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Home My WebLink About01-2682 FX ANGINO & ROVNER, P.C. 717/23s{;791 FAX 717/238-5610 RICHARD C. ANGlNO NElLJ. RoVNER JOSEPH M. MalllO TERRYS. HYMAN DAVID!. LuTZ MICHAEL E. KOSIK RICHARD A. SADLOCK JOSEPH M. DORIA JAMES DECINTl JOAN!. STEHULAK 4503 NORTH FRONT STREET !lARRISBURG, PA 171!().!708 WWW.ANGIND-ROVNER.COM E-MAIL: DLUTZ@ANGINO..ROVNER.COM May 31, 2002 Jon LaFaver, Esquire 317 Third Street New Cumberland, PA 17070 Mark Silver, Esquire 500 North Third Street Harrisburg, P A 17101 Cory Snook, Esquire 1013 Mumma Road Lemoyne, PA 17043 Re: Smith v. Reinhardt Gentlemen: Enclosed is Plaintiffs' Arbitration Memorandum. This Arbitration is scheduled for June 11, 2002, at 3:30 p.m. in the Court Room of the old Courthouse (Second Floor), Cumberland County, Carlisle. If you have any questions, please feel free to call me. Very truly yours, ~ David L. Lutz /mtg Enclosure cc Michael Scheib, Esquire (w/enc.) 246865.1\DLLIMTG ~< '- - .'- _._~, -'--,'--',:"~':t'~: ,~,'- -",,,,-,., - - , "-'''-'''',1\-'1 ""-". ,-, 'o,'-"__~_ -,',' ". ,.".,,'" -~"'__~1~_'":' .. - "1-- - ", ,.-, ., -,-,_,_,",_ __ _ ~~"~ ~_~~_ _ . ,_<. ~ __ .1: It . CATHERINE SMITH AND RICHARD SMITH, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CIVIL ACTION - LAW v. NO. 01-2682 Civil Term . JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED PLAINTIFFS' ARBI1RATION MEMORANDUM . I. Facts On Aprilll, 2000, at approximately 8:00 a.m., Plaintiff Catherine Smith was injured in a rear-end motor vehicle accident that occurred on the New Cumberland exit of Interstate 83. Mrs. . Smith was stopped behind the white line at the end of the exit ramp when a Honda SUV,driven by Defendant Joseph Reinhardt, III, collided into the rear of Mrs. Smith's stationary vehicle. . No police were involved initially, but the parties drove to a nearby gas station where they exchanged information. While in the gas station parking lot, a Lower Allen Police Officer drove by and Mrs. Smith "flagged down" the police officer. At the time, there were no apparent injuries and . the property damage to Mrs. Smith's Chrysler New Yorker and Mr. Reinhardt's Honda SUV was relatively minor. . II. Damages Pursuant to Pa. R.C.P. 1305, et seCl., Plaintiffs' counsel has provided defense counsel with . Mrs. Smith's medical records. . 240722.1\DLLIMTG . .,. '''-*''.;' :, . . . . . . . . . . -~~;- ,I A. Past medical history Dr. Barry Moore - Aoril2000 surgery Mrs. Smith had received treatment from Dr. Barry Moore since December 1997, primarily for neck pain. She saw Dr. Moore on March 14, 2000, for evaluation of right-sided ann pain and numbness. On April 28, 2000, Mrs. Smith underwent a posterior cervical laminectomy at C5-C6, bilateral decompression, and bilateral foraminotomies at C4-C5, C5-C6, C6-C7. B. Jerome Korinchak. M.D. - Familv Doctor Mrs. Smith had been treated by Dr. Jerome Korinchak, her family physician, since 1998 for a variety of symptoms. She was seen extensively in 1999 and 2000 for pain in her left hip, neck and shoulder with occipital headaches, difficulty with balance, clumsiness in her legs and stress incontinence. On April 11, 2000, the day of the accident, Mrs. Smith presented to Dr. Korinchak because she was experiencing pain in her neck, upper back, and ann. She related that she had been in a rear- end accident earlier that day and had an increase in the burning and pain in her neck and thoracic area. Dr. Korinchak diagnosed her as suffering from acute cervical/trapezius and thoracic strain as a result of the motor vehicle accident. Mrs. Smith was seen again by Dr. Korinchak on May 24, 2000, for follow-up of her thoracic pam. He advised her to continue taking her medications and to return in two months. On July 5, 2000, Mrs. Smith returned to Dr. Korinchak. She was continuing to experience discomfort, but it had improved. Dr. Korinchak instructed her to continue with her current medications and to return in six weeks. When Mrs. Smith returned to Dr. Korinchak on August 15, 2000, she was still having discomfort in her right thoracic area radiating around the right side of her rib cage. Dr. Korinchak 240722.1\DLL\MfG 2 . .. . . .. .. .. .. .. .. .. 11 advised her to continue with her medications and he added Celexa. He ordered an x-ray of her thoracic spine, chest, and right ribs. Because of her continuing pain, Dr. Korinchak referred Mrs. Smith to Dr. William Polacheck, an orthopedic surgeon. Mrs. Smith returned to Dr. Korinchak on September 21, 2000, after she had seen Dr. Polacheck relative to her thoracic pain. Dr. Korinchak recommended that she continue with her medications and physical therapy and instructed her to return in four to six weeks. On October 25, 2000, Mrs. Smith was seen by Dr. Korinchak and because her symptoms continued, he ordered an MRI scan of her thoracic spine. The MRI revealed a small right paracentral disk protrusion at T9- II O. Over the next couple of months, Mrs. Smith continued to see Dr. Korinchak. Dr. Korinchak determined that Mrs. Smith sustained a thoracic and rib cage strain as a result of the April 11 , 2000, motor vehicle accident, and that her right paracentral disk protrusion at T9- II 0 was aggravated by the accident. Attached as Exhibit A are Dr. Korinchak's February 26, 2001, report and office records. C. William Polacheck. M.D. - Orthopedic Surgeon Mrs. Smith saw Dr. William Polacheck on September 13, 2000, for the discomfort at the lower portion of her thoracic spine with pain radiating along the inferior border of her right ribs. He diagnosed her with chronic thoracic pain secondary to her motor vehicle accident. He prescribed a course of physical therapy and indicated that if she did not improve with therapy, she was to consider having injections. Attached as Exhibit B are Dr. Polacheck's office notes. 240722.1 IDLLIMTG 3 .. . D. McCuen and Associates Phvsical Therapv Mrs. Smith was seen for her initial therapy evaluation on September 18, 2000. The therapists determined the treatment plan would include instructions on a home stretching program, ultrasound, soft tissue mobilization, and gentle vertebral facet and costo-vertebral joint mobilization. Her therapy was performed three times per week for a period of three weeks. On October 6, 2000, it was determined that her course of physical therapy had not decreased her symptoms and she was discharged. Attached as Exhibit C are McCuen & Associates Physical Therapy, P.Co's physical therapy records. . . . E. Steven Morl!anstein. D.O. Rehabilitative Medicine Dr. Korinchak referred Mrs. Smith to Dr; Steven Morganstein, and he examined her on November 8, 2000. He detected tenderness on the right side of the lower thoracic region. He also noted tenderness extending along the lower ribs and into the anterior rib region. Dr. Morganstein's diagnosis was that Mrs. Smith had sustained a thoracic and right rib strain as a result of the motor vehicle accident on April 11 ,2000. He also indicated that even though the disk protrusion existed at the time of the accident, he felt that it had been aggravated by the rear-end accident. Dr. Morganstein referred Mrs. Smith for epidural steroid injections and prescribed Celebrex. After undergoing injection therapy, Mrs. Smith returned to Dr. Morganstein on December 13, 2000. She had made improvement in her condition. Dr. Morgansteinencouraged her to continue with her home stretching program and recommended another injection. Mrs. Smith had her second injection on January 3, 2001. Mrs. Smith returned to Dr. Morganstein on February 6, 2001, an unscheduled visit. Mrs. Smith was experiencing increasing mid-back pain and radiating numbness around the right chest wall region. Dr. Morganstein prescribed Neurontinand a TENS . . . . . 240722.1\DLLIMTG 4 . ',7'".;-",.,- . . . '. '. . . . . . . II Unit. On March 20,2001, Mrs. Smith returned to Dr. Morganstein and reported that the Neurontin and TENS Unit had helped. Mrs. Smith continued to do fairly well after the injection. However, in the beginning of2002 her mid-back pain increased and she returned to Dr. Morganstein on February 18, 2002. Given her chronic thoracic pain, Dr. Morganstein referred her to Dr. Rolle for a third epidural injection. She was also taken off Celebrex due to stomach upset. Dr. Morganstein saw Mrs. Smith in follow-up to the injection on March 18,2002. At that time, she was doing fairly well. Dr. Morganstein encouraged her to continue with home exercise programs and prescribed her Lidoderm patches for pain. She will be seen for follow-up in approximately three months. Attached as Exhibit D are Dr. Morganstein's February 5, 2001, report and office notes. F. Jithendra.Rai. M.D.- Anesthesiologist Mrs. Smith was seen for her initial pain management evaluation by Dr. Rai on November 15,2000. After performing a physical examination, Dr. Rai administered a thoracic epidural steroid injection. On January 3, 2001, Mrs. Smith returned to Dr. Rai and received another injection. As indicated, Dr. William Rolle performed a third thoracic epidural steroid injection on February 28, 2002. Attached as Exhibit E are Dr. Rai's trea1mentnotes. III. Conclusion Mrs. Smith continues to suffer from chronic right lower thoracic and back pain. She presently uses Lidoderm patches when the pain is "really bad" and uses a TENS Unit on a daily basis. She has "good days and bad days," but the thoracic and back pain is a daily problem. 240722.1IDLLIMTG 5 . Based on the documentary evidence attached hereto and the testamentary evidence to be . provided, the Plaintiffs respectfully request that this Arbitration Board enter an award in their favor. . Date:~/~\ .-\) d-- '" ANGINa & ROVNER, P.C. ~tt LD. No. 35956 4503 N.Front Street Harrisburg,PA 17110 (717) 238-6791 Attorney for Plaintiffs . . . '. . . . 240722.1IDLLIMTG 6 . ,b," ..~.." ,- lYI GREEN HILL FAMILY HEALTH CENTER 'I. A SERVICE OF HOLY SPIRIT HEALTH SYSTEM ~r ' February 26,2001 _HI Mr. David L. Lutz Angino and Rovner, P.c. 4503 N. Front Street Harrisburg, P A 1711 0-1708 .~ RE: SSN: Accident date: Catherine P. Smith 182-46-3905 4/11/00 Dear Mr. Lutz: !It 1 am responding to your request for information with regard to the above referenced patient who has been under my medical care since January 22, 1998. She was evaluated extensively in 1999 and 2000 for multiple symptoms including difficulty with pain in the left hip, neck pain and shoulder pain with occipital headaches, difficulty with balance, clumsiness in her legs and stress incontinence. She had also developed discomfort and numbness in her left arm and numbness into the fingers of the right hand. She had also been beginning to drop things with her hands and had difficulty lifting heavy objects because of decrease in strength. She was eventually evaluated by Dr. Barry Moore on March 14, 2000 and was diagnosed with nerve root compression and spinal cord compression resulting in cervical myelopathy. He recommended posterior cervical laminectomy and decompression. I. !It On examinations prior to the accident in April of2000 she did have discomfort and tenderness obviously in the right paracervical musculature with a lot of spasm. This would also involve the trapezius in this area as per my office notes. On April 11, 2000 Mrs. Smith presented for her regular follow-up appointment and related that she was having the same problem with her neck and arms. She unfortunately had been in a car accident that day where she was rear-ended and immediately thereafter had an increase in burning and pain in the neck and upper back She did not notice a change in symptoms in her arms or legs, but had fallen again in a home she was cleaning because her legs just gave out. Dr. Moore felt that a lot of those symptoms were related to the cervical myelopathy. Her examination that day revealed tenderness and spasm of the posterior cervical musculature as prior. . . . Your Partner For Good Health 503 Bridge Street · New Cumberland, PA 17070 (717) 774-8400 . Fax (717) 774-8607 '~~,,-, _.0'_ ! . I-I ~- , "' ~ .. . . .. . .. .. .. ,. " '''%~~'' Page 2 RE: Catherine P. Smith February 26,2001 There was more marked spasm in both trapezius muscles with a noticeable elevation in the right trapezius and extreme tenderness in the whole upper back area. Her deep tendon reflexes were hyper-reflexic in the lower extremities as prior. She was diagnosed with acute cervical, trapezius and thoracic strain related to motor vehicle accident and she was set up for preop laboratory studies. She had so much pre-existing discomfort that it was unclear what the extent of injuries were from the rear end collision, although she definitely had a worsening of the upper back pain at that visit. Her surgery was performed on April 28, 2000. She was rechecked in the postoperative period where she was still having postop pain with decreased range of motion of her neck, of course. She continued on the medications and was followed by Dr. Moore. She was re-evaluated on August 15,2000 after she had fully recovered from the surgical procedure. She had minimal discomfort in her neck, had less headaches, had no discomfort in her arms or hip, had better balance and her urinary control was back to normal. However, she was still experiencing discomfort in the right thoracic area extending around the right side of the rib cage which was the same pain she had experienced immediately after the accident on April 11,2000. After the accident and in the preoperative period, she was having so many other symptoms that it was not clear, as noted above, what the extent of the injuries were from the accident. After the August 15, 2000 visit, x-ray ofthe thoracic spine and chest were obtained and were normal. Right rib x-rays revealed an old healed fracture of the posterior aspect of the right fifth rib, but no other acute abnormalities. She was next evaluated on September 13, 2000 by Dr. William Polacheck, an orthopedist, who felt she had chronic thoracic pain secondary to motor vehicle accident and felt that the rib fracture was very old and not a cause of the current problem. She was sent to physical therapy which really did not seem to relieve the discomfort. She next presented on October 25, 2000 in follow-up. She continued to have right upper back pain that radiated around the rib cage and her exam revealed exquisite tenderness and spasm along the right parathoracic area along almost the entire length of the thoracic paramusculature. There was also tenderness along the mid posterior right rib cage. She wished to continue on the same medications at that time and MRI of the thoracic spine was ordered. rT" _I1m'; T' ~ ~ II iI Ii 11) .. 'iI II . II " ~'~">1"~"." Page 3 RE: Catherine P. Smith February 26,2001 The MRI was performed on November 6, 2000 and was compared to aT-spine MRI of 1997 of which I do not have a report. It revealed a small right paracentral disk protrusion at T9- Tl 0 that did abut the right side of the cord, but did not produce significant spinal or foraminal stenosis. It was felt to be without change. She was next referred to Dr. Steven Morganstein who evaluated her and sent her to HealthSouth for an epidural steroid injection. When last seen on December 6, 2000 she had some improvement in the back pain, although still had discomfort there. She was to see Dr. Morganstein in follow-up. She was scheduled to return to my office in March for her regular follow-up of her other chronic conditions. Within a reasonable degree of medical certainty, it is felt that the client's right thoracic injury and subsequent symptoms were related to the motor vehicle accident on April 11, 2000. Even though her studies have included a thoracic spine MRI that reveals a small right paracentral disk protrusion at T9- T I 0 that is stable, it is felt that the trauma from the accident most likely aggravated this disk and also resulted in a thoracic and rib cage strain. What future treatment will be required and its cost would best be ascertained from Dr. Morganstein who is currently coordinating that aspect of her care. Prognosis in her case with regard to this injury would also best be determined by Dr. Morganstein. If you have any questions, please contact my office. Sincerely, ?!-".;( ~cdd;<<<! Jerome L. Korinchak, M.D. JLKfwap ,., '-'~,- ~'" ., . '\ r- , " ---" '- II PROB It SOAP 0\ II ATE .P. I, f. R T v-. }-"TlltN't t.'[l;s! ./ CALLER' \'!" ONSET- ;I DATi:. #'1/,;> t . -~-- lNlf: f Date 1 ast seen - /OoB .. HON.E#2 PIIONE- ClC' HEAD FEYER HEADA.CHE NOSE COLOR SORE THROAT - !!ARPAIN CHEST COTJGl! N<lN-<'RODUClIVE ClIESTPAlN SOB ABDOMEJ'/ PAlN DJARRHEA NA\JSEA VOMITINQ ~rlD / . ~ ~ 3-tt ~ ~_ {U ~~ , .' qf ;:~~ - ~lt~. "it;;;j)l:~1. J.- d, ::it!-'I^^-- .. . '. HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES ---- -. GRH 100 7/96 II ~%~ -"":'_-~_'r'_ ~ ~- ~.r-I - ~-, .-. . ,- i@;.' .~ \... ; ." .. PROS # I SOAP l DATE/PROGRESS NOTES . i. I. ,\I .. \I . II II 'q.~;''''-~> TELEPHONE MESSAGE Diln; /:1' )- .p.p TIME. 9'. c9 A DR.: < ~ATlE/>IT:"t/~.I~L~ PHONIUl. fJ (-.;7;2./'.o PBONEn 1N1T: CD:\e. \~ ga CALLER: (>NSET PHARU.CY~ PHOIIE: llEil>> FEVER HEADACHE N(lSE COLOR SORE THROAT EAR PAIN 0llUT COUGHNOt/.plWDUCTIVE CIll!BI' P JIIN SOB ilBDOMEN PAIN D1MUUIEA NAUSllA. VOMITING bob /, y~( ~')C# .' ~ r c ;r---- . ~~ ~ h p-<fIv,.; ~ " TEL&PHONII MJl8ltAGI- DATE:l#ZD/c.P mtE: ,',Co DJ.:lUrv INIT:~ PilTlENT:~ PHONE#hq38'-~ PKONEN%: h:neto.s+see.n CALLER: ~ PHARMAcy.frA \ f'V~ L. ) PHONE C13R-Wl.ocJ.) ONSET: 2d.o. \fS HEAl> WOS~ COHEADA9nB t ~ COUGHNO~~ :::;?MEN ~ LORCllu~ c~A~I- Rlf. T!lIlOA T soa _ - DlAlUUIEA ~RPAIN _NiltlSEA -V TlNG ------ DD13 IJ/~/PJa c- ~tf( ~/(J)~ ~~- HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES ~~liH :~TH~RtNE ~ ,;, J~ 52 J ~Jf~~ ~ 7Q J. G. '-{ , l"R .-. ..- GAH 100 7/96 .. . ~~~" ~~~~ >>, ~ r r ' ~ II '. PROS # SOAP DATE/PROGRESS NOTES '. ~ . w-<i . ,. . 121061OO CATHERINE P. SMITH S TIus JS a 48-year-dd wbJte fen1aIe who presents m follow-up She has had MRl of the thora<ac spme whtch has revealed a smaI1 ngld paracenb>d disk protrusIon at 1'9- no She has seeD Dr Morganstem who has referred her to HeaItbSouth and she has had one epl<InmllDJectloD m her b8cIc With lII1pI'OVelIIOI m the pam She stJIl bas some d1scomfort, but not as severe as pnor She IS feelmg.nuu:h better, her daughter bas a new boyfnend and IS hvmg lD SIuppensburg. There IS much less stress at home She COIllIIlUes to walk hard. but IS copmg well He, only oomplalDt now IS Iiunonliea. o Blood pressure 120n6 ENT reveals Dasal congeSbon, ctear postnasal dramage Neck IS supple Wllbout nodes Heart regular JlIte andrllythm. Lungs are c!0jIt Abdomen IS soft Back. reveals toss tenderness m the ngIn parathornclc musculatme, there IS less spasm ExtremJbes neg;rtJve A 1 Henuated 1horac1c chsk staIDs post eptdunll ugectJon 2 HypertCD8l0D 3 lhstory ofanbytluma 4 S1atIlS post C-spme surgery rl>r myelopalhy 5 HyperhpBlemla 6 Depression P I ContnWe all her IegUlar Jned'<:ahons 2 She Wlll begut AUel!l3180 mg dauly for the Iiunonhea 3 She Wlll rctmn for faslmg lab work to mcIude Chern profile, hpld pI<IfiIe, LDL, hver profile, TSH and unne clip 4 ~ WIll can With prolllems, otherwISe return m three lDClnthS and P 'n W i r . !Ill . HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES ~ J I: ,r, .. ,\ T H ~ R l ,l!: '1 1~ J2 52 ]:~J~3 , ~(-~3 ""::1' -....R "" GRH 100 '. 11~ "-, .;~'+=-~""""'" --,--~, '"""", ~, , , ~~-".. ~, " , , ~ .-, -- It tt:4 ~OGR'" NOTES A 1 "l1IoaIcAc; ...... U 1 . 1.... wIudc ....;.- 2 RcIiolWlI... . f' 3 HailiIa~.hI:I1n. 4 :8)-. ~-~ S HlIloryof~ 6 SIIIlIJplIr~ IIUIF1far ...~! 7 li)....1$ ."... 3 0..-' .... P' 1 Sllewlll~ ... Oft 1he_..L -r-- ....-.<Wer..~- ,-......... as. doeI.lIOl wuhto lab 8Il)'liw1g Ibal will 8IIb her aIf.cpy 2 ~ _ to ~appbcd 10 Ibll nata lowerlipb 1 d. 3 MRhflhet...,a.ocdeIed. 4 She II ~1Or an a~ Ortbopedlc lIJlllClIIIlIII s ShewlllcaU'MIh""'~or_pIIIlIIems .' JK/wap 9- 6 She may DlIQd~ Jeftml 7 She will lIIheirwu:e _.. SIX weeks and p r n. .. .. .. . . . '. !i~ HOLY SPIRIT HOSPITAL GREEN HILL FAMilY HEALTH CENTER PROGRESS NOTES ~MlrH CATHERr~E p 11 J2 52 J33043 ~ ~ :l ~9J5 ~qH ~~R ,-.. -.' GA.H 100 7/9if> .~",~,"""~" ~ ".,,. ~ ~ ,,, ,. .' I I I j "'"~~ ,~ it '. II 7 II PROB # SOAP DATEIPROGRESS NOTES .. - .. .. .. it ~ fit fit 1012510O CATIIEJUNE P. SMITH S ThIs 15 a 47ryear~1d wh1le female who presents m follow-up The herpes smqiel< IS resoh'mg, sbe still has a large area of denudelI skm be!leath tI!e ngbt S1de of her lower hp The pam and sweIlmg bave lIIllIkedty gone down She IS still USUJg Vallrex and Denav:tr She coUtmuesWllh the nght upper beck pam winch tad1ates around the nb cage nus IS apparently related to the accJ.dent seveml1lWDlhs aiIo NoDe of1he """',,""" seems to be \IeIpurg Wlth the drscomfort o Blood piesSUR: 132/82 ENT IS l1el!/Il1ve WIth the excepllon of a denuded area beneath the nght Sl~ ofher lower hp The swellmg IS down 'l11elio IS no ve$lC1lIat1on JIO\V Neck 1S farrly supple with healed postenor scar, DO nodes or thyromegaly Heart regular iate andlJlyt.bm Lu1Ip are clear Abdomen IS soft Lower extrenntJes WIthout edema Back exam reveals exqwSlle tendllmess and spISI11ll1oog the !1gb! pamlhol'llClC area both from the cemcaI down almost to the lwnbar sprne There Is aIso exqmsne 1enden1Css lI\'Cl' the nnd postenor nght nbs '. . HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES. ~MI:H :,\rHERT~~ ~ , J~)~ j~ J~~ , ' -"" . R -III .""""""-""'",,,,",);:'''"'''''' ,< =-, . - ~ --" 1 I r-' . . . . . lit . . .. . . ,. '. ~ '. , 0. . ,\\ \ ~fy2. D4TEl 0 m1ilPillDNE MESSAGE 1lIft,{iL TIME: )\'.60 D....$~- l:- flIONJ:1119~ 8Qi pJI(IllI:n p~ e ...np. "'R\.~o.~.\ ~: pH()llE: aUo CIIUT AlIDOME1'f otfRt' 1BVER 1lEADACllJ; COTJOIUIOM.PJODUCT'lYB PAIN .u. A (" _ ..,- ~,.. !lOSE COLOR Cl!IIlST PAIN 1ilIARllliEA TlI"\ ~ .u 1':;>' SOU1\lMl.l.i - SOP. Nll.QSOJ. " ~~o. VI \~ f o"W.~1f'tl1'Yl \:"-. "r?t C'CJ\fe ~9A C' v~ fi:~*~~S~~iI~? 1 n {" A~" '1!~ 'r'\ \'s 'f"YV)s\ D ~ bacJ<.... J1,,,",, ,It t#~~ -c{lt1.I- A t~ Jt,.UI, :Y - I l&1fMl1 CATBUlINJ: P. SMITH S. 'IlDsIU4"'.~. f'.d. '.'~~'__.' .' wll!)JI!'U''''llIllIla..''''... .11.1'_. _..._~. ,....I1p.. .....__.,. lIP .bu1llM:r1la4~......ol....-..._bad~1ti1llll. ....lIOlb.ea....._1W...... hasllOlbad .."., _ _OtMtodler,.,1J" .. .....' tf..ClIlIII:dthc_.......c:IIlalObullu~ill&IlIllIl..IiIJIt~ oerviaI1-. o EENT Bylllll1<Jl1lll!l. TMnormaL NOIe18ct.'. Oral ~ aDd phatyDxbemp. RiaItt ~ IIp nMlIIk _ve ~ aBdedmlla ~,mod.lotthc naI1llQwer..JIpllld ~~.lDIo dle __dle dim. 11Ils lsvery ~1OWl and ~ There ~ ~.....Jy leUr Illlxllenllll ~ IIIIl also ,P........,'C>iS aIIIIIlI ""JIO"'AIly 1be n&bt;1IIRnor ccmcal area Wlth IIOIlIe ml1d -iv '1""1.,. tIIe1e also HaIt~ rate aDd&ylbln.. L\mt$... clear F.xlmmDes without edema A: Wtud....,~x...1ower lipWl1htellllllalll~ p. I &em IiemMr ol/lllD/rltfive Illnes dally to !be lema @ 2 Sbe will also begin VaIIrex 500 me __ two b I ~ for the next wock.. 3 She will call d'th15 dots not ~ UlIpIO\1e or If. has _ ~ 4 She will olherw1se retutn for herreplar "'I'Pl- next wed<.8Dd 11 r n. lKIwap ~ HOLY SPIRIT HOSPITAL GREEN Hill FAMILY HEALTH CENTE PROGRESS NOTES tMrr,~ C,';H~R:~~ p 1~ 02 S2 0~3J43 "A? :6 !9JS SRH eTR ~ J r'\ , ~ I. .'Kl"'ffl<'.'_""-1':':~""'=~'l\l'l"""'~w " ~ 1-; , 1 .. -~-I ,",- r ._, ~1'""~' ~ ". ~J. ~" "~ '" ~ , lit :PROBI! . SOAP DATEIPROGRESS NOTES 09l2lJOO CATHERINE P. SMITH S T1us lSa47-yeat-<l1d wllllefemale who presents mfoUQW-up She IS feelmgnmch better on Celexa,bas nmchless emoI1ona1 ups and downs, more control of her lfl1lablhty She coDlmues to have nght sided back pam, has seen Dr Polacheck who felt tIus was ChrolllC thoral;tc pant secondary 10 IIIOtor velncle 3CCldent RevIew of her x-rays reveal an old beaIed dJspIaced fiactore of the postenor nghtlifth nb nus could have been sustained m the. motor velncle accident In April She bas been sent to physical thernpy, It ts \teIpulg muttmaIly at the present tnne She refuses to take any pant medtcme al the present tmu:, IS IlSIIlg Momn She IS stlU on Llpttor, Premann, Tenormm and the Celexa 20 IlIg. U1twn really does not lllve any rehef o BIoodpressure 110m, pulse 72 ENT IS nepve Ned<.lS more supple With hl:aIed postenor scar There IS nmch better range of _0 Hearl regular rate andrltytbm. Lungs are cleat Bad< ts exquwteI.y 1ender aJong the nglllllJP'I paralhoraae area espeaally medial 10 the scapula There IS also tenderness along the mIdngbt postenor nb area Abdomen IS soft, benign. ExlIenUbes negatIve A I 2 3 4 5 6 7 1 2 3 .. . ;1' p . '. lit ,. 4 RIght postenor nb fiactore, may be secondsIy to motor veluele acctdeot Rtgbt tboractc back pam With spIISIIl HypertensKlll, conlrolled Status post C-spme surgety for CCMcal myelopathy Htlltory of ~culartachycardJa Hyperltpldemta DepteSSlon She will contmue on the same medtcabons She Will contl1nte With pbyStcal therapy for the next three weeks She Will call With contmnmg symptoms or worsemng She may need an alternate Orthopedlc or appowtment She Will return In four to SIX weeks and p r n - "'- . HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES ~ 1'-';': Ii': {\ ~ H _ r{ .. . _ ? " J2 S2 )c3J43 ... -I.: ~ '-. :9J5 ~Of.! ':'':"R GAti 100 . 719G ,,':'~fO'>:~'W'-"~""_""'~_ , __ -- , 11 ~ -- ~" . 1 ' ~, ,"--"""". ~ ~,.~~~- ~ '- c . ~. " PROS # I SOAP I DATE/PROGRESS NOTES . TELEPJIONZ MlSSAGE DAn:~\~(b TlMEW,50 DR.lt",q \1\<S4Am:NT' ~~, C(',.~~va, PBOIIl:u,938- .i~ NuNEn: \ \ CALLtR, s<\C "'~ ./d PIWlMAC'i: )... f!'P PRONE: ONSItT: IlUII CIII$T ABIlOMEN 0\--r" I'IM!k 1VlA:DACiIll COUQK~ PAIN 'iIr\ ....L NOSE COLOR. _ CIIIIST PAIN DWIIUIl!A \l.I!.: SOlU! TlIJOA1 SOB llAtlS!A. CTC. mcI )J. U'\ -A~<{,~( f' ~ \r-.~ ~OImlNO s;:O(" \':.~...s-es.~\()ns ~. ~,f\L11\~IJ..r~ ~\\c)!;-~~~a ~~ .. .;:--- .. l,~.'''M'''' 'If ~ ~~~:f..~.~;~~ ~< 00f:~ II . . . ,. .-..J ., . . , II ItOlY SPIRIT HOSPITAl GREEN HilL FAMilY HEALTH CENTER PROGRESS NOTES ~ ."1 J. ' f I \,.. ,,\ ~ H ~ It ~ ~ -: p ~- 02 52 J33J43 -<c '~'9J5 ~qH ::-TR ,....., "" .... GRH 100 ~.r86 ___" --' '" ~' ill "~~~~, 1-' " -~--, ": 1 . ~ " <'I~--' ~ <-,~ il / " --l..Jl :r " --- ~ . PROS # I SOAP , DATElPROGRESS NOTES , 1 ELEPHONE ~IESSAGb DATE 9/Q~lO_ T,,,r8::-":1-5 DR JjQCJ.- _ JNJTW~ PATJF"t<;:~1-~ PITO'E# 1 q3<f: ..:3;3.8Q mO"iE# ~ "J3.1:..:5t.d.oi-) -iJO (AWR~1f "JI\""'CyrMrVJ..LvJ I'ITO~E 9&3iJ?[D V (.J 9MFT-f;-~ f" ,n (tlESl + "nJ)O'IE~ '. J......-V- - ....J "--.fr\ 1_1{ HEAO\dIL + COuGH ~,')N-PRODUC.TIV[ -Pi\l"l \y{T ,/ +->"'0'" COLOR~ CITESTPArN"- ~DI,\RRHE" \l V +SORETHROAT if - SOB-- -NAUSEA J')<; o~;; ~r?Jf)::;ff$~~'~r::~"~"-] . (ed2-u-t- c 0 S 0 ('0 ~(O G- ,. ,. ,. TELEPHONE MESSAGE <, DAU. 7-//.c.::'~:' Th'\1E: Y <--.f.:-- DR.. V/.-. PATIENT. ;::'/~?--:' 7X~ PHONE#J.9.J""'-:.3 z y= PHONE#l ../ (,/ :;;L -5""...... CALLEll: .r/. ~/ RMACY' PHONE: . . / ONSET' Jr. ~.J 0 <.':' .-=:' ( HEAD ----., CHEST ?--~~,': '" FEVER llEADAc~.i-:: COUGH NON-l'RODUCTIVE (t-./ (;j::)NOSE COLOil.~);[!"" ~<CHESTP~~ . (t;)mRETIlROAT ,- _, SOBC- (+.:EARP~/.3<, ,C-J' ea.. >-J Cle. t ., c<=>/d'JQ~'--" . <.: ,/' ,.Lc. ,/'//<> .;-~ _ ~ . /' .+- /. -;r' /./' '..2. '-' ).e~ >1 . -t~~ h-P ~~)//;. " " ~Y-~.r-~""'/ "--'..r>.K.... /' .('. ?~~--~;:~~~ :;;~~~ . A", i 1.~~'1:. L-)V~g/~ ;, - -c? C'<~d ,t...L.......r'! !NIT ~ ABDOMEN ) PAIN .-----.., DlARRlIEA l=.-.) NAUSEA VOMITING ,. " ,. . HOLY SPIRIT HOSPITAL GREEN HILL FAMILy HEALTH CENTER PROGRESS NOTES ( 'I 'I . " .. I .I. l t '- ,-. , h. f( . ~ "", ..12 52 " < ~9J5 o 0:' 3J4: ~ r,~: : T H ,. GRH 100 7/96 .1 I j,u~~,""",=~~~ 1'1 , .~< .",.,v - '....~ '\ "Y -. II PROD # I SOAP I DATE/PROGRESS NOTES T.ELEPHQNF.: MIlSSAGE /1 /' DATE.I:.l.?'-~<i' TJM~ __ ~~ PAnENU4J.- ~or.>:NI -.!Z.7 r-J d~aONliu. y/;. >.-r;) CALLETl ~_ \'HAR~lACY _ _ _,_, __ PRONE =~~\()I'ONSET _ = $t;c~h~ U .d--r-i ~~,- I , .. Il'IIT~ IlEAD FEveR !ISAD 101I: NOSS COLOR ORE TIlROA T PAIN CHEST COUGH ~ON.PRODUCTIVE CHEST PAIN SOB AlJOOMEN PAl, DfARRH6A NAUSEA VO"IITING . , . fi " . ,. . Iii HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES SMITH CA;aE~I~E p . JL 5" ._'3J~3 L : 9 _1 ) -J PH: T R ~,-... -'""" GRH 100 7180 . . . . . ~ <!\i;~~0",C"}'=_,~"__ ^ -""~~"",, ~., ~ ~ ~ r \- " - .~ W"' >11""""" 11 .. . . . . II II ill . ',. ~ . -.......... ',,- - - 08115100 CATIlEJUNE P. SMITH S Tbts IS . 47-'Yel1Hlld wh1te fenlale who presents In fuUow-up She can not take BuSpar as 1t gave her . Jot of heartburn and nausea She Wishes to try sometlung else fur ber nerves winch are shot over her daughter's treatment of!>OI, reec"! blIL~ ~fbcr grnnddaughter, etc She IS still havmg discomfort 111 the nght Ihornc1c area I3d1atmg arol1lld the nght SIde of the nb cage after the car acclllentback 00 ApnIIl, 2000 Nothmg has really been do""about tJu. because she was gomg m for c..spme surgery ,.,,;:!:~ "-:'0 ~'^: clear whether the pam was related to tJus as she had so many other symplOnlS from her nee!<. The neck surgery has resuited In rehef ofber pIllII, she hasbeUer range of mollon, she has no discomfort In ber anns or Inp and has much better balance and her unnary control IS back tG nonnal o Blood presaore 118184 EN! IS negative. Neck IS more supple The UIClswn IS well heated. Hean regular rnte dDd rh}'lh-'TI I."::::;l:' ,to ole",. _'>bdomen IS soft Extremlbes WIthout edema. Pulses mt8ct Back exam reveals exqmmte tendf:mess overthe ngbt lower pIIIllbuuhIIr musculature WIth spasm There IS also tenderness along the nud nbs om toward the paste, "1 _ '-!!!OI) . _" A I Rule "lit th<mlc1c (.w$l_ fraclure vs disk dlsease 2 Rule ollt nb fracture 3 HyperteIJSlOn 4 Recent c-spne SlIrgeIy S Resolving cemcaI myelopathy 6 History of Svr 7 HyperllpIdenua & Depn:sSlon P 1 Qmtmue reguJar mechcaUons 2 AddCelexa20mgdally, IDtnIln 50 mgq6h pr n Jl"l1l ' 3 X-my of the tbomcJc $pIDll, chest and nght nbs IS ordered ,/ ~ 4 She wdlIllIloW. -up WIth Dr Moore on ~ IS, 2000 and roll d15C1lSS further her em S She wdI call WIth any worsemng, JllIIy Ju:ed MRI 6 She WJII return in SIX weeks and p r u - --t :. ~ HOLY SPIRIT HOSPITAL GREEN HILL FAMILY H!ALTH CENTER PROGRESS NOTES ) v '. . :'q, I... t,ft,;[ I" J2 5'- 4 . '~~ ~ :9J5 .' ,...2.3J43 '"; P II :-,. R OFlH 100 7/91'> ',~t,~,," _ _ ~ =~. ~'<'"""" _~ ~~ eo ~ - . '""",,'''''' -, .~-....--~ , lj F_ . PROB # SOAP DATE/PROGRESS NOTES . -I-oD P . . '. k<:.t' err a1.M-J. . ~ M 1 r fi ~.\ T I, "52 . ;. II HOLY SPIRIT HOSPITAL GREEN HILL FAMIIi.Y HEALTH CENTER PROGRESS NOTES ,....., .-, ~. d ~ . -'l:,~.[',,-'iwro-~~,~~~~." _~, rr .- " ~ " ~ :. ilt :I II :I . . :I . It GAH 100 7/9" 4" ~ . "1 lL_ 1 ~- PROS # SOAP DATE/PROGRESS NOTES 071OS1OO CATHERINE P. SMITH S ThIs IS a 47-year-old ",Inte female who ~ to foUow-up She IS back to work fuU-ume, IS bavmg some <hscomfort In the poStencc neck: a-. ~ sbe IS l1I8If<llClIy lIItpl'<lVO(f WIth m""....1 symp!Dm& to ber 1~ She IS no longer """""'_ and she was able In,work. t hi:lI!fs.UIdiy WJlh:lIIUUtlIlIlproblems A1ocnldrops llt!helast. VlSltCllllSedan exlXeme bummg, but PaIimol hclpe<l With !he aIk;JgJc OOJWIII'll'ViI1a."...pI08IS Her nerves are fauly shot cnrertbe_ WIth ber cptIepbc do..gIl....wholS expectuIga baby m Aus/m She ISexinl1IIeIy dJsFcspe.Jdid oftbe patJentandtbe ptlIe.ot's lmsbandllllly move her backm WIth lbemThe Jl'I!Ielll Idate$ that rf1lus lJ~ s\lc is lIl()\IUIgto OInowilh her other """gIl.... She bas a foIlow.up WIth Dr Moore on Jtdy II, 2000 o Blood ..._ 132J\U, -.148196 EN'! IS neglll1ve N..:luevea1s a heaImg IIlCISlOn of the postenor neck area There IS shglll decrease to t81Jf!Pofnaowm. Then:: are no nodes. or bnuts He8n teguIar mW and Ibythm WIthout mumIUr Lungs are clear ~ IS soft lil<lremiI1esare Dqlll1Ve Neurologic exam:reveals decrease to nght biceps Jerk and hyper-refleJWl to the nght peteUar relIex No _.....- edoIIla. A 1 Slalus post cemcaI spme mrgmy 2 ResolvIng CClVIl:al myelopatby 3 Cenka1 and IllIpezlUs SJlBSIIL 4 fIypmIensIon 5 Hlsto!yofSVT 6 Hypcrl~," 7 S.-Dlal anxiety and depresston 1 She wt1l wmm.... !he same med1calIons 2 She wt1l blIve a.bIood JIIl'lISIIre check III two weekJ; 3 She wlJ111y BuSpulSO mg one-baIfb Ld for one week: and then one whole 1ablel bId 4 Shewtll call wtth ~"""Ig or WOISelU1lg symptoms S She wtIl oIhetwise retunI in S1X weekJ; and p r IL p .(/ IIV.... ..,tllI"" I........::J......M... GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES "i;"0mf!;"'-Iq""n)ffl~~ _ '1 '! , -~~ -~, ~ ~-,o , "'~_,_ .- -~ ~ /"" , . . . . . . ~ .=::~l_l .- s; ~''''''+':''i~:::ttil.~'''. . '.'ll'JHI"tlC~~~~"JirQoIIr. sm.,--mach ~v~r=:'~i:1n~~C~:~~ _ ".' ,., J&l1t1.._.....~llIi\.wll*of 0: =- i3lll'5. -----'lb-~..E~~1~lP~~..$ar ~.. '-'~l .tl''j1r ___~ '. . ,. .,' lIAillHo .',1 ..... .. 11' .....,.__~t1:':tl' ....-- I.. t?-~ :::r ,.' ~ ~ ft."" ... 1 ~-- - JlU"~ A: I. ... ~~IIt,IP lio~H" . 2. ~"'.'l( - 11. ~ 3. ~.",.... 4. orsvr s. 'It.. ..; 1 ' 1 .~:...~~....~. 2. .__ . ...._iIJl:!Idl.l.J,Uh- 3. _wflkIlII:__ll'.lJ.i J;/;>'~,i;. r I 4. .....~ - '!d. *-.M....~.... S stiewilb",lilra~-' ~dlIiilt:l&lilO~ P: . . -'If'"~----- , . HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES :Mr~rt C~;H~~~-3: ? 11 J2 52 J53J43 '32 :6 :9J5 ~~H eTR J-. ~ GRH 100 "-.::196 'FO- . , -- .&:"to{.~,~ ~ ;r~ -- I:, /~ 'II' ~ II .. ~ PROB it I SOAP DATE/PROGRESS NOTES .. 04/11/00 CATIIltJUNE P. SMITH S nnusa47,_..oJd.1>1uk: :limJaIewhopesents mfollow-up She IShavtng!be _ P'~ ....\hher1ll:Ck__ The drug _on alfbcling her skin baS resolved She un1brtunaIely was rear-<:oded today lJl her car and bas !lad an rncrease ill bummg and]lllm mIbe1leCk-...4 b,.J.. smce She hlI$ no dilfinitcdllulgc1l1!be-symplOmSlIl bet 8IllIS oriegs Sbeilas fallen agamioday down limlIe stairs III a 1i0tllC BIJe was c\eanmg WIth her legs JUSt g>vmg out Dr Moore feels a lot of these symptoms are related to her cervtCal spondylosis o Blood P'~ ll2178. ENT 1S ncgpllve. Neck _eals 1eDdo:mess and spasm of the postenor ceJVlcal musculature There is IDlIlIced spasm III baIb tnlp:ZIlIS _Ies WIth IIOl1teable elevatIDn m!be ngbt trapczlU&, extreDIe ~""" m tins whole area Heart regnlar rate and rlIj'dIm LulIp lire ,!ear Abdomen IS soft ExtreJmUes negame DTRs are hyper-rellex1c m !he lower extremities A 1 CcMadJllllllllyloSis WIth cemcaI myelopathy andspmal cmd ~on. 2 AllUlIe cem<:aI fJalJezJus and tho1acw SlIlII1l re1ated to moIo1 ve1uc:le a<:c1dent 3 1I)l"'.I._..... ~ HisIoty orsvr 5 1fwr.rI;putom.. 1 Sbe w1ll~ llIl:llettegJ1la--lr-~. 2 She MIlItave lID to mclode COC, BMP, hepmc: penel 3 She will have to tIlIUm flIrhetpreop lID and possiIile x-ray 4 She wdladlwlth<>mlnnri..gllJ""UAm. or 1l'llIlIl:Dl1lS swce!he accuIent. 5 She willlllhetwtse tIlIUm m four to SIX weeks and p 1 n p . rf JKlwap .. .. .. .. .. <. Ijf; HOLY SPIRIT HOSPITAL GREEN HILL FAMilY HEALTH CENTER PROGRESS NOTES , . ...J... '" ., .... . \ ~ I; _ I ~" .'J 5, ].~J.\3 l. ?9,) -,oy :;-R ~ ~ J L II GR!'t100 ',. :':i!i~1Jl;Vf~ ~~"""'!~"'" '-If r\ , , . , , ~ -_. ~ '. CA1'BEJtJNE P. SMITH S . a 47--yqar-old 1\'lIiIe female who JftICillI wilh tonIJlh..... <<a rash on.. arms, and -... chest an:a, QCCkaDllfilcetiJr seveDI/... ltsetllled~be/llA.aftc.8Iadel1Sonla. SIIe ....~_I!--\III"".lIut bas bee1loo tbore a bit $be 11 S<:l1lp1o law: ocmcal decolllp!e8llicm ill IS in ,.n......d pPlI, but the ~ seems to be bdpng. TIns nuIIl. aad lite 1IllS tIClt bad aoy other ~ after revICW ofher bisIory Q. IlIood pressuR 1l6f78 f!N1' is Neck. -'I and .-al'the plllIIauJr cemca1 m",""',,,~aod 1r3pezIU5 'There an: DQ DOdes or bruits Heart iilythm Luap ~ clear ).~ IS soft Exll:mwIIcs WIIIIouI edema .SIIm exlIm--. a IIIdf. JIIIP1Iar1lllJh _ _, lIIaiIlI.y tllc iUllrior cllest, arms, ttld:: and flIce 'nvlft: IIlliI a few areas of~ _ of~ benukty bIilMIW thcJuldofs A I Possible drug , Z Can _ 0IIIet conlaCt ......,..tis p' I anllbe only ~lioas that bave gMll ha" Idlef; we will on !be _ fur tIIc proseDl1mle Z odrolllO me: 1M given and Zyrlec ]0 mg dally alon&wi1h ~ cream 10 3 SIIc w1II call sQaaldthe -.. OOfthu'", or..- ao4 s..-JIlIllY ...to be . She will aIBo QIl sbouId lh1l' _1lfter tbemedlcllllon is ~ / 5 SlIe wdI 0Illenrisc reQmllbr her ttguIar appoinlIneftt and p.r D. . . . '. . . HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HeALTH CENTER PROGRESS NOTES J-.. ~{'iL\H ":A1H-=.K:>.\- P Ii J2 52 Jj3J43 :5 '. 't. -: 9 J 5 -; R H -:- T R , ,.--- .. GAH 100 7/96 ---- ,- .~ ,.. , ... ~ . ','M!\ffi~~"tl!'~=_,,,., .. -' -" I I' .. -~,~ ~ -~~~". . ,,- i~ .. ,. 'ij . .. . . . . . ;,'~i"'_",_~ ~. ..' .... ......~. i , . fjJ>--ft Dear C ' iI~ " ,<,,4u, GREEN HILL FAMILY HEALTH CENTER A SER.VrCE OF HOLY SPIRIT HEALTH SYSTEM <';'-.Jf' I am pleased to inform you rhat the results of your recent laboratory ! ~test are within '. normal limits. r~ 0 " @ /~~.>- - c'/ J. /Ud~_A r~~. Your Pap screening was entirely normal. Repeat m _ months / years. @ 5 1-1', /1.<-1- ( /t;WtLt,k.. -Il!e be< L~ -/- Your diagnostic tests show an abnormality: cholesterol protein sugar thyroid Instructions: urine throat culture Please return the TINE test card, Dr call the office with the results. Please schedule a NURSE VISiT for a posr treatment urine test to make sure your treatment was effective. Our records show that you did not have the which Dr. ordered. Please call the office so that we may reschedule it. Please schedule a NURSE VISIT-for your next hepatitis B immunization. Please contact the office at your earliest convenience. Thank you, ,L1I6.<v....di..J.:/L / " . --=-- Green Hill Fa~ Health Center Physician / Staff member GRH 180 11/97 'r' ~~ Your Partner For Good Health 503 Bridge Street. New Cumberland, FA 17070 (717) 774-8400 . Fax (717) 774-8607 " . ~"- ~~~ lI"l\IiIlP'~1'l ORTHOPAEDIC SURGEONS OF CENTRAL PA, LTD. ,. SMITH,CATHERINE 2615 GRANDVIEW DRIVE YORK HAVEN, PA 17370 ACCOUNT # CHART # SS # 9761l 11386 182463705 September 13, 2000 ,. Jerome Korinchak, M.D. 503 Bridge Street New Cumberland, PA 17070 . RE: Catherine Smith Dear Jerry: . I evaluated Catherine Smith in the office today, September 13, 2000. She is a forty-seven year old woman who was involved in a motor vehicle accident in April. Ever since that time she has had discomfort at the lower portion of her thoracic spine with some radiation along the inferior border of her right ribs. She had cervical surgery by Dr. Moore two weeks later for unrelated surgical spine problems. She has been under Dr. Moore's care but he never treated her for her other back pain. She had radiographs performed in August and they were basically negative. Her pain radiates to the right side. It does not go down the left side. It is intermittent in nature. She has no true rest pain. There is no radiation of the discomfort into the lower extremities. She was in therapy for her neck but not for her back. . . '. PAST MEDICAL HISTORY: She has had the neck surgery noted above. She is on Premarin and Toramin. She has no known allergies. Her family history is noncontributory. I went over her review of systems. She has had ulcer disease in the past. She has a hiatal hernia. She has had a rapid heart rate in addition to her hypertension. .. PHYSICAL EXAM: She is 5 feet 2 inches tall and weighs 164 pounds. Her blood pressure is 134/80, her pulse is 75. She appears comfortable. She has no difficulty sitting and transferring. She has no paraspinal spasm. She has no localizing tenderness. There is no deformity of her thoracic or lumbar spine. She has good alignment. She has 2+ patellar and Achilles reflexes. She has good motor strength. She has no clonus or long track sign. She has a negative tension sign. Hip flexion and rotation are comfortable. I cannot palpate any area of deformity or abnormality on her exam. .. .. ;:~~.~~r -ll!'f~ ,_ _0 ~,' .,<, -I '! ' . , 1- - ill . ,. ,. ,. . ,. ,. ,. 'I ,. :,"~,~- " RE: Catherine Smith September 13, 2000 Page 2 RADIOGRAPHS: I reviewed the films of ribs. She has an old fracture at T5. old. There is remodeling of the bony spine films appear normal. her thoracic spine and This appears to be very trabeculate. The thoracic DIAGNOSIS: Chronic thoracic pain secondary to MVA PLAN: I see no sign of a nerve injury. She has no evidence of a bony injury. Sometimes this type of pain is hard to treat. I recommended a course of physical therapy for her at Valley Green. If this is not helpful you might want to consider sending her to Dr. Momin for some local injections. I have had patients with chronic thoracic pain that he has treated with intercostal blocks and they have gotten relief. Hopefully, the therapy will be of benefit. I will follow her as needed. Thank you for having me help in her care. Sincerely, william J. polacheck, Jr., M.D. WJP/rjg T: 09/20/00 (dictated, not read) TK-FAX sent to Jerome Korinchak, M.D. PATIENl UNDERSTAND~; INSTRUCTIONS . ~~~~ r I -, , I' - I o &!,oslic Radiology 'i'IImography 'asound '. Scans t.!. 'it . ; Bridge 81. I Cumberland, ji070 "774-7351 . I I Old Trail Rd. , rs, PA 17319 . ) 932-2677 . : WalnutSI. ~ ~rsburg, . 7061 I 692,3097 . 'lOth River Rd. ; fax, PA 17032 , I 896,3352 .hambers Hill ; "isburg, PA 1 . 1561.8022 ,~ .. <"~,, ~,-~~ "'-~- ~ITH RADIOLOGY, INC. , () II U/ <: "SZ-. ()^J /' ~ ,.f!- ~ {lJ-r"'\ , (y 'L tyJ ~jJY ~\ ...,-..9' (6' NC3905 August 16, J t-'-c~ !) ~ 1).-:",' I' 2000 , #'" t," ,uv /"')1- l' J~rom~ Korinchak, M.D. Gr~~nhil1 Family Practic~ 503 Bridg~ Str~~t N~w Cu.b~rland, PA 17070 '1'" II ) '\ RE: Cath~rine Smith SS#: 182-46-3905 DATE OF EXAM: 08/16/00 D~ar Dr. Korinchak: CHEST AND RIGHT RIBS (5V): CLINICAL INDICATION: MVA in April, 2000. Right ant~rior rib pain radiating to th~ upp~r back. Th~r~ is an old h~al~d fractur~ of th~ post~rior asp~ct of th~ right fifth rib. The rest of the rib cag~ is intact. The~e is no intrathoracic complication secondary to chest trauma. Th~ cardiomediastinal contours, intrapulmonary vess~ls and pulmonary parenchyma ar~ noraal. There are no pl~ural effusions. IMPRESSION: 1. Old heaI~d displaced ft"actut"~ of the post~riot" right fifth rib. Th~r~ is n~ intrathoracic complication s~condary to acut~ chest trauma or displac~d right rib ft"actut"e. - THORACIC SPINE C2V): CLINICAL INDICATION: MVA April, 2000 with pain radiating to the upper back. The disc spaces and vertical heights of th~ v~rt~bral bodi~s are .aintain~d. No significant abnormal curvatur~ is s~~n and no oth~r abnormality not~d. I~IPRESSION: No ft"actur~ or other 5 igni ficant abnot"mali ty. SSIl kj 08/16/00 I I ~~,--,,"" ,~ Ie fit fit fit e' PROGRESS REPORT DATE: 10-6-00 PATIENT: Catherine Smith PHYSICAL THERAPY DIAGNOSIS: Thoracic Sprain/Strain 20 to MV A PHYSICIAN: William J. Polacheck, Jr., M.D. DATE OF INITIAL EVALUATION: 9-18-00 ATTENDANCE RECORD: 9 - VISITS 0 - CANCELLATIONS 0 - NO SHOWS TREATMENT PLAN (CURRENT): I. Instruct patient in home stretching program 2. Ultrasound to painful area 3. Soft tissue mobilization 4. Gentle vertebral facet and costa-vertebral joint mobilization PROBLEM LIST/FUNCTIONAL LIMITATIONS STATUS: Initial Evaluation Current 1. Right thoracic/rib pain 5,8110 1. Reported her pain on 10-5 was 8-9/10 and it started 1 Y, hrs. after she got up in morning 2. Intercostal spaces remain tender between 8th through H th ribs on the (R) 3. Same 2. Tender to pressure over the (R) 8-IOth ribs and Decreased trunk ROM 3. Symptoms worse in AM after arising or With prolonged sitting 4. Housecleaning that requires her to use the (R) upper extremity increases symptoms 4. Patient has resumed housecleaning. Working as much as 10(+) hrsJday PR~GRESS TO SHORT TERM GOALS: . ".L-Patient will be faithful to home exercise program .." . ~'2.necrease pain and tenderness to 2-4/10 . 3)' Restore normal tnmkROM .,., Ie e It lj ,-- hT"".i'''~''''-'''''''-'''''''''''''' MET NO PROGRESS P ARTIALL Y MET '.' PROGRESS TO LONG TERM GOALS: :\1. Restore full pain-free ROM <'2:' Decrease pain to 0-2/10 with ADL's and with her work as a domestic P ARTIALL Y MET NO PROGRESS 'TREATMENT PLAN/RECOMMENDATIONS: It does not appear that physical therapy has helped ':indecreasing her symptoms. Perhaps a TENS Unit would be helpful. Uyou have any questions regarding this patient's physical therapy program, please feel free to ". . c.o. nract me at our V al~e~reen Office. Thank you for referring this patient to our service. ~-Jr(~~_ 'Eric F, McCuen, PT. EFM/lr .. cc: Dr. Jerome Korinchak McCuen & Associates Physical Therapy, PC. 240 Grandview Avenue, Suite 101, Camp Hill, PA 17011/(717) 737.9818(8170 AdamS Drive. Suite 101, Hummelstown. PA 17036/(717] 566.8006 1790 Old Trail Road, Suite F. Etters. PA 17319/(717) 938-0584/5 Kacey Court, Suite 203, Mechenicsburn. PA 17055 FAX 737-2815 ~""'"r'l'\lI~,il 1-, ." , PATIENT NAME C,,)It,;, .5.. ,U; . DATE DESCRIPTION/DAiL Y NOTES SIGNATURE II lO/-2-/i "'. //;. /)>,,_ ,-1'<,- dn'- irJ <1#/,- vip ,- ./,4c /}7d,,7'/")<: -2- iYO :;>, - . [(. -11 II t7~"'7/! l-/,'c1f Me "nO" . (/ ,z-:,,;.. s.l.,,,K 'r ,7 I! k id.'/C\-e - <.-- ;(;: ..:s;::...-c- (f) h'7t1<,.~~, r;-) 11,"M.- CAy / c/: 5/.""7"- , ,.hr" <'''A'/?e~ r._<:"" iIv t:f'ah-r ~ ~'-,,,p...-c- /Jei lon/iO/J . / V- I II /P. o..pAc- k'.JT3-.. L V- S d?-;~. Irvn"'-- r,,/7, ACYl t? : CI Af-./AA./ C( "qrt' V<' :f?- j' -1~~r,,"-;-c-. A..e,."/:._ A 111 '-' s-/ . t-. / (/(/', }{a,,,,,,.. 'Dcs;J-/..n s ;;'.-o.'r/>~/4' I<Jh;~ 5if7l7/1C'1 h, ,,,,,,I <,,,.- i../ , /' / J /J .. l&Jakl, J-v " D; (f.or,f. v7, /- ,IT a", fl /l." W /-. . , /L" ,>'\. ':;<\'-V'C> "',,,-, '<..~ ~1.. -r:: ~ '<0-, I.. ~....Jl.( :>- -S-..-c.""-- jO-3-CJC' J t. '1 '1. ....-l.,P__ ~cY-<----7- .- DrJ-lV '--'~ /04-"-"-:;" - '!I o ."\s-. =,,--<'-<-- ~~.;\..- ~ -- b...{' ..e 7 \:. 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(/ v { ilIo , Meet/ell & ^.~_~oei:lICS J'hY_~i(7;i1 Tlh'r-:ll"" 1>,-' -'lI_~'J\a -~~. . , =~ .~ .......,...,~ _,",_,,,,w;.t".-- e~",,"~' .,'~--'^' ^'~ PATIENT NAME !ill L~H"cnl^L );,t'{\l '/--tv DATE Z;COD '), <:: it 05 ,~ , "'- '1~\'1~{)O DESCRIPTION/DAILY NOTES I SIGNATURE II C-<- ~::z-~~~<"'--... d." \.......<-~,~- """-0 '~.- ~~'&Lv ~ <',,'v----< ,. '':;'' , ~" '--:?\.... -, ~,>-,--~_.~<_. . \,~ "E.~ '-'''')'''~ \f'~ ir: ~ ...J'~-'-. J." ,I:. cf- e--Z u ('c. ',*-- . , o~-L..::J ~) .LLL--'- (} <77: ~ , ~;}.... G' '" t--c-~. O^LO- ,t, C.-.::l...\_OO ?: C"'Nt::\. ,~. ~..~'-.(, tn _.~ "--L.,\ "" -'->', , , <-'It:~ J2<-; \l......_ \..l." ,>-~ -1- .... ~ , 'S.-c-<--- T Lc,,____ ,L_i:... -n, '""\ c,..; "< ""'- h-'- \jL ~ il-c..-..JL f-,..)!_,fLJL ~~'iCF<;' t>-. " ~. .~--............. "-~ ,\. "~b ,< '" ~~........... ~ ---....:-c...-..-_~~ --:::. ~<:--!..- /,v-p-:t ,1,> l/.\, d cr- ;;>"(.,"'0 i'OJ::. l-Jc--J-c "'/~/ /c) 'u ---s.. A.-. -.:p .' Cf7\'1:t 1'-)$'-00 S.' \.,LJ c"-j, ;;/ .,,-.l...=-.. c- C..- '-v(:~:...L-..., YlA_t'.(;,<~ ~. \l'-l(\ \ ., . '. .//. ^"....::b.....-(:., --1VI....~ ~-( t.. OiU " I...I..':!-~v.. .w ft'l''Y'v<-''''' ',7~, ,- 1< ~ 7'(. ,- L-v~.cit:,.( ~'~/-.......-"" , 'Ie fl.kCucn & ^sso("i:I(('.~ l'hysio::lI '11., ; "1''-' 1'.1' ,- f~'.J'I!lf,!'Jj;'f,i~,,,,,~n i=,.._,^,~ -0' ~ !__ ,J P! - P"!__ ~~""~ ,~"_ ""p- ~,- IV' '::uen and Associates Physical Thera Evaluation Form Patient C~Wtv\..V ~{}h Dx CS94\-~-"-"..-c..~~,,,-,>~ Date cr.. (~-6'd Age Work/Status (~\.. ",~ ~lo"~,,-<c-'- Leisure , Date ofonset~~ \.. . \}oDO Prior Level of Function IV~, -<L~.~~"'L- c'''c~'~ ~'-"'- PastMedicalHist ry~"'" o\AL.. cQ,~ ~~-c- 6,0, 'k~.:>'---'~ i1j \'ill ....\.,..:...cO- c~ ~<'-?".:t.~....t........_ ~.,-,. . I ~ c.~:.k CurrentHistory-;:r~ 6~.:,. \ . "'..,~ ~...~ ~~M~j .~v~ c.-< -+ ~ \~-,- d'~_,,-- 1:( \"'- "c.~_\:",--.__ _.<~ be ....._--..:.\;\~-L-.c C.-<._ S\............. u.<....A,. ..(L-CL':'~ ~-<LLJ '~-lf.L or,{L~ ~<N~V -s'------ U c-"\, L::J <A..-r"",- S -<~ h.o_~ '\ ;~ <:0" '-"--<s. '\~ <--\ ~ . ""'.v"'--' r .. . ([I I j \.' . , III Numbn"" ... Severe Pain :r: Moderate Pain J, Shooting pa> O~ o 0 10': Pain ., I I I I I I I I I ,. . Scale No Pain Worst Pain Where did pain start?\\d>'C-.._-rJ<\G.~~ Where did it spread? 7 24 hours day l / Intermittent Increasing L-fS~ic t~ Decreasing_ Nature '\l.;.\..:, ""--......-..c~ Aggravates <;.'-.. " . L-L -;: . oS ,~., 'S \.. . ([I II '. '--"R\~~~~~_"""'I_ ,~ n. _. ~t!' . ~- r. Medications 1--4)><,-<---~ ~- ~,<r i k--~...i:.z- '''< '_'::- ~7 ~ 'U.\...~-,,'- ""---- Radiological >--~ c,L..-, ... Sk~_u ,--<C..- ~_ '7~.0- \l....\,., \'--y, ("--.;> L.\.( r~ '"'-r ._ Gait: Normal; Guarded; List L R; Limp b~; to and from chair guarded: ,c.fl?--<r " Sitting Attitude- constantly R L Ischium; Moves Posture /- / / Active Spina'! Movements: Restricted I- Blocked /1- Pain > , restricted X; Hypermobile CS'5LS F .......-y~:.. <:"'LC'\."-,--- ~ L..:.:> rL <:-' t"'..->;.->- C-C~"'" -" ....~~ ....~ 'S::.. ~",~ RR CS,TS,LS FB ----"'--,. /' /r SBL // ,7/ RR RL BB ,~ r'-'"~~~' .- ~1'~':IT"1"!'1-,,","'.'~ ~ ~ I, --'-- ~"--..._____ \lJ.--. '--" .\.~ "k- ~.A~ "\b -\I.-\"'0(\;' <-~ I \Lu..~-<- J0~~ ~~ ~<-="'-'- Long Term Goals (functional) I \ ~~ ~....JLL.""'~-""""'-"~ \k,,,,-,--- o p,.~,- C\-\.--<'~ '--"~{' ~ .~ c9..-0~'>..,.,"~ G~al~ discussed.ztith J'ati;~miIY:~ Freq.uency .~ y ~~Li P1 S'.gnaturc ~-' . ~ .A1 C Ld---.--S..."'\ '_ Date /-r:>- <~,,::::, "' \i:II Neurological: . ,r? 0 SLR: LE:fJ 70 REJ /,,0 Cx Flexion Dorsi flexion Reflexes: LJ-4 SI C5-6 C7 C5-6 Sensation R L~/0L Ii Knee JK Ankle JK Biceps JK Triceps JK Brac Rad L -...- - L~R~ L R_ L_R_ L_R_ . . Sacroiliac: Standing: PSIS L_R_ASIS L_R_ Sitting: PSIS L_R ASIS L_R_ Leg Length: .-::\ Supine & / Sitting Compression ~ Distrac\ion ROM i ^ IT-' v' '1-' L.-.- . .. I Strength t..A..\E L-::J y...... L . Girth p/^ . . l,. , 'W"""'>""'",""""""'_~~""'''><'''''"~'''._"_ J! C-, p' 'ltioll .,,-~~~ "-V'<--/ A~ ~":l~C] \)t/A..-, Y \- , Ii Ii , I '~ "'-' cl::.: ~. o. ('> ',\. <:; .J.--- 0.'" L ~- \L..! t;::,. ~---c-' - ~~'d"k'-'_~ .\....~ l)..'--~'o<- -~"""'-'U--__'" c.L~.~\...-_ ~j .~_ 4,-,"~~-'1 '/.- Tender ~Central Pain ''2: Spasm '- '--- ~~-.- -~ --, ~ ". f;.-4-C-<-- _':';~.:....~ -q -<,,>Q___~ 1--'-<."'-- \.. -<..0, . ~lL \/_~~~ r~~" d-. ~~t>> -vo:....-...:..~~ ---:S:-I....- ~~"-s::. o?_~-~ Recommendations: "-"-.":l. Time frame / t.,o\{ :to ~~~''-- 1'0 o~~ Time frame g <..::,\rio. Duration . .-<'Ai. V. 2: :r <.-0 I.C <;;: ~.:/. " ~,-~ 1l'~ ,,~,. . ~ ,~~"",_~r~~"'"' .. C~, (t~t f ,r'jll ( , j ff0f, Patient: 'Jb Year ',<1 )\V'\ I . \ :v Date er // s' '111 q 9bl 'l/:A) q;:"':l-~ Il/Z)" 2- On Initial Evaluation ~ V\'f' I I Ultrasound I ),~ (-\ <-_ L-/v~ ~ Co~ pulseci@ t,~~ ~\~ L.~...... {"",iAJ Intensity: . , .S ,~)"_-.:~ ~~~~f'~<....~.~\"."" ~ v---- ~ ---" ,/. - / V --:X-\- _ ~~ L./ - ----- I ~~\.{ ~Q.b \..l>..,. ~ V i-lr- 1;,(' I V s " ~--'L"--" ": \>", -\. '<t.., '..- . ~ V 1,\ '2 '\' / 9~r ',J Z'o --t~V Io-~ ij'FJjU '0"""15'0 ''''//.~, f'^..U- -0 I.C c::"" t:'.~~ ;<;.,......, ,<~ ;f"/5-,.,...,;;,'{.l- I . (I (I I (I I .. Total Treatment Time '?, 0 3.-;;:- l[!;, 10 '/.-" 55 Clinician Initial L [j//"l yJuff t;fj, ) I ~ 1<p.:jJ "7 fl1...-/' ~ 'l /1 r-/ , v '7.U , , ~ ) -, , 'It,-,~~ J.k L1\ > - , Clinician si81atuYe + 'ti ~ ill . (I . ,_ Inial! ~(rwL~ tlr'<J--AO ~li\ . 11?J- Cl1l1lclan SIgna re + Initial . - Me' Clinician signature + Initial c uen & ASSOCIates Physical Therapy, P.C. cum' . ~ Clan slgnat re + Initial ;j -:.-,,,,'f,,""""O='" ~_~ '~'_'f"""" r ! - ..- " ~~ .~~O 1 ~_,~:I .~ dl_ -,-~"","' '.~ iI!I Patient: C:-.-_"-<\-"..c'- '-....X..-- "--,-.\. \^~ y ear 1;$-(~':_:TC::::c.) .. Date /0/3 /<~ ~,,- Initial Evaluation / ~"-- 'S0~- "-" ~ /.- ~ "- ? 17'-<-:-- Ultrasound - " - pulsed<f~ ~C9' ,f,iJ;v{J1Ad o / /I'-<.""'z ,@ Intensity: "S,-,'/--,> %c>~\,- <(' -<<,p",~~ ~\""-<;. ~ ;t.~ ,';':.~ (~") ~~ // ;€d/.5<'> ~ X/.t T-c~ ~'--Gz V ,1(/" ,?Q~ .~'. ~k4"tL->~iJE: B( )<5'4) . .' ,A-R, Cd; 15 [/ . ' _\ ""'15 J>ur ./VI- U. 2':C~ <:;. C:>OLU~ ~'7" "'" v '..k- ~ . Jj,/- .~ e+-/a k~ ~ )1i-H- Pi / . J I I I I I I I I Total Treatment Time 30 /,ro I I Clinician Initial 2;;:4~/ 3vJto I <II '8 '8 . it it <II ,~ ~- Clinician signature. + I 'tial -J: A__~,f' /7'kc-,~- /r0~~ Clinician signature + Initial / Clinician signature + Initial McCuen & Associates Physical Therapy, P.c. Clinician signature + Initial <II '~,ffi.'IDf<R~."~l ,,~,---- T I -- "" ~, II'I!!" _.., .~ DATE: .ft NAME: 11 INSTRUCTIONS Indicate where your pain is located and what type of pain you feel at the present time. Use the symbols below to describe your pain. Do not indicate areas of pain which are not related to your present injury or condition. '. KEY I //I Stabbing xxx Burning I 000 Pins and Needles I = = = Numbness I . . . ~ . . II J ~ . ~ \ ) . \/ . lID \ J \-' . 11 " '"~'" -, ,1l'I ~ I: , , ~, ~^ ~ ~" -=~,~~""'~." 1~'C-' fJ ~ ~ .~ . . INITIAL EVALUATION DATE: 9-19-00 "PATIENT: Catherine Smith :PHYSICAL THERAPY DIAGNOSIS: Thoracic Sprain/Strain 20 to MV A PHYSICIAN: William J. Poiacheck, Jr., M.D. DATE OF INITIAL EVALUATION: 9-18-00 . . PROBLEM LIST/FUNCTIONAL LIMITATIONS: 1. Right thoracicfrib pain 5-8/1 0 2. Tender to pressure over the (R) 8-lOth ribs and Decreased trunk ROM 3. - Symptoms worse in AM after ari~jIlg or With prolonged silt iug 4. HOllscclc:ming that rcqlljl<'~s ht.~r (<.> use the (It) uppor extremity increases symptollls . TREATMENT I'LAN: 1. Instruct patient in home stretching program 2. Ultrasotllld to painful area 3. Soft tissue mobilization 4. Gentle vertebral facet and costo-vertebraljoint mobilization . .' .:.RECOMMENDATIONS: None at tltis time : SHO.RT TERM GOALS: (One Week) ; L Patient will be faithful to home exercise program '.' ...2. Decrease pain and tenderness to 2-4/10 >/i '.,.;:,: ...3~R~store'nonnal trunk ROM -."",/:;.:,.',::.:'. . {:;L;;?;"!~ONG TERM GOALS: (Three Weeks) 't' ..1,;<:,: ;.,>:"." ;.'~,i::: '.,,;:-. " . ..;;;-;,,:;>>....,.'ii[L:.Restore full pam-free ROM }iii:::.;,~:i,jji;:Decrease pain to 0-2/10 with ADL's and with her work as a domestic ::~7.:~: ~-::>;;.~, ~,../ ~~\,':: '. '. '. .W::', i\..t;;\FREQUENCY IDURA nON: Three times a week for three weeks :~~J}~!{'Y:;:'X<:dtt.~;~::.~;{~' . ," ;1:\:\'i~{;~~~~iAj~ you fo; referring this patient to oUr service. Should you have an?, que.stio~s or fnrther . ::;::'!'$%!wmendations, please feel free to call onr Valley Green office. ThIS patIent s complete evaluation form . ~}{fis~<:l\~abletouupon r\'<luest... . ...... . ", "i'i"',,-, ./ ~( ~ <,.:', .....\.,:,~.~ f~ '. 7'Sf ~~. ":r'~'" :"""""'.~*f.:"''''''''''''' - "'""'-"- '71)3tf~i1;~:::;'j:~:J "..' ~'Y.l~: . .",...,...,.......,.Enc.F. McCuen, P.T. f{~\\i!.~~~w~~~. . ,~~~.'."n';l>:Jl;~!:l~bi..& ,1(;... :~I~:~j;.::''''~t~...\i::$'F"i':,~:';:r..: ~. .. 'J<.~~;~\.::.<;;.:.i,.1:..1.::,.i'l".'(~ .:: ' ' . ...;~F,?;~:':~'i\!i,F'J?r. Jerolt)e Kormchak II:... !,;... ...~;., .... " McCuen & Associates Physical Therapy, PC. , :,i.:', '240 Grandview Avenue, Suite 101, Camp Hill. PA 17011/1717) 737.9818/8170 Adams Drive. Suite 101, Hummelstawn. PA. 17036/(717) 5uB-8t.'OO ':".:.:';:;~' 1790 OLd Trail Aoed. Suite F, Etters. PA 17319/0111 !3'38.QS84/5 KneEl,! C<')\j"'t. Suitn 203. Mr.chonicsollr'l. PA17(l~5 FAX 737-2B"lS ~ . . . . . . . . . . l~,~r..<c..1 ..t .... \..,; . ~ ,) . I.j') THOMAS t I. MAUN, M.D., F.A.C.s. MD~0878{)"E JOHN S. RYCHAK, M.D. MD-013473.E WILLIAM J. POLACHECK, JR., M.D. MD-025240-E BALINT BALOG, M.D. MD-027512-E CRAIGW. FULTZ. M.D. MD-D31422-E ERNEST R RUBBO, M.D. MD~029545-E ROBERT T. MAURER, M.D. MD.(l29J9fj.E SAMUEL). AMUSO, M.n. MD-tI0800i-E Qfficos, C1mp HilI 761-8644 Harrisburg 234-5976 Hershey 533-2348 REFILL S 0 ,/ JRTI-IOP AEDIC SURGEONS OF CEf ZAL PA, LID. C ~~ 'S.--Dtf!.. NAME ADDRESS "-'l((J ~~- i'):~ DATE (, "~' J~~.v1 ........., o T1<V'L~ ~~ -f:::'"(~''f:- G~ U/\jl. )..C <>>-f /-(0 cj}c'~J 2.0 -t<. /'A V A , . ,,'Ir-: 0 ~~C:--'\ c~Cy <r <;G.JJCY-.;...l U "}' <.~ I SUBSfITUTlON PERMISS'BLE .~ .r I ')~~A I M.D. IN ORDER FOR A BRAND NAME TO BE DISPENSED, THE PRESCRIBER MUST HANDWRITE "BRAND NECESSARY' OR "BRAND MEDICALLY NECESSARY" IN THE SPACE BELOW. 234 OEA< . . . . . . . . f' "" lit ,,_?~~- .m~# m~ ARLINGTON REHAB & SPORTS MEDICINE Steven E Morgans/ein, 0.0. Michael J. Woods, 0.0. 02/05/2001 David Lutz, Esq. Angina and Rovner, P.C. 4503 North Front Street Harrisburg, Penna. 17110-1708 RE: CATHERINE P SMITH D.O.A. 4-11-00 'Dear-Attorney Lutz: I am writing in response to your letter dated January 29, 2001 regarding Ms. Catherine Smith. Ms. Smith was seen in the office for initial evaluation on November 8, 2000. At that time she presented with the Chief Complaint of chronic mid back pain as well as pain radiating along the right lateral and anterior rib cage. Her symptoms occurred as a result of a motor vehicle accident on April 19, 2000. Prior to the evaluation, she had undergone an MRI study which revealed evidence of a disc protrusion at the T9-T10 level. She had apparently undergone a prior thoracic MRI in 1997 (prior to the accident) where she was noted to have similar findings. Additionally, she was noted 'on x-ray to have an old healed displaced fracture of the posterior right fifth rib. My impression at the time of her initial evaluation was that of thoracic strain, right rib strain, and aggravation of T9, TIO disc protrusion. She was started on Celebrex, and additionally referred for an epidural steroid injection. At the time of her follow-up on 12-13-2000, she reports that she was doing better. She responded well to the injection and although still eA~eriencing some back pain, she is no longer experiencing any radiating symptoms. At that time, she was recommended to undergo a second injection as well as to continue with a home exercise program. She has not returned for any additional follow-up since that time. I believe that Ms. Smith will need to continue with a home exercise program to improve spinal musculature flexibility. She additionally at times may require repeat epidural injections if she should experience any further radiating type symptoms. Overall I feel that her prognosis is fair to good, Cost of future treatment will be dependent upon her need for follow-up visits as well as injections on an as needed basis. 805 Sir Thomas Court. Harrisburg, PA 17109. (717) 652.6623. Fax (717) 652.2630 "!lUll'll. ,. ,- . RE: CATHERINE P SMITH 02/05/2001 Sincerely, s~ 11rJ:s tAC. . Steven E Morganstein DO . . . '. . . ,. . '~ SEM/cj Dictated but not read. Ene: Chart copy ~,,!';'liIl!'!l\!'~""" ~ , -. , ~ -""' ~~" ,. m.~J# m~ ARLINGTON REHAB & SPORIS MEDIONE . Steven E. Morganstein, 0.0. Michael J. Woods, D.O.. 'r.e 11/08/2000 . Jerome Korinchak MD 503 Bridge Street New Cumberland, PA 17070 GX\l~ RE: CATHERINE P SMITH . Dear Dr. Korinchak: . I would like to thank you for referring Ms. Catherine Smith for physiatric evaluation. As you know, she is a 48-year-old female with chief complaint of chronic mid back pain. She additionally describes pain radiating along the right lateral and anterior rib cage. She indicates her symptoms occurred as the result of a motor vehicle accident on April 191 2000. At that time she was the restrained driver of a vehicle that was rear-ended while stopped at a traffic light. She reports the other vehicle was traveling approximately 35 to 40 mph and there was enough impact that it pushed her car into the intersection. She actually reports that she had already been scheduled to see you in the office that day and additionally was scheduled to undergo a neck surgery about one week later. She in fact did undergo what appears to be a cervical laminectomy performed by Dr. Moore for some chronic neck pain. She reports that this did help. It was around the time of her surgery that she actually also began to experience increased mid back pain. She denies having. any history of thoracic or rib pain prior to the motor vehicle accident as all of her symptoms previously were in her neck. . . . Ms. Smith reports that she was referred to Dr. polachek for orthopaedic evaluation_ She underwent a three week course of physical therapy at McCuen and Associates which did provide her short term temporary relief. She was referred for an MRI of the thoracic spine which I reviewed today. There is evidence of a small right sided disc protrusion at the T9-T10 level. There is mention in the report of a prior thoracic MRI done in 1997 and the report indicates that the present findings are unchanged from the previous study. She also presents today with x-ray studies of the chest and right ribs dated August 16, 2000. There is evidence of an old healed displaced fracture at the posterior right fifth rib. She again denies any previous trauma to that area or any known history of rib fracture. She actually at the present time denies any symptoms along that area. She reports she has had no additional recent treatment or testing. I Ii- I I , ~ Past medical history is significant for hypercholesterolemia. She is i i i , I I. I I 80S Sir Thomas Court. Harrisburg, PA 17109 . (717) 652-6623. Fax (717) 652.2630 :''''''~~~~'!'!<'I~_ =~o,l!l - ,-~....- ~ . " " if . ,if " . ,. It ,~~ RE: CATHERINE P SMITh 11/08/2000 presently taking Lipitor, premarin, Tenormin, and Celexa. She has been using Advil or Tylenol as needed for pain. She has known allergy to Aspirin. On examination, Ms. Smith is a 5'21', 155 pound female who does not appear to be in any acute discomfort. She ambulates without any evidence of an antalgic gait. There is localized tenderness noted in the lower thoracic region on the right side in the area of T9 through Tl1. There is no evidence of any paravertebral muscle spasm. She additionally has tenderness on palpation extending laterally along the lower ribs and into the anterior rib region. Light touch sensation appears to be intact. Lower.extremity neurologic testing reveals intact sensation and full motor strength. Deep tendon reflexes are equal and symmetric. There are no long tract signs. Additionally on palpation over the upper thoracic region and the upper ribs, there is no evidence of any discomfort or spasm noted. There is no scapular winging or muscle atrophy. It is my impression at this time that she primarily sustained a thoracic and right rib strain as a result of the motor vehicle accident on 4/l9/00. She does have a right sided protrusion at T9-TlO which although present prior to the accident appears to have been aggravated by the accident. I believe this can explain more of the radiating pain that she has been experiencing along the right rib cage. I believe that the fracture at the fifth rib is an old finding and not directly related to this accident. Given her lack of response to physical therapy, I believe at this point she would benefit from a trial of an epidural steroid injection to the T9-TlO level. I am also going to start her onto Celebrex lOOmg one tablet b.i.d.. She has been scheduled back for follow-up in about 3 to 4 weeks to see how she did following her initial injection and. I will make further recommendations for her at that time. Thank you once again for referring Ms. Smith for evaluation. Sincerely, s~ I(~~- b-O. Steven E Morganstein DO SEM/sf Dictated but not read ;-~"-I- ~ -~ --- November 6, 2000 RE: SJlITH, CATHERINE 2615 Grandview Drive Yorlt Haven, PI. 17370 47 10GB: ss#: 182 46 3905 STUDY: Mal thoraoic Bpin. REFERRING PHYSICIAN: Jerome Korinchak. MO CLINICAL HISTORY: Back an4 right rib pain. Mal PULSE SEQUENCES: Saqittal T1 T2 Axial T2 1) 2) COMMENTS: comparison i. lIlad. to a thoracio 'Pine Hal: pertormed in ~. , --'" The thoracic cord demonstrate. normal morphology and .iqnal character. There is nonaal vertebral body aliqnment. Thera:.t. no 10.. of intervertebral body heiqht. Minor disc apace narrow1~q is pre.ent at T9-10. Bone marrow .i9nal is within nonal lilllt;a. Axial imaging again reveals a small riqht paracentral 4iao protrusion at T9-10. This do.. al:lut the right aide of the cord. There is no signif ioaot spinal or foraminal stenosis. AlloWUIq for 4ifference. in teohnique, I do not identify llny appreciable ohai1q.. The remaininq levels show no <Iisc abnol1llality. spinal or fOlr..1na.l atenoeis. CONCLUSION: Stable and .mall right paracentral 4isc protrusion at T9-l0. Thank you for referring this patient to us. sincerely, -~ V"c- 'i'.. Paul S. Petek, M.D. PSP/lcm 2\3\3:01'-1 ~O/W: Q 6f:n OO/90/~~ a liIi NOV-07-2000 rUE 12:59 PM Smith Radiology.Inc. Fax:717-774-7529 p, 02 .... . . . DIII~e "'OdlOlotY ~y Il~ C.T. Scans ~UI.I. . " 1S15 Brid;.o aL New Cun>b..la~d, Ph 17070 (717) 774-7351 . :. liS W.lnul 51. .\.1mersburg. fA 17061 :717lb9l-:lU!I7 . 16 South River ltd. flel;r..., PA 17032 :717) 8!l1\.3352 . WlO Cl>ombors Hill Rd. lI.rrisbu"" p" 1711I .717) 561.lI02Z '. . :)~~p- "~jMlII FAX NO, Nov 7 'l 11:46 P.02 ~,ie.~ ~lTH RADIOLOGYt INC. D-r NC3~ RllgU5t 1&, !tiN Slro.. Korinchak, M.D. Groonhill F~.ily P~~oti~. 593 Bridg. Str..t New eu.berland, PA 17071 REt Catherln. Slith 551, IIlt'!-4G-39tJ5 DAT~ OF EXAMI 08/16/80 Dear Dr. Korinchakl Rd. CHEST AND RIGHT RIBS (SV), \ CLINICAL INDICATION, "VA in April. 2000. ~ radiating to the uppar D~~k. II hor. i. an old healed fracture of the posterior aspect of the right fifth ; ib. The rest .f the rib cag. 15 intiet. There is nO intrathoracic c.mplication ..~o"dary to chest trallla. The ~ardiQ..dla,tinal eOntollri, intrapul..nary v....l. and pul.onary parenchyma are n.rlal, There ara no pleur~l effusions. Right antarior rib p~ln t~PRESStONI t. Old hpaled dl.placed fraeture of thl po.terior right fi ftk ,..lb. TIler. i. no. intrathoracic c..pliC';oH... .econdary to acute che5t trau.a or di~plac.d right rib fl"a~tUt~9, THDRACIt SPINE (ZV); CLINICAL INDICATION: ~VA April, f000 with pain radlatinR to the upper back. The disc spaep5 and vertical heights of the vertebral bodie. ar~ .aintained. No significant abn.r.al curvature is seen and no othe,.. Ilbn.....ality IIOhd. l~ESSIQNI NO fracture .r .ther significant abnor.ality. M.D_ !Sl5/1kj 08/1!'./00 - ".' ~., -.--'''''"'"1'' ~.,I!'I_~ J""""~H" _ w._~__"~~-'_' -- "~ lit {I {I " . .. {I . . " ~i:~:~.~__ ma~ ARLINGTON REHAB & SPORIS MEDICINE Steven E. Morganstein, 0.0. Michael J. Woods, D. 0. 12/13/2000 Jerome Korinchak MD 503 Bridge Street New Cumberland, PA 17070 RE: CATHERINE P SMITH Dear Dr. Korinchak: MS_ Smith returns for follow-up in the office today_ I am happy to report she is doing significantly better. She got good benefit from her epidural injection. She still has some pain in the thoracic region but no longer is experiencing any radiating pain around to the anterior chest wall. She reports she has had at least 50~ improvement in her symptoms. She still gets some discomfort when she does more physical activity and particularly reports some problems when lifting her grandchild. Examination at this time reveals improvement in her range of motion and she has less tenderness. Her neurologic testing is within normal limits. Overall, I am quite pleased with her response to her initial injection. I did discuss with her today the potential benefits of a second shot. She would really like to go through with this after the holiday season. I have explained that typically individuals with response as she has had to the first shot will get even more benefit from the second injection. I have also encouraged her to continue with a regular home stretching program. At this point, she is going to contact the office if she develops any increased symptoms and I will see her back as needed. .. Sincerely, Steven E Morganstein DO SEM/tld Dictated but not read 805 Sir Thomas Court. Harrisburg, PA 17109. (717) 652-6623. Fax (717) 652-2630 ~ ~I'- - r~ , Th, Ar.in~~~r GmUD @ :. .. .. .. .. .. . .. .. .. "~. "01:0" r'......l,i}1:D ,D",~-" f .:o.....J HEAL THSOUTH Rehabilitation of Mechanics burg Acute Rehab Hospital 175 Lancaster Boulevard Mechanicsburg, PA 17055 SPECIAL PROCEDURES CLINIC Malik N. Momin, M.D. - Medical Director (717) 691-3731 (717) 691-3858 - Fax PROGRESS & PROCEDURE NOTE ^ d -. .,-,'~ J,c~l u j ~;';vi Patient Name: Catherine Smith Date: 01/03/01 PROGRESS: Mrs. Catherine Smith returns for follow up today, following a thoracic epidural steroid injection on 11/15/00. As you know, she is a 48-year-old lady who gave a history of being involved in a motor vehicle accident during which she was struck from behind. The patient had twisted her back and then developed pain that radiated from the right side of her mid-back up front almost to the sternal area. Imaging studies showed evidence of paracentral disc herniation at the level ofT9- no. The patient reports that the injection did help her. She still has a certain amount of pain. The injection might have reduced her pain by about 30-40%. She would like to have a second injection to help her further with the pain problem. She presents today, as requested by Dr. Steven Morganstein, for a second thoracic epidural steroid injection. EXAMINA nON: Upon palpation, there is minimal tenderness over the paravertebral muscles at the level of T9 and no bilaterally. Much of the soft tissue tenderness at the level of T6 and T7 and at the mid-axillary line has improved. Range of motion of her bilateral upper extremities is within functional limits. Muscle strength is 5/5 in all the muscle groups of the bilateral upper and lower extremities. Reflexes are 2+ and symmetrical in bilateral upper and lower extremities. Sensory examination is intact in all the dermatomes of bilateral upper and lower extremities. PROCEDURE: The patient ~amily member _ has been informed of the risks and benefits of the planned procedure. ."- rT f-' 1, - ~~- ~.~ "',.>>='" H. It . II . . it II . '. Ii . 7il!~~L. __~ -:.;. 02/06/2001 Jerome Korinchak MD 503 Bridge Street New Cumberland, PA 17070 RE: CATHERINE P SMITH Dear Dr. Korinchak: Ms. Smith presents for an unscheduled office visit today. She called the office yesterday with complaints of increased mid back pain. She additionally describes radiating pain and numbness around the right chest wall region. Since her last visit she has undergone a second epidural injection. She reports about two weeks worth of good pain relief, however over the past week or so her symptoms have increased. She reports that she takes Celebrex. Examination today reveals localized tenderness across the thoracic region, right greater than left. There is localized tenderness specifically along the mid to lower thoracic region. She additionally has tenderness on palpation across the right lateral ribs. She additionally describes numbness to light touch sensation. At this time I will start Ms. Smith on Neurontin, 300 mg. I PO t.i.d. I will also have her obtain a TENS unit to try to help with chronic pain management. I will see her back for follow-up in three weeks or so to see how she is progressing. I will also consider additional chronic pain measures at that time if she is still symptomatic. Sincerely, Steven E Morganstein DO SEM/ cj Dictated but not read. -1 "~ ~~ .. ~ March 20,2001 ' lit Jerome Korinchak, M.D. 503 Bridge Street New Cumberland, PA 17070 PATIENT: Catherine Smith ACCT #: DATE OF EVALUATION: 3/20/01 ill Dear Dr. Korinchak: .. .Ms. Catherine Smith was seen for follow-up in the office today. I am happy to report that overall,. she is doing significantly better. She reports occasional minimal amounts of mid- back pain, but otherwise, her symptoms have been under good control. She denies any further radiating pain into the anterior chest well region. She's had good benefit from her TENS unit and additionally feels that the Neurontin has been helpful, although this has caused her some sedation. " PHYSICAL EXAMINATION: There is some minimal localized tenderness along the mid to low thoracic region on the right. There is no evidence of any associated muscular spasm. She has good trunkal rotation as well as forward flexion, although with slightly increased discomfort. There is no evidence of any neurological deficits. ,. ASSESSMENT/PLAN: Overall, I am quite pleased with Ms. Smith's current progress. I have encouraged her to continue with her home-exercise program as well as continued use of her TENS unit. I have recommended that she gradually try to wean herself off the Neurontin, initially eliminating one of her daytime doses. At this point, I will see her back on as-needed basis only. ,. Sincerely, ,. ga ein, D.O. edicine and Rehabilitation SEM/lma . Dictated: Transcribed: 3/20/01 3/22/0 I 'f . ;~lfK,!, :,,/w '! ~, ~ pRISM Physicians "-{ Rehabilitation, Industrial & Spine Medicine, p.c. A Sl'r(lm1ll ,~,. ,I/t./,...,f Sa\'l.....; '0 RWl'r..lh.. (Ju,rllf\"~('!I;" Physic"IMl1dicil1e Rehabilitation Elet:tro?iagnosis ,:. :'. ,-\~ ,x~ik,; "V\iil'iA1i, \\-~V.~~: '. Michael F. Lupinacci, MD Si Van Do, MD William A. RoUe., Jr.. MD Daniel C. OcFalcis, MD Eve-fen C. Hills, MD, "MS 175 l:mc,lSrel" Boulcvard P.O. Box 2023 . . Mechanicsburg, PA 17055< Phone 717 691-37S5 Fax 717 691,3834 450 Powers Avenue Re:rf EnErana Harrisburg, PA 17 I 09 Phone 717 561-4242 Fax 717 561-4903 '. p ,,~~ .~ February 18,2002 .. Jerome Korinchak, M.D. 503 Bridge St. New Cumberland, P A 17070 i. RE: ACCT #: DATE: CATHERINE SMITH 21892 2/18/02 Dear Doctor Korinchak: . Catherine Smith returns for follow up in the office today. She was last seen nearly one year ago. At that time she was doing fairly well. She reports she continued to do well until about two and one half months ago when she began to experience increased mid back pain. She describes pain primarily along the right mid thoracic region with some pain radiating along the right ribs. She denies any numbness or tingling She denies any low back symptoms or any lower extremity involvement. She reports she was unable to tolerate Celebrex as it caused some GI upset and she has been utilizing Advil. .. PHYSICAL EXAM: There is tenderness on palpation along the mid to lower thoracic region, extending from T7level down to Tll. There is a mild degree of associated muscular spasm on the right as well. She additionally has tenderness across the mid to lower ribs on the right. She does have slight increased discomfort with deep inspiration. There is no evidence of any splinting. There are no neurologic deficits. .. IMPRESSION: T9,nO disc protrusion PLANS: .. Ms. Smith has previously gotten benefit from epidurai injections. Her last shots were done greater than one year ago. I am going to refer her to Dr. Rolle to undergo an ESI at the T9, no ievel. I am hopeful again this will provide her with significant pain reiief. I have given her some samples ofMobic to try as well and encouraged her to continue with home exercises. She will be seen for follow up after her initial shot. .. Sincerely, S.t..I'&-~ ~~ Steven E. Morganstein, D.O. Physical Medicine and Rehabilitation .. SEMlkts Dictated: 2/18/02 Transcribed: 2/25/02 . ,. ~,'~ill<~ >~r-( I' . 1 ) . V pRISM Physkians (If Rehabilitation, Industrial & Spine Medicine, P. If SrcrlnHu ~r M{(I/((rI Srrl'l(n III No/prr the Quo,tal' ,.f 1.~lj.: Physica!Medicine Reh<lbilitation Electro?lagnosis ..,.~.. ....'1)';........ .'.y........ "( :~l '.; '.. " Michael E Lupi/l.1cci, MD Si Y.11l Do, MD William A. Rolle, Jr., MI) Daniel C. D~Falcis, MD EVccctl C. Hills, MO, tv'lS Steven E. Morganstcin. DO Julia Deputy, PA-C Jennifer L. T.1ll11l't, PA-C Rebecca H. 'Lingenfeltcr. P^~C Vincent J. Reed, PA-C t'vtJria Trees, PA-C 175 Lancaster Boulc\'Md P.O, Box: 2028 Mechanicsburg, PA I !055 Phone 717 691-3755 Fax 717 691-3834 ' 450 Powers Avenue Rear Entrance Harrisburg. PA 17 I 09 Phone 717 561-4242 Fax 717 561-4903 www.prismdrs.com email: inFo@prismdrs.colll .~~ ~~._~.,.".,..-. PROCEDURE SYNOPSIS .~ pRlSf'1 It .. PATIENT: ACCT #: CATHERINE SMITH 21892 DATE: 2-28-02 Physicians of Rehabilitation, Industrial & Spine Medicine, P_< PROCEDURE NAME: THORACIC EPIDURAL STEROID INJECTION, PARAMEDIAN APPROACH WITH FLUOROSCOPIC GUIDANCE . PHYSICIAN REQUESTING PROCEDURE: Steven E. Morganstein, D.O. CLINICAL SCENARIO: ~9 year old female with a history of back pain since the motor vehicle accident in April of 2000. Later on in the year she had an MR1 of the lumbar spine which demonstrated disc protrusion at T9-10 pushing paracentrally to the right. She states she has pain in her low back which mdiates to the anterior aspect of her right trank and also occasionally down the lateml aspect of her right thigh. She denies persistent weakness or numbness in her lower extremities. She denies bowel or bladder dysfunction. She was evaluated by Dr. Morganstein who felt she would possibly benefit from an epidural steroid injection. ,~ Spurnl11/ of ,I,{~di[ill SCl'1Iias /0 Rw.orr the Qllulll} of [~f" Physica!Medicine Rehabilitation Electrodiagnosis . . PAST MEDICAL HISTORY: Significant for hyperlipidemia, hypertension. Mich,ld E lupinacci. i'vI[) 5i V:m Do, MD Willi.lln A. Rolle, Jr.. :\10 Oanid C. DcFaki:i, MD Everett C. Hills, MD, MS Steven E. Morganstein, DO . MEDICATIONS: She is on a diuretic plus Premarin, Lipitor, ES Tylenol. ALLERGIES: Naproxen Sodium, Aspirin, Tetanus Toxoid. SOCIAL HISTORY: She has a 5 pack year history of tobacco use. Denies use of alcohol. Julia Deputy, PA-C Jennifer L T:mocr, PA-C RcbccCl H. Lingcnfdter, PA-C Vincent J. Reed~ PA-C iv[,lria Trees, PA-C . PHYSICAL EXAM: 5/5 strength in all muscle groups of the lower extremities. Reflexes normal and symmetrical in the lower extremities. Sensation is intact to light touch throughout the lower extremities. Straight leg raising is neg~tive bilaterally. . DIAGNOSIS: Thoracic disc injury. ANESTHESIA AND FLUIDS: None. [75 Lancaster Boulevard P.O. Box 2028 Mechanicsburg, PA 17055- ,. LEVEL(S) INJECTED: Right T9-1O. Phone 717 691-3755 fax 717 691-3834 APPROACH: Paramedian. FINDINGS: After appropriate needle placement injection of contrast demonstrated flow into the epiduml space flowing both cephalad and caudad to the needle tip. No vascular spread was appreciated. -+5l) Powers AVt::llllC ReaL' Entrance Harrisburg, PA [7 J 1)9 . Phone 717 561-4242 Fax 717561-4903 .. www.prismdrs.com cm;.lil: info@)prismdrs.com '""[t."",_ ~, . ,~" ~, -- ~~ -', ~ r !;. "1' ~Wf"~' it Page 2 Catherine Smith 2,28,02 ,. . The patient was prepped and draped in a sterile fashion in the prone position after infoffiled consent was signed and all patient questions were ~nswered including the risks, benefits, alternative treatment options, and prognosis. The risks include but are not limited to infection, alkrgic reaction, nerve damage, paralysis, epidural hematoma, syncope, headache, respiratory or cardiac arrest, and scar formation. All vital signs were monitored prior to, during and after the procedure. Oxygen saturation was also monitored and noted to be greater than or equal to 92% throughout the procedure. Cardiac monitoring revealed normal sinus rhythm. The patient was lightly sedated prior to and during the procedure via IV infusion with the anesthesia noted above. " Using the AP projection, the level noted above was identified under fluoroscopic visualization and the soft tissues overlying tlus structure were infiltrated with 2-3 C.c. of I % Lidocaine without Epinephrine. An 18'gauge, 3 Y," Tuohy needle was inserted down to the posterior-superior aspect of the inferior lamina and tllen "waiked off' superiorly into the epidural space. The epidural space was localized ,vith loss of resistance teclmique and negative aspirate for CSF or blood. A 1-2 c.c. volume of Omnique-240 was injected into the epidural space and flow of contrast was observed to confirm needle position. Radiographs were obtained for documentation prnposes. A 10,c.c. volume of fluid containing I c.c. Trianlcinolone (80 mg/ml), 5 c.c. of l% Lidocaine without Epinephrine and the remainder of the normal saline without preservatives was mixed. Initially, 4 c.c. of this solution was injected as a test dose. When after 60 seconds there was no weakness or numbness in eilller lower extremity, the remainder of the solution was injected into the epidural space. . . The patient tolerated the procedurc wcll and was discharged after an appropriate period of observation. If there are any complications. tlle patient was instructed to callus. The patient is to follow-up with the referring physician as noted above within one to two weeks. . ,FAAP]\I[R, FAAEM, DABPM ehabilitation . W ARljah Dictated: Transcribed: 2-28-02 3-1,02 '. . " .'~~[l~__ Co'- "-r~ . . . . . . . . . . . P"\ TrENT: i\CC'T: CATrmRINE SMITH IJ\TF: 2-28-112 21892 ,:!it ) OUTPATIENT RE-EV ALUATION II PATIENT: Catherine Smith ACCT #: 21892 DATE OF EVALUATION: 3/18/02 . HISTORY OF PRESENT ILLNESS: Ms. Catherine Smith was seen for follow-up in the office today. She is now about 2 weeks SIP thoracic ESI and reports that she is doing better. She continues to have some pain across the mid to lower thoracic region, but reports that she feels as though her symptoms have improved after the shot. She continues to utilize her TENS unit 'II . PHYSICAL EXAMINATION: She is able to ambulate today without any evidence of an antalgic gait. There is localized tenderness noted extending from the T9 level down to the thoracolunlbar junction. There is no evidence of any associated muscular spasms. Neurological testing is within nonnallimits. ASSESSMENT: T9-l0 disc protrusion. II PLAN: I am going to hold off on having her undergo any additional shots at this time. I have encouraged her to continue with her regular home-exercise program. I am also going to give her some samples of a Lidoderm patch to apply directly to her area of pain. II I will see her for additional follow-up in 3 months. She is to notify the office prior to that time if there are any additional problems. If her symptoms increase, perhaps then an additional injection will be indicated at that time. II S~4-~ ~~ Steven E. Morganstein, D.O. Physical Medicine and Rehabilitation SEMIlma II Dictated: Transcribed: 3/18/02 3/20/02 II ,II ,1~'~,"'1""_' ~,~m I'" . , r-, . . . ~ P~1 Physicians of Rehabilitation, Industrial & Spine Medicine, P.c. ;[ SprClflml "f :H,ilir,]1 Srn'irr, 10 N.(JI~"r du QII,dlf.V <;( I.~f;" Physical Medicine Rehabilitation Erectro?iagnosis Michael F. Lupinacci, MD 5i 'I.1n Do, MD William A. Rolle, Jr., iv'ID Daniel C. DeFalcis. MD Everen C. Hills, Mo, MS Steven E. Morgansrein, DO Julia Deputy, PA-C Jennifer L. Douty, PA~C Rebecca H. Lingenfelter, PA-C 175 Lancas[cr Boulevard PO. Box 2028 Mech;l,nicsburg, PA 17055 Phone 717 691-3755 Fax 717691*3834 450 Powers AI'enue Rear Entrance Hmisburg, PA 17109 Phone 717 561-4242 Fax 717 561-4903 _0;<' ~ . . . . . . . . . PHYSICIANS OF REHABILITATION, INDUSTRIAL & SPINE MEDICINE, P.e. 45O POWERS AVENUE (REARl, HARRISBURG, PA. 17109 PHONE: (717) 561,4212 FAX: (717) 561,4903 C ' \ '~ STEVEN E. M~G~IN> ~ OS00866f.N. I II r<-. ~ NAME: 0. '\ Q ~ I Y\.L . t'i\\ DATE: ~ ADDRESS: , ,-__ - -.- __'_ - - _ _~ DL\GNOSIS: Rx L ~ cia cUI N\ ~Q. --\G \\~ 77lo tV'-~ +0 ["'--.-- '",-ck -,,"-~11 A ~/??c~/ /2--><< ..ff ~';,';;".,'::;",," ~,;~"U SUBSTITUTION PERMISSIBLE UNLESS BRAND NECESSARYIS INDICATED ON PRESCRll'TION "- -----r--- /7(1 (~~(l f C/ 1){Ltte.",J if 5L( :, ' HEAL THSOUTH Rehabilitation of Mechanics burg Acute Rehab Hospital 175 Lancaster Boulevard Mechanicsburg, PA 17055 SPECIAL PROCEDURES CLINIC Malik N. Momin, M.D. - Medical Director . (717)691-3731 (717) 691-3858-Fax INITIAL PAIN MANAGEMENT EVALUATION . Patient Name: Catherine Smith Date: 11/15/00 . Referring Physician: Dr. Steven Morganstein DIAGNOSIS: 1) Thoracic radiculopathy. 2) Displacement of disc, thoracic (T9-TlO). 3) Degenerative disc disease. . " mSTORY OF PRESENT ILLNESS: Mrs. Catherine Smith is a 48-year-old lady who gives a history of being involved in a motor vehicle accident, being rear ended while in a car. The patient reports that she twisted her back and had sudden pain in the mid-back that radiated from the right side of the mid-back underneath her arm and up to the front of her chest. The pain has since been persistent. She describes the pain as a constant sharp shooting sensation that shoots from the middle of her back up front to her chest and into the sternal area. (She has had neck problems before.) She reports having a numbness in her right upper extremity from the right shoulder to the right hand. She has difficulty using the right arm. Any activity with the right arm makes the pain worse. She has tried pain medications, but these only help take the edge off the pain. Lying down onto the left side or lying on her stomach helps to relieve some of the pain. She has trouble falling asleep and tile pain also wakes tler up at night. She gives no history of weakness in her upper or lower extremities. No history of any bladder or bowel problems. " " PAST MEDICAL mSTORY: I) History of cardiac arrhythmia. 2) Chronic bronchitis. 3) Hypertension. . PAST SURGICAL HISTORY: 1) Cervical spine fusion in Apri12000. 2) Hysterectomy in 1997. 3) Umbilical hernia repair inthe 1980s. 4) Hemorrhoidectomy. _(l'c.~"~(\ \Jill" . . ,) w ,0 ~~ .,_" ",__.JI....,. p- r r ~, .iIll Initial Evaluation Catherine Smith Page 2 CURRENT MEDICATIONS: Premarin, Atenolol, Celexa, Lipitor, Celebrex, and ES (I Tylenol. ALLERGIES: First aid cream - causes hives. ,. FAMILY/SOCIAL HISTORY: The patient lives with her spouse, daughter and granddaughter. She is self-employed. She is still working full time. She smokes about 3-4 cigarettes a day for many years. No history of any alcohol abuse. .. REVIEW OF SYSTEMS: No history of headaches. No history of blurry vision. No history of sore throat. Gives history of chronic bronchitis. Gives history of a smoker's cough. No history of chest pain. No history of exertional dyspnea. No history of palpitations. No history of abdominal pain. No history of weakness anywhere. Gives history of low back pain. No history of any psychiatric problems. (I PHYSICAL EXAMINATION: Vital Signs: BP 120/68, P 72/minute and regular, W 160 pounds. General Appearance: The patient is an adult female, well built, well nourished. She does not appear to be in any obvious pain or distress. Examination of the Thoracic Spine: No kyphoscoliosis is noted. A linear midline scar is noted over the cervical spine extending up to C7. Upon palpation, there is tenderness over the paravertebral muscles anywhere from T6 to T9, extending from the posterior down the mid-axillary and almost up' to the anterior axillary line. Range of motion of bilateral upper extremities is within functional limits. Muscle strength is 5/5 in all the muscle groups of bilateral upper and bilateral lower extremities. Reflexes are 2+ and symmetrical in bilateral upper and bilateral lower extremities. . Sensory examination is intact in all the dermatomes in the bilateral upper and bilateral lower extremities. HEENT Examination: The head is normocephalic. Pupils are 2 mm, round and react equally to light and accommodation. Extraocular movements appear intact. Oral mucosa is moist and pink Neck: The neck is supple. No jugular venous distention noted. No carotid bruit noted. No anterior cervical swellings noted. Respiratory System: Air entry appears equal bilaterally. Lung sounds appear clear bilaterally. Cardiovascular System: Heart sounds, 8 I and 82, are normal in intensity and regular in rhythm. No murmurs are noted anywhere. ~\\~ y.,~~\\\S'?) ~Cl,"~ (I . (I I>> . ~1<lmfl!frt:lijr! F!i"!'!Il ,-~~~ 1'1 ~'. . ~.~-~~, i.w " ,. " 11 11 11 It . 11 .~~~....-- Initial Evaluation Catherine Smith Page 3 Abdomen: The abdomen is soft and non-tender. Bowel sounds are well heard. Hernia orifices appear nonnal. Extremities: No calf tenderness noted. No pedal edema noted. IMPRESSION: Mrs. Catherine Smith is a 48-year-old lady with a history of having been involved in a motor vehicle accident when she was rear ended from behind, following which she developed sudden onset pain in the right side of her mid-back that radiates anteriorly to the sternal area. Imaging studies, namely an MRI of the thoracic spine, showed evidence of a small right paracentral disc protrusion at the level of T9-10. Apart from tenderness in the region between T4 to T9 along the paravertebral muscles, she is otherwise neurologically intact. PLAN: I shall perform a thoracic epidural steroid injection today. If this gives the patient significant relief of pain, I shall perform further therapeutic injections in the future. D: 11/15/00 T; 11116/00 JR/jb /" $if' JITHENDRA RAI, M.D. n\)?G \\f>..?S\\S\.l f' c. \') ~\l\j0 \\'i..\. v ': '. "d>: \ , 1-'-~"""'1.~ ^ ~, l I ~ ~ , ~ ~ - ,,,~ ~ ~"--" I HEALTHSOUTH Rehabilitation of Mechanics burg Acute Rehab Hospital 175 Lancaster Boulevard Mechanicsburg, PA 17055 SPECIAL PROCEDURES CLINIC Malik N. Momin, M.D. - Medical Director . (717) 691-3731 (717) 691-3858 - Fax PROGRESS & PROCEDURE NOTE . Patient Name: Catherine Smith Date: 11/15/00 PROGRESS: Mrs. Catherine Smith is a 48-year-old lady who gives a history of being invblved in a . motor vehicle accident during which time she was struck from behind. The patient twisted her back and following this developed pain that radiated from the right side of the mid-back all the way up front almost to the sternal area. It has been continuous. She has had trouble using the right upper extremity secondary to pain. Imaging studies showed evidence of a paracentral disc herniation at the level of T9 and TlO. She presents today, '. as requested by Dr. Steven Morganstein, for a thoracic epidural steroid injection. EXAMINATION: As per the initial evaluation. . PROCEDURE: The patient ~family member _ has been informed of the risks and benefits of the planned procedure. Thoracic epidural steroid injection #1. . In the fluoroscopy room the patient was pbJ.ced in the prone position. The skin over the mid-thoracic spine was prepped and draped in a sterile manner. The skin and deeper tissues at the level of T8-9 were numbed with 1% Lidocaine. Using a translaminar approach at the T8-9 level, a 3 1/2 inch 20 gauge Toughy needle was advanced under fluoroscopic guidance using loss of resistance technique into the epidural space. Needle \8 position was confirmed on AP view. Aspiration was negative for CSF and blood. 10 cc of a mixture of normal saline and 80 mg of Methylprednisolone was injected into the epidural space. The patient tolerated the procedure very well. . COMPLICA TIONS: None. ~~?-.f(..\S~\jf(..G \\t.C \\ lQ 1.\\\)) . :-"'"Ii1~'II!I!IJ"r~ flI'lil!IfJ! ' ~rl =, ,.. '" Progress & Procedure Note Catherine Smith Page 2 '. I . FOLLOW UP: The patient will follow up with Dr. Steven Morganstein for further recommendations and treatment. Should a repeat injection be requested, the patient was instructed to give us a call anytime after two weeks. D: 11/15/00 T: 11/16/00 JR/jb /,fj{ JITHENDRA RAI, M.D. . " . lit lit lit lit . \\f:o..~~\S~\}~G. \i't.c' ~ ~ LU~ . '. '~'!r!-1~ -.l!iilJl-11 ,_,~U _ ,_ .. ~: I' :1, 'I ., 1 .. .,~ ;'~ HEAL THSOUTH Rehabilitation of Mechanics burg Acute Rehab Hospital 175 Lancaster Boulevard Mechanicsburg, PA 17055 SPECIAL PROCEDURES CliNIC Malik N. Momin, M.D. - Medical Director (717)691-3731 (717)691-3858-Fax PROGRESS & PROCEDURE NOTE ,It . Patient Name: Catherine Smith Date: 01/03/01 .. PROGRESS: Mrs. Catherine Smith returns for follow up today, following a thoracic epidural steroid injection on 11/15/00. ,. As you know, she is a 48-year-old lady who gave a history of being involved in a motor vehicle accident during which she was struck from behind. The patient had twisted her back and then developed pain that radiated from the right side of her mid-back up front almost to the sternal area. bnaging studies showed evidence of paracentral disc hemiation at the level ofT9-TlO. ,. The patient reports that the injection did help her. She still has a certain amount of pain. The injection might have reduced her pain by about 30-40%. She would like to have a second injection to help her further with the pain problem. She presents today, as requested by Dr. Steven Morganstein, for a second thoracic epidural steroid injection. .. EXAMINATION: Upon palpation, there is minimal tenderness over the paravertebral muscles at the level of T9 and TIO bilaterally. Much of the soft tissue tenderness at the level of T6 and T7 and at the mid-axillary line has improved. Range of motion of her bilateral upper extremities is within functional limits. Muscle strength is 5/5 in all the muscle groups of the bilateral upper and lower extremities. Reflexes are 2+ and symmetrical in bilateral upper and lower extremities. Sensory examination is intact in all the dennatomes of bilateral upper and lower extremities. The patient ~~ily member _ has been informed of the risks and benefits of the planned procedure. PROCEDURE: ,. .. . W!'.~R\S\3lJf\G J~~ '2. '2. 1Um :[1. ].._, '1""" .... ~"-, ] I -.=." . !!i \. \ ,,. Progress & Procedure Note Catherine Smith Page 2 Thoracic epidural steroid injection #2. ,lit In the fluoroscopy room the patient was placed in the prone position. The skin over the mid and lower thoracic spine was prepped and draped in a sterile manner. The skin and deeper tissues at the level of TlO-TII were numbed with 1% Lidocaine. Using a translaminar approach at the Tl2 vertebral level, a 3 1/2 inch 20 gauge Toughy needle ,. was advanced under fluoroscopic guidance using loss of resistance technique into the epidural space. Needle position was confirmed on AP view. Aspiration was negative for CSF and blood. 10 cc of a mixture of normal saline and 80 mg of Methylprednisolone was injected into the epidural space. The patient tolerated the procedure very well. i. COMPLICATIONS: None. FOLLOW UP: The patient will follow up with Dr. Steven Morganstein for further recommendations and · tit treatment. Should a third injection be requested, the patient was instructed to give us a call anytime after two weeks. tit D: 01/03/01 T: 01/04/01 JR/jb /~ llTHENDRA RAI, M.D. Cc: Dr. Steven Morganstein 'it . ,,,,""ICQ,\mG !"'.. . . . ., 't'" ~~ ?,,\ . . -~ """'" ~- ~-, ,. .",,- . ""~~",..,,-"'~'''' If II dil ,. " . " .. .. .. .. ;. . CERTIFICATE OF SERVICE I, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of PLAINTIFFS' ARBITRATION MEMORANDUM upon all counsel of record via postage prepaid first class United States mail addressed as follows: Michael Scheib, Esquire 110 South Northern Way York, P A 17402-3737 Attorney for Defendant Dated: C) / ~ \/~ '0 240722.1IDLLIMTG ,- ~-->':,"~ -, _"c' ,- , - j'"" ... IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action, Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED DEFENDANT'S ARBITRATION MEMORANDUM I. FACTS This lawsuit arises out of a motor vehicle accident which occurred on April 11, 2000 at approximately 8:00 a.m. The accident occurred at the end of an exit ramp for Interstate 83 at Exit 19. Mr. Reinhardt has testified at deposition that he brought his vehicle to a complete stop. As he was waiting at the red light, his foot slipped off the brake. As a result, his car floated into the rear of Plaintiff's vehicle. The panel will see photographs which show the minor nature of this impact. II. ISSUES The primary issues for the Arbitration Panel to decide at the hearing are as follows: 1. What injuries, if any, were caused by the extremely minor impact; 2. The nature and extent of Plaintiff's pre-existing problems; and 3. Plaintiff's credibility. 1 , '":""-"1 , '. ~- ~ !,,'7j-., '-'1--+ '", _ ,~. ,_ - ,{. - . ~ " .... f III. DAMAGES In the Complaint, Plaintiff alleges that she suffered a chronic thoracic strain, rib strain and/or fracture and an aggravation of a T9- T1 0 disc protrusion. A. Dr. Barrv Moore's Records As previously stated, Plaintiff did suffer a pre-existing injury. Ms. Smith has been a patient of Dr. Barry Moore since December 16, 1997. At that time, she indicated that in May 1997, she was playing with her 85 lb. labrador retriever. As a result of this, she injured herself. Dr. Barry Moore treated her for thoracic pain. Dr. Moore sent a letter to Ms. Smith's family doctor and opined that he " has seen numerous people with this type of injury and frankly only about 50% of them ever get total relief of this type of problem. There are indeed in my experience about 50% where the problem will continue unabated". See Dr. Moore's report which is attached hereto as Exhibit 1. B. Dr. Korinchak's Records Ms. Smith's family doctor is Dr. Korinchak. The earliest records available to counsel are dated November 1997. The records indicate that Ms. Smith was having problems with her back prior to the visit with Dr. Moore. A copy of this office note is attached as Exhibit 2. On January 22, 1998, she was seen by Dr. Korinchak. At this time she was having back pain which he felt was a muscular spasm. The notes also indicate that she was under a lot stress with her cleaning jobs, her marriage and also with her teenage daughter who was giving her terrible problems. She was given the diagnosis of thoracic spine herniated disc, chronic back pain and depression. A 2 '. '- r '. copy of this office note is attached hereto as Exhibit 2. Ms. Smith returned to Dr. Korinchak on February 12, 1998. At this time he continued with the diagnosis of thoracic spine herniated disc, chronic back pain and, depression - improving. A copy of the office note is attached hereto as Exhibit 2. Ms. Smith was seen by Dr. Korinchak in September, 1999. At that time, she was having a one month history of increasing left hip, back and leg pain. She said that she had been having difficulties for the last couple of years with her left back and hip. (emphasis added) She states that the pain was so bad that she cannot sit for any period of time, that she was having difficulty sleeping because of this aching and throbbing in her low back. A copy of the office note is attached hereto as Exhibit 2. Ms. Smith was seen by Dr. Korinchak on April 11, 2000 and stated that she had fallen down a flight of stairs in a home she was cleaning when her legs gave out. She stated that she had increased burning and pain in the neck and upper back. The note indicates that Dr. Moore felt that these symptoms were related to her cervical spondylosis. There was no mention of any back or rib pain. A copy of the office note is attached hereto as Exhibit 2. In late April 2000, Dr. Moore performed surgery on Ms. Smith's cervical spine. Ms. Smith was seen by Dr. Korinchak on May 24th. At that time she stated that she had less pain in her arms and that the hip pain had resolved. She also stated that she had fewer headaches and did not have any other symptoms. A copy of the office note is attached hereto as Exhibit 2. In July, 2000 Ms. Smith returned to Dr. Korinchak's office. She stated that 3 '~''''k~: " ':f~":_'H0~,_t" '-. , -I ~,,!,-,- , 'c," .".-, ,-,. .T , -, " - . r"" '- . she was back to work full-time and having some discomfort in the posterior neck area. She also stated that she was able to work 8 hours with minimal problems. At this time there was no mention of any back or rib pain. A copy of the office note is attached hereto as Exhibit 2. On August 15, 2000, (4 months after the motor vehicle accident) Ms. Smith returned to DL Korinchak's office. She indicated at this time that she was having discomfort in the right thoracic area and radiating around to the right side of the rib cage. This is the first time following the motor vehicle accident that Ms. Smith told a physician that she had any pain in the thoracic or rib area. A copy of the office note is attached hereto as Exhibit 2. On August 16, 2000, x-rays were performed. They showed the old displaced fracture of the right fifth rib. On November 6, 2000, Ms. Smith had a thoracic MRI. Dr. Potok of Magnetic Imaging Center compared this to the thoracic spine MRI performed in 1997. He did not identify any appreciable changes. His conclusion was a stable and small right para-central disc protrusion at T9-1 O. Dr. Korinchak's letter is dated February 26, 2001. Since that letter, Ms. Smith has seen Dr. Korinchak in August and November. During this time, Ms. Smith was not making any complaints of any continuing back problems. A copy of the office note is attached hereto as Exhibit 2. C. Cumberland Orthopaedic Associates Records Ms. Smith has also received treatment from Orthopaedic Surgeons of Central Pennsylvania. Plaintiff's counsel has attached a letter from DL Polachek who is 4 ,~, '-"i ',0 .,. ,- .1."-." - - ~ - . ^ -' ~ - " . f affiliated with this office. However, Ms. Smith had also been seen by Dr. Malin who was formerly associated with this office. The records indicate that back in May 1997, Dr. Malin saw her on several occasions for lower thoracic and upper lumbar spine pain. He gave her prescriptions for Vicodin, Flexeril and Medrol Dose Pack. A copy of these records from Dr. Malin's office are attached hereto as Exhibit 3. D. Dr. Moraanstein's Records With respect to Dr. Morganstein, it appears that Ms. Smith saw Dr. Morganstein on March 20, 2001. She, however, did not return to him for more than a year. At her deposition in January 2002, she indicated that she had been able to "control her pain since the March 2001 ". Thus, it appears that she has only sought treatment for approximately one (1) year following the motor vehicle accident. E. Dr. Dahmus' ReDor! Dr. Dahmus performed an independent medical examination on March 13, 2002. Dr. Dahmus felt that she probably did have some pain. His primary concern was when did it actually start. He noted that Dr. Malin's notes and Dr. Korinchak's indicate that the pain had existed a long time prior to the accident. She denied to Dr. Dahmus that she ever had any back pains. He also questioned her credibility. He noted that if the radiologist believes that there was no significant change, then he did not believe that there would be a significant injury. He also found it interesting that she "forgot" to bring the May 1997 MRI with her and denied that she had ever had any trouble with her back even though the records indicate 5 '--", -,-".' ,_~"" .'.'".,,,,,e'i-. -~ -- ,J.'_-'""-T_'_~_- - ~, 1 . , --, < otherwise. A copy of Dr. Dahmus' report is attached hereto as Exhibit 4. IV. CONCLUSION A review of the records clearly indicates that Ms. Smith had a pre-existing chronic back problem. Although she refused to acknowledge it when she saw Dr. Dahmus, the records indicate that she was complaining of back pain and treated for the same. In light of the pre-existing complaints, the lack of any significant treatment and her lack of credibility when dealing with Dr. Dahmus, her claim cannot have a significant value. By: GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS Ji*.&i,Jlff Supreme Court 1.0. #63868 Attorney for Defendant Reinhardt 110 South Northern Way York, PA 17402 (717) 757-7602 6 '''.'"0'''. , \' ~ ~ ia' ".~ '. . NEUR___ LOGICAL SURGERY, LTD. ~ '. ~ ~ 4 . ~ ,..........,,". . '.ij]{-'t'mlllr,v 1Jri,'<" ,1f"d'll1ll,jl/lI'l' P,I//(I'Fi-.I'-!M Y;'/"I'b'l//I': ///- fJ9/- ;.1'(1(1 Fm"imilt: //i-fJ9/-11/9 Barry I't ,\\oore. .\\.D. C;eorge R. 1101h. ,Jr.. .\I.Il. Rogor II. O,,,Jahl, .\\.D. William J. Boutlel', ~\.\).' December 17, 1997 Jerome L. Korinchak, M.D. GREEN HILL FAMILY HEALTH CENTER 503 Bridge street New Cumberland, PA l7070~1931 RE: catherine P. Smith Dear Dr. Korinchak: I recently examined Catherine Smith, a 45-year-old white female, on December 16, 1997, for evaluation of continued thoracic pain. , As you are aware, this patient was in ,good health until early May of this year when she was playing with her 85 lb.labrador retriever, pulling on his leash in a virtual tug-of-war with her right arm crossed in front of her body. She did not have any immediate discom- fort that particular day but about a week later began to develop severe pain in the upper interscapular region from about the mid- border of the scapula up to the base of the neck. She also noticed pain radiating through to the anterior chest just below the clavicles in front. It was painful to take a deep breath. She had no true radicular pain or any neurologic deficit at that time. She was ini- tially seen by Dr. Malin and placed on a Medrol DosePak which did help to some extent. She also stayed off her house-cleaning work for ap- proximatelY five weeks and did feel a little better, but upon return to work for two weeks the pain returned full force. She then was placed on'Vicodin and Flexeril. She was unable to take .the Flexeril because it makes her so drowsy. She initially then underwent a trig- ger point injection of the interscapular muscle area on the right side and this caused significant relief of pain for a short period of time. A subsequent second block which was primarily an epidural steroid did not help her at all. At the present time she continues to have the severe pain In-tiie interscapular region, particularly in the upper in- terscapulararea. The pain ends about the level of her bra strap which is at the lower end of the scapula. It is always worse on the right side. She notices some aching in her shoulder and dOW1l her arm. There is some pain up into the back of her head and still some an- terior chest pain. She does not describe any pain in the lower thoracic region or around to the abdomen or umbilical area at all. She has no lower extremity disturbance. :\'~"""", _ ~ ''''. ~ . ,1I!!IIIlfl3I1llII~!lb ~_ ~, ~=,,'o ~ ~~." " -. I 1 l'~ ~r , . ., Page 2 December 17, 1997 RE: Catherine P. smith ,~..~"~_....-",' ..." On examination today, her neurologic examination is entirely nor- mal. She has normal muscle strength. Cerebellar tests are entirely normal. Deep tendon reflexes are brisk and equal bilaterally. There are no pathologic reflexes and~er sensory examination is normal.' Ex- amination of her back reveals significant spasm in the right trapezius and along the medial border of the right scapula. There are very tender areas near the upper edge of the medial part of the scapula ,and about midway down the muscle attachments to. the medial edge of the scapula. Once one gets to the lower edge of the scapula the muscle spasm and pain disappear. Holding her arm outstretched or putting her arm across in front of her increases the discomfort. There is no sig- nificant spasm on the left side. There is no tenderness down around . the lower thoracic area in the T9, 10, 11 area. The patient reaJ,ly has exquisite tenderness along the muscle attachments along the medial border of the right scapula, and this of course is the entire source of her pain. Review of the patient's thoracic spine films reveals very minor degenerative changes and she has an essentially normal looking thoracic spine x-ray. Review of the MRI scan reveals a small right- sided defect at the T9-l0 area which is probably spondylitic or an asymptomatic small disc protrusion: this is not playing a role in her present symptomatology. In conclusion, Mrs. Smith has a very common injury which occurs when the arm is outstretched and one is pulling something across the front of the body from the left side. She has a severe muscle strain of the muscles which pull the right scapula toward the spine in'the midline. These are the rhomboid and serratus muscles with the trapezius muscle overlying these. These muscles, however, which cause the scapula to move back and forth across the chest wall and pull it toward the spinous processes are indeed the muscle that are severely strained. We have seen numerous people with this type of injury and frankly only about 50 percent of them ever get total relief, of this type of problem. There are indeed in my experience about 50 percent where the problem will continue unabated. This is not a surgical problem. ' I recommended to Mrs. Smith that she try some muscle relaxants by mouth to see if this would provide her with any relief. She was given a prescription for Soma 350 mg. to be taken four times daily. If this does not help ~lgDtficantly, I would then place her on Baclofenwhich is a more. peripheral acting muscle relaxant to see if that would give her any relief. If these medications are not very helpful, we would then suggest that she try some deep massage therapy to the area which may indeed provide her with at least temporary relief on awe~kly C",,", =, ., ~. - , I ~ ) l?age 3' December r7, 1997 RE: Catherine P. Smith basis. ThanlCyou""for referring this interesting patient. She is going to get back to me concerning the muscle relaxant medication and I will keep you informed of her progress. Very truly yours, BaAAJ1}3, ~"fb' 'Bar~ B.Moore, M.D. BBM/ms "..~.,-,_'"_"''' " , ~"0lljl'f!!'1'l ' > .~ I,' ~ f I ~ , .~~~~~~ "J , ~ ~ -' " I I'" , t' ! ! I f;c li::, . !' :..j I., I;:j I:;. ,. I......r I", .r.O.... ..... i!riATEf "1? .1' r: B.P.t....WT. , i:"! I'" f'~ "~,;:t t .~.~ 1;',1 DATE !, '-. '" 1>' t.. I B.P., i. .' f t.-' "'1 ....... ;C.. r;..... .,,' t' ;~' .,~: ( ...~; f:' , '- (:\ t ;:.....1 f" f:,'........ !;'l If' I: ,I't '.~ROB#. i. ." I . I . I I < I d ~ i ---- fll .~ ~4:: W DATElPROORESS NOTES r. OX ~; --- - n II ji! . " i .....\ t" "'1 I 1'1 !. ;. r I t .., t j..'H f' , . I f ,'\ 'o' ,. '.' I 19: f'l" };;.....t, l,":: l' '" 1 ; '., I I" .., I !, '., I I" i, '..1 I i'. I I'" j. ,'! " r Il~ fHQLY ~P1RlT HOSPITAL i" rOREEN HILL FAMILY H~TH CENTER ". t! t PROcflRESS NOTES' "II.l. : : I r. t. GRH10?;.. $:; , 7/96 I' ., .--- t ~."."'Ji. I..... ~., ?' . .,~. j ..':'j -.. ~'... r j', '.,. '.\' , . }; .... ':t !-:,' 1;-.,_, 1", ;-- 1; - ~.,::1:" --",,-~ ~~f r ;'. { ,: ,--':1-: . . PR~B #.1 SOAP DATElPROGRESS NOTES ...,~. 1 . ii:;l; C"~;;"".;n..'" SMITH #033043'; ........ I'.' '1.12.1..~.' 2/98 ". ~it.j. ,1"lr.l~"'I~ j':',,--, ,r.,.-., S 'Forty-five year old wlute female who presentll for physical exam 8lufPaii sDleaf~ She IS stI!tll j'c,;foUowed by Dr Barry Moore TIuSls felt to be muscular spasm She uses Soma eSpectaJ\yllt . '. . 1 ;;;haSTegular menses ahhough bad two penods JI\ November Sbll15 Wil1~ilot DtstreS$ botI1~ll\;Mi'J I !"andmth her lnama&e and also Willi her teenager who has been glVltili \tel temtil: prob~\I;s$:iS!' U,eijeaSlly and 15 not sleeping well at night She feel. tired most of the nine Slie also' ha$'llompf' " , ; 'at mgbt She apparently bas bad ",me ~e of SVT m the past and \Ilid been mmntamed ortlndbi81 'Ii j feels tins does not control ~ at mght and. tins 15 worse when me IS mole ujiSet . ~ji. ;Iif;~ '0 BP;I22/94 and 128Jll2,later 122190 Oil the nght and 110M 011 the left~i Eye.n~;" ",;[ con.gcsted Pharyn'\ reddened posteriorly Wtth clear dnunage Neck.ls supple1v1thout nodes, IllUllS ; regular rote 8IId rhythm \VlIlWUt defirute mlllll1UJ Lnng5 are clear,Bl'eMlS ~WrthoUi massetbr"a '~" J" healed scar on the supenor aspect of !he left breast Abdomen '0 salt. nOoi'end& andb.....gn\; "J I}' mtroltn5 CeM'CISnormal PapIStaki:n Bimanual exam reveals nD,rm81!lDJd!l"e utenu;[Y!:. "". 1; "I'" Iii,; ~o external tagl;, no lIIlISll, wIth brtlWll heme Ilegal1ve '!Gal ~'es ~out ed~; ."~ ...'..... 7..................... j'.....:.;..'. Neuro.,. ...... 10glceumWltInnnonnallmnts Urmal}'SIB tmceofDlood .'.fl.' .i'....,..... .'.'t. ........'....~'... :'. ~i.. ..1." ..~.." !N.'l ,A 1,'1nuIllOtyofSVT-notwelloonttolled ii} >'iIl '~Lf,.':iI' ..".t "'}' 21i' ThorllClC spme lienualed disc "i ;'" ...~ 'cii '.i... :.' .........f . ,.,;.,".' 3~.'.'.:"'... Chromc back pain followed by Dr Bany Moore }~i . I ..1.':.'.' [:....;~.~.I,; o. ....1. F'Depres5lOll' \] 1"1' ; >f~'I'.'.::........' 7~..,.f.".'.'i;~~~~:c~ ;~. fi ,i~j... ,II:. :1 Ru... out early lI1el\IIjlause 'If; ~,:~:. t, 'l 'P; l*I:':Mammogram 18 ordered it~ - Ir (1t< t ,< L:: 2 ~[ Sbus referred to DIs Maffitt, Pease and Lun fOr evaluaUon oft!uS uttcrimttent mpIa ' (, f H~..~' medH:1Ile off the beta blocker It was explamed to the palleut that Shdlllll)l1be more i:\i;p~~~ear l' I It.:.:...... 3 'I ..SheWlII so Uy Astehn 1Ill.. sa! spray two spmys each nostnl b.I.,.......~. and.......... ..Pro...'bIc.. Will.... b..e,...be...........p,... 11.'..18f.....'.).~. . , I." .. .... II\! '1\""'II'}-r" ; 1 i U . S ""II retum for fasting lab work to mcIude CBC, cheln2;1>ni~ Plus,f:n... :~tr4.TSH,~.. ....'...fro.....'. .'. g~.ln.'~ ! :; . croscopic analySlO Iflier n1lllnmognun retums Willi any coiltmum'g abliormahltes,'ishe!Wlll ' j ,'-':; -Hamlm ^,\ . j '{:"'*;-' ' : , 5;; She will also bave a BP check when her lah work IS drawn" j' ~~i ;i", 6:\ She wIll retUrn m Olle month and pm ::::' l'iiI: , 1..1'.00..... bfu,' I." ~/ll.' :t Hi'" l .,,4 I DATE.;l, '/.:1 ii , , jl ~t , ~'r (- '. i 1 I . ..' . OLY SPIRIT HOSPITAL ; GREEN HILL FAMILY HEALTH CENTER : ,J :u PROGRESS NOTES I ! -GAH 100 1M - ';,f~~W~~,~~"'~,l,~.=~ . '. 1 T'r" 11II!II!IRf' ~ _-'\lilT fillrll I fIIP~='~!'!',,__~ <. ~~ PROS # ~ ( ( ) j o A p GFIH 100 7191J 1"-,, " _ _ 1l'#IWl'-~i' '-I" " ~ -" ~ <, " -" :.j to,i ""J -k h j'~i ,i !,1 ,..' .:. j ~ '1 -::" ::_-'j j;.:-:;I p,.;,; < !r,- t:1 - ,., >j . J l .~, { ''i_ II lL I F'f ~~ ___"___~'~''''''''___._I~O'''.''- GAH 100 7"" ;:1' -- " , ,I, il~., :i .' . '. I Z. 3 tl 4. j S. -~ 6 P. 1 I 2 3 4 5 6. .' . ~ ~- . .", , .. J. j .' '. I . .....' .Ml:H~,T;jt:H.lNE J . .J "- 5 '- I.... - I ~ .~ . I . ,- '1>- ~ - ..~- ~ ~- . ~ ~J~,~ if \-,'11 '!!1Y', i)ll'j\1If-Ij':1 '1ltl,~~ , , '''' ~ _.- ~'~::;' ::, ~- -:-~" 4',,~:;;;' " 04IUIlI0 CATBE. IUNlt P. SMlTB. ,. ~..,' .k . '~':.'''.'. :.' . ,^) . -~,' . 110''''''- S . Tblsl..4? ~_-ald-w.lalcbalewbopaealSmfollow.oup .,..:hariIsIbeIlllllle'. .' dn!gRlCllOll ~lIenlall_lIllIlIIwd. Sbeuilfottlmate\y _ ~ tliiIlIy m lWw,iiiliuiU' lIIIllpllll m_1IlICk.... ~ bddo._ Shcb8SlIIlclel'imliedlaqelli1bll~m_1i\.:l1l;Ql-.~ down IOIIIl: IIIairI m a Iiome sIic _ "'-mg WIth II<< 1epJVSI glV1118 ciutDr: MllirIe t=Is a'IDler, . 'P , ~::::r- 122118 ENT IS . Ncck:reveaIs lerl4t.i~J~ $ . i ot)Ilr;~~i J 1PorIaed.PIISllIl~ ......... muscleIr-=able elevaban m 1IIi1iQlbt +::~..: ..' :le8UIairatelllllldlytllDJ. LImsa~dear J>--~ II 10ft ExI>-u~~~~are\ ~"~.'" !A. . "'.1 Ccmcahpmilylo$Q with 11CrViciIl~ aud spimlCIjcd "'. .' . ...;..ollr, ,2 Acule c:amcal tIapazlIIll aDd thoraCIe strain related toiDoiOr~ acCtcIciii<l: 3 Jr,pcrk1lISIlID ,j,i . II: . ." K~: 4 H1&Iary ofSvr,I' I :.~ :i',: . u,--o--o.-.. ", ". ,', R.4,: ;;I. .ay.-.....-- ':' - ~i R,'-'V iP 1 Shnlll__GIlWIl\8IIllIt----.. ,,', ~ ~ ~:i! 2 Slnllll1aw lalliIlu IIIClude cae. BMP. hIpaIiI; pIliet; f;! J.'.....i.I... . '3 She1Vlllbawtona.mforherpreoplallllllllllpaallilcx:n.y; I '~'f.. , . 4 Sllr;wlIlc:all\llllll"'...,.......'li.r.'I~""'.ar~_ih=iilcldllat.j i!' 5 Sbe 1VIll otherMBe Illt1Imm 1bur to SIX weeIIs lIIld~~ 0; ~ .,~.~;' if,; 'l~:t ~.~f: ;f ,:-;...~ ;(t: ",. , , , ". ~ - , , - SOAP DATElPROGRESS NOTES , ;,- ~- ;" -;, _;..c, ,.-~ , ,~;i ~-t: , c. l .'~ . ,. ;,Jr. ~~.: ;,,)] GRHlilO 7"H1 -- :1 i ~ 11 ~ I"fl 1 i J, 5" . 'I: " ~9,1. I \ . ",) ,. Il ., HOLY SPIRIT HOSPITAL GREEN HILL FAMILY HEALTH CENTER PROGRESS NOTES .' :1'_( d' \"-;~Ii._,_ , ,'lI!!lI . , 1'1 , 1-'1 . 1 '""",, 'fll,'JI" ,~ I~W I n'.~"" __ ~,'- A,~ - A: I ,. t I'! I ~l "ill. ili * liC \ ;. '. 1. CHjj~ .T:IlJi.11l ... . . 'i '. ~~,.~~, ~ ~,~.~ ":;.:=J~lljt~'l::'~-,:t~.=ot . r::.i...::,-",,,lrilf~4~""'.lI1Il\li .' . .;!!t'." ..t."'";::!'A....~. '~."~..r nl.jj-=-.};lir7~IJ..~=r~".. '~.' !,.~.::: *8\..........' 1fIM~.I 'L~..""-- .-__. tii ....._~,;.lllo..:-;.r .... y ,.,,,.~ ' , ' I' ". -W' ,.......-..-.-.. , _ ,.~~,~,:l~ : :.'!"!'~_" n.. r-~.. . . ". . ".'j"-TI,' . i. It '", '1'!N . .... ....lj ~' ~,;f>1I ,-: -:. '- t~- -'; ...._me... b.dL' " .",. T ~la~ ~ ." 'm. ~~,~'If., ... ~.q. , . ".17'-- ..sr"-it .1 I ..,. ~"_1IIIIIIIlIf_p.rL 'lbr. WIlIlIII' 1r'1" Illwd: ill lilt 8IIIlim "l~l ;., .~ I. " i'!H~ij -~1 .. ~frJ.TAL....... .' .t ~T'1;<?EIIITERI' ~~'l" s,I~:f .;. ,'. ....i........ :: '~ I ',: ;; ~~.... ~: ~I' ..1 ,i', , f \t n, ,~ :'.;.'lr1i.. .i......; ;. i;; -~- ,I -. '; !. .(J.fo VvJ . p- GREEN HI ~ I ~. ,'1 ... i , Ii h ;~ o!! : 9..:; ? ";t.. "'i - .. .... "'...... ~ ~ rJ .. "1: . ........ G~H 100 I I .... ~..t..,...... - ----- d "';i;fiij'-,)~ .."",. 1'1 I '~1\1~~1 ,"!~ItII" '--.-!. PROS #. SOAP .',-- '."......l...l~. '.'..' , " ~'~','" ~,t'~ .. .'~' ...... ...,.....'.. ................. . ,;' -~-';, '. :: ~ ; I' \_;r "" ~ '-i' 't J . "1, ....." -:;; DATElPROGRESS NOTES 1 . , ~ " I , " '.' \ J'" :;~"I.I:L '.' . . .e. ....!l 'Irill!;! 071ll51OO . CATHP1NEP.SMlTB'." I ..i' . ..,.i.' Il"! S TJus III a 47 ,1lIINIId willie timIIe who JlI'lISllII1Il III tillIow-up ~ lIW10 wodt1Uli' .ti. 11= pl!Iitcrl\lr 1ICIlk lIRll, IIat a 11 ~ IIIIp'OV<ld Mill mm..illll $yIIIJllmDIl1ll \Iii: legs. tiil lilt.... '.. sbletinrork 8 hounlllllay WIth nan......1 ptobIelDs AIoc:nI dmp$ltllle_~clbsed8D ~.' \be a1itqlc OIIP.J11111l1lVida SJIII1IlvDIS Her _.are fludy shotCMr.......:;,.l.. WiIh"~ .. ill At/a!isl She IS exaemeIy dumpectfiI1 at IIIl! paIleIIt and the prIIIcDt",~ iDay imWe Iief:_ ~!lIlahrt1us...,... au IIIIlVIIIgto OhIo WIth lulratber~"!: SbclbaStt,~lIi(~i OBJood .....l:J2.92, Iller 14&'96 BNT IS DegBtMl NeckrMaJs hllillll.lrK:/BIOIf . . ib&bIi~ 1Il1llll8D at11lO1lOD. TbeteIlleDO nocIlls OJ: Inns Heart ~111l1d ~WI." .... '1t~ ..ud Elm.-.- are IIe8IIbve NeIlfoloSJC IllllIIIl meaI5 &ic!usefm ri&t>t blc:eptjeiktD4' plIlllII!Ir1llOex NoJl""iP'..ledllma. . I ..~ j i PW!I A 1 Stalulpostanu:alspmelmply r" ;t_,':~; t -'I'j:;.1 . 2 RIlsolwIgcemcllllll)~, (. . 3 Cervlcal8d-.. llSSJlISIII. i i.i ii ~ ~....-( 1,1.. ~ r+ .&~" J 6 0.-1.......... I '.' . ,; ~.P'"""""'--' ~ ! 'i . 7 S....i'l""'A11IlIlIlCI;y ll1ld dl:praISlon. . i P .1. SbDwdl-n....\besame-carons IJ,. 2 . WIll iIIwe a bIDod pmwrecheck III lwo weeks .: '.~. ! i . 3 SbD wlIIlIy BuSpalSO:mg 0Dl>haIf'b,1 d. for ClIIC week l1IId then One whole . , . 4 She WIll call W1Ih w....nnIIIg or wonemng symptoms . j 5 SbD WIll otba..ise JIlbmI In SIX weeks and P [D. \., ...""..... yr.._.. ',~r"...&. t GR!!EN'HILL FAMILY HEALTH CENTER , PROGRESS NOTES p i :-; ! ~ :~ ! "f GflHtOO 7/95 I. J' [, i . . M"'" ,1\1 ~;I!% "_, , ~'T'~- -lor . ~'fIl\lIIiIIIIJ,~, -1~~!Iil!' I I" 11I'!'!It!Il' I ",-, - ~_""""""IF-= -, JV ;.~' t-,?J! I . , "\. , -' "-" ;:' ~,i \)-; i ~ . "'" i:~ "'~: .:, .~ I ~ . ....1 .J." 08Il5lllO CATIIERINE P. SMrI'IIiiii,.,.. I" .~ . ' ,.i.....". ,.\; ,J". l';'t'., "1"";'\' S:r1I1S1sa 47.,.ear-olci wlute fI:maIe wbo pr_DlSlIl folJow-up She am1Dllf* BaSpii'as l1lIIISCllShe WIShes III tI:y lIOIIIClhmgelse for her_ wluc:b.m shot ~hes\<lll'i&l-'s ~tof gron"'.i.llI-'. etc She IS slIll havmg chscomfolt m 1bc ngbt1hmaclc _ ~~1IrclUIIIl thenpi['. . lICCId$itbBck 011 Apalll. 2000 NOIbms. bas really. been done abont t1nJ.:.beCaUselihe Wasgomg. "''1t: ctear....hetherthe pIIIIl was reIaled totbJS as she hlId solllall1 a1bcr lI)'IIlpIijmli1l:bm1iCr neck. N' "r ofherpiim, IlhebasbetterJlllll!ll afDlllUOll, shellasno dlll.....,tilIt mberBrml~hIjllmdbaSmiu:h .,. . conll'OhsbuktoDlll1Dlll .~~. .~ Ill! .ji~>l~t o . . Blood JIlllIi8UR 1181114 ENT IS neptrve Neck J!lJllOle supple;~;n.e IDCJIII!!B IS MI1Iiti8le,al! LlIlIgS 8rl' clear Abdomen 15 110ft ExtnmuIies WIthout edomIa Pulses IIIIal:t Badi::eumreveliJj lower piIII1umhar ....,....Ilatme wilh IIpIISDI. 1'heIe IS also tendemeslI along thi: rD1d ii'bs out towa.Rl. illf' A .) Rnleoutlborac1c~ftaclmcV5 dlSkdlSlllSllf:. '.':. '1. .."'.j".... '..'.':'..... .2 Role out Db ftac:lure.;il l: J: ~;i1 3 HyperIeIISlllD..". .'.' '. 'i' 11:1. . D____ C ;1" i. 'i,:1 ,tfl. 4 ---- -1IJlIIIC lIIIfllmY ~!? '" ,"ilw;iir 5 Re&o1vmg c:emcal m"c1op1tbyJ'li' '. .! . r~~! 6 "''-'afSVI' ;i", ,i< '7:111 . H-,,,,,,-..ifi .'j1 r,,,, 7 ypet '''-'J'''j'- ;, .:~" , tlJl1:' ,8 DepIssnm cci,j. ; '. ~,~!,'.. I ('An........!llIUIal' mMICl'll0D5 :i\1, ....~ ~1 2 Add Ceillxa 20mg dIIIIy. UIIram SO mg" 6h PUt pUll', ..,~ '. ~i~l 3 X-myoftbthomcicllpllle,cMalllldnglunbusotdeftid.>.. " :;;I! .4 She wJlIfollclIMP WIth Dr Mome 011 September 15. 2000 iuill will cIlscIiss I,' 5 She will. call WIlhaayWOllllllllll& may need MRI ......... .1. .........'...!.'.. '6 She WlII saum m IlIX 1IIleks IIId P In' .l .,. 'if . .~ , ~ ::;Ift. I ~ .~ ~ l~j .1IId tbec:ar P r -- -I- GRH100 7196 .... I 9< . ~:M Ll ~I ~A 7 H. JJ -j,UiJi:tMr 1".., J; 5....2 - ':- ~i'",,!; , ".l"<J ":~ 2 - j t. ,-7"9' "oJ '.... ,4. ;:., J 5 ~ PIP- f' ) ItH !"~: 1 1 ....11.".. I... : \'. ;",IH.T '., 'i. .' .11 ".!. . 110LY SPIRIT HOSPITAL . GREENHILL FAMILY HE:ALTH CENTER PROGRESS NOTES "~"""',~ ~~" ~-~ ~~ ~ .- I I T - ~ -- 'imlT!If' I't'ln I "'~ t' !'l'~~ ~"~ ~O,~_ _"~~___. 1"'''''''';~"' ^.~ ' ,-" ^ '. i , DIagnostic RadiolocY I Mammography I Ultrasound ' C T. Scam M.RI. 1515lindgc ...... l\t''U ( u n)b~rhUld. p~ 17"7" (")"') 'i''7..\--?'lSl 179\1 Old Tr..tllld EUen.. P \ 17;14.1 1717> 932,21.77 415 \\alnul ~L \ldler\burg. 1'\ 171161 1717,692.31197 36 ~oulh R".r Rd "...lIfa\., PA 17052 1717Ih96.':."i! q(lU Chdmber.. JhH Rd 1I000rrl..hm J..:. p '\ f"l'fiJ 171 i I ~M.K021 -~"W?~AA!<~ . .'~ I' t fIJ ~, 1; ~.i,. · f :~jl r'~ ',-, I. !f..,. '."".. ,.:.i.....!. i 'j.l. .... : i I --- .~ ,.,..'...1., ". " ~: j d 'i~ _ 1 ~ , ~.. if~i, I.' Oby,IrJC.i @tb ~ ~~ ~. :1 I"" ~ . I^ .-,.)~ ~ lf~j , - jt L"C . '.';1 ~.ii~,. - ::,- ~! It" W' L"rt. n. 11 hfij ,.,...> 11 j', I '.:1. (7]>.; Sf; .r;~ Ii [;;:11 ;, ..t.....'~/~._il ;l ".. "''''''. "" '''' blJH' ~ . fh -d. if I "j'_ ~~:1 il1t T~'"' G ..i~ "1. ,.tH ~ \n~ 'f - ""1,-:-.' ;-:' I,: I' 'i~ . ~, i! -, ~ . jr. I"" :-~ .i:;:9;tc - M!""".'li It':I:jl .. lp " ij; RE: Cathel"lne Suth 111' 1 ~ III ;,;~ ~~~~ ~:2~~=;~~a/16/00 ., :;~! I :! " III ~ te L ~ J I lJ.Jj'}"chak; 11 f' : " IIG"I~,:H..1; R[B5." SUI; 'I:i, !~ ill. il litO ;' " ,.. _. ,'... "'m,, ,,' ""c .~ ~ II tl' e uppef r, ';;',1 m i' 'a oi~ healed fract~l"e of the postenol" aSPIIc:t of the !'lght f1fth l~ if ,I ,)1;1 of the~l"lp cage a lntac:t. There lS no lntrathol"llC1c'1 :~' i! ,Hi' !fec:ondarr tp chest trauu. The Cal"dlOudlasttnal contgul"s,~ 'i! l! Ji ~;l;:~sell ard ~~l.onary parenchyu are nor.al. There 'are "9~ i.~ II ,II In -I ' ~ II ~~ Old healed dlsplaced fl"ac:ture of the post.rlor rloht ~ ,I ...tl..... ,.ftft.hr~b........... .'.,...i...:r..... hlll"te l$hnot ltntl"athgraCdll: COIIPldlcatlhotn. b. II If.' :uc:ol!oarV: t,~, ac:u e c es rau.. 01" ap ace r19. i l"l.'.ir tl 1,.'1:. ~.'.ifrac Ul'f') !j: 'l; J 'i(~V): .' . ... !IIi :t1 it . .. . L\ 1ffTI:ON:MVrtp:r' 2000 Wl th paln l"adut ~ng to the upper 11'~ 1.:,11' C:~,f and 'I.~l'hc:al" hetghts of the 'Iertebral blldle5 ill" ,l i."l.:.':.:.'; lNiJ stgn1lul nt ,~bnllr.al CUI'Vilture 15 uen and. no lither :~~; ;, '1 Wied. I it Slgnlflcant abnor.al1ty. m l'l'~ 11 ill I.I,. i.i,!. ~~~ 1" :, ,.',.f,;,~,'. -, ,t jf:-lf I ~, ,. 1 II'!' I 11:: '.~.ll :.' i...:....~ . ~' .........,..'.. i~ ;' 't ' }'"rt- \~. j... ,~~ I . .l~c...........l .:.',,',.',.,"'; ~. ',' I' Ii! ' It I h.lt i~l ..l......~f lJ l!~ l...... . !1.1 [;; '1' '.....' '. '. Ih Jff .. :' ii ~~' 'a . J~ ;f;' . ,,_'., ;~ .~,i.'" .1 ..~ "'....ili 1......'1 i "~' 'ti! l.L-,;~ !i' '~ H-_ . !t.:j; : jr:~ , 'rL~ 1 ~~. """.,-...,,~ "~~ -'. 1 r' ~ "'''''~~l'''~ili':''ii'/!fl~ '"''''''~ . , ,~". ". ~ < ~" RE: l I ,~ . --..... -i- I? I i ,I ',t j, I! .... '~ ifll~1 ~ . - t I ' ;i,~~<?" ...lIt ,!~'pM!B~NJi:' . ,J.R 'Gfp.navie,w rive r'~I "~. ir.~io' Pt~..~l . ,,' J~.I',I t 1: "Ii: i~~r~ fe,rT Xorinchak, MD [fffliii! Taolt: and right rib pain. . '. . ~}S~ ;J.) il; .sagittal rl T2 l~!<< ;. "n :~Axial T2 ...IJ',.i" . c....~... ..' ~.'. ..U.'.:.....' 1.,. is made to a thoracic spine: , .{ P81#. ,O~! in 1997, ' , ,',.. ....... f .. "{ ~, :". 4.ns:!:~te8 nOrlllal lIlcrphololJY and signa;.' 1'=1,,11s nO~lj VC\rtsJJral J:lody aliqnment. . There. 1s noJ :febraJ, MY httight. )[U\or disc .paoe narroW;Lng i~f . :1~1 ~~1I1Pi .iqna.l is within normal limits. I '. ~f1a~l\ ,:re~_a1,1I a BlIIaU ri,qht p!,racentraldi_~4 '!!;i;10. Th;L;d~es abut the r1ght s1de of the cord,'~f ~:gi~.ntisp ,a~! or foraminal si:enoais. . Allowing fO), . .!fmriqur' i:d~i not identify any apprec1able chanqeT . :~l'.bfW f tisc,abnormalitYI SPin~l or foraminail .lk.1..' st~_b. 1. ;;. Ii..n. d slIall right paracentral. disc{~ jEil: pro,l1illf at T9-10. J' e...'t.....rr. i '.t is..:p....,atient to us. '1';; .;: if; .'~. i '. ~; :::~t~U:D. r! , Jt:t. il: !"~~i <: .... {!i ,. l'if:, it', It .( Ii, ~f.t ,. :'j ,~ lr~ j~" . ,It \1 l!t'~ J~', It' '-', --- - :r t l~ g ,I" " ll.i Co; ;, j.i; ~f', . t1 ~ 'ii.' 'f' .~ ..1~; ffl (ll ~ J~...:la.. rv~""'.,,:, ; . . /; .. , . .......1. ..;. ! , :~. " ;:j " " jf. it ;,....1. i~~ >, H &1 ':I it; I .... :! " ~L~ ~ .,J 1.......,1 , i,' . "it it .J i~{ IK ,Ji! @i'\" ': i !i~ ~;~, 11 I!l" .! ill ~,~.~ n ;&}, ~' . ! ;H 'j~il !itf 'ii,' fi I~ . :~,;"'.,if 1,1 '.i."'" }f, :;j~H I. "'.c.~..;.,...'.lt. Ii ' ,{~ if !'fll if.l:l!f 1[.'" '~;:n.: i' ::-<f[1l ~.1 :.' "0i. it ~fI ". . .;;,;;, ~ I ttl I. if 11 ,.,.j ...... '1 11i .'1 ,:, '~' : ..,.1. iI' i,../.I;'.; '" t~.i. '1i;'11 ~ '. jt" :, ~.. E& iil rl'~ '~I 'j "I' l...~ ~~ ,i" ;.;,:~,..,:..'_..".: W if .; 11' ,.~;; 'I." i. ~I~ ]} II ,", .: .~:": l'.~ ~:;t;o;lf I ;~j1 ti.'; :,,:,;;t. H II ,Jill ~i ,':';,.:'.jl ": ~t ;: )l n ~ I! :;.~ .0.,.:11,. W ( ry,;'1 l~ r '-n ".;\ j . I '" ...i...... 'i ~ I~" ':-:: i E f r~, "~~ j {. !i 11'11 ':! 1.& ~:I ..r--:J '~~ t~r ' ~i'~ ". ; J ",~.f" , 0'" 1 q't{- '?'~v '" ". ~-f':':p~'" ~..i:JI:o\l ." -<'It' ..}> ,,," , .- -Jv,,\:;<o , <~: .:ti '1' :"tl~ ..~ .)1 ..,~; j,tJ fit "'?,1""1l1'"\""fj,~,,.~ ,,1iW'~~l'>r n, r r -"'l'I-'1ll!1!i!ll~~ I .. '1!f!III!IlI!\!! i=--- ~ C'_ -ll__lln~~"'/!'iIl!!!!!!"1fWf'".1i:~'i 1'_'''_ . ~ ~-'.- _ ,_, , J -, L II .... , ...) '-' PROB # "SOAP DATE/PROGRESS NOTES 1'ltL. . " i 08122/01 JKldf CATHERINE P SMITH i f S; This is a 48 year old w1ute female presents after havmg some type of reaction eailiec in the month. She had an episode where she had difficulty swallowing and breathtng. Had swelling ofber hands and fllCe and evCllltuallypassed out. She was taken to l;b.e hospital where she was;initially feli to have myocardial in18retton but this was ruled out. She haS been under cardiology. care since! She has had li!PJl8i'ent cardiac cath, which was nonna!. Than had a tilt table test which revealed tfuld orthostatic hypotension and than bad an EP study; this revealed no evIdence of a Problem there It was not clear what caused the syncope or the reaction. ,She was told to decrease the Atenolol to 2Smg daily and han followup appointment with ~e catdiologJst conung up soon. She has had no furIhe[ syncope still has some intermittent lightheaded spells. She seems to feeIiworse aftet!she takes the sma1l dose to Atenolol everyday. She still has a lot of situational stressfat home She Just 0: ~~ ~~~~gative. Neck is supple wilhout nodes or thyromega1y. H~art regular ~ate and rhythm. Lungs are Clear. Abdomen is soft. Extremities negative.; I' A: 1. Synoopeofuncertam etiology., 'I 2. History of hypertension - well controlled. i 3. Orthostabc hypotension. i 4. Headaches I 5. Herniated thoracic disc. I . 6. History C-Spine surgery I 7. HyperlipIdemia 8. Depression and ,situational stress P: 1. She will continue her regular medIcation except discontinue the Tenormin advised tins also should her blood pressure remain down. 2. Return in five d/lys for BP check. She will call With any problems. 3. She will fuUowup with cardiology. 4. Return in 4 to 6 weeks and p.r.n. , ..r-' tl rH ~'\THER::'l:: p I 02 52 J~3J.3 .3~ l .'t_\~ -,r'l' 'TIR I ! I I' \ II ! -- 1jI0LY SPIRIT HOSPITAL GREEN H'LL FAMILYHEAL1H CENTER PROGFtESS NOTES -'--~,,-,-:..~--, ,~ ,~'" 1')-,' I,' .Jl'l'.J-,""", ~- ~"^' ,"~~ ~ 'o!>'" " -- .....~~... PROB # SOAP DATElPROGRESSNOTES GRH 100 7196 ~-W~;l'f'1Wf''''''''"''''''''''''''f''''r~ l , 11/6/01 CA1'HERlNE P SMITH s 49-year-old white female presents In follow-up She IS not sleepmg well, is up every mommg at 2-3 a.m. She has exl1'eme stress With her daughter and the granddaughter They had mom out with the boyfnend for 1 week but her husband forced her to come back home She IS still extremely d1S1'espectful toward the patient, curses her, calls her a whore and has stress with her husband who WIll not let her dlsciplme hee or speak up. She 18 lICtuaUy considering movmg out after CJU,.stmas. ,. '. She IS having a lot of headaches, feels her heart raclDg agam Midrin IS not helping With the headaches. She has had increasing facial redness and leSIOns on the center aspect of her face, needs to see a dermatologi&t She 18 still mcounselmg. The Atenolol bad been stopped by catdiology, but she definitely has symptoms again. ReView of systems as above BP 166/110 Pulse 110 ENT negative Neck is supple WIthout nodes or thyromegaly Heart regular tachycardia without murmm Lungs are clear. Abdomen is soft Extremil:1es without edema. .' Skm exam reveals telangectasias and erythema of the face. r Hypertension. Uncontrolled 2 TlIChycardJa 3. Situational Stress with Anxiety and DepreBSlon 4. FlICiaI Skin Lesions 5 Hyperlipidemia 6 HIstory of C-Spme Surgery 7 Herniated ThoraciC Disc 8. HIstory of Syncope She Will restart the Atenolol sOmg daily. Continue her other regular medical:1on Ambien IOmg at h.s... She will ~ m 2 days for a BP check She IS referred to dermatology fur evaluation of the skin lesions She will continue with counseling. Call with problems. Return m I month and p.r.n. She may need to be rechecked in cardiology since the blood pressure and heart rate have increased llIZaIR. 'JK/Jld - o A P "I' 1 -,- ,~~f'!l , '\ II' I \,\--.".1.." ~ Ii' I ,\,,' , " 99 Nqvember Drive, Camp HiII,PA 17011-5097 Phone 717-761-8644 . Fax 717-761-6860 CU~11berland OrthopaedicAssociates, LTD. qo l-'t,OOC) .t. ; Thomas H. Malin, M,D" F.AC.S. William J. Polacheck. Jr., M.O, Craig W, Fultz, M.O, May 14, 1997 Jerome Korinchak, M.D. Green Hill Family HeaJth Center 503 Bridge Street New Cumberland, PA 17070 RE: Catherine P. Smith Dear. Dr. Korinchak: Enclosed you will find an MRI on Catherine P. Smith. She was seen in my office today on Friday May 9, 1997. This MRI is positive for a disc at T9, Tl 0 which correlates with her symptoms of pain, the onset of her pain and her present problem. The patient has responded well to the use of the Medrol dose pack and the medication that has been prescribed. She will be unable to work. She works cleaning houses where she is self employed. She will continue and finish the Medrol dose pack, the Vicodin and Flexeril. We shall see her in 3 weeks. If she is not relieved of her symptomatology at that time, she will be . a candidate for lumbar epidural injection. As always, thank you for your kind referral. /' Truly/yours, 11/' ~ " " '~ f ' "I /,""'" rVUJ . /, - " , . . Thomas H. Malin, M.D. TH/vVjcs Enclosure PRACTICE LIMITED TO ORTHOPAEDIC SURGERY l'f CU~J.Lber1and Orthopaedic rtS$ociates, LTD. 99 November Drive, Camp Hill, PA 17011-5097 Phone 717-761-8644 . Fax 717-761-6860 t., Thomas H, Malin, M,D" FAC.S, Wiliiam J. Polacheck, Jr., M.D. Craig W. Fultz, M.D. May 8, 1997 Jerome Korinchak, M.D. Green Hill Family Health Center 503 Bridge Street New Cumberland, PA 17070 RE: Catherine P. Smith Dear Dr. Korinchak: I saw your patient Catherine P. Smith on an emergency basis in my office on May 6, 1997. This 44-year-old white female had the onset of severe back pain approximately two weeks ago. She has no history of injury. She describes the pain to her lower thoracic and upper lumbar spine. It has been worse for the past one week. She has no history of injury. She has no leg pain. She has had some tingling to her right arm. Walking is not a problem. With steps she has pain. She is not able to rotate in bed from side to side. She has a problem sleeping because of the back pain. She was seen on Sunday at the Holy Spirit Hospital Emergency Room. She had x-rays but she does not bring them along. We have a report which indicates mild degenerative disc disease of the lower thoracic spine. She was placed on Toradol which has not given her relief. She has pain with a deep breath or with coughing. Sneezing worsens her pain. She has no difficulty with urination or defecation. She moves very slowly around the office. Physical examination reveals some tenderness over her spinous process in the area of her lower thoracic spine at Tll, T12 and L1. She has back flexion here to approximately 350 with extension of 00 and lateral bending of 00. There is no sciatic notch tenderness. Her sitting root signs are negative. Straight leg raising produces some back pain but it is very mild. Her patellar and Achilles reflexes are normally reactive. She has no extensor toe weakness or s~moryc::hanges. With her increased pain with sneezing and coughing, it appears that the patient may have a thoracic disc or high lumbar disc. To give'her more relief, she was prescribed Vicodin, Flexeril and a Medrol Dosepak. Because of the character of her pain, she will require an MRI of her thoracic spine from T9 to L 1. 'l ,1lO,WiI! I'" PRACTICE LIMITED TO ORTHOPAEDIC SURGERY f !' , . , -1 ~~ ~ ~-~ . RE: Catherine P. Smith May 8, 1997 Page Two We shall see her in one week to ten days in follow-up. We will hold off on physical therapy at present until we can have some better definition of her pain. Thank you for your kind referral. Thomas H. Malin, M.D. THMllms jH,-., ~,' " 'I' -~.. -, 1-1' . r'- ,,"'-' " , " BALINT BALOG, M.D. RIOlARD J. BOAL, M.D. ROBERl'R. DAHMUS, M.D. STEPf1EN W. DAILEY, M.D. WILLIAM W, DeMUfH, M,D" r ,A,CS, JOHN R. I'RANKeNY II, M.D" F AC.S. MARK R. aRUBB, M.D. RICHARD 11, llALLOC!<, M,D, JAMES R. HAMSIiER., M.D., f' AC.S. _.._~ ,/"-' / ".-/ 6IP' .f' GREGORY A. lIANI\S, M,D, ALEXANDERKALBNAK, M.D., FA-e.S. ROBERI'R. KANED.A- 0.0" r AC.O.S. RONALD W, LIPPE, M,D" r ,A,C.s, JASQNJ. LITTON, M.D. BRNESTR. RUBBO, M.D. WILLIAM J. POl.ACffeCK, JR., M.D. STBVBN B. WOLf', M.D. TIfOMAS J. YUCHA, M.D. ORTHOPEDIC INSTITUTE OF PENNSYL VANIA TELEPI10NE: (717) 761-5530 . (800) 834-4020 fAX: (717) 737-7197 www,orthoinstiluteofpa,com March 13, 2002 Michael B, Scheib 110 S, Northern Way York, PA 17402-3737 RE: SMITH, CATHERINE p, 2615 Grandview Drive York Haven, PA 17370-0000 18246 3905 1'9824125 Dear Mr, Scheib: This is in reference to CATHERINE P. SMITH who I initially saw in the Powers Avenue Office on March 13, 2002 for an independent medical examination, Catherine is 49-year-old female who comes in today for an IME regarding her continued thoracic pain, She is getting pain in the mid-portion ,of .her thoracic spine that radiates around the right side up underneath her breasts to her sternum, She says this all started back when she was involved in an auto accident in April of 2000, She states that she was seated at a red light with the car behind her also stopped, For some reason she says. the car behind her. just took off very quickly and hit her from behind, She saidunforttinate1y just at the time that She was hit she. was bending over reaching to turn the .channel on. the radio, She said she has had pain in this area ever since. I will go through her physical exam now and then go through the records review and try to put these two together, On physical exam today she definitely has tenderness in the midportion of her thoracic spine from about the area of T8 down to about T11, She has mild tenderness on both sides of the spine here, but she has very little tenderness to the left of the spine, Most of the tenderness is to the right of 'the spine, She definitely haS pain to palpatiorl ftollt about T8through T10 around the spine and then wrapping around her chest to her sternum, She does not have tenderness below her umbilicus and she does not really have tenderness to palpation at the umbilicus, She has no tenderness to the left of midline until you get almost back around the spine itself, All the tenderness is definitely from the right of the sternum, underneath her right breast, back to the right side of her spine, There is no swelling here, Of note is that she is wearing a TENS unit today, There are no skin changes, There is no swelling, There is no sign of inflammation or infection, She had no tenderness over the lumbosacral spine to palpation, She has no tenderness in the lumbosacral muscles to palpation: She has no tenderness in her. neck to palpation or in the neck muscles, She has a well-healed surgical ORTtfOPWIC SURQOONS. LTD. CAMP HILL OFFICE 3916 TRlNDLB RD. ADDRESS ALL CORRESPONDBNCB TO: 815 POPLAR CHURCH ROAD, CAMP tULL, PA 17011 UARRlSBUKG OFFICE CAMP HILL OFFICE HERSHEY OFFICE 450 POWERS AVE. 890 POPLAR CtfURCH RD., sm. 108 32 NORTHEAST DR., 3TE. 201 CAMP HILL OFFlCB 875 POPLAR CHURCH RD. "'~~ " ill!~"'IIU' -~ ~~. - ,~" "~" ~c~ , ", =, . . . RE: SMITH, CATHERINE p, PAGE 2 March 13, 2002 scar on her neck from where she had a laminectomy done by Dr, Moore, She has full range of motion of both shoulders without difficulty actively and passively. She has 5/5 strength throughout her upper extremities, Her sensory exam is intact throughout her upper extremities, Her deep tendon reflexes are +1-2/4 bilaterally at the biceps, triceps and brachioradialis, She has no evidence of impingement in either shoulder and no evidence of instability, Range of motion of her neck is full, Range of motion of elbows and wrists is full, Basically from about T6 up she is totally normal, She has a negative straight leg raising test bilaterally, She has normal sensation throughout her lower extremities, She has normal strength throughout her lower extremities, Her deep tendon reflexes are +1-2/4 bilaterally at the knees and ankles, There is no swelling, there is no sign of atrophy, there is no sign of any other abnormality in her lower extremities, Basically from the thoracolumbar junction down, she is totally normal, Basically on physical exam the only abnormality is the tenderness that she has at the area of her thoracic spine from about T8 down to about Tll on both sides of the spine, minimally on the left, significantly on the right, and the right pain wraps around underneath her breast to the sternum, She is presently taking Lipitor, Premarin, Tylenol or Advil for the pain and the Atenolol for her blood pressure, She is not in any physical therapy program at the present time, She did go through therapy in the past, She is presently being followed by Dr, Morganstein and by her family physician, Dr, Korinchak. She just two weeks ago had an epidural steroid and/or facet injection done. She is to see Dr, Morganstein next week to report how this worked, She says the shot definitely helped the pain in her back but did not do much for the pain that starts at about the mid-portion of her ribs, that is the mid-axillary line extending to the sternum. That pain is about the same, She states that she gets pain all the time, Sometimes it is very bad, sometimes it is only aggravating, Sometimes it is a very deep burning type pain, It is basically always there however, She states very very assertively that this pain started when she was in the accident, I asked her several times if she ever had trouble like this before, and she says she did not, She says she absolutely did not ever have trouble like this before her accident, She brings with .her, x..rays. that I :r-eviewed-. .These appearing thoracic spine with minimal degenerative with her an MRI scan from 2000 after the accident. herniation at the T9-10 level, 'show>basic~lly "a normal change, .she also brings This definitely shows the Of note is that she did not bring the scan with her from 1997, She is not presently working full time, She says she works maybe three to eight hours a week at the job she was doing prior to her injury which was basically a cleaning type person, She did not mention anything about the injury that she had when she was hurt '.~""" "). "r"'" ~, I' . - , "1 ~=~"' . >> , . RE: SMITH, CATHERINE p, PAGE 3 March 13, 2002 by her labrador retriever back in 1997, She did not mention the fact that she had an MRI scan done in 1997, She also has "forgotten" that she had an MRI scan done in 1997 which showed a herniation at the T9-l0 level that basically according to the records is unchanged from the scan in 2000, Of note is I have not seen the scan from 1997, therefore I could not say that there is no change, She was basically treated by Dr. Malin through 1997 for this type of problem, She had pain in her back that wrapped around to her chest, She had a positive MRI scan at the T9-l0 level which basically matches the scan that was done in the year 2000 according to records, Interestingly when she went to see Dr, Polacheck, she told Dr, polacheck just as she told'me today that she never had trouble in her back prior to her accident, This is the same thing that she told Dr, Morganstein according to his records. According to the intake sheet from Dr, Morganstein's office, it states on the front, are sympcoms recurring, and it says, no, .This is the intake sheet that the office staff fills out with the help of the patient, According to Dr, Morganstein's notes from 11/8/2000 when he first saw Ms, Smith, it states "she indicates her symptoms occurred as a result of a motor vehicle accident on April 19, 2000, At that time she was a restrained driver of a vehicle that was rear-ended while stopped at a traffic light, She reports the other vehicle was traveling approximately 35-40 mph and there was enough impact that it pushed her car into the intersection," This is interesting in that she told me that the car behind her was already stopped and basically he floored his accelerator and then hit her, Obviously there is no way if a car was stopped behind her and it only went a few feet that it could be going 35-40 mph, Therefore what a lot of people are being told is not correct, According to Dr, Polacheck's notes from September 13, 2000, the same is true, He was told that the problem all started in the motor vehicle accident in 4 of 2000, It is interesting to read Dr, Morganstein's letter to Mr. Lutz dated 2/5/2001. In it he states "she had apparently undergone a prior thoracic MRI in 1997, prior to the accident where she was noted to have similar findings." Basically I do believe Ms. Smith has pain as evident by her physical exam today, The question is when did it actually start, Obviously it has been there for a long time prior to the accident as proven by Dr, Malin and Dr, Korinchak IS not.es. The questi-on is was it made ,worse by the accident. If the Patient was totally honest, I would say it had, However, she has not been totally honest and therefore I don't know what to believe or not, Obviously the judge or jury will have to decide who is believable here or not, The fact that she told Dr, Polacheck it started at the time of the accident, the fact that she told Dr, Morganstein it started at the time of the accident, and the fact that she told me it started then, and that she had absolutely no trouble with her back prior to this, even though obviously she was treated for almost a year by Dr, Malin including getting an MRI scan and injections just as she is getting now by Dr, Malin goes against someone not being able to remember that they had trouble like this before, Therefore ;.1 _ ,J ;,"I'r. I , 1 - .. . . . . RE: SMITH, CATHERINE p, PAGE 4 March 13, 2002 some of her history is incredulous at best, As stated I do believe she has pain, I do believe she has a problem, The question is, when did it start, Unfortunately the jury is going to have to make that determination whether they believe it happened at the time of the accident or whether she was having trouble all along as is very likely the case since she was already being treated exactly the same way by Dr, Malin as she is being treated now, The problem with thoracic disks is that they can come and go as far as symptoms are concerned, I would like to see the 1997 scan, If I truly believe just as the radiologist believes that there is no significant change, then it is hard for me to believe that there has been any significant injury, although without seeing the scan I can't say that, However it is interesting to me as previously stated that she brought her x-rays and her new scan with her, but she did not bring her old scan with her, and she denied very strenuously the fact that she ever had any trouble with her back like this beforehand, even though, obviously fram ,the Tecords, she did, I hope this information is helpful to you, ~~~,. Robe ,Dahmus, M,D, RRD:gld "")i~__Q <_ ",,".< " 11"-' ^ ~ I -. . .. . . ~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE ,::+h AND NOW, this ~ of June, 2002, I, Michael B. Scheib, Esquire, a member of the firm of GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS, hereby certify that I have this date served the Defendant's Arbitration Memorandum, by United States Mail, addressed to the party or attorney of record as follows: David L. Lutz, Esq. ANGINO & ROVNER, P.C. 4503 North Front Street Harrisburg, PA 17110 (Attorney for Plaintiffs) GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS BY: Michael B. Scheib, ESQUIRE Attorney I.D. No. 63868 110 South Northern Way York, Pennsylvania 17402 (717) 757-7602 Attorneys for Defendant Reinhardt ':'oH~ ," " ~ >~---'~"i"-'-. 'T"e"cc','", ._"_' '"".'" He. '.:'1' ~ ',,",_'.. -.'"_' ~"1,"~, ,_~" - . ~I . _ . ,,__, ',"'" .,,__ >n. _ce lAW OFFICES GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS ROBERT M. STRICKLER ROBERT A LERMANO PETER D. SOL YMOS CHARLES B. CALKINS PAUL G. LUT;Z- MICHAEL B. $CHE1B" ROBERT H. GRIFFITH - OF COUNSEL 110 S, NORTHERN WAY YORK, PENNSYLVANIA 17402-3737 TELEPHONE: (717) 757-7602 FAX: (717) 757-3783 EMAIl: ,jnfO~~sISC.COfII ANN MARGARET GRAB LISA M. DiBERNARDO THOMAS B. SPONAUGLE WAYNE E. BRADBURN, JR KRISTI A. GOHN Micl1ael B. Scl1eib's EMAIl: MscheibdVaslsc.com OAlso Member MD Bar "LL.M r,~axali(:m); also Member CT Bar "Also Member NY and D.C. Bers May 22, 2002 VIA FACSIMILE AND U.S. MAIL Attorney Jon F. La Faver P.O. Box E New Cumberland, PA 17070 Re: Smith v. Reinhardt Court of Common Pleas of Cumberland County Civil Action No.: 01-2682 Dear Attorney La Faver: You are the Chairman for the arbitration hearing for the above-referenced case, The hearing is scheduled for June 11, 2002 at 1 :30 p.m. I must respectfully request that the hearing be rescheduled. I have a commitment on the morning of june 11, 2002 and do not believe that I would be available at. 1 :30 p.m. I have spoken with Attorney Lutz who represents the Plaintiff. He has agreed to the rescheduling. If you do not object to the rescheduling, simply notify my secretary. I will have my secretary contact the Court Administrator, and the attorneys on the panel and Attorney Lutz to arrange a new date and time. "1." .. ~_ ~ - ~", ,. I.";''' ',_ ,~~~ Attorney LaFaver May 22, 2002 Page 2 . If you would like to discuss my requests for a rescheduling, please do not hesitate to contact my office. cc: ,"{ " ."-- "~ - . V0V-22-2002 13:47 - " LAWOFFI~; ,:,:,-:. GRIFFITH, STRICKL.ER, L.ER.&,'O~CALKINS RCSSRT M. $TRlCKLE~ RoeSRT A. l.ERMAN" PinER O. SOL YMOS CHA~~ES. B. CAlKINS PAU1,'~. LUrz~ MiCHAEl. B. SCHEIB. "0S,NORTtt~i~Y.....", . YORK. PENNSYLV""N~17'f02,3T.}7, n;lE~HOtle (7,1ll'l;~,~' .' , , FI\X'(1'1l767~" ~MA1L:l~ , , A~N MARGARET GRAB USA M. D;BERNAROO THOMAS ~, SPONAUG,E wAYNE., BAAOBURN, JR. KRiSt, A, ~OHN . ~ ' . Mi~al!llB. $(:hClib'seMAII.; M~O~~ . ": S',,~~.T H '3~!FFlr-H:~~OF COUNSEL; ',,"'. " . " " . ' : ~A.l9ol'{1~r7loor0b-Biri;:: ,>. "; -'~L,M FaXB1Ion)~;a\sq M~!'1bef CT al3~ ~ ;.,150 W-1;':'1>t>'.lr N.Y,;rn~~~:.Q, en '. Jon F. LaFaver, Esq. Date: l'fIay.22, 2002 Fax#; 717-774-3869 PagliJ;,' 3titkluding this co'iibt Sheet. From: Michael B. Scheib, Esq. Cecelia A. Seymour, Secretary Subject: Smith v. Reinhardt Court of Common Pleas of CumberlandCoO~ty Civil Action No.: 01-2682 ',HE INfORMATION TRANSMITTED BY THIS FACSIMlUHSCOi.il~ ATtORNa,YPRlVILEGED AND CONFIDENTIAL AND IS INTENDED ONLY FOR TIffitiS;COF'M iNDIVIDUAL 0R'ENTITY NAMED. IF THE READER OF THIS MESSAGE IS NOT TID;: *l'E.~CIPIENT, oai~ EMPLOYEE OR AGENT RESPONSIBLE TO DELIVER IT TO THE INTENDED;REcli'JlENT, YOU SHoUtDBE A WARE THAT ANY DTSSEMINA TION, DISTRlBUTION OR COPYINO:oF;~:60MMUNICATI~~S STRJCTL Y PRORIBITED. IF YOU HAVE RECEIVED THIS COMMUNIC*tIO~ tN.ERROR, PLEASEIMMEOlA TEL Y NOTIFY US BY TBLEPHONE, AND RETURN THE ORIGINAL MESSAGE TO US AT THE ABOVE ADDRESS VIA THE U, S, POSTAL SERVJCE, THANK YOU, 7",,_, ,_ _~~, ,-1',,','" '",p,' , , I' r ~r' , " , - . "~"-22-2002 13: 48 ~ ~ LAWOFF,I~~t ..,:.::;,:,;, . GRIFFITH, STRICKLER, I.ERMAN;i'.Y~~'CAlKINS' '~DE~kT~1':!STRli.~L,SB:,;: ; "':'8:;:RTc~',:L~~~';Q.N< ',' . ~,,:,;:c;: ':;', ~:"L Y\!105 - .' ~;,. ;':, --: ,-- ,~:_'<H':S 110 s, NORTHERIlliMii\Y, .. , YORK, PENNSYWA~"..i~t#i2-,i~7i . reI.EPI-IONE: (717) 7$!~~ ' FAX: '(117) 7S7..a~ EMAII.; !!!.f9:@Q~,' '_U_;~ L~' '-;:: Mith3el B. Sct1ijlb'~ EMAl~ ~j;ctI~bI!1c61~ ~m: ;\":-:::-lA;:... 8, SCHEIB" "\':'8S,,; H (;R:lr:r:!TM. OF COUNSEL ",~:':e' ''''9'~'';''f ::,:) ga( -'_'_ \/~ !_--8~:;':;Q~;: 2i8O MElmbtlr CT Bar ',\':':l V:Orl"t:-<:'r ',,'V OIr'ld D.C. Sars May 22, 2002 VIA FACSIMILE AND U.S. MAIL Attorney Jon F. laFaver p.O, Box E New Cumberland, PA 17070 Re: Smith v. Reinhardt Court of Common Pleas of Cumberland Cou!ity Civil Action No.: 01-2682 Dear Attorney LaFaver: ANN MAAGAR~ GRAB LISA M. DiBERNARDO THOMAS B. SPONAuGl.E . WAYNE E. BRAOBURN, JR KRISTI A GOHN . You are the Chairman for the arbitrationhea~nflltti~theabove.refetenced case, The hearing is scheduled for June 11, 2002 at 1 :30p;m. I must respectfully request that the hearin9~re,S'Oiiieduled. I ha'lietacommitment on the morning of June 11, 2002 and do not belieVetllatit'would be avaif8!ile at 1 :30 p.m. I have spoken with Attorney Lutz who repre$ell1;$ i!hePlaintiff, H61has agreed to the cescheduling. If you do not object to the rescheduling, si~ply~o:tify my secreta;~, I will have my secretary contact the Court Administrator, and thll!lJtttirrieyson the paneiiiind Attorney Lutz to arrange a new date and time. '<,QY-22~2002 13:48 P.03/kl, ~~tQrney LaFsver May 22, 2002 Page 2 If you would like to discuss my requests for.a.~Eis:p~Ja'clllng, pleas~ct0n(lt hesitate to contact my office. '!f~'';I,? Viii /'cd&J(r ~tHAEL B. SCHEIB MBS/cas cc:_ David Lutz, Esq. Mark Silver, Esq. Cory Snook, Esq. rnbs/reinhardt.ltr TOTI'IL P. 0, ,c. LAW OFFICES GRIFFITH, STRICKLER, lERMAN, SOL YMOS & CALKINS ROBERT M. STRICKlER ROBERT A. LERMANO PETER D. SOL YMOS CHARLES B. CAlKINS PAUL G. LUTZ" MICHAEL B. SCHEIS" ROBERT H. GRIFFITH - OF COUNSEL OAlso Member MD Bar -ll.M (Taxation); also Member CT Bar "Also Member NY and D.C. Bars June 6, 2002 Attorney Jon F. LaFaver P.O. Box E New Cumberland, PA 17070 110 S, NORTHERN WAY YORK, PENNSYLVANIA 17402-3737 TELEPHONE: (717) 757-7602 FAX: (717) 757--3783 EMA1L: info/1i)oslsc.com Michael B. Schejb's EMAIl.; Mscheibtalaslsc.com Re: Smith v. Reinhardt Court of Common Pleas of Cumberland County Civil Action No.: 01-2682 Dear Attorney LaFaver: Enclosed please find the Defendant's Arbitration Memorandum. ANN MARGARET GRAB LISA M. DiBERNARDO THOMAS B. SPONAUGLE WAYNE E. BRADBURN, JR. KRISTI A. GOHN If you have any questions, please do not hesitate to contact my office. Very truly yours, /z ,;/ 11 Jwfplc MICHAEL B. SCHEIB MBS/cas Enclosure cc: David Lutz, Esq. w/enc. Mark Silver, Esq. w/enc. Cory Snook, Esq. w/enc. mbslreinhardt.ltr '."",," . -',",<. -,_" ,',"",," 'd. ~.' ,,,,'v. .,,, "L",,,'. . ,,,~_. ., . ,- ,'~ '" , ~ , ,~_. " A CATHERINE SMITH AND RICHARD SMITH, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CIVIL ACTION - LAW v, NO. 0[- :1l>.J>~ c,'u~L Y0U'1 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED NOTICE TO DEFEND You have been sued in court, If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Complaint and Notice are served, by entering a written appearance personally or by attorney and filing in writing with the Court your defenses or objections to the claims set forth against you, You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the Court without further notice for any money claimed in the Complaint or for any other claim or relief requested by the Plaintiff, You may lose money or property or other rights important to you, YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE TIffi OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP, COURT ADMINISTRATOR 4th FL, Cumberland County Courthouse Carlisle, Pennsylvania 1710 I (717) 240-6200 NOTICIA Le han demandado a usted en la corte, Si usted quiere defenderse de estas demandas expuestas en las paginas sugnuientes, usted tiene viente (20) dias de plazo al partir de la fecha de la demanda y la notificacion, Usted debe presentar una apariencia escrita 0 en persona 0 por abogado y archivar en la corte en forma escrita sus defensas 0 sus objeciones a las demandas en contra de su persona, Sea avisado que si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin previo aviso 0 notificacion y por cualquier queja 0 alivio que es pedido en la peticion de demanda, Usted puede perder dinero 0 sus propiedades 0 otros derechos importantes para usted, , LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATEMENTE, SI NO TIENE ABOGADO 0 SI NO T1ENE EL DINERO SUFICIEN1E DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUlR ASIS1ENCIA LEGAL, COURT ADMINISTRATOR 4th Fl., Cumberland County Courthouse Carlisle, Pennsylvania 17101 (717) 240-6200 228076.lIDLLILC2 OR\G\NAL ':; :","L,,:--, , '," ""-"'~"', ","3,'-:. "., ',":T"Y '<P+,': ::~~t./' :-"r'_,,;;, . --'r' ~" '" ,-, - ~ -~ -'I ~~ {;' " ,~ " .. CATIIERINE SMITH AND RICHARD SMITH, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA v, CIVIL ACTION - LAW NO, 0 J. .2 t. PoL {txj -r.u- JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED COMPLAINT L Plaintiffs Catherine and Richard Smith, citizens of the Commonwealth of Pennsylvania, are husband and wife, adult individuals who reside at 2615 Grandview Drive, York Haven, York County, Pennsylvania. 2. Defendant Joseph Reinhardt, III, is an adult individual and citizen of the State of Maryland who resides at 654 St Marys Road, Pylesville, Maryland, 21132, 3. The facts and occurrences hereinafter related took place on or about April 11, 2000, at approximately 8:00 a,m, on the exit ramp of Exit 19 oflnterstate 83 ("1-83"), Cumberland County, Pennsylvania, 4, At that time and place, Mrs, Smith was operating her motor vehicle, a 1987 Chrysler New Yorker, and stopped at a traffic light while exiting 1-83 at Exit 19, 5, At the same time, Defendant Reinhardt was operating a sport utility vehicle also exiting 1-83 at Exit 19, 6. Defendant Reinhardt caused the front portion of his vehicle to collide into the rear portion of the Plaintiffs' stationary vehicle, 7, The foregoing accident and all of the il1iuries and damages set forth hereinafter sustained by Mr, and Mrs, Smith are the direct and proximate result of the negligent, careless, wanton and reckless manner in which Reinhardt operated his motor vehicle as follows: 228076.1\DLLILC2 "f",o-,^--- ", ,""'~\"f-'~ "". "'~, >. '.-"=""r'" ,r'''I'' ""~"~'-"d,~ ",,> _"'<' '" ,"=,'1 __~, 0' ,~ .,,~ ~ ~< " ',",,', ~ ii' I ,I II II il I I, 'I " " 'I II II I! \ I I - a) failure to have his vehicle under such control as to be able to stop within the assured clear distance ahead; b) failure to keep alert and maintain a proper watch for the presence of other motor vehicles on the highway; c) failure to apply his brakes ill sufficient time to avoid striking the rear of Plaintiffs' vehicle; d) failure to travel at a safe speed; e) failure to keep proper and adequate control over his vehicle; and f) driving his vehicle upon the highway in a manner endangering persons and property and in a reckless manner with careless disregard to the rights and safety of others and in violation of the Motor Vehicle Code of the Commonwealth of Pennsylvania. CLAIM I Catherine Smith v. Joseph Reinhardt. III 8. Paragraphs I through 7 of the Complaint are incorporated herein by reference. 9, Mrs, Smith sustained painful and severe injuries that include but are not limited to a chronic thoracic strain, right rib strain and/or fracture, and an aggravation of a T9/Tl 0 disc protrusion. 10, By reason of the aforesaid injuries sustained by Mrs. Smith, she was forced to incur liability for medical treatment, medications, injections and similar miscellaneous expenses in an effort to restore herselfto health, and claim is made therefor. II, Because of the nature of her injuries, Mrs. Smith has been advised and, therefore, avers that she may be forced to incur similar expenses in the future, and claim is made therefor. 12. As a result of the aforementioned injuries, Mrs, Smith has undergone and in the future may undergo physical and mental suffering, inconvenience in carrying out her daily activities, loss ofIife's pleasures and enjoyment, and claim is made therefor. 228076,1 IDLLlLC2 2 ~. ,,-.' """"~:'"",'''''S'''.- -, '/,,,",," ",~-'> .', ~',~, ""1-,,' ,~". ,,_'_',_ ~'''''r",,',,7''~-',~A.''''''''''_I= -,' CO" '".,~"_._ _ ' i~d),--,~,,- ,-" 'i. 13, As a result of the aforesaid injuries, Mrs. Smith has been and in the future may be subject to humiliation and embarrassment, and claim is made therefor, 14, Mrs, Smith 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 Smith v. Joseph Reinhardt. III 15, Paragraphs 1 through 14 of the Complaint are incorporated herein by reference, 16, As a result of the aforementioned injuries sustained by his wife, Mrs. Smith, Mr, Smith 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. WHEREFORE, Plaintiffs Catherine and Richard Smith demand judgment against Defendant Joseph Reinhardt, III, in an amount in excess of Twenty-five Thousand ($25,000,00) Dollars, exclusive of interest and costs and in excess of any jurisdictional amount requiring compulsory arbitration, Date: 5-)-01 ANGINa & ROVNER, P,C. ~L LD, No, 35956 4503 N, Front Street Harrisburg, PA 17110 (717) 238-6791 Attorney for Plaintiffs 228076,11DLLILC2 3 .',,- _A"':. ",''',C,'.' .,c', ",:~-,~;,~?-",y!",?,-,,~ ,,:,,~:~ l -",1 ;'.._.;_,c.~",?,~~"I"'?' .,,~,~, ,,' ('.,'" 'I """",~~ ," ,~ ,-' "",,, .', _ _,~-V,,"'~', t:'- "" -- ._~..- " -' !I, VERIFICATION We, Catherine and Richard Smith, Plaintiffs, have read the foregoing COMPLAINT and do hereby swear or affirm that the facts set forth in the foregoing are true and correct to the best of our knowledge, information and belief. We understand that this Verification is made subject to the penalties of 18 Pa,C,S,A, Section 4904, relating to unsworn falsification to authorities. WI1NESS: eL; ~/'fL Catherine Smith . . ~/','3o /0/. ~' / :3/ 30 10/ AdtJ .Ld Richard Smith Dated: 228076,i\DLL\LC2 :">,=,,,,, -"'~r"'%-~~":""__' ,-',c"~ , .""1""".)1'<, ,"~, ,~ - "-I~''1' ',,f''' ',0 ".:,~,."..,'tlo'''O,_'''';'-O' ",' _ ~,' ,"1" - -. ~,~ ."",~.",- 1'-" -"-, ~ ~. ,-' . -~. . ~.~ ~ I I I I ~ 'I !j ! !~'- - ~,= <." ,,~." .' ~", ,. --- 0' >,.~~,.<'''~ - , ,', '... .".,.." ".",. -"-..0 ,";b '>-'W.-.'~ '~~"'W,,,~'O., '''''~'~~'~ .'1 pD r 0& \l~ 0 ~ ..2: 0' ~ o a "'- ~ ........ IN Lv ~ ~~ ......... J (") -Cl~~ r11r-r z"-r ?Q~,;,-: c:: c:: ~:z\:; C~: C ;pc::. .~,: -, -<: -- Ul 11iJ1Ur (::) r,.~.cQ ,!:::V ---". .::~ (f' -,,--{,",'" '-'-:l.: ~~J (0:;, ;:'_",r-n ::::'1 :r,: ~ I (,.'::: r;: ~ en ':'0 -< ,,"- l'I~, ~.,"n"R",r;.'",,,:~.L .,_.., ~~~1~,~J!\1fl!i~,.,..~:J;f~)t~.~!T}7)'i,1<It!j'\ff~.ffi$~~~~~ ''\!".,-, 1l' i. ~:qtv" I. . .' CATHERINE SMITH AND RICHARD SMITH, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CIVIL ACTION - LAW v. NO. 01-2682 Civil Term JOSEPH REINHARDT, Ill, Defendant JURY TRIAL DEMANDED PLAINTIFFS' REPLY TO DEFENDANT'S NEW MATTER 18. through 24, The Defendant's New Matter, paragraphs 18 through 24, fails to set forth factual allegations that require the Plaintiff to admit and/or deny said allegations. The factual allegations contained in the Plaintiffs' Complaint are incorporated herein by reference. WHEREFORE, the Plaintiffs respectfully request that the Defendant's New Matter be dismissed. Date: 1)r;1;.....D~ ANGINO & ROVNER, P.C. D'~ J.D. No. 35956 4503 N. Front Street Harrisburg, PA 17110 (717) 238-6791 Attorney for Plaintiffs 233824.1IDLLIMTG ,~-"jr--,",,,,-,-'x,:_',<,,- .t:'.~,-:" ,~,~, ~. '_j,C,le",." ",' -,,"',1" ",~."'",,..r'''"' ",;_, . ",;;i.' :~ ~~1r~~< , ," 'ili' ~ .., 'I , I,." . CERTIFICATE OF SERVICE I, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of PLAINTIFFS' REPLY TO DEFENDANT'S NEW MATTER upon all counsel ofrecord via postage prepaid first class United States mail addressed as follows: Michael Scheib, Esquire 110 South Northern Way York,PA 17402-3737 Attorney for Defendant ~eJ / ~1J~wi M T. aets -- .-1 ..'V (" ~D 1 Dated: 1./ I ) 233824,lIDLLIMTG "~'T'"""____';'l"lr' ",1"""#' ;",,..p<,~,:;=..,,.:,-"'-" > T'...".~'.' .~". '_'I' "I,~' ." . - '.'" . r" .'" - "., ..,. ~" ~ r !-1 -,~- -< ~ ' "" r''' , ,~ "~ _l'lff ,~~ .,-~,.~~~,,,... " k~';;;">l',:';'-;>" --",. ,-,",,},~,.;~,".'.' -.;;v ";., ':'N"~__"-"~""""~' III HllllniJilIIlI\ " .' ') " '-~-, ~~~~~~~~~i!I~~i'lll~~~~~~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED NOTICE TO PLEAD TO: Catherine Smith and Richard Smith clo David L. Lutz, Esq. ANGINO & ROVNER, P.C. 4503 North Front Street Harrisburg, PA 17110 You are hereby notified to file a written response to the enclosed New Matter within twenty (20) days from service hereof or a judgment may be entered against you. GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS BY: lMJ~PJL Michael B. Scheib, Esquire Attorney for Defendant Supreme Court I.D. #63868 110 South Northern Way York, Pennsylvania 17402 Telephone: (717) 757-7602 II" ... , .~, !,~,,!, ." r~ ',' "'-:"""'~ ~ ,-'''"'. _-_ '''"'''t.. I,. N _,'_ ,; 0'<" v "', ',~,_~ _,~_ ,,_ , IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED ANSWER WITH NEW MATTER OF DEFENDANT. JOSEPH REINHARDT. III. TO PLAINTIFFS' COMPLAINT Come now, Defendant, Joseph Reinhardt, III, by and through his attorneys, Griffith, Strickler, Lerman, Solymos & Calkins, and Michael B. Scheib, responds to the allegations in Plaintiffs' Complaint as follows: 1. Denied. After reasonable investigation, Answering Defendant is without knowledge or information sufficient to form a belief as to the truth of the allegations set forth in paragraph no. 1 of Plaintiff's Complaint and same are denied and strict proof thereof is hereby demanded. 2. Admitted. 3. Admitted. 4. Admitted in part and Denied in part. It is admitted that the incident occurred on the exit ramp of Interstate 83 at Exit 19. It also is admitted that Plaintiff was operating a Chrysler New York. The remaining allegations are denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 4 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. ,"""~:""'"-: '", .:~. ," . -(C -;.1"'-';~, ~,., ., ,', , "'1, ~i'" " ""I~~" ~~~ . , ' l - _,_~ ,., 5. Admitted. 6. Admitted in part and Denied in part. It is admitted that the vehicles came into contact with one another. The remaining allegations are denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 6 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. 7. Denied. This paragraph states a legal conclusion to which no response is required. It is specifically denied that the Defendant was negligent, careless, reckless and that he: a) failed to have his vehicle under such control as to be able to stop within the assured clear distance ahead; b) failed to keep alert and maintain a proper watch for the presence of other motor vehicles on the highway; c) failed to apply his brakes in sufficient time to avoid striking the rear of Plaintiffs' vehicle; d) failed to travel at a safe speed; e) failed to keep proper and adequate control over his vehicle; and f) drove his vehicle upon the highway in a manner endangering persons and property and in a reckless manner with careless disregard to the rights and safety of others and in violation of the Motor Vehicle Code of the Commonwealth of Pennsylvania. 2 ~"";,,,:"T-'f'':',;,,>,''~ ,. , ",',~,''';':'.'"",'/'''''''''-~'~''f'' . '".;< ""1"'1,'-"";"'".-.. ,.. . '" ,~ _ ' 1 . 1'" On the contrary, at all times relevant, Defendant acted in a lawful, careful, safe and prudent manner with due care as required by the circumstances. CLAIM I Catherine Smith v. Joseoh Reinhardt. III 8. Paragraphs 1 through 7 of Defendant's Answer With New Matter are incorporated herein as though fully set forth at length. 9. Denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 9 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. 10. Denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 10 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. 11. Denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 11 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. 12. Denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 12 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. 3 !C,.',.,,,,,, ,,-. - _'c<' ,,"'" ""'J,- ""., _ Cl,,-, '. . >,<".', ~ /~ "';-'1-. fY - '_"" [."'" .- , ~. 13. Denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 13 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. 14. Denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 14 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. WHEREFORE Defendant respectfully requests that this Honorable Court to enter judgment in his favor, together with the cost of this lawsuit. CLAIM II Richard Smith v. JoseDh Reinhardt. III 15. Paragraphs 1 through 14 of Defendant's Answer With New Matter are incorporated herein as though fUlly set forth at length. 16. Denied. After reasonable investigation, answering Defendant is without knowledge or information sufficient to form a belief as to the truth or veracity of the allegations contained in paragraph 16 of Plaintiff's Complaint and same are denied and strict proof thereof is demanded. WHEREFORE Defendant respectfully requests that this Honorable Court to enter judgment in his favor, together with the cost of this lawsuit. By way of further Defense: NEW MATTER 1 7. Paragraphs 1 through 16 of Defendant's Answer With New Matter 4 i~~/ ~'~''''-:~'>;''',h,'1'"'";,,,,,-,,/-'i1''"'''''''''' .,'_1'''', . '.-Ic-'P~' , , I,,' ',,-."~' ',_'_ :Pf_, ~. '-c' -j- ," , - ~ ,-. , are incorporated herein as though fully set forth at length. 18. Plaintiffs' Complaint fails to state Ii cause of action upon which relief can be granted. 19. Plaintiffs' injuries, if any, may be barred or limited by the Motor Vehicle Financial Responsibility law. 20. Plaintiffs have selected limited tort option. 21. Plaintiffs' injuries, if any, were caused by the acts and/or omissions of a third party over whom Defendant had no control. 22. Plaintiffs' injuries, if any, were caused by events which either predated or postdated the motor vehicle accident which is the subject of this lawsuit. 23. Plaintiff was involved with a prior motor vehicle accident. 24. Plaintiffs' have not incurred any out-of-pocket expenses. WHEREFORE Defendant respectfully requests that this Honorable Court to enter judgment in hisr favor, together with the cost of this lawsuit. GRIFFITH, STRICKLER, lERMAN, SOL YMOS & CALKINS By: MIC B. SCH IB, E a IRE Supreme Court I.D. #63868 Attorney for Defendant Reinhardt 110 South Northern Way York, PA 17402 (717) 757-7602 5 :),,";:':'\,-"" . - <'~~'r'"~,ij''',,,,\,'''1't~;:-" '""'~",'-"~, .'~.""'I\"r~ .'Y.-- '.;,,'1','0, _,t." ,} ,,', ~- . VERIFICATION I verify that the foregoing facts are true and correct, upon my personal knowledge or information and belief. This verification is made subject to the penalties of 18 Pa.C.S. ~ 4904, relating to unsworn falsification to authorities. Date: -7/1 (PJu I rj?",~, ", -"'.',','::'~"'-~' ,:<i"';,~"..:-:",.-,- "~'., ~,'l"-I.-;;-lf--"''''f ., 'I '~'_~~ H'_I_'"e ...,.,,'..- IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE "1 "+ h AND NOW, this LL of July, 2001, I, Michael B. Scheib, Esquire, a member of the firm of GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS, hereby certify that I have this date served a copy of Answer With New Matter, by United States Mail, addressed to the party or attorney of record as follows: David L. Lutz, Esq. ANGINO & ROVNER, P.C. 4503 North Front Street Harrisburg, PA 17110 (Attorney for Plaintiffs) GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS BY: Michael . cheib, E QUIRE Attorney I.D. No. 63868 110 South Northern Way York, Pennsylvania 17402 (717) 757-7602 Attorneys for Defendant Reinhardt r,:~'~,e., " '. "'"'_,'<~",,,,,..,,,,,.. .," ,.,,'~,,'"'_"--"-'~_<,," _.'".,r"_'<"~,.".".",,"' r~ , "._ _, M" , _, '",'~<,.' ,," , ., ". Q ~ ,'. ~">~H' ~ """",,,,,, H'A""h' d,," """'~"rlGlnlli_nrlr"': 'it'" . ~~ .~~C-,V.,,~. "~~",,~,~~~~W,",,-"'l,"!;'f~~,*~~W~~'l\~<!?'~~IM'j!~~'!lf!lNl!llU " , CATHERINE SMITH AND RICHARD SMITH, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CIVIL ACTION - LAW v, NO. 01-2682 Civil Term JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED PLAINTIFFS' SUPPLEMENTAL RESPONSE TO THE DEFENDANT'S NEW MATTER 18. It is specifically denied that Plaintiffs' Complaint fails to set forth a cause of action for which relief can be granted, 19. It is admitted that the provisions of the Pennsylvania Motor Vehicle Financial Responsibility Law apply to this case. 20, It is denied that the Plaintiffs have selected limited tort as the Plaintiffs have selected full tort. 21, It is denied that Plaintiff Catherine Smith's injuries were caused by acts or omissions of any other party but that of Defendant Joseph Reinhardt. 22. It is denied that Plaintiffs' injuries were caused by events which predated and/or post-dated the motor vehicle accident. However, Plaintiff Catherine Smith has suffered injuries in the subject motor vehicle accident as a result of the motor vehicle accident causing an aggravation, activation, and exacerbation of her pre-existing condition. 23. Denied. 24. The Plaintiffs have sustained some out-of-pocket expenses for the cost of medications purchased that were not fully reimbursed by the Plaintiffs' automobile insurance carner. 234857.1\DLLIMTG ~;,.~" ~ "," ..~,JI ,"_.=..,=-=,='Ck."".,", '~<,-r>,.--._.,.~,,_ _.___., H' ~. ~, .'.' "'~.. fr" WHEREFORE, the Plaintiffs respectfully request that the Defendant's New Matter be dismissed. Date: 15/0'\ -\) I ANGINa & ROVNER, P.c. 9ft- David 1. Lutz J.D. No. 35956 4503 N. Front Street Harrisburg, P A 1711 0 (717) 238-6791 Attorney for Plaintiffs 234857.1IDLL\MTG !1;'T">~?"" ~!i""""'-" o~r~~""~',_~.r""~""'c,,,,,'''''1' .'0 .' ~<,~_ ,-':',"-1" P " fi~,",~, -,- , t- I' ~ ,. ,,,~,,,"_.- ~- - << - - VERIFICATION We, Catherine and Richard Smith, Plaintiff, hereby verify that the facts set forth in the foregoing document are true and correct to the best of our knowledge, information and belief. We understand that any false statements therein are made subject to the penalties of 18 Pa,C.S.A. g4904, relating to unsworn falsification to authorities. WITNESS: 2 //~/{? / / ' /~~fi/t ~~ ~erine Smi CC5//P/o/ ~~ Richard Smith Date: 200367.1IDLLIMTG :~'!".,~ .~" ffi!'JJ\'\r,',".c""~ '^"'~~,'":'7,,., "' ','",,=__.~~<o~ ,'. "'__'1' "I' '_" ,~. _ L'_ _, ,"~ ,-.<, ~,c.~ _ j' ~ ,,,-"' I ,'_""-,.C",,,. ,. . " .~. - ~;' CERTIFICATE OF SERVICE I, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C" do hereby certifY that I am this day serving a true and correct copy of PLAINTIFFS' SUPPLEMENTAL REPLY TO THE DEFENDANT'S NEW MATTER upon all counsel of record via postage prepaid first class United States mail addressed as follows: Michael Scheib, Esquire 110 South Northern Way York,PA 17402-3737 Attorney for Defendant Dated: 1/~-\-V\ 234857.1\DLL\MTG \Ii" , t"':'~-'.11\":'~"':,3,','i-"';"':':'" ,i_,,~. '~": 1::1'--'_."(>"""':' '''-''''c''I'''':__' ",~, :~'-r, - :,' .~'-':.", '!" - , - -I 'C',-::', '_" - " " - ~ "-.~.,. - " " o,-,,~ ," ,. - ] '" .^., f! !I !L .~ ~ - '" H _<. . ". "/'i<"~",,,,, -,,"'C'''' '"' ',.,' ;,' '. ",',so""'" " r'l,L'~',i;;'-;'- .,'~ -'h' ,""",;,,~~'>I'.'-"";"" .. ~ ~~~ ~ In .!"'" -"'<'~'" ," '"" ""Dr,' nlf:'::: ----;---- ,.(---- 0~.-. r:: ~_-. ",?C ~~~ =;! ~2 ~:; ,- C") ~-::;" f',) i'..> :,,) cn ".,. :1Iii1r~ilr~1"'itr~f;~~~~~~1~!1J!~!f\1lIlr.!mli!ll_!JImll!!ll~,,,~i , CERTIFICATE PREREQUISITE TO SERVICE OF A SUBPOENA PURSUANT TO RULE 4009.22 IN THE MATTER OF: COURT OF COMMON PLEAS CATHERINE & RICHARD SMITH TERM, -VS- CASE NO: 01-2682 JOSEPH REINHARDT,III As a prerequisite to service of a subpoena for documents and things pursuant to Rule 4009.22 MCS on behalf of MICHAEL SCHEIB, ESQUIRE 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 prior to the date on which the subpoena is sought to be served, (2) A copy of the notice of intent, including the proposed subpoena, is attached to this certificate. (3) The parties have waived the twenty-day notice provided in Rules 4009.21 and 4009.22 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: 01/30/2002 ~~I~ MICHAEL SCHEIB, ESQUIRE Attorney for DEFENDANT DE12-217158 70562-L06 ;.;Pl' ~" ~" "- ~.' ," -, ',.," JAN~23-2002 14:24 ANGINO & ROVNER, P.C. P.02 4SOJ NORTH: fRONT STR'EET tVJlJll~'9\,:ao, Ph 17\10.1706 717 n3~791 fAX 717/238-5610 RlCHAllD C","UOGlNO mo.J.~~ J09I!l'l1M.~ 'IUu!.y s.'HYiW< DAvtDJ.LU'l'Z MlCHAELE.KosD< l\lClWID A. SADLOCK l06E1'H M. DoRIA )AMl$ D5ClIiTI lOAN L SlOHUI.\K WWW.ANCINOoROVNER.COM '&MAIL.. DLUTZ@ANClNQ.R.OVNEll.COM January 16,2002 Michael Scheib, Esquire 110 South Northern Way York,PA 17402-3737 Re: Smith v, Reinhardt Dear Mike: Receipt of your January 14, 2002, correspondence isaekoowledged. This letter will serve to confirm that I wilI waive the 20-day notice. . Please let me know about the probability of the independent medical examination. Very truly yours, n lU:l.. .' u--N David L. Lutz DLL:mtg 234058,JlDLLIMTC) TOTAL P. 02 I~~".". -, l .~ ,-, ,~ , " ~~, , . , COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND IN THE MATTER OF: COURT OF COMMON PLEAS CATHERINE & RICHARD SMITH TERM, -VS- CASE NO: 01-2682 JOSEPH REINHARDT,III NOTICE OF INTENT TO SERVE A SUBPOENA TO PRODUCE DOCUMENTS AND THINGS FOR DISCOVERY PURSUANT TO RULE 4009.21 WILLIAM J. POLACHECK, JR. ,K.D. MEDICAL TO: DAVID L. LUTZ, ESQ. KCS on behalf of MICHAEL SCHEIB, 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 the twenty day notice period is waived or if no objection is made, then the subpoena may be served. Complete copies of any reproduced records may be ordered at your expense by completing the attached counsel card and returning same to KCS or by contacting our local KCS office. DATE: 01/30/2002 KCS on behalf of MICHAEL SCHEIB, ESQUIRE Attorney for DEFENDANT CC: MICHAEL SCHEIB, ESQUIRE - 106467-23 Any questions regarding this matter, contact THE KCS GROUP INC. 1601 MARKET STREET #800 PHILADELPHIA, PA 19103 (215) 246-0900 DE02-176910 70562-COl \S::J!ilUlfll!llllf;n _ ~~, !!:I< _ ~r_~' ",. ." COMMO~WEAL TH OF PENNSYLVANIA COUNTY OF CUMBERLA..'iD CATHERINE & RICHARD SMITH VS File So. 01-2682 JOSEPH REINHARDT,III SUBPOENA TO PRODUCE DOCUMD."TS OR THI~GS FOR DISCOVERY PURSUAl\"T TO RULE 4009..u CUSTODIAN OF RECORDS FOR: WILLIAM J. POLACHECK, JR., M.D. TO: (~oIm.. ai P~~C1" or =-~::i::r) \.-\'i:::.in ~'Il!':-:::' (~) d.ays mer seNic! oi this subpoena. you u'! ordereoci by tne C':Iu.rt to pToduc't the foliowing :oc:.3.menu or :i':ings: t:.11'H' A'1''l'Ar.H'Rn MCS GROUP INC., 1601 MARKET S.T, #800, PHILA.,PA 19103 II 1,~d4no'1 Yau "'a~' ..in'"" ar ",~J l.gibl. copin of the .!XUm.n" or produ.. thinp I"e<!"...,ed by this .ubpoen.. ,ag.'"'' with th. c."ilk... 0: ,o"'plion... to the parry making !!li. "'I...., at t!l. adcl:ss llste<i abcv.. You lu..... !!I. rip' '0 ...i<. in ad\'",... ,h. ,...onabl. ca., af preparing the capies ar producing the thin!, .....giIL If ~'ou f.1.ii tc ?,=,=dl.lcr the documents or things r~quir!d by :his Sl.Icyoen.a.. wi:.:.::n twenty (~l ':4YS -..':':rr i:s se:"",':::!. t;,e pury '."'ing :~J. '~:pc.na may 'Hk. c= ord.r comp.lling you to comply w;th i:.. nus St"3?OENA WA5 :::3t!:D ATrrlE F':lL"E7 c:r~ F-':Ir.r..:'I/1:SG PE~SOS: :\...."lE: ."OORE:: MICHAEL SCHEIB, ESQ. 11 0 S. NORTHERN WAY YORK, FA 17402 215-246-0900 T~:..E?HO~= S.':?:\!.\-!! ::=t.o"R'!" ID I: ,....rrORSE'l' FOR: DEFRNTlANT DATE: ~::J. ~u :ri/l t .;)'1 :Jr')C);).... , !'!oHlIaa""",lOoric. Cl' vi.... J aa-,.. tJ _ P ~(//A/YA '-....... Sui of the Court (:':1. i /97) W"~ ,~"' --~.....,',' <, '" ~'... .,"" ." . EXPlANATION OF REQUIRED RECORDS TO: CUSTODIAN OF RECORDS FOR: WIUlAM J. POLACHECK, JR.,M.D. 99 NOVEMBER DRIVE CAMP HILL, PA 17011 RE: 70562 CATIIERlNE SMlTII 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 indudiDg the present. Subject: CATHERINE SMITH 2615 GRANDVIEW DRIVE, YORK HAVEN, PA 17370 Social Security /I: 182-46-3905 Date of Birth: 11-02-1952 8U10-352818 70562-L06 !'\,.,1., ", ','i",'~' l,-r"~ l f',1 r ,,~ . .~ -~ ~ .,. . " " ,no . "- ."~,,,.o "." '"'" __<'",,"0",,"". _',~" ~ ~ -"-..~",,,'~"'" ~=r. ,-_'~ "~M~"""'" ~.,"".,. n CO ..;:-- lf1}11 Z~JI 2::: r-- Ct:l '," -.... ,,;,. ~~: ?P ~~~ L --' -< C) I'IJ """!'.. rrl c;:; I -~ ::;;' j"j c> ~,~ 5J ....::,: :)1 ~ "115lt.\'l!\j/~~~.., ~, uNII~~.!I7'~flIil'l1fl<t>,.;q,&'"";!&""n",,,"'~'"','~"l-P<i""~Ii''R1;:'~I~~~",'!~.jj)lW!,~"'1-'Jjo!!~!!J!II1,~"~~m~~~! IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE -rh 01 fI1J1aJ1J.fl ZilJ2. AND NOW, this L of~,~, I, Michael B. Scheib, Esquire, a member of the firm of GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS, hereby certify that I have this date served DEFENDANT'S ANSWER'S TO PLAINTIFFS' INTERROGATORIES PROPOUNDED UPON DEFENDANT, by United States Mail, addressed to the party or attorney of record as follows: David L. Lutz, Esq. ANGINO & ROVNER, P.C. 4503 North Front Street Harrisburg, PA 17110 (Attorney for Plaintiffs) BY: Michae B. Scheib, E QUIRE Attorney I.D. No. 63868 110 South Northern Way York, Pennsylvania 17402 (717) 757-7602 Attorneys for Defendant Reinhardt f'>, ^ , ,','':''1?,'';'~'''''":'' "~<" c - ";,,,";'10 ,','-, -'"1-,.'" ~^ ~~ :J v ~ [I :1 II il :! 1 if if li- T'I ,- r" -~_.. " - ~, ~'~ Q t,,1 L >'"" " ~-i (') C ~[ Z -r -< 0) :.0 :::J ,,;) ~,...".~,"tr~:",,,,,",,~.,.,...._ ~,~ ~~,?;~l?I'~Pl-!!Rl;f*,W1~,~~~~!j!;t:'Jll~4l!/1~~~! r-~ - '... CATHERINE SMITH AND RICHARD SMITH, Plaintiffs IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PA CIVIL ACTION - LAW v. NO. 01-2682 Civil Term JOSEPH REINHARDT, Ill, Defendant JURY TRIAL DEMANDED AFFIDAVIT OF SERVICE This is to certifY that on the 7th day of May, 2001, a true and correct copy of a Complaint was mailed to the Defendant, via certified mail, return receipt requested, at 654 St. MariS Road, Pylesville, MD 21132. A copy of the certified mail receipt No. 7099 3400 0008 6631 7618 is attached hereto. Do~ RETURN OF SERVICE This is to certifY that on the 11th day of May, 2001, a Complaint was served upon Defendant, via certified mail, return receipt requested, at the above-noted address. A copy of the signed return receipt No, 7099 3400 0008 6631 7618 is attached hereto. ~ Sworn t.2-.avlJ. subsc*~ l/,;o:i me thi~'day o.~' 2001, Notary Public My cOJlllllission expires: NOT,I>II!4,l$l!AI. U!A A. H/OYFJoV. loI'IIo'Y Public IIorli\t>>J'lO, D~"1'~in C"..,tv, PA My Cam/lIlIoion I:xpl... IIIoft 6, 20G2 233&11.1 IDLLIMTG ~,~. ., :1""".1"",,~~. ",-<, .0 e".', ",",,'. '0''''\' ,>.10''1 '_'""""_,, -,~,"",-.,-",., ",~",>"" ",- ~ ,~ " <0 .-'I JS '" .-'I ,." JS ..J]' Postage (';,J J^J.Af.'A.P l0T'jF\ ~ ~ ' ;-0 I '1 Certified Fee <0 .0 o o Return Receipt Fee (Endorsement Required) Restricted Delivery Fee (Endorsement Requited) o o "'" ,." Total Postage & Fees $ Name (Please Print Clearly) (to be completed by mailer) ~ -Sireet:p,p'CN. o.;-or"PO-e;o-;:No:"------..."--..----.---...--~..I...--:.--u--..n..--0---- t:l .cily,."sUii"e;zip:;";r---n.......--.---....---..nn--..---....... _..n..___n__nd.__~.__. '" Ps Form 38001 JUI,--l9!;19- - ~- '. "',0'. ' 1.? 'geeEleveJse tOt\J:i~ttggtl I __ ~ _' 't _.~.""-"' <"" _ .f"'r<' _ ,..... .. . Comple~ items ff 2, and, 3. Also complete item 4 if Restricted Delivery is desired. . Print your name and address on the reverse so that we can return the card to you. . Attach this card to the back of the mail piece, or on the front, !f space permits. 1. Article Addressed to: D. elivery address different from item 1? If YES. enter delivery address below: Agent o Addressee DYes DNa ! M1' ~>Cpt, fu"hL(o!+ ({r i LP'5~L) 51-. ~('1 So f2cJ, I V'c(u'.-vYle...V11b 'O-i1~ ~ I .In 3~S ice Type ertified Mail 0 Express Mail o Registered ~eturn Rec~lpt for Merchandise o Insured Mail /D C.O.D. 4. Restricted Delivery? (Extra Few 0 Yes 2. Article Number (9apy fram service la~eQ /(,CtCl ;2,~bD. O'OD9: PS Form 3811, July 1999 tolo'SI IIQ i~. Domestic Return Receipt . 102595.99-M-,789 ,,,,-..." n - , ~ CERTIFICATE OF SERVICE 1, Mary T. Geraets, an employee of the law firm of Angino & Rovner, P.C., do hereby certify that I am this day serving a true and correct copy of AFFIDA VlT OF SERVICE/RETURN OF SERVICE upon all counsel of record via postage prepaid first class United States mail addressed as follows: Michael Scheib, Esquire 110 South Northern Way 'tork,pJ\ 17402-3737 Attorney for Defendant Dated: 1..Y5 ,i) \ 23381 Ll\DI.LIMfG 't,,,:", ;." ..""""",,,,,o~, . .~'. ",."~<q,,.,_ ." ,e ~">r ~",. _ _. _c_", _ ~~ 5 ~$ ~ > 'R~" - -", ~ <'~~ ,. ,',.~"o"~~."C, , . n C:.J ~o:-; , !"~ ~!!IIII~~;$l~~~~~~~_J;F. _,~ . ..-- 'ot "'" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE ~ AND NOW, this 1S day of August, 2001, I, Michael B. Scheib, a member of the firm of GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS, hereby certify that I have this date served the Notice Of Deposition by United States Mail, addressed to the party or attorney of record as follows: David L. Lutz, Esq. Angino & Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110-1708 !~"", ^ ,', ,.,,~ '.}?1 '''''~~,-,~''''','''' 't_--'~' _-','~ _,.',.,. _ "'_~_' , . IT '. .--- ~ ' , "'0'. '.;,'h> -'.~,' .~_" .,' ~ ,~ "". ,''''"^ ~.~. _'.;~'"'' -B,.'''o',"",>''',~r,,,,,""' ".~",.~.,,~ - . , IF ... () t-.::> CJ- C 'fl ~ ;:::...... ;po "Om c:: " ml"1i G) - Z:n c &51~; I :! !11 \.0 ' , -<.~' ~ ~~'> '.) - Po', ';;' -"1 ZC' :::;--t) ~ :Pc' N (.:)lll Z ''0 i~ ::2 :oJ 0'> -< ~I '"'i~>~,,'","~ """,,,,~~~~~,i/'Ji!j;i~~~!t"'~~ .,~I . . IN THE COURT OF COMMON PLEAS OF CUMErERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE ~ AND NOW, this <(5 of August, 2001, I, Michael B. Scheib, Esquire, a member of the firm of GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS, hereby certify that I have this date served DEFENDANT'S RESPONSE TO PLAINTIFFS' REQUEST FOR PRODUCTION OF DOCUMENTS, by United States Mail, addressed to the party or attorney of record as follows: David L. Lutz, Esq. ANGINO & ROVNER, P.C. 4503 North Front Street Harrisburg, PA 17110 (Attorney for Plaintiffs) GRIFFITH, STRICKLER, LERMAN, SOL YMOS & C LKINS 1 BY: Michael B. heib, ESQUIRE Attorney I.D. No. 63868 110 South Northern Way York, Pennsylvania 17402 (717) 757-7602 t"f~M"lIffi~ '.,_ .~,,'.~'" ',' , .,'''r ,-- "-- ~ ". ~ { - ,,"', ~ , ,"~ -., ~~. -" "'.- ~. , ""..:~o ~~.,,'''~ ",,~,,'B "''',,~' '"~o,A -" .,"',.''''''--'",..1',''.'' - (') c: s: m\Jn:'1 fT' Z-r' ZF" O):}" -<;" ~C' .P"C'" ZC-" "-1- ; Pc Z =< '-"'TU " CJ o '-1'] )::>0 ~~ I In ~ r,,,) ,~_~-.~ i:!) ;>.;:; r'~l '-, '}.,,: :0 -< ,'V OJ .,~,.rf1!ill~"~~Jj;~~~~~~~_.J. ~"'~F~,,~_1 , I- . a. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED AND NOW, this CERTIFICATE OF SERVICE 'f-h r; day of November, 2001, I, Michael B. Scheib, a member of the firm of GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS, hereby certify that I have this date served the Notice Of Deposition by United States Mail, addressed to the party or attorney of record as follows: David L. Lutz, Esq. Angino & Rovner, P.C. 4503 North Front Street Harrisburg, PA 17110-1708 Michael B. Sc eib, Esquire Supreme Court ID No. 63868 110 South Northern Way York, Pennsylvania 17402 (717) 757-7602 I," 'il " ,,< ~9 '- ".. " _'r. " -';$."\"~.' ::.; ,A\C-"" H"C'" ., 'V' "'WliilOlillffilOlr ., '.ll~'It' Q c;" vfj~ l"tlrr: Z::L; 05=~ ~ ~~~., ,v~:~; /:. :~ c:; ~-.':) c:: "";'\ :~.J ,~,..) .::; (;) ,~-"'I~.",",.,,:", "-IoWl'~.~f!jlr"'"_1$l,'1I1'l!;I:J!i!llll~~~A1~~~,jf~rrm1 r' .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE .'-/h AND NOW, this /J of July, 2001, I, Michael B. Scheib, Esquire, a member of the firm of GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS, hereby certify that I have this date served the INTERROGATORIESIREQUEST FOR PRODUCTION OFDOCUMENTS OF DEFENDANT TO PLAINTIFFS - Set No.1, by United States Mail, addressed to the party or attorney of record as follows: David L. lutz, ESQ. ANGINO & ROVNER, P.C. 4503 North Front Street Harrisburg, PA 17110 (Attorney for Plaintiffs) GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS /1 BY: Mi hael B. Scheib, ESQUI E Attorney I.D. No. 63868 110 South Northern Way York, Pennsylvania 17402 (717) 757-7602 Attorneys for Defendant Reinhardt ;'-,,- "''''!:~"''",'<:,':1-" '"~"'~^" ,;'07 ~"',<< o<""W'; -' _ I:' ,I' " I,' - 'I" ". ~l ~ fP t .,~. ~"~ ~'. , <, ~~," ." .~, , "' "., .' '_'0": ,~. '. ""''''',~" ." ,,'r,~'^, ~',O'"".,";'~"'wi>" .,&<.~.~ ,. 'i I'Jti'f"Tr , C) c:: <C. ---,- r:-';;=- ~~:[:- ;-'- .0_, ".. r-~ ,'--- C~) " " ,< _'''1:,:,,~':rlJllRI~~\I'i~T'!fl1j''~~W!~ilm'l'!1{.~~~~[\ll:~~.,,'i'';; . IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED PRAECIPE FOR ENTRY OF APPEARANCE PURSUANT TO Pa.R.C.P. 1012 TO THE PROTHONOTARY: Kindly enter the appearance of Michael B. Scheib, Esquires of Griffith, Strickler, Lerman, Solymos & Calkins, as attorney for the Defendant in the above~ captioned matter and mark the docket accordingly. GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS BY: MICHAEL B. SCHEIB, ESQUIRE Attorney 1.0. No. 63868 110 South Northern Way York, Pennsylvania 17402 (717) 757-7602 Attorneys for Defendant Reinhardt Dated: ,;;i}" ,,"'" ' '-~"~'.' 'C"'~,:"", "--"-:'C-?::,,,'f- _'~ ~';''''.,1.1'":', ''''''/::f~'l'',',';"--i'[.''.'-.' _."~y"--,,,,.. ". '1- .. , ~/ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED CERTIFICATE OF SERVICE ~ AND NOW, thiS~ of June, 2001, I, Michael B. Scheib, Esquire, a member of the firm of GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS, hereby certify that I have this date served a copy of Praecipe for Entry of Appearance, by United States Mail, addressed to the party or attorney of record as follows: David L. Lutz, Esq. ANGINO & ROVNER, P.C. 4503 North Front Street Harrisburg, PA 17110 (Attorney for Plaintiffs) GRIFFITH, STRICKLER, LERMAN, SOL YMOS & CALKINS BY: 1ttdJ 1-- Michael B. Scheib, ESQUIRE Attorney I.D. No. 63868 110 South Northern Way York, Pennsylvania 17402 (717) 757-7602 Attorneys for Defendant Reinhardt -'-';"-":T' ,;..,"",~<l'-b'd ~-',,,,. ~"-"~,,, -. ''','-J';',' \ ',' . ..,". "__~, __. ""'-. .---~,.,'^. .. CATHERINE SMITH and RICHARD SMITH, Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA vs. NO. 01-2682 JOSEPH REINHARDT, III Defendant CIVIL ACTION - LAW NOTICE OF HEARING PLEASE TAKE NOTICE that the Arbitrators appointed by the Court in the above matter will hold a hearing on Tuesday, June 11,2002 at 1:30 p.m. in ~the Court Room of the Old Court House (2nd Floor), Cumberland County, Carlisle, ., :s ~Pennsylvania. If this date is not satisfactory to any party involved, please z: z: '" ~contact all Arbitrators and other pa~ties involved to determine the next z: < :possible day, after the date fixed herein, check with the Court Administrator's '" BOffice to see if the hearing room is available on that dar and, if everything i> '" ~is satisfactory for all concerned, give a written notice of cbange to all '" '" ~ Arbitrators and counsel . ..l y; Z o ~ .. oTO: ~ '" u i;: .. c ~ ... Mark Silver, Esq. 500 N. 3rd St/ Harrisburg, PA 17101 Arbitrator Cory Snook, Esq. 1013 Mumma Road Lemoyne, PA 17043 . Arbitrator Michael B. Scheib, Esq. 110 South Northern Way York, PA l{t~~ for Defendantt David L. Lutz, Esq. 4503 N. Front Street Harrisburg, RA 17110 Atty. for Plaintiff "'!~" - "'''C'>-),' II -.,' Plaintiffs LN TIlE COURT OF CmlMON PLii:AS OF C~!BERLAND COUNTY, PENNSYLVANIA N\'f. 01-2682 CIVIL Term" JlIl Catherine Smith and Richard Smith vs. Joseph Reinhardt, III Defendant RULE 1312~1. The Petition for Appointment of Arbitrators shall be substant~ally in the following form: P~TITION FOR APPOIN111ENT OF ARBITRATORS TO THE HONORABLE, THE JUDGES OF SAID COURT: David L. Lutz, Esq. , counsel for the plaintiff~M~ in the above l. 2. action (or acticns), respectfully represents that: The above-captioned action (or actions) is (arej at issue. The claim of the plain~iff}n the action is $ ltN"~""ctoJ;d The counterclaim of the defendant in the action is The following attorneys are interested in the wise disqualified to sit as "arbitrator's: and Michael Scheib, Esquire case(s) as counselor are other- David L. Lutz, Esquire WHEREFORE, your petitioner prays your Honorable Court to appoint three (3) arbitrators to whom the case shall be submitted. Date: 2-26-02 cc Michael Scheib, Esq. Respe~mit~ed, David L. Lutz, Esq. ORDER OF COURT AND NOW, fir hAl g ~ ' M~dJ.;- in foregoing pet~tion, ~ ~a... ~ Esq., and ~~~L ,Esq., are appointed arbitrators in the above-captioned action (or actions) as prayed for. consideration of the , r Esq., }/1..c:dC- ~ P. J. .-'" "!"",",'I-'''''-''''-, ,.".. . ~ r ,. '! ~,=~= ,"" ~, "-" . . " ,."~"",'~'" . .', '';'~","';,..,.' "."' ,,-,'~' ''''-' . 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':, ' , - " i ,\,d1~,~",~I_.;.";, ' ~I. /1'- 'Il, i; i'11!N1L.",,_ IN . !~.."~~,,,.:l..}ll!l J,I,J .,~'~;~~~~~~!"il!fffljjf&WM~,T'~'WI1!"'!'Wf"""','Wq'''''W'i;j[:H$'YI'$~t!:'~~.~iii:Clf#'f!f#:i"1',,*'l>ilRW;l~!o~ _..",.~~.~! , ~j,iI;, /~ \....Jr:~ el"l V1 ~ -.J- PdtalY~ S:\M lit. ,; In The Court of Common Pleas of tI ) ) ) ) ) ) ) Cumberland County, Pennsylvania 0/ )lo. ;;, fo 1?"2- 19 Cj(//L- Josr~j, V fr1.'17 to V- J-f 7 / J OATH We do solemnly swear (or affirm) that we the Constitution of the United States and the wealth and 1:hat we will discharge the duties 'C air:nan ~9~ AWARD We. the undersigned arbitrators. having been duly appointed and sworn (or affirmed), make the following award: (Note: If damages for delay are awar~ed, they shall be separately stated.) lth _ Q.~ ~ ~ ~ tt:e -= &f-dLJ'jr IV> ~_ ~4 IHItt.t:J., elL vtt applicable. ) . Arbitrator. dissents. (Insert name i= Date of Hearing: ~.. Date of Award: 2-- NOTICE OF ENTRY OF AWARD t" -' \..^ . Now. the I'"'::> day of J vJ\.L ~O'O?..., ~, at ill. -\?11., the above award was entered upon the docket and notice. ther~of given by mail to the parties or their attorneys. ' Arbitrators' compensation to be paid upon appeal: $ f;)?!o. aD By: '~,- , I I ">" f3IVJ8X:1t;'~ ,~ - ,'^:..",. ",,^ >. .','~~" C'''^'"',-' ,'""" ~. / ~_ __ I,JJ J cry; r Ie, f Ct t/ e v A~ ,4v~ S/..vkjZ;:};.k'; , /;1 0 C/fRO L s-..; )Jew CVpYl pey/ah cI / I;; /7 () 7 0 j/lll/1€ f( S I L VE J( SOD;/ 3,-d Sr: /-.1 . I l/Vr:;, &- /710/ N a r r /.5 p ~) ,-~~ { () j/ f JI1 OiJ K' J:J.& .. ~ /o/:? (V/JJ4?#ta, )~q,j /}t /78 t;-3 /-em 41)4(' / -f~~, "}J-ojoJ.-. '3>~ ~ ~ - -( "" ( k ~ (' f F ~ ~ .$ '>l.: J;1 .,., o ~ ,..~ ~ '- c> "'ClCf] c:: -... m r,' 1Ol: "'" :z: ::D :z:r;:- - '-0 cf>.,c-: c,...) . ~.~ <, <Ci S' ):>: :z:0 ~ ",,0 ~ J> c:: Q, :z: o ~ .:D , . -rill o -n -n :x '-:? ::;1 :\1~ -om ;'39 ;:j~ 6:l1 0,,0 "'-l'f1 o -I ~ "< 0:> y;> J ~ tr' l:'" .1"" ~~_M~~< ~~""f. .,,~~IlD!lfd~ ~~W'Jft>;l~~:iiil~~'''''Wf-''''''K'~iP:i'1~''''T*:E!'f.,*@,~:''4mJm ,'." _ _ ~~ ~~_..~I1P1I~_i Catherine Smith and Richard Smith IN TBECOURT_OF CCMMON PIn.s. ~~T,^~:m !"O:r;;.:";T'J' ~'1i1'-"<:!:vT::1.~ 'TI~ 'Ju..-'-~'\.I...;t"'....,_ ..., ',-..d~.:"', .__....h.,~_ ...--- vs. Joseph Reinhardt, III No. 01-2682 Civil Term NOTICE OF APFYL FROM .WJ..JID OF EOP1ID 0::<' P.RE.l'l'~.'!'ORS TO 'l'~ PROTE:ONCTJI.RY: Notice is given t~t Plaib;tiffs appeals :'ron the a1-TlU'd of" the board of"' arbitrators entered in tnis case on June 13, 2002 A jury trial. is demandedL]1. (Cheek~ cox if a jury trial is demanded. ctherwi.se j~"'Y trial is ,vai i/'ed . ) I hereby certify that (1) the compensation of the arbitrators 'has been paid, or (2) ~X\ll:a~D~:~X~ltX~~~li\:~KR~xxRxR~R~~h1fflx ~~. (Str~ke out the il'lapplicable clause.) -~ i~~~~~iZAt~5~ey for Appellant NOTE: The, demand for jury trial on appeal :'rom comDUlsorv arb it rat ion is iZCJ."erned by ~e i007.1" (b). - .~ ,iJ ~ ~'i{ ,-0' ,:'1 l~ (b) No a~f1davit or veri~icat1on is "!10","'~""'':'~ - -'-:.................. . cc Michael Scheib, Esquire ~(\-tt: 02 - t9-le - D d.. ':,,'>c,', . ~" ~ , , "-"'., >~~ ~~ . "">"" ~"" , "~, 0 . , "-~". ,""Z~""-' ~",,',", """~',h;.4', 'N~.",.",~",;.",i~",j ,-", ,,""'0 ".11I""""'''''''''''0<''" ''''''''''j;r""'''~ ., [' l (.) .tel. 'i ?v ..0 (') r~ C) '.~,,' 0 c: , ~-~ -i] ,?:', ~ . -or.:> '0"- '- () ~~,:r; .,-,". ~ -~. " () 7r'- r...) ;T, S -, .--" en -'-":' C'.;; '.-' / . ,L --l ~....,..:: ----. ~~? ~ ~.::c; :~ ~~:~ Z;; --'3" C) >2=~ ~? c;m Z N )>! ::;! ~I 1- -.J ~: Ii .\ !i Ii II Ii fJ)' PI! .,,~, "r~"1"_M,,".lI.,' . ~^ ,__~~~I'~k:"W!'~~~!lI~f.'i\iIIiIl~I!JII!~~~.",. !~.i o__^ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CATHERINE SMITH AND RICHARD SMITH Civil Action - Law Plaintiffs, vs. No. 01-2682 JOSEPH REINHARDT, III, Defendant JURY TRIAL DEMANDED RBAJ;~ TO: PROTHONOTARY Please mark this matter settled, discontinl.led and ended with prejudice. ~ BY: David L. Lutz, Esq. ANGINO & ROVNER, P.C. Attorney I.D. No. 3 <:;q ':>~ 4503 North Front Street Harrisburg, PA 17110 :,:'" '::,.r:",~~~I><>-"~""'I-' j,. -~, - ~t'-'I-<;("!"""" ,W ':' ' ' -'-I." '/, -, ~~. ~~ i~ ,__,,_,^ _"r .< ,,~,,_ ~"l[fil,.,_~ ""~,_"e "f!l~JJlllt.,..... > -"~- ~." 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