:22 section III 36:21 14:19 40:10 stinging 1'1 13:25 syndrolDC(11 17:H sce (361 5:25 7:6 sixth 111 27:20 15:3 15:9 systcm (I) 16:24 H:14 H:15 9:2 size 111 2H:IH stop II) 35:21 9:17 10:13 16:14 slice 111 28:13 stopped 121 14:17 -T- 19:10 19:24 20:3 slices (I) 2H:15 35:21 tablell) 20:7 20:15 21:15 37:19 21:2) 25:20 26:IH slieing(l) 28:14 strain 1'1 6:14 19:7 taking 1') 5:6 5:22 2H:17 2H:20 28:21 slight 12) 17:7 35:25 29:19 47:H 2H:22 2H:23 32:6 slow (2) 20:IH 29:17 Street 141 1:13 3:3 teach III 13:3 32:16 34:H 34:17 slowing(11 3:7 4:6 telephone (I) 25:15 36:3 36:20 38:25 17:5 strength 111 34:6 39:4 39:10 40:10 societies (I) 5:2 stretched 11) 30:15 tend 111 29:16 41:15 42:5 43:2 soft 1') 2H:21 45:24 structuring 111 29:8 tenderness (II 11:7 45:) 46:1 tends (I) 45:9 sceing 12) 9:9 39:3 sojourn 11135:14 studies 131 21:19 22:1 tenns (4) 25:6 31:21 22:2 22:3 22:5 scem 121 13:16 13:17 sometimes IS) 10:20 study (III 17:25 18:3 32:3 33:2 send (II 41:11 10:21 12:7 21:20 21:24 2H:5 2H:9 test (41 11:13 16:10 sends 111 16:24 37:10 28:10 2H:25 29:12 16:23 17:20 sensation 131 6:17 somewhat 141 6:25 29:24 29:25 43:17 tested (I) 15:21 7:22 )5:2 15:3 H:24 3ll:7 46:1 subjective 131 23:22 testified 12) 3:23 15:9 sore 1'1 10:IH 33:15 25: 10 25:23 30:3 27:17 sensory (II 16:25 sorry 141 22:6 26:14 34:25 testifying 12) 3:H sentences (I) 40:)2 35:11 35:12 subsequent III 10:11 36:IH separate 111 16:12 sort 1') 12:25 24:3 subtleties III 3H:1I testimony 12) 47:7 serious 1'1 18: 12 3H:1I 43:9 such 121 45:2 47:17 47:2ll set(11 47:22 sounds 121 33:22 35:3 suffered 111 5:24 testing 1') 5:8 H:4 Index Page 8 HUGHES, ALBRIGHT, FOLTZ & NATALE 717-540-0220\717-393-5101 Ii " " "",, ',,--' , ' \i.) () Multi-Page ". tcsts - yoursclf ALLAN J. MIRA, M.D. 42:2 understand (71 210:6 wcakness 121 15:10 41:IH 16:23 Townscnd's 121 3H:15 26:7 2/o:H 2(>:13 37:9 tests I"I H:18 9:25 27:15 30:25 40:5 wceks 101 9:17 10:14 16:IH 16:20 16:21 43:12 University 121 4:16 13:9 14:19 17:4 IH:5 20:21 traction III 13:5 4:IH welcome 111 40:15 Thank (51 21:4 32:10 traffic 111 35:21 unless (II 40:11 WHEREOF(II 47:22 40:)7 46:3 46:5 trained (114:15 unremarkable 121 12:16 whiplash 11) 36:14 themselves 141 IH:16 training PI 4:23 38:16 willfully III 10:21 29:2 29:7 29:14 9:25 20:22 13:8 UPIII 10:14 Wilson I') 1:13 3:7 therapist I') I3:H transmit III 17:2 17:2 19:211 21:10 4:6 44:20 45:5 transversely III 2H:14 2H:12 2H:15 35:23 winter 121 35: 10 35:15 therapy (') 12: II 12:14 trauma 121 19:4 29:10 7:22 7:22 13:1 13:10 13:15 upper 1171 10:19 wintering (21 26:12 44:11 traumatic 111 33:11 8:5 IO:IH 39:21 14:17 44:10 13:2 13:21 15:10 44:24 traveling 111 39:24 16:10 17:5 17:6 within I>) 5:4 H:3 thereafter (21 23:16 treatment 126) 4:10 32:13 33:5 33:9 37:1 3H:H 47:5 39:21 5:25 9:11 10:12 39:7 39:10 42:25 without 121 36:)5 therefore (II 30:12 11:12 12:22 12:23 USCdll1 24:24 36:IH 13:12 14:15 14:16 third (01 19:23 34:25 using 121 24:22 30:23 witness 151 3:16 19:14 19:)7 20:5 3:22 47:9 47:21 35:)H 35:23 20:7 20:10 20:21 usually II) 14:17 thought (2IH:20 IH:6 22:21 23:6 39:7 47:22 three IS) 17:24 2H:3 40:3 41:25 42:10 -v- WITNESSESJlI 2:( 39:1 41:24 41:25 42:22 44:15 45:9 WNL(I) 37:1 three-dimensional (2) 45:23 VIII 1:3 words (2) 23:1 2H:21 2H:1I 28:16 trouble JI) 24:2 vanlll 35:23 work-up II) 42:6 throbbinglll 13:23 true (II 47:20 Vanquish 111 11 :1 worSeI'I 13:15 13:23 through IS) IH:)6 try 1'1 12:H 21:9 various II) 32:7 19:11 2H:19 31:4 32:10 21:21 vary II) 12:7 worsening (I) 25:10 39:9 trying 121 16:H 29:3 vaseular[21 33:24 wrist 1>1 15:13 15:16 throughout (I) 37:2 tunnel II>) 15:15 15:24 34:2 15:22 16:2 35:2 thumb 17) 13:25 15:4 15:25 16:13 17:7 vchicle 1101 5:24 wrists 1'1 34:21 42:4 15:9 18:11 30:1 17:H 21:2 32:23 6:12 H:23 10:4 43:9 30:6 30:11 32:25 33:8 34:20 10:H 16:3 17:IH writes (II 35:19 thumbs (II 30:2 34:23 35:3 42:3 IH:20 21:1 29:13 written (21 5:7 23:24 times I'I 14:22 42:6 35:24 42:H 42:IH turned II) 10:20 45:23 wrote (I) 40:13 tingling (II 34:5 turning III 34:6 versus 121 3:10 2H:14 tiny (2) 17:3 28:21 -x- two I') 14:5 14:22 vessel 111 33:23 tipping 12) 7:211 38:1 20:17 23:4 26:17 video 161 1:8 3:4 X112) H:6 H:9 tissuc (21 46:1 46:2 27:25 35:17 40:12 17:10 17:13 31:7 H:9 8:19 18:22 tissues (21 28:2) 45:24 40:23 31:10 19:10 21:23 25:19 today 16) 5:23 20:24 two-dimensions (1128: 17 VIDEOGRAPHER 161 28:9 2H:22 43:17 21:11 31:1 35:20 typc (0) 4:H 9:2 3:) 17:10 17:13 44:1 36:1 12:22 45:19 31:7 31:10 46:10 today'sI213:4 311:23 typed III 41:9 viewIl1 28:16 -y- together (1\ 2H:15 typcwritinglll 47:11 viewedJll8:6 year(7) 4:18 5:6 tolerance (2) 13:7 typewritten 121 31:16 Virginia (0) 1:1 7:1 20:17 22:15 19:2 34:24 3:9 3:13 31:17 26:12 39:22 tolerate [219:16 19:5 typiealtl) 31:22 Virginia's III 35:20 years [0) 4:17 4:19 tolerated (I) 13:5 typically 111 32:6 visitl161 13:IH 19:12 32:H 42:IH too (II 38:12 typing 111 35:19 22:11 22:23 24:20 yourself (0) 22:5 top (2) 2H:2 32:12 27:24 25:16 25:24 32:22 25:16 31:5 31:14 typo [II 3H:23 39:IH 39:20 torticollis III 32:16 41:4 43:3 43:14 totally 121 38:4 44:14 -U- 43:25 44:6 touch II) 32:4 ultrasound II) 12:25 visits [21 14:21 39:6 toward 1') 13:22 15:1 Um-hmmlol 22:13 vitae 121 2:15 3:17 30:9 36:9 3H:25 40:25 vulnerablc JI) 30:15 towards II) II:H unablclll 26:22 town 121 26:9 26:11 undated [II 3H:23 -w- Townsend 11>1 6:19 under 121 34:25 47:12 waivesJl) 17:1 7:6 IH:1 21:16 ]5:18 36:11 37:)4 undergraduatc (II 4:16 walking [11 24:3 3H:14 3H:22 40:23 underlying (21 8:25 waves II) 17:1 41:2 41:10 41:11 45:17 t"') I..".; u HUGHES, ALBRIGHT, FOLTZ & NATALE 717-540-0220\717-393-5101 Index Page 9 Aug-24-9B lO:4BA AN~O & ROVNER PC 71,~3B5610 P.03 I 1': ~' 1'\1 \ fJ!J!h.I.fA T I ON S ftQr-k9.:Enteric f'iGtula ~te.~,enting as MulL.icentric 00 te_olllyeUt 10, 1977, Clintcal Orthopedics A CI inl cal A.n.~~y'sis of lluadric~,p9 Function After Femoral Shoft fracture !..!!-'i!!.'!.~. Journal oC Rone .nd .Inint Sur8-~r"y. ,Ianuary'-"19BO CONTINUING EUUCATION Has attended well over 50 hnurs annually of acredltted continuing education enurSeS and has continually Made an exceeded requlremonts to achieve the Physician's Recugnition Award, "' ~ r Poge OFFICE RECORD ALLAN J, MIRA, M,O, Name BRANDT, VIRGINIA DOB: 8/27/23 1/96 OFFICE VISIT: This is a 72 year old female with a chief complaint of ~eek pain. Said that she was rear ended in a car May 7. she was tne driver, felt a jo t but not a lot of pain untii later the same evening. Saw Dr. Townsend a couple of days later for evaluation. She had some symptoms radiating to the shoulder blades but none other in the upper extremities. Her leg are fine. She has improved overthe last couple of weeks. Still has the neck llno shouloer blade area discomfort. Occasional quick shot of pain down to the lower back area. She has some pain in her neck with lifting some stiffness or cramping of the finger. or spread of the finger. For the past year she has mild neck symptoms. She is 81~are of some arthritis there and elsewhere with symptoms that flueuate from time to time but nothing disabling. She is right handed. EKMI: Flexion range of motion is 80% normal. tolerate well, extension she feels some gritting and pulling in the area of T2 spinous process. Rotation is good at about 70% in both direction. Tipping is about 60% both direction with the right side causing some pain in the right trapezius area. Deep tendon reflexes are hypoactive in the upper extremities, symmetrically. + - in the lower extremities, ankle jerks 1+ and equal knee jerks are 2+and =. X-rays of the cervical spine shows degenerative arthritis throughout the lower and upper cervical spine with no evidence of fracture or subluxation. Flexion extension view done later shows no change in this satisfactory alignment with no evidence of subluxation or instability. IMPRESSION: rello1ving. Acute cervical sprain 2nd to motor vehicle accident of May 7. 1996. DJD cervical spine. PLAN: Suggested some range of motion exercises. Continue C1inoril. prognosis is satisfactory. Recheck in 6 \~eeks. A~~~~~r_~, 6J: _. I think the ,/12/96 NOl'A'fION. Patient was called d t . d h I an OL t at her flexion and extention x-rays coked okay. She stated she was doing pretty well. She will be seen as scheduled lab/ajm U3 '. v'~.~ OFFICE VISIT: This patient is a little bit better. She is better in that she doesn't have any sharp shooting pain in the T2 area down her spine. She is still sore around the T2 area. When she turns her head sometimes she feels a crack. Occasionally it seems to have to go into place by cracking. She has pain with reaching across with her' arms and pain inferior to the righ t scapula but not arm pain, dysfunction or other abnormality noted in the upper extremities. She is taking Clinori1 twjee a day which she has done for a long time and over the counter Vanquish. '_0. '"""\ f""". 7/11/96 continued...... EXMIINATION: Her range of motion is symmetric in all directions at 80X with pain in the T2 area with extenaion. She hns tenderness right greater than left medial scapular region and inferior to the right scapula. She has good gait and overall posture consistent with her age. IMPRESSION: Acute cervical sprain secondary to HVA 5/7/96. arthritis cervical spine. Degenerative RECOMHENDA'rION: I would like to have her try Naprosyn instead of Clinoril but if that doesn I t work she can go back. I would like to get a bone scan to evaluate for inflammation, possible :oeeult fracture in the cervical spine. In addition, physical therapy for modalities, traction as tolerated, active range of motion and home exercise routine. I would like to recheck her in one month. AJM/ele 7/22/96 NCYl'A1'ION: Naprosyn EC 500mg IBID 1160 I refill. A.lM/ cl.c 7/29/96 NOl'ATION: Called patient to report that bone scan is okay. as scheduled. clc/ajm 0.L~_ We will see her 8/8/96 OFFICE VISIT: This patient is seen in follow up. She continues to have some pain in the upper back eervieothoracie area centrally, a throbbing pain which is fluctuating from better to worse at times. It is n 1itt1" worse today. She has had physical therapy for 9 treatments and it seems to make it somewhat worse. She just finished the Naprosyn and it didn't seem to help as much as the Clinoril did. In the arms she h,,~ r..al1v no symptoms with the exception of stin\!in\! paresthesias in tl,e right thumb. It has been there since the accident. The pain ~n her left arm and forearm is now gone. EXMlINATION: Tenderness over the trapezius on the right side. She has a prominent C7. Flexion is 60% of normal causing pain in the right trap. Extension is 60% causing no symptoms. Right rotation hurts the right trap. Traction is tolerated with some pulling in the mid cervical spine area. Compression is tolerated well. Upper extremity evaluation shows biceps to be +/- as are triceps. The proximal muscle strength is intact as is the distal with some evidence of DJD of the thumb area and bilateral carpal tunnel incisions. There is no Tine1 but a little tenderness over the right incision. Sensory examination is decreased over the right thumb and' index finger. Intrinsic function, however, is good. Shoulder and elbow range of motion is good. She can rest on her right side without any significant pain in her neck or arms at nigh t . 'IMPRESSION: Acute cervical sprain secondary to MVA with minor right C5 radieu10pathy. Degenerative arthritis cervical spine. RECOlliIENDATION: Continue eonservativ'e' treatment but I would stop physical therapy and go to C1inoril ins tead of Naprosyn. The bone scan. as above, showed no uptake to suggest recent fracture or other significant abnormality. Hopefully it will be tolerable and improve through time. I would like to see her in 6- 8 weeks for a recheck. AJM/ele -' , . ~ r Pogo 2 OFFICE RECORD ALLAN J, MIRA. M,O, Nomo BRANDT. VIRGINIA L. DOB: 8/24/23 1/3/96 OFFICE VISIT: This patient continues to have some neck pain with radiation and burning to the right medial scapula. She also is annoyed. even more so sometimes on certain days and including today. with stinging in the radial aspect of her right thumb. She has had previous carpal tunnel surgery by Dr. Barry Moore. She told me that at that time she had neck pain and quite a severe time of it with neck and bilateral arm pain and burning symptoms which did respond to bilateral carpal tunnel release. She continues to take Tylenol or Vanquish and that has been helpful for her to some degree but only partially. EXAMINATION: Her cervical spine range of motion is symmetrical at about 70% of normal in all directions. Rotation to the right and lateral bend to the right will cause some pain to the right trapezius. Movement of her arms and elevation overhead she has some increase in stinging in her right thumb. Neurologically reflexes are hypoactive in biceps and triceps. There appears to be some weakness in both biceps and triceps on the right side, probably a bit of weakness of extension of the wrist as well. There is not any significant noticeable weakness of the intrinsies. There is a slight Tinel' s sign over the carpal tunnel which radiates out to the thumb. There is no dorsal hand paresthesias or Tin1e's sign. IMPRESSION: Recent motor vehicle accident with cervical sprain. 2. Cervical spondylosis with right radieulopathy. 3. Dysesthesias right thumb, possibly related to #2. 4. STatus post carpal tunnel releases bilaterally. RECOMHENDATION: I would like to work her up neurologically by getting an EMG of the right upper extremity and ~mI cervical spine and ask her to see Dr. Barry Moore. She is familiar with him from his previous carpal tunnel surgery and also in that he has put a shunt in for hydroeepha1is in her husband. I would like to see her for a recheck in 3 weeks. She tells me that she is planning to go to Florida shortly after that. Hopefully, we will not have to delay her departure. In the meantime, I recommended Advil for anti-inflammatory effect 3 tablets up to 3-4 times a day with something to eat instead of the other analgesic she is taking. She seemed to understand this plan and appreciate it. AJM/e1e 1/3/96 NOTATION: An appointment could not be scheduled with Dr. Moore prior to the patient's departure to Florida. nr ~' ~ /"'"'\ .:LECTROMYOG RAPHY ) NERVE CONDUCTIONS ~\~r lL . '::'.'-:":-. 1\llan J. Mira, M.D. (/ ~'~7J~6{ 9, 199G))' , 4 \'\ ,/1 Excel 2-channel EMG by Cadwe ~ /l ' '''.../ '- "'""'\ NAME ADDRESS Virginia L. Brandt 698 Brandy Run Road Newville, P1\ 17241 COB. 8/24/23 Outpatient Method. IMPRESSION ) LOW NORHIIL NERVE CONDUCTIONS m TIlE RIGHT Ul'l'ER EX'J.'REHITY. NO FOClU. EHG lIBNORH1\LITIES. The patient has proximal pain in the arm after an auto injury. Motor and sensory nerve conductions were performed using .25 ms stimulation. 11- responses of relatively low amplitude are shown below for the distal median nerve to the opponens pollicis (previous median nerve release). Segmental ulnar nerve conductions are intact. F-reflexes were easily obtained. COMMENT Needle examination revealed no neurogenic findings in the right deltoid, biceps, triceps, pronator, brachioradialis. 1\ paracervical exam was not done. JCJ/gmj GnIN 5 K NERVE CONDUCTION STUDIES RR 2.11 SHEEP 5 . . . . . . . . . ...............................................................................................,,,....,.............................,,.................."... . . . . . . . . . """."",:r\,:,~,."!"""",,,L,, : ~ ; ; : : 2::~Q,:'..::..t..::::'::::::!:::::::':,::..:!::':,::':...:::::::':::':,'::,l.:.:,:~::I,:'::...:,:... : ":"":: ::: . '. " . '. '" ...............:.............................:...............:...............:...............:...............:...............:.....1-......,.:.......".... : .. : : : : : ; _"h' auh . .... . ..... . . . . . . . . .............................................................................................................................................................. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . '::::::::::::-:::::.:':::'::::::-::.:'::::::':::-:::':":'::::::::,,:':::'::::::::::::::::":'r:'"..,,':,,r:::,,':::..'r::'::':':r:::""'" p~ 250 uS TEMP OFF ST"M LEVEL 72 MA 303 V ucv ON~ny f"OOTGHll'CII I . .........., '.' 850 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717) 243-3944 IM.ZII RIGItT HEDIAN MOTOR OWl ET APB ("Ol J.lRIGT 4.5 nUTl~ CUD 7.9 AXILLA 0.0 tROO 0.0 0101' (CM) loR ll,ll 2-1 IB.ll 3-2 ll.ll '1-3 O.ll SEC-O NCU ("0) (Mo'O) I 3.'1 52.9 1l.0 ll.ll 0,0 O,ll AMP (uV) O-P 1 'lBllO 2 'lBllll 3 0 '1 0 RI:VII:U nl::OJ:flN nO'JOn .-- J.t~ a~~NkN, M.D. eJAIG N~UROLOGY ...... " 1"""\ [' , EMG Data -\, f \ I Date: Patient: Physician: October 9, 1996 Virginia L. Brandt 6:00 pm 'I Summary of EMG and MeV findina~ , ' , i I Nerve site NERVE Onset (ms): CONDUCTION REPORT Delta Dur (ms) (ms) Ampl (UV) Dist (cm) NCV (m/s) , I I I " i I I t I' ------------------------------------------------------------------------------- ( Median Motor wrist 4.50* ante cub 7.90 ~ Ulnar Motor site 1 site 2 3.00 7.80 4800.0 3.40 4800.0 18.0 52.90 1.84 15.2 3.75 1.65 8.4 16.0 42.70 9600.0 4.80 8600.0 25.0 52.10 27.00 10.0 ( Median Sensor wrist 3.41 palm 7.16 side Muscle EMG NEEDLE STUDY Nerve Root Fib Psw Ply Fsc Rec Comment ~ Ulnar F-Wave Wrist 27.00 .------------------------------------------------------------------------------ Rt Deltoid Axilla C5-6 0 0 Nml 0 Nml Normal \ Rt Triceps Radial C6-7-8 0 0 Nml 0 Nml Normal . Rt Biceps Musc C C5-6 0 0 Nml 0 Nml Normal I Rt pronat teres 0 0 Nml 0 Nml Normal Rt BrachioRad Radial C5-6 0 0 Nml 0 Nml Normal j ( I ~ ~ ~ Carlisle Hospital and Health Services 246 Porker Street. P,O, Box 310 . Carlisle, Pennsylvania 17013.0310 . 1717) 249.1212 r-- DEPART~,~,~T OF RADIOLOGY CARLISLE IMAGING ASSOCIATES, P.C. BRANDT, VIRGINIA L. 698 BRANDY RUN ROAD NEWVILLE, PA 17241 72Y 10/08/1996 X-RAY 112063 MED. REC. 11124925 DR. MIRA ALLAN MRI OF THE CERVICAL SPINE The study consists of mUltiple sagittal and axial images in routine pUlse sequences. The study is compared to the previous study from outside dated OS/25/88. -C:=.:=-- - The study is evaluated in conjunction with x-ray examination of the cervical spine from MAB done~06/04/96. ....,.,. .':_:'-".;.0'" --. The vertebral alignment is normal. The marrow signal intensity is normal. Narrowing with associated degenerative changes, consistent with degenerative disc disease involves the C4-C5, C5-C6 and C6-C7 interspaces. These changes have progressed since 03/25/88. No significant abnormality is noted at the C2-C3 and C3-C4 interspaces. At the C4-C5, C5-C6 and C6-C7 interspaces, posterior osteoarthritic ridges are Been to project toward the spinal canal and intervertebral foramen bilaterally encroaching upon the adjacent spina.l cord causing moderate central ana pefiPIillraf -splria1.Bl:enos~s. } .e:;- . - '. -J No significant abnormality is noted at the C7-T1 interspace. The associated appendages are otherwise normal. The appearance of the spinal cord and the posterior fossa is otherwise unremarkable. The paraspinal soft tissues reveal no abnormality. IMPRESSION: Degenerative disc disease of the C4-C5, C5-C6 and C6-C7 interspaces, p]ogressed since 03/t5/88.j Central and peripheral spi~~~enosis at the 4th, 5th and 6th cervical levels '.siiie to osteoarthritic ridges, p~ogress~d since 02/25~~) CKL/nb P: 10/08/1996 0: 10/08/1996 10:25 am T: 10/08/1996 12:15 pm CHARLES K. LOH, M.D. ~ CHART/PHYSICIAN ~ """" Carlisle Hospit~_A and Health Services 246 ParkerSlreeto P,O, Box310 0 Carlisle, Pennsylvania 17013,03100(717) 249.1212 t"'"\ DEPARTh" f OF RADIOLOGY CARLISLE IMAGING ASSOCIATES, P.C. BRANDT, VIRGINIA L. 698 BRANDY RUN RD NEWVILLE, PA 17241 72y 07/17/1996 X-RAY 1/2063 MED. REC. 1/124925 DR. MIRA, A. NUCLEAR MEDICINE BONE SCAN RADIONUCLIDE: 99mTc-HDP IV. DOSE: .94 cc = 21 mCi. Delayed total body imaging was performed with HOP, for evaluation of possible neck trauma following a MVA. Bilateral renal function was documented, and skeletal tracer distribution was relatively uniform, with a mild increase through the cervical spine and shoulders, both wrists, both knees, and both mid feet, likely degenerative in origin. Focally increased activity is identified in the 1st CMC joints bilaterally, in the AC joints bilaterally, and the right glenohumeral articulation, at the base of the 2nd or 3rd digit of the right foot, and there is focally increased activity in the anterior tip of the right ribs, likely at about the T8 or 9 level. Subtle prominence of activity in the sternoclavicular articulation on the right is also noted. IMPRESSION: Although there is mild activity in the cervical spine, there is no evidence of acute fracture by nuclear ~edicine cr a. ncreased act1v1 y 1n both ~ou1aers cOUla be traumatic or degenerative, but given the degree of symmetry, chronic degenerative changes are more likely. Focally increased activity in the MTP junction of the 2nd or 3rd toe on the right, and focally increased activity in a single anterior right rib are the only findings suspicious for acute trauma. ~ RAND J. CUTHBERTSON, M.D. RJC/gav T: 07/17/1996 03:40 pm CHART/PHYSICIAN !'"'"\ r-.. ~ Radiology~ r t, ' , . ~.i. '-...~ BRANDT, virginia L. (72) 698 Brandy Run Road Newville, PA CERVICAL SPINE WITH FLEXION AND June 6, 1996 19996 Allan J. Mira,~.D'// EXTENSION VIEWS \J \....... COMMENT: The current study is evaluated in conjunction with an examination dated 8/29/75. No fracture or destructive lesion of the cervical spine can be identified. Osteophytes are noted involving the 3rd, 4th, 5th, 6th, and 7th cervical vertebral bodies. Mild diminution of the intervertebral disc space height at the 4th, 5th, and 6th cervical levels is noted. There is mild encroachment upon the left 3rd, 4th, 5th, and 6th and the right 3rd, 5th, and 6th cervical intervertebral foramina by spur formation. Moderate encroachment upon the right 4th cervical intervertebral foramina by spur formation is noted. The prevertebral soft tissues are normal. Limitation of motion of the cervical spine is noted in extension. \ , , j , CONCLUSION: 1. Degenerative disease of the cervical spine. 2. Limitation of motion of the cervical spine during extension. HCP/ro D: 06/06/96 T/M: 06/06/96 Herbert C. Perlman, MD I .... All qffiliCllt qfCllrlisle lIos}lilal omllltaUlI Services Medilol AIls Building. 220 Wilson II,. luHel02. (o,lisle, fA 17013.717,249.0100 "'"'" 1""0 Oil tOl tel - <f:.:::-1 (p Please mark on the diagrllln bel0l4 \41th an X whet"e tile center of the frost intense discomfort is. Trace from there with a line! where, if at all, the disccmfort goes fran there. ~ '!,{ .k~ n .... . << " (" \ I FR,rlt-fl' BACK '-' \'nlBt .few words would you use to describe the pain, perhaps relating it to sane other familial: type of discanfort? \i. \<' :""::;":>;;>,, ,':0';::':\<, ..,," """"" ALEXANDER SPRING REHAB, :. ,,' \'::'.'27.'Bro~k~oodo':i\Venue' 'ca~liaie, pennaylvania 17013 (717) 245-2341' '),i,;i" ; ,}::, ,::Tk;~':J1t:~~Ti~N IS . FO~: YOUR RECORDS. 'THANK YOU FOR YOUR REFERRAL ..,:.:;..'::'~<, '~;~.<{;..:<','-;;::'''''/,~.ff:,i::~:':'~: ~',.\:'.-'" ,,*INITIAL";EVALUATION" ," .:;.':.:......\...>:'..:::r :..~.:.';:~.;,,-,,','\,:'.', ',:' . PATIENTi!:':, "':':'vlrgiJlia'Brandt;" BIRTif'DATEi:08/24/23', :' .:'[,', PHYSICIAN,';,':,'Aiian'Mirl\; M;"D; :-" : ,'.,:',',,' ,.,...... -',.r', '" .' ' '. .:,'; ~::.,' :"" . .~ si" ,Mre" Brandt' is' a 72 yr;old f,emal'~ .whci 'works only occasionally with her involvement in voter's tabulation. She reporta onaet'of R cervical discomfort on 05/07/96 aa a reau1t of an MVA~ The pt; was stopped at' aredlight.when a car rear ended the pt.'s car. ,H~r head whipped back,&'then forward. she was not taken'to'the hoapital but later that night she noted stiff- ness & tingling discomfort at ths neck. She worked ths following day & on 05/09/96 she saw Dr. Townsend. Thisdisco~fort did not go away & ahe later noted pain from the ee.'vicothoracic level to the sacrum over a two day period but theae symptoms then discontinued. She later saw Dr. Mira for examination. At this time ahe c/o pain & aching in upper thoracic spine & under the R scapula. she also notes tightness in th~ lower back. she states that when she is lying she notes a pulling in the R upper trapezius. ' Shs also c/o an inability to hold the fingera in an adducted position. She also c/o pareathesia in all fingers, R > L. Pain level, 4-5/10 but constant. Pain is aggravated with prolonged R cervical rotation & ahe c/o a pulling pain in her hand when she is using the hand railing at stairs. Medications: Naprosyn & Vanquiah in the morning for headaches. She is alao receiving hypertension medication. Radiologic studiea: An x-ray with reaulta pending. has a hx of significant arthritia. , Medieal,hx: Chronic headachea, hypertension, arthritia.,She denies cardiac or diabetea involvement. :: 0' ' :", ':;";DIAGNOSIS: Cervical str'ain .0',";. DATE PT INITIATED: 07/15/96 , PATIENT IDI:' 566023.'0' Bone acan is acheduled for 07/17/96. She 0: Obaervations: In the standing position a mild functional scoliosis is noted which ia concave on the L in the mid & upper thoracic spine. The iliac creat is elevated compared to the R & the L shoulder ia depressed vs the R. There is a slight decrease of the lumbar lordo- sis associated with arthritic changes. Cervical active ROM: Full flexion, '500 extension, 350 L aidebending, 200 R sidebending, 400 L rotation & 500 R rotation. Trunk rotation has been limited prior to the MVA secondary to arthritis. Neuroloaic scan: UE strength & sensation is normal & equal bilat.. Reflexes are absent bilat.. Periodic finger numbness is reported in both hands though it is not present at the time of examination. Palcation: Mild pain is present in both upper trapezii & the R leval:or scapula. More aignifi- cant tenderness is present along the thoracic spine from TI-T7 with restriction of thoracic mobility noted. Similar restrictions are noted in the R & L ribs at these levels. A: Mrs. Brandt presents with thoracic strain & aprain with spinal motion at theae levels following an MVA on 05/07/96. discomfort & return to most function within 4-6 wks.. rib restriction & restriction of I expect moderate reduction of SHORT TERM GOALS 1. Decrease cain 30-50\. LONG TERM GOALS 1. Minimal discomfort. 2. Increase thoracic spine and rib mobilitv to cermit movement with minimal cain. 2. ADL with minimal restriction. 3. 3. stimulation, jt. & rib mobilization, ROM exerciaes, SIGNATURE: ,"""" ".-. 27 BrookwoodAvenue ALEXANDER SPRING REHAB, INC. 'carlisle, Penneylvania 17013 (717) 245-2341 ,', ", ,P~EASE'REVIEW, SIGN'AND RETURN. THANK YOU FOR YOUR REFERRAL. . ".. . .:: ~ '", , " . "P~ OF TREATMEN'r"., N~ ;:.;,' ,'.:',/.;:': :'.'. ,Viraiiiia Brandt ID I 566023 DATE INITIATED 07115/96 ,'" ".,":'i" ',' ."" '" ,."; . '.', '",,: ' . ,', DATE':OF 'BIRTH'".,'., : '08/24/23"" :.~ ,':\\:1.,' ~.,: ",',:' .'..; , .,;" ,," . PHlrS'ICIAN . ':'A'ii~n'Mira;'M.D~ .,'.' ....... PERIOD COVERED 07115/96 08/15/96 . DIAGNOSIS Cervical strain. PERTINENT 'MEDI~1iL INFORMATION.' . .'....'.. J DATE.OF'ONSET"': 05/07196 . '; , , . " ~HAB POTENTIAL SERVICE Phvsical TheraDv ASSESSMENT I ' Thoracic strain/sprain with PLAN OF TREATMENT. " .. ' TBANK,YOU FOR REFERRING THIS PATIENT TO OUR SERVICES. ' FORMAL INITIAL EVALUATION WILL FOLLON. HAJOR FINDINGS' IDENTIFIED DURING " ,QNITIAL?) INTERIM 1. 'Pain level :,4-5/10. , ' 2. Tender midline Tl-7. Non tender cervical spine; Painful R 3rd - 6th ribs. 3. cervical' ROM." full flexion, 350 L sidebend, 200 R sidebend, 400 L , , . , ' . 'rotation, 500R rotatio'n. 4. Neuro'scan.' normal etren9th bilateral upper extremitiee. Absent reflexes bilaterally. Normal , " sensation. Reports periodic finger numbness bilateral hands. 5. Mild pain bilateral traps and R levator. VISIT INCLUDE. rib restriction as F~QUE!lClr. 1 ANTICIPATED DURATION. 1 we11.c.. after 2 Gl 4 2 3 tV MVA. 5 x/week 5 6 7 8 weeks TREATMENT. 1. Moist heat. 4. Home nroaram. 2. Electrical stimulation. 5. Postural education. 3. Joint mobilization. 6. SHORT TERM GOALS 1. Decrease Dain 30-50\. LONG TERM GOALS 1. Minimal discomfort. I I 2. Increase thoracic sDine and rib mobilitv to Dermit movement with minimal Dain. 2. ADL with minimal restriction. 3. 3. SIGNATURE. ~/ Date. 07/15/96 Dictated but not read. Christopher K. Fisher, P.T., Pt-001447-E PHlrSICIAN COMMENTS. I certify that I have examined the patient and rehab services are necessary and will be provid- ed while the patient is der my care. The plan of treatment will be reviewedt4ever 60 days or as patient's condition w r ts. This patient does not require a social needs sses ment. PHlrSICIAN DATE ASR 01,/96 ) ~ ('-, 1 ALEXANDER SPRtNG REHAB, INC. PATtENT: V:",f",;, ?-r"..-d+ , 7 /'+::1'11:4 Wol 7i' /VIllA- "'''' '101 ^,,,.., ~ '''''-1 C.., ,,~~..., 7" . ,- -k I ,? I I I' , c.-u\~,r; "'1/"~~-'_. ~ -rC.o,"",,, ",.."..., ("-,..-,') -r(;2:)...,\.-..J' (3-1. \ I ~ .-e.-s -\-.- \ J-.. ...1 ..J- /1': . "'-~ f . /,;'), e.-. _ J.-I4l, I P r ,S,-"",/, ~"7 /~.f ( I ';}4-0<'-11.-". "".,..i:/,'...n-lr....- r: z.-?,,,/")~, t:=.....4d..,.,I', ",,..)d -rt....rAG.'e.. """",;,,/,). "~,,s t!^~ ho.....,~ -1...""...,1 ~I/ ~..,(.,,/....- ~ c-?~,..~' A: p: ,.r ." /I. q LP s: 14,nrl tn+:, I,l -8 r!;;\;nrl f1. 6: ~ t.()i~ .:.~o.jI1 F. 1 , bn.s.r. -h1"II, ;.i.;/'(J . -TI) +1) r:I IlLI i h f! rl t(-, )' , tll':. s.l '3lht E -::;\1r..\ r ffi1+ , i/. 'J l..l tlb'lli'N I ~ . , ,..' \ I" " """-1/1' ",.- f '{oS :' " l. L . "J ;;m\ p/t.... ,7/7-...../4(;, 5~ f.J"/I'l I~ r..;;'o /.::,dr",! _I.VCo,-<4" '-f'e ,L'" '{-e..s-k.rc:,/,'(' (bS...b'l ?" -h:. ;,J-"'~"", t' C>~ .-,-......O'~ @I/~/J~'" '1' ",_-1-&-, .c",s<=.,.,f r<2.S+1'"I,,--h!2~" T @ SC-<Lp"ial. (ii:"Jf.2,b -I' '+I..,~.- (/l,,,u' ...",<;4-'-of_4'..-~< -t- ",,;. R.::" ffP -r 1r:;:<;5 I, _ ,,' 1~.c..cJ f ~ n,,,u -r -./, .....,.b./,~ ,'" I J f. (vI r::~. .-r-L-t..,_ ~'_ -rr;, ..,,- ;uu!'; .f,.J.... ~'.;.,.\c.; 5" ' ':". .- ), ...1, ,..,.....i~ , ' '1 .;..~),.., J. I~..... <'~.~,..,.Jio,;l"" .....u-1-.,.._ <: 'r.- 0,.-,... ...., -.. ...__),...,.~J_...._ :;:- . I.r- I t , CI1..u- -t ("> .:~ t. _ ....f"-'+. .-<1 I ' 4 '. ,l.,d.-'" ,\ (.. ~~~~:...-+';f'>l"""': _c:ar)d.,..':<.~..J jl '. c.... -l- ;; 'M-~P _G)vvt.:Jb)).-:O.1-.l-.;J- ~- ~~. , )\ ',1.1 \~,., I ): fi)I. '-I e F - :-.h'. -I-J-.J)rr;. [ I ( ::; 1')1,-.1 . ~. I rl ; i, '!l C' (i fI ('Ir I'll /0-1 rJ'i, ~ht: ' +h,; rOo '.'.- If: ~r.,,- ern ,. ~ - " tr,."I: 'IJ,";l :501N 'l. ;.-; [, J-.,(..Ii~':~ f'l. i '$ f+h()f) " h,~"./ (I:t; f. '!-5; 1'1 r i,; ,1'1"1 ;- :) L'I" I( rot:, 1/~"luJ; (. f-'~ y-7 ,-f::~,'1)L~1. ':h::u.l-/ ~. I, fh""0i :!;-: Lo' ~ ,~ Carlisle Hospit(~ and Health Services 246 Purkcr Slrccl . P,Q, Box 310 . Curlislc, Pcnnsylv(lI1iu 17013'0310 · (717) 249.1212 ,-, DEPART" ._. ~T OF RADIOLOGY ('\, CARLISLE IMAGING ASSOCIATES, PIC. Iii DIPlNDANT'1 IXHI.IT ~ BRANDT, VIRGINIA L. 698 BRANDY RUN ROAD NEWVILLE, PA 17241 72Y 10/08/1996 X-RAY '2063 MED. REC. '124925 DR. MIRA ALLAN MRI OF THE CERVICAL SPINE The study consists of multiple sagittal and axial images in routine pulse sequences. The study is compared to the previous study from outside dated OS/25/~8. ..-::'-~ ........-.. The study is evaluated in conjunction with cervical spine from,HAB done on 06/04/96. . -. + "- ~ ------ x-ray examination of the .. ....'_. '~...-:::::::-- The vertebral alignment is normal. The marrow signal intensity is normal. Narrowing with associated degenerative changes, consistent with degenerative disc disease involves the C4-C5, C5-C6 and C6-C7 interspaces. These changes have progressed since 03/25/88. No significant abnormality is noted at the C2-C3 and C3-C4 interspaces. At the C4-C5, C5-C6 and C6-C7 interspaces, posterior osteoarthritic ridges are seen to project toward the spinal canal and intervertebral foramen bilaterally encroaching upon the adjacent spinal cord causing moderate central and per1pn9rafsplrial-Stenos1s. I ~- -, . -------...--_.. .._____...__.___ ____......+____.. _..J No significant abnormality is noted at the C7-T1 interspace. The associated appendages are otherwise normal. The appearance of the spinal cord and the posterior fossa is otherwise unremarkable. The paraspinal soft tissues reveal no abnormality. IMPRESSION: Degenerative disc disease of the C4-C5, C5-C6 and C6-C7 interspaces, Plogressed,since 03/t5/88'l Central and peripheral spinal stenosis at the 4th, 5th ano'-nncervical-levels "due to osteoarthritic ridges, p~ess~ since 02/25~~) CHARLES K. LOH, M.D. CKL/nb P: 10/08/1996 D: 10/08/1996 10:25 am T: 10/08/1996 12:15 pm ~ CHART/PHYSICIAN ~ ........... - ro..... ".JI cO...WI:...1. co., eN"............ IloLINOII VIRGINIA BRANr1l' 7-29-86 Go over test results. Results were absolutely negative. I have told Virginia to check her- self on the palF-ilile lymph node or lipoma in the left flank. If there is any changes, it should be checked, otherwise, return one year. JAT:gm:: '{- '(-rT :'1 '0"'" ..." COLweLL co. CIC........U.N. II..LU.OII -',WoP ~ (""". ... :11" ",... .. DIll.. u~ TiLi.a. , o. breasts and elvlc exam not done trace edema both ankles pulses Intact. s eoa r s, cerv Cll a s p. Schedule BEgin Low c ee a and elvlc and PRofile E. cholestol diet at this time. , o . W e 0 . \ . ! ~ i ri ht breest pain, she has had ~ Stool is heme test Pj>" OOntinue e u Diezide 1 A.M. daily PAN. L :~. : " ~] ~x>...*~*****~**w~~x S!..L' ~~S/O:.. I 'C;'C'~ ~ " 266 :0:/';/0'_ .~ Blood tel -, . :'.';:." , ~ l~ ....... ... .- ~ I 0, ~, . . ., ~ . . r. lS-26-e8 ~ *~***************i HO~C 65 I'IS/0L , ~ Breests themselves ere J.B no n ., I ...Jllo. r- .... ::If.JAA; ..0-. ~...,......~ ',r 17 :;~~'~~.~.~ rEMP~!':~" - .... ;;j C;!<4>'. ;OIL 'I- __~ .. (( p~~ ...L I 1. -~, J,../ n . 7'/ A ...... ~A~'4.""',' ,0. -A~.u" .../ I~ ;, ". . I+~ft h~~ft""::: WftW" ~ .. u~, 1';:'." ":~~;--" ~. comoleins nf si' nAin in "n+" h,,~ri.. ..;;",.i~i -.. She nseds,helj Diezide end Nelfon. ~ . IJ.rql 1'01 J I ' / :;:~ . 'Y:~~~~~T ..,G~ "~," ~. ~-".. '''' ~ L !:.If.J' U ) rr=.: ' ha. ..n .";;'n" fss~. a. though it na.aJ. drip. ...,- ....... .. '" n..u, "'.... ..... .....J' .... ...~-- -~... ,..._ "n~ Mft . ~., .... __' with Bxudats .Decifica~~y in the DOBt.rior pharynx, neck .upple with anterior cervical aaenopa","y, '-ne.",: ......ear "'0 auscu..."a",,,"on ...... ._~_ _n;: ":f .1... A. INf~uBnza P, Amantadins and Rutuss and cover with !:;ry'tonromyc:a.n, ana sugges..ea :tJ.u vax nex.. year. il I,,'~'h , .JtJJ'r.r '-&/17l:... ~ -/,. % ~"..~ .~_n,,(, rt/J ~~7.. ~ -, ".,. :"';,7 ~ '- /~ " ,/ . -'/~ "l1J /},,h I"" , ~~.//) -,-, - ~LJ j l;or/ .n .-... ~fJ.:. /A, , ,~" ~ / / " >>"': 'J /r " , C-'~/ 1.1 Ilh '" ,. r- ,\--\ j,~R./ I J II .., "IOU .:_~~ !::~ft" ft" ,,0: +h.. .....~ft+ ft~"D . 'Yo- A.a fJ. , - III .. ~ .... J.A , :. IV... J U... . , , ..'... ...~ _L v.+' .1+,houah eh. wi~~ begin. Marked post I. ..,..,. I.~ )1... h_ PIF <t"J .' , J 1 ,\ , ! , i '!. . I I ! I ~.; '" il I I, , ' I, If I I .., ......,. /? II' . <... I tY' , /11_ A - /'AC,v-'/F - fJJ- m/l ~ ......, ~J I/.. /!ll!.. IAJ~ II:){ ~ L? ////~ . // , GRAHAM MEDICAL CLINIC: Brandt, VirllinU. S: Mrs. Brandt comes in with a history of per".".e... ne, ...:" .mu ~lgnl. .~an. a.z"aness c.. c"n .,,-, h'''~'-''~'' ~..__ .~, ... ,', . cositions. It is associated with some nausea. She has not had any trouble with her hearing, CDL_IU. CO""""". CHA....AteM. ILLINOl. ;''. . I did stl"onglv 01" an eva u. h.1" to s. I"....ul".ne. W.. giv.n .bout eve. go g. h.1" .'1'. pl"...ul"e. m.a.Ul"e . . : "a , Heal"t RR no M. Hel" BP is elevated. Hel" extl"emities wel"e essentially nOl"mal. . a 1ng er her Antivert. P: She is in NAD. Her ears, nose, and throat are essen la ". 2. P: We an '-' her on Altaee ~mg Q day "'... POt'W 1111 COf.WUL IT.,..... CMAWAMlN.ILLlNOI' ...... ',' CONTINUATION " , . a ., toenail on the left foot reat toe. Exam reveals and ingrown toenail. n",rown oenal .. . .. . . ~ .. c , needed. Joseph A. Piorl, D.O. co. .; , C' . , , .. sionificant SOB or scutum production and possible low grade fever. 11. er ear5 no :1.n.)ec\o:L. ... ... I JJ..': .,~- . ." anterior cervical adenopathy. Heart RR no 1'1. suc le with Chest CTA. , ... , ... .. ,~ the same dose of Altace even thouoh her BP is somewhat elevated as this may be secondary to the recent infec~ion. Wl ~ ~rea~ Mer Wl.M , ... . ~, .. - , D.O. ".... DAn H.... \1 . to- ""'t.. ::_ .. ~ '\,. - ,...,/->', CONTINUATION n \1.\ I'" I' AOOft... D.TI \~ ..- 7['if_ ,:l 0.6:,1:"" ~,,~ , _ _\AD B/~ . tiT W1:\io TEMP. (~ ,..'" -~ "601 ....... ~.'t.'t.~^-- ... ' I / fJ, , I//{ I.... ....... r( J I 'VT ho-A' (' ., " ;,;- -- 11HMHI'I rll,oU1L;HL. CL.J.N1C: tlrano't, ...lr91n1a ~: ~', '.'L' ,.. _~ - siDnificant di~%iness and now she has a drv co~\gh. Thill may all be ,;econdary to the ~ce. Mer Dl000 presll~lre lS ll'tilDle. \,;nllb. " .. :----. '.. -., A: Di%%iness DOIISibly lIecondary to the AI'tace. to. ~e ewe .8,ang .0 ~o ..ne.." ..n~ " ..'..~ ,:,~r ~~ ;:;.:_':'- -_.:. "DD ;:.;:;.:, "hD ......11. Joseph H. Pion, D.O. ~7 J _ _ /. ~I/ /VA1t--~ V , 7 ~- A- / , I3RAHAM I'IED!CAL CLINIC: Brandt, VirFlinia -';j~li::-';jw .. . .- ~-..-.-.- ... -.-.rr . _..--~~<-'"'-- ,--- -,... --~, '"' ~ft~_"'_D c' had been channed from Altase to Norvasc for her hypertension. During this time her blood pre~s~,,:,e _ W2-,;noU. -:n:~~ I L n?" "ee" very 8009, ~~--.,-- -r=.., ',~,_. -- .~- I'\':;:~CD ~;'~, "h~ ",-_...,,~ as ,;he ill switchino o...er. When 6uoke with her tnls mOI'nil,!?, 1 ilSH"ti her to L:ome in I-ridilY, a. ~~ Sl'iT-wT.. .,,, IH~ u, .ne ':'......"_ .... 'I" ._"'- '"~- -",...~..,-_.:;. u;:..;.; ~" ..,..:." M'''+- -+.;:',-,,, ,,_ prescl-ipticm retill was pi..."n today, will await blood pre",;ul"e ch~CH on h-iday. ""1o'1V~, ...n"~j , / V':j,tJ "t-0- 9:> f,V I '1 of V l> I . /;. \4 ;..--, ~~!b- /1" -;.. -~"'7-- /_-_/ of /~~) A7:) 0:;- J. ~ //./I~. ./. 7 '/ "'V / / / ~ Y /' ' -.....7-?' . ~ ltOfIUT'I """"'.,,""::11 "lI'IIUAlTQlMWl:) llll" " o.~c. . A Virginia Brandt S: Has returned from her sojourn in Florida for the winter. Her onl y Icomplaints are some dizziness, especially when she looks up, down, or when she first gets up out of bed. She is also complaining of leg cramps in the calves at ,night. Medicines are Ativan, Norvasc, Clinoril and Meclizine. Health screen with TSH prawn. 0: Ears clear. Eyes PERRLA, EOMI. SCM clear. There is no nystagmus. Nose, throat unremarkble. Neck O. Chest clear. Heart RSR no H a or R. Abdomen unremarkable, extremities no edema, pulses intact. I instructed her in stretching exercises to help prevent the cramps, will await the health screen and TSH to see if there is a metabolic problem, continue present medications, RX is given. A second problem of Virginia's today is that at 4:30 p.m. on 5-7-96 she was coming down Allen Road to stop at route 11, traffic was stopped because of a red light and there was a car behind her. A third van apparently came up behind that car and hit the car behind her which was pushed into her vehicle. She had slight forward jalt and had some mild neck pain afterwards. she says that today 48 hours later, her neck feels fine and she has full range of motion. There is no neurological deficit. A: Minimal injury, mild whiplash but without symptoms at this time, it is unlikely that there is any conti~ing or severe damage. Her neurological status is WNL throughout. Jay A. Townsend, M. D. 5-9-96 , . , . " ... ' .-"'.. - , - I CONTINUATION - Virginia Brandt S: Mrs. Brandt cornea in with significant left leg pain radiating from her thigh down to her mid calf and it causes her fairly signi~icant,pain since she flew home from Florida approximately two weeks ago. The pain is worse posterior to her knee. She has pain with walking and she describes it as a persistent sharp pain. 0: Her exam reveals mild edema and mild erythema and some tenderness posteriorly, she has tenderness with range of motion testing of the left knee. She has negative varus valgus stressing tenderness. She has marked tenderness with flexion and extension. X-ray reveals mild if any DJD. A: Knee pain, etiology is uncertain. P: We are going to get an ultrasound of her leg to rule outDVT , at this time. J. Pion, D. O. l ( '. t~.-.-..JbI- .' r"":, . Virginia Brandt s: Virginia Is a paUent who Is seen In our office on an Irregular basis but who Is followed by numerous other doctors, She sees gastroenterologists, cardiologists, and other specialists In Camp Hili, On occasion we get reports from them. She recenUy has had numerous studies Including a colonoscopy. She comes here for refills of her medlcaUon, She Is a known hypertensive, on Lorazepam and Norvasc. She also takes Mecllzlna on a pm basis for dizziness and she uses Solendac? for osteoarlhrlUc ' complaints. She has no acute problems today. BP 136170, P: Refill medications, she Is about to leave for Florida vacation and she reports that she has had a pneumovac within the yea~st had a flu vae yesterday when she was seen at an Intemlsfs office. Jay A. Townsend, M. 0, (~ ' . '0'''111' I COIo.'U. .,.,...... CHA..'AJGN. .&.I,IHOI' . ,