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01-04207
NICOLE TYSON, a minor, by and through her parent and natural guardians, MARY JO and WALTER TYSON, III, Plaintiff, v. IN THE COURT OF COMMON PLEAS CUMBERLAN® COUNTY, PEN/NA HEATHER KOBLISH, ~y~ ~~aD~fendant. ~~x~+~",~f~A PRAECIPE FOR WRIT OF SUMMONS l~o~ TO THE PROTHONOTARY OF CUMBERLAND COUNTY: Pleas issue writ of summons in the above-captioned action. Writ of Summons shall be issued and forwarded to (X) Attorney ( )Sheriff. Respectfully submitted, NEALON & GOVER, P.C. By: Brian N. Zulli, E ire I.D. #: 85948 2411 North Front Street ,~~ , ~ Harrisburg, PA 17110 Date: 717/232-9900 WRIT OF SUMMONS TO THE ABOVE-NAMED DEFENDANTS: You are notified that the above-named Plaintiff has commenced an action against you. J~{,. e2~1 Date PROTHON'OTA C Clerk/Deputy NICOLE TYSON, a minor, by and through her parent and natural guardians, MARY JO and WALTER TYSON, III, Plaintiff, v. HEATHER KOBLISH, Defendant. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA NO. 01-4207 ORDER AND NOW, this /8~ day of ~~~ :P_~-x,~c~2~..~ , 200L, upon consideration of the Petition to Approve the Settlement, it is hereby ordered and decreed that a hearing will be held on ~ _e,~2ua~L~ ~ , 2003 in ~ ~~ g~ ~ ~ • /~ • , of the Cumberland County Courthouse to consider the Petition. By the Court: ~c~o l2/• 2l -01 C.R~S. Y f~J ~~ ~j ~ j Ct3 n ~ .f iS ~ ,mss ~. ~-_. Y i.~- . ~, r_ Est K C=3 `~ , ~ ~ NICOLE TYSON, a minor, by and through her parent and natural guardians, MARY JO and WALTER TYSON, III, Plaintiff v. HEATHER KOBLISH, Defendant IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA N0.01-4207 ORDER AND NOW, this ~ @ day of ~~,bvva-y , 200? ,upon consideration of the Petition to Approve the Settlement of the claim of a minor, the settlement in the amount of $5,000 IS HEREBY APPROVED. The settlement funds shall be deposited into one or more savings account in the name of the Minor Petitioner, Nicole Tyson, in banks, building and loan associations, savings and loan associations, or credit unions, deposits in which our insured by a federal government agency, provided that the amount deposited in any one such savings institution, shall not exceed the amount which accounts are thus insured, or in one or more accounts in the name of the minor investing only in securities guaranteed by the United States government or a federal government agency managed by responsible financial institutions. No withdrawal can be made from any such account until the Minor Petitioner obtains majority, except as authorized by prior order of this court. Proof of deposit shall be promptly filed of record. Petitioners are further authorized to execute the Release attached hereto. BY THE COURT: /~ J. s c rv Y ~J1~1~vri ~>>Si~` ., ,t.A~r , ~~:~ra - cc' - ~ -~'-'~Gnl~i+J ~t~bJ.C)i'~~~~.'r I ~' i ; ~ I, i .. _.. ti ~, ~-; .. NICOLE TYSON, a minor, by and through her parent and natural guardians, MARY JO and WALTER TYSON, III, Plaintiff, v. HEATHER KOBLISH, Defendant. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA NO. 01-4207 PETITION FOR APPROVAL OF COMPROMISED SETTLEMENT AND DISTRIBUTION OF PROCEEDS OF A MINOR'S CLAIM 1. Petitioners, Walter and Mary Jo Tyson, are adult individuals residing at 473 Woodcrest Drive, Mechanicsburg, Cumberland County, Pennsylvania. 2. Petitioners are the parents and natural guardians of Nicole Tyson, a minor, hereinafter known as "Minor Petitioner" having been born on July 17, 1985, and who resides with Petitioners at the address stated above. 3. Respondent, Heather Koblish, is an adult individual residing at 14F Rebecca Dr., Duncannon, PA 17020. 4. This action was commenced against Respondent with the issuance of a Writ of Summons on July 10, 2001. 5. This action arises out of a motor vehicle accident that occurred on July 17, 2000. On that date, Nicole Tyson was a passenger in a vehicle operated by Mary Jo Tyson, which was struck by a vehicle operated by Heather Koblish. A true and correct copy of the relevant police accident report is attached hereto and incorporated herein as Exhibit "A". 6. As a result of the subject accident, Minor Petitioner was transported to the Holy Spirit Hospital for treatment of injuries including a cervical strain and anxiety relating to the accident. Minor Petitioner was discharged that same day from the hospital and told to wear a cervical collar to support her for two or three days, apply moist heat for 15 minutes three times daily and take Advil or ibuprofen for pain. On July 18, 2000, Minor Petitioner presented herself again to Holy Spirit Hospital due to pain in her right forearm, wrist, and hand. She was diagnosed with having a wrist sprain. Copies of the relevant medical records are attached hereto and incorporated herein as Exhibit "B". 7. Minor Petitioner then treated on October 2, 2000 with Central Penn Physical Therapy. She treated with Central Penn Sports Medicine/Physical Therapy for her neck and shoulder pain as well as persisting headaches and pain in her right wrist area. She treated with Central Penn Sports Medicine for approximately ten times. Copies of relevant medical records are attached hereto and incorporated herein as Exhibit "C". Minor Petitioner was released from Central Penn Physical Therapy on October 23, 2000 with limited functional levels. 8. Minor Petitioner then presented to HealthSouth for her same conditions. Copies of relevant medical records are attached hereto and incorporated herein as Exhibit "D." 9. Minor Petitioner was also evaluated by the Neurology Center, P.C., on October 31, 2000. At that time, Minor Petitioner continued to complain of tightness in her back and right shoulder. She also complained that her right arm shakes when she writes and complains of headaches. On November 20, 2000, afollow-up was done by Dr. Todd Samuels and he stated he believes the frequent headaches are related to the overuse of Excedrin. On February 13, 2001, Dr. Todd Samuels did another follow-up on the Minor Petitioner. At that time, her headaches were resolved, and she did state she had spasms involving her right arm after bowling. She was advised to break into physical activity a little more gradually. Copies of relevant medical records are attached hereto and incorporated herein as Exhibit "E." 10. Medical bills for Minor Petitioner's treatment have been paid as evidenced by the letter attached hereto and incorporated herein as Exhibit "F" 11. At the time of the accident, Respondent's vehicle was insured under a policy of insurance issued by Allstate insurance Company providing per accident liability coverage in the amount of $100,000 with a limited tort option as evidenced by the policy declarations page attached hereto and incorporated herein as Exhibit "G." 12. In order to resolve the claim of Minor Petitioner, Allstate Insurance Company has offered $5,000 in full settlement of their claims against Respondent. 13. Petitioners have agreed to accept said offer. 14. Petitioners understand their right to obtain counsel for themselves and for Minor Petitioner, but elected to proceed pro se. 15. The undersigned counsel has been retained by Allstate Insurance Company for the sole purpose of seeking court approval of the settlement agreements described above. 16. Petitioners understand that the undersigned counsel does not represent any party in this regard other than Allstate Insurance Company and has agreed to allow the undersigned counsel to proceed accordingly. 17. Any fees generated as a result of the involvement of the undersigned counsel will be paid by Allstate Insurance Company aside from any amounts involved in the above-described settlement and will not reduce any of those amounts whatsoever. 18. The settlement proceeds of $5,000 will be deposited in a federally insured banking institution for the sole and exclusive use and benefit of Minor Petitioner with the right of withdrawal by Minor Petitioner when she becomes 18 years of age, but not before her eighteenth birthday except by prior approval of the court. Proof of deposit shall be filed of record. 19. If the settlement as described herein is approved by this Honorable Court, Petitioners will execute the Releases attached hereto and incorporated herein as Exhibit "H" and seek court approval to do so. WHEREFORE, Petitioners respectfully request that this Honorable Court enter an Order approving the settlement and distribution of proceeds as described herein and authorizing Petitioners to execute Releases in favor of Respondent, his insurance carrier, and Petitioners' underinsured motorist carrier. By: Date: ` Respectfully submitted, NEALON & GOVER, P.C. Attorney I.D. #8: 2411 North Harrisburg, PA (717) 232-9900 17110 Front Street ~~ COMMONWEALTH OF PENNSYLV. -'1A POLICE ACCIDENT REPORT ~REPER TO OVERLAY SHEETS ~ REPORTABLE ~] NON-REPORTABLE ~ r, ua 7„ 2/-OC ~~ ,Cs PENNOOT USE ONLY -- POLICE INF~RNiATi~N ~ `s" ~:~ ~ ` ACCID ENT I:OCATION ~~' ' - ' - , ,,; , G ,,.., ,~. ; ;~ _xT ,.y _ ; x . ., ,.; . 7. INCIDENT. , / ~'7 - ^ ~ 20. COUNTY .- ~/ ~ CODE I ' NUMBER 7 / ,N(73 ~'Y~i Zt 2. AGENCY- 1 / „ -.P ' /~ /~ 7~r ~~ P~ / T JCE ~ '~ ` 27 M ICIPAI,~Y~ i. _ p ~ ODE / ~ /~ l u+-~- / NAME 1't/ -1~ UL !//J lei 3 4 / , St OL PRINCIPAL ROADWAY INFORMATION PRECINCT . . ZONE < 5. INVESTIGAT R ~~ nn BADGE l ~-~ I SN ~ 22. ROUTE NO.OR , )-(~ I I - ! t/Ti NUMBER STREET NAME VJ 6. APPROVE BY BADGE _ 23. SPEED //,, 24. TYPE 25. ACCESS t ~ ~ NUMBER LIMff 7 HIGHWAY COMROL 7. INVESTIGATION ~ 8. ARRIVAL I ZZ~ INTERSECTING ROAD: DATE _ - ! ~- TIME ~:.,--.,.~- .;4y, ,_ -mss wm«~ ~ 26. ROUTE NO.OR x3~~ r ACCIDENT lNF_ORMATtON ;; „~,, STREET NAME 9. ACCIDEM ^ I ~"~~~ 10 D YOF WEEK ~./ ~~~' 27. SPEED 28. TYPE .ACCESS DATE ` / LIMfT HIGHWAY COMROI 1t.TIME OF t 2 ZO 12. NUMBER 7 Z~ IF NOT ATINTERSECTION: DAY OF UNITS 13.#KILIED 4.#INJUfjEO 15' P ^ S 'I ~ 30 L ACCI EM Y N li!~ IJ• SEGMEM MARKER ~ ~i C~7~/~•~-ice / 16. DID VEHICLE HAVE TO BE 77. VEHICLE DAMAGE 31. DIRECTION 32. DISTANCE ,~.,.^ N S N/ "~ ~ REMOVED FROM THE SCENE? 0 -NONE UNR 1 a . MI. FROM SRE FROM SRE ~1 C~ FT UNTf 1 UNR 2 7 -LIGHT CI II 33. DISTANCE WAS ^ ETE ESTIMATED Jr~„I MEASURED Y ^ N 11pp~~ Y ^ N ~ 3-SEVER UNR2 Z 34 CONSTRUCTION O TRAFFIC PRINCIPAL IMERSECTING 35 L~1 . . O ZONE C MROL 18. HAZARDOUS I~T~ 19. PENNDOT ~ D~ ^ 'f ^ MATERIALS Y N ~ PROPERTY Y N ~ ~ -~~.r»~UNi T _ '~ ~ #2 , z: ~ -~ `~ °~~ UNIT ~ ,~R.. r.~~";«'i/«„ .1 , ,,# aYT Y u+s~ f-.u .. ~~ ~ ~ _ _ ~ . .r-t*'u^~- .a...r.~Lw.- ~ ~ ~~ ~ ~ ~ ~ ~ ~ f 36. Y N. A / ~~ 38. $Tj1 37. / ' I ~ Z~ ` S 36. LEGALLY Y N TAT~F 3 37. REG. (' --7 /'~7 ~ ~ PAR ED ? ^ l PLATE Z d U PARKED? ^ PLATE LU ( J E'i 39. ATR7 OR S~3 iZ 33;3 So ( _ 39 0^"••'~OR 1-/~ p / j OUY-0 -TAT i t ~t-TI,~p SZ LJ O V~ I V j O ~.f 40.OWNER f}-Tt'!'rc~La~ ~ ~!! ~] 5 `~ ~ E vfAti7-E2 J . 5 ~l L ~I 41. OWNER ,,// //~~~~~~ ` i'~ { ~~'~L'4 D~ • 47. OWN \~ h` 1 ~ • U 7~ ~ ~ ~© ADDRESS ~" - Y l ADDRESS i C ``~~ 42 '~" 1~d 2~ ~C E (~ .~t- (j ~// , / ~~ 42. 9i~7 ~S ' ^~ /~ f ?~`~'~ f'~ M E - IT I/V BZIPCODE , ~`•' ^ CL• & PCODE ~ 43. YEAR n 44. MAKE ,• ; n -„ - - -- - --- ] ~ ~1 `1~ 43. YEAR ,~ 44. MAKE ~~`~ 46. IN 45. MODEL- (NOT // ~ ~,~ ~ /~ ~ ~ ^ ' ^ 46 I q ^ ^ ~ OT >~C7~J -. Y N VNK BODY TYPE) U~--W UNK Y N BODY TYPE ~ft-lfv~(r~ 47. B O DE ~ 48. f O 49' 47. ~ ~ 48. PECIAL - 49.VEHICIE !' ~ , Y P OWNERSHIP USAGE E OWNERSHIP USAGE L 50. IN R I A L IMP~CZ SL E O ~ 52 52 SRA OL 50. IMPACT 51. O T O r I STATUS SPEEO E NS _ POIM L 53. VEHICLE 54. DRIVER - 55 DRNER ~ ~ 54. DRNER 55 DRNER 53. VEHICLE CONDRION GRADIEM PRESENCE GRADIEM PRESENCE CONDRION 56. 2 3 ~ 4 z S-9 ~ 57. ~7fT,~ / ' S6: l 8' SAS 3 3 ~ ~ 57. NUMBER 1{ y~ NUMBER 58. DRNER ~ / L ^~' Lt S ~ T ~ 0 /~D ~ Q S8. D R n^ 22 ~~ 5 6'7~/ (~ V NAME ~y ~i - / -' /~ NAME n n, 59. ' / ~j ~~ / _ ~ /~~ ~5L ~ ' ~ ` n 59. DRIVER ' /7~ L ~~j ~S / ~ /C `~~~~ !/ _ -. V - ADDRESS G f . . ~-t` ADDRESS 7 60. CfTY, STATE T vW ~ n n_ I-Za2o 0` 60. Cff1', STATE // _~-{ S~U2C /"~ l~o,J bfPrNIG ~E YI BZIPCODE 1l . ~ &ZIPCOOE G 67. SEX 62. OPIZ^ZI-?.5~ 63~FjOyE q~35~ .S$~`ff '"' 61. SEX ~ 62.H R OF IZ~!/-~/ 6~ E ~~~ l ~o B RTH O J C~ l i 64. COMM. VEH. 65. DRIVER ~ 64. COMM. VEH. 65. DRNER ~ Y p N CLASS Y p N CLASS 67. CARRIER 67. CARRIER 68. CARRIER 68. CARRIER t ADDRESS ADDRESS 69. CffY, STATE - 69. CITY, STATE dZIPCODE &ZIPCODE 70:, USDOT# ICC # PUC# 70. USDOT# ICC # PUC# 72. VEH. 73 CARGO 74. GVWR 72. VEH. 73 CARGO 74. GVWR CONFIG. ODY TYPE CONFIG. ODY TYPE 75. NO.OF 76. HAZARDOUS 77. RELEASE OF HAZMAT 75. NO.OF 76. HAZARDOUS _ 77. RELEASE OF HAZMAT I AXLES ~ MATERIALS Y ^ N ^UNK^ AXLES MATERIALS Y ^ N ^UNK^ ' AA35 m9B, 3 2 7 3 1 4 6 PAGE. PennDOT-BHSTE .-~ ~ /i/ 78. RESPONDING EMS AGENCY ~ ~(, ~ f~. 3 ~ r .DENT #: / ~/7- crt7 79. MEDICAL FACILITY L SPt 2.lT SP~Ti4-L ACCIDENT DATE: ~-/7-~ 80:pEOPLE INFORMATION , -!r B C D E F G NAME ADDRESS ~ H I J K L M 3 ~ 6~~2 JI ® a © Q 3 ~ $ 3 ~ 9 ,~alr~a-l~ ~>-~ic.ct95 SA~E~-s aPbfL VI D f.~ Q 6- ~ Z I F `/ 3 1 e P~2 V Z v o o ~ rr b 3 F 1 ~ I 9 Nic.vt.~ Tys„~ s,~ A-s ~~~ V2 99 59 ,~- ® / 2. ~f ~ Iro 3 i o x21s~ T ys~ s,~r.f .~s ~~ ~Z c, ~ o ~ o, 2 (o F t 3 1 O ,M.~,a,~ i ys~ S,a~wcE .~+--s o~~2 JZ `J 49 9 ~j ,4 c~ / (87) ILLUMINATION ~ 82 WEATHER ~ ~S3 ROAD SURFACE 86. DIAGRAM - I i i wA 84. PENNSYLVANIA SCHOOL DISTRICT (IF APPLICABLE) `(2 D ~(2 D 85. DESCRIPTION OF DAMAGED PROPERTY - ~ t.`A1lZY ___._....___..__.........._ ~~ OWNER - - - ADDRESS ~ - 115 t t - ) I ~I (L 4 PHONE ` ~io'((-~ ~ ~ ~ (iu- 87. NARRATNE - IDENi1FY PRECIPfiATING EVENTS, CAUSATION FACTORS, SEQUENCE OF EVENT ,WITNESS STATEMENTS; AND PROVIDE ADDITIONAL DETAILS. LIKE INSURANCE INFORMATION AND LOCATION OF TOWED VEHICLES,'lF KNOWN. \/ 1 c,:~->4-~ EX I T l n~ - 1C_ F (-F F~-D Tv fL rt I N C~ ~~' T OnJTV V S t I 5 ~°-~TtF ~f 2 w Ass ~-~2~ v~-u.., irU ~Tr~ Urv ~ S 1 I ~ r~ 'Te~E r/6r T C,A-nl-c - 7"rfc° ~IT+,s-6S5 Lsv~ Fowa,.,s-„.~v \!1 ta,9T of IC F} Fo-2b. T~ tn.rl i ~S S. S Ti9-Tc +~ T~{A-T ~/ 1 ,~U (.La~ O-v~ i N ~~T~ ~ /v-p(LTN- Q-cS~T-v~~~ Tj~a9-mil C . A-y~3 cINIGNVwIJ tl6K/GCS lnJ Tr},Gr CL16~ ~. N E C%,9-.^'tE i~J ,.4~ ~fL.crf' T s ro-P Q,.t7- J2 r~N7la/v-C~ G~l-O7~Tl~'a/ U I S T 2.vC k- V Z (n1 'T!-{~. j~~T cJ-s27~ Qov-y~'~ C.R~a~1~. INSURANCE INFORMATION C PANY ~T~. /NDtrT'7N// ~• INSURANCE INFORMATION COM NY („(..S~TZ /l~~• ~. UNIT 7 OLICY c-? ~7~+ NO ~ ~1 (~J ~ J J I ~ lq UNIT 2 POLICY O ~+ NO ~ ~~ O ~O O~ ! ee. NAME ADDRESS PHONE - ~ Lt aril A A. Gat,bw~t.t_ lSy/ (92A'wlNlEc,s ;9'vtr M~c.N~re.S$v,CG PA- /~oSS" ~0 4!-~~g" WITNESSES NAME ADDRESS PHONE 89. VIOLATIONS INDICATED 90. SECTION NUMBERS (ONLY IF CHAR ED) TC NTC k UNIT 1 ~~(( ' ~/ ~fF./f. Ejv~~[,lp. ~ O'Y~ ~~S l A~ UNIT 2 97. PROBABLE 92. TYPE 93. RESULTS [~,NO TEST 97. PROBABLE 92. TYPE 93. RESULTS [~J,NO TEST 94.INVESTIGATION USE ~ TEST REFUSE USE TEST REFUSE COMPLETE 7 UNR 7 O o ~._ _%~ UNK UNIT 2 O ~ .~1 ~,_ _% O UNK YES IX7f'NO V BSI ~ AA.45 (7/98, 3 2 7 314 6 PAGE: Z PennDOT - BHSTE CHIEF COMPLAINT ADM. DATE: 07I47M2000 Auta accident and neck pain HPI This 15 year old, female was the front seat restrained passenger when the automobile was involved rn an acadent She was ambulating after the accident 3h~ tlid speak to her mother pnor to amvaE here and than started having some hyperventrlaUon=type of symptoms She darned any abwous nlury to her heatl but does complain of pain rn the ngM side of her neck PAST MEDICAL HISTORY' Posltrve fbr conoussran Z years ago MEDICATIONS None ALLERGIES NKRA. REVIEW OF SYSTEMS: Constitutanal No weight loss, wsrgM gam, fever, or chills Eyes No waron lass, eye pain, double vlsron, glaucoma, or cataracts E1VT No vrsron toss, earache, dimness, nosebleeds, emus trouble, ar sore throat Cardiovascular No chest pain, palprtabons, swelling of feet, or heart murmur Respiratory Unable to control her breathing Gastrantestrnal. No naysea, vomiting, d~nhea, conahpabon, abdominal yarn, or rectal bleeding Gerntounnary No blood in unne, panful unnatlon, or frequent unnafion Musculoskeletal Compiarns of numbness of her extrsrrirlres, face, and mouth Skin No rashes, lumps, dryness, rtohrness, or sores Neurologrpi No drarness, blackouts, secures, paralysis, numbness, or ttrgirng Psychiatnc No depression, mood change, or navamness Endocnne No diabetes or thyroid disease a HematalogrclLymphatrc No anemia, easy txursing, or swollen glands Page 1 of 2 Camp Hill, PA 17011 EMERGENCY ROOM REPORT NAME Tyson, Nicole M " MR# 438392 ROOM' ER1 I7R RAMESH ARORA, MO ORIGINAL NAME: Tyson, Nicole M MR#: 438392 AllergrGlmmunologrc No known allergies PHYStCAI EXAMINATION YIta1 Signs reviewed on nuraa's notes. Young female of thin bmkl who is hyperventilating ~_ HEAD: Normocephal<c Atraumatrc EYES: ConluncWa prnk Lrds without Iesrana PERRL NECK: Mrkl tenderness, nght trapezrus area No spinal defarmrty or tenderness CHEST: Non-tender to palpation GIlABDOMEN: Non-tender NEUROLOGICAL: No lateralrzrng neuro defiut She does cpmplarn of some paresthesras of her extremities PSYCHIATRIC: She appears anxious, restless, and hyperveritilatin~ SKIN: Normal color and turgor Na rashes or lesions. CCIURSE IN'THE DEPARTMENT Ati~an 1' mg sublingual:-end soft cenncal collar was,grven, ' to patient Routine cerncal spine x-ray was else ordered CLINICAL IMPRESSION Cervical sprain. Anxiety reaction PLAN As per instruction sheet RAMESH ARO MD RA/gn . DOC # 89254 D 07!1712000 T 07/19/2000 3 38 P ' 000092 2 of Camp Hill, PA 17011 EfiAERGENCY ROO1rA REPORT NAME Tyson, Nicole M MR# 438392 ROOM ER1 DR RAMESH ARORA, MD ORIGINAL ._.... , Holy spie# Moepltal Department of Radiole~y and DlagnoaNc irnag~ Camp 11111, Psrtnsytvanla 17071 (717) 783.28D0 PATIENT: TY50N, NICOLE M DICTATION DATE: Jul 17 2000 2 40P MR#: 438392 TRANSCRIPTION DATE: JuF 17 2000 3 02P SOC SEC: 999-07-1785 ORD DR: RAMESH ARORA M D PT TYPE, E ADM DATE: 07f17T2000 ARRWAL DATE: LOCATION: ER1- HOSP SERVICIE: ER1 ***Final Report"** EXAMINATION: CERVICAL SPMIE (2V) 72052 -Jul 172000 COMMENTS History Nack pain post MVA left No gross fractures are Identrfled No prevertebral soft GssuE awelkng is satin The hBad rs tilted to Bra CONCLl1310N; Negative AP and lateral waves Standard supplemental wows are adwsed DICTATED BY' WILLIAM MILLER M D /JAS DATE OF EXAM: Jul 17 2000 SIGNED BY: WILLIAM MILLER M D DATE/TlME: Jul 17 2000 5 42P Date (gyp ` Rssulte reYraWed yy M D.iD a ~: Imaging SerolCes Corrsukation Pa®e 1 ,.~ InN{st Lab t~.x-!te a Qrdars: [ ] Acetemmaphen [ ] ESR I j Alcotal [ ]Glucose [ ] Amylasertipase [ ] HCGS I [ APTT [ ] Lrver I ] Sload Cultures Profile I ] BMP [ j Lyles [ }CBCP [ 1PTP [ ] Tox Screort € lumle TOx Screen [ ] Thromboiypc Lelia [ ] TYPe a C"rasa ~e of untie [ 1 Type a screen [ ] U/A f ItSnneC85 I ] Monem • [. ] AaG's papetl W I 1 EKG gaped al ( 1 Peek Flows aB1oMAfter Reep.Tx I 102 r Mln [ ] Raeplretery 1k [ ] oa searetlan () Tlme $satl: t Illbalcrtalons 1 IV's ~ Addltlonal ardara l ] CMP [ J SBpcylalB I ] Warkmaa'6 Camp DN9 Screen CRP S A O .~® O9tB/tI111BrIR, erum I ] 1 [ ] ratane [ ] ther I ] OICJOxm [ ] Theophylme ] j Dllanlm [ ] Thyroid Profile IV: fJ&Bf ~~ 6.A(EIB/.ISHB/ D6,9PIS Infuse at_ - axlhour. R^d1c~ AbdlOb t 9 ~ 'K abWn old records. a r arree UB ( ] [ ] [ ]AMtle R L I 11J99pne [ ] panda R L [ ] Marldlda ~' L ~ ' [ ] Cerv Splna lateral [ ]Nasal ~KBR~MReWr* I ]Dlblt R L - T 1 Cheat Rtn /Port !TPA ( ] PpMe I I EIDOw R L [ ] Pyaloprern IVP - t'Yl^ ( ] Faclal - [ ] Pobe R L [ ]Femur R L [ " ] 9houkler P L [ ] Fmger R L [ ] Skuq - _ ] 1 Foot R L [ ] Slemum [ ]Forearm R L j ]T/SpMa [ ]Hand R L [ ]TPo/R6 - R L JWp R L [ ]Tae_ _ P L [ 1 Humerus R L I I Wnat R L K ~ I 1 nee R L ~ ~/~1 [ 1 Other LmdOATMx~lrl i 1 . Spclel Plocsahrroe: r ,,, ` Ullnwuntl LCTW I 1Abtlanen ] ]C'f Scan at ~~ ~~ [ J Duplex Doppler ] ] VO 9an I ] GaI1NW~r ( ] 61her [ 1 t'ek7a T1marCRTnm. SdIVI1~d ( ]eetecrapAG~cunure [ ]SpVlulncas [ ] Cerwwl [ i sma c a s , [ ] cnlemyma [ ] stew o a P l 1 u~. V Wwm l l ~IOOF G DIIIIdl9 [ ]WOUM C85 BIIII Clawltleaolon: I ] 4avd I [ ] Folbw up I AoddeM [ ] L II [ ] Cep I ~ [ J Msdloel I III ( [ ] Medcal Non•Emergerwy [ ]LweI IV ( ]LawiV kolY Splrlt Hoapltal Camp HIII, PA John R Dtr#z Emergency Center Physlc,an Order Slfeet za66CU i~V 11RB J0 aR W CHART COPY InlUds: $lOnatul'B: R R Illltl~e: Sipnafiire: R N Inklais: aN Inklals: n"~r 91gnMiva:'r'>`~ r n , o ~__ R.N ] ' ' ~ ' ~ ~^ i3aS92 F , .,~a, t".AtE ~ e7~ ~~o^c^ES~ r4 ER3 rTrl7/t4Ry 73Q-8523 ^^1-^T-175 Er GROUP rTJ]7iCr• • Ih~ "`~ Date: -) - Loq~lftrnfte Nettle: ! t v 3 ~.J . Age;L~_ Tti~a Tune - ~.i ~ f^ FMD ~ Tlrne to Exam Room ~!,.~~ ~ ,okAimal }~ S Command [ } r/Camed T r x CHI Cam: 5 .-. , c Piece In[ury ocwmd: P I ~~ 11 lnduclry [ 1 Hecreaaen a t ]tither liMorme ownlnau rraal [~lem .[ ] FarnayfB.V ,{ ] Aaeorde [ ] Ea7ataramedk ~ ~' ' ~J Temp: ~ Pulse:1.~_Reaplratfona:Zl~.~IP~PUbeth~ ~O „~ AliergiealReactlons: . Latex allergy [ ] N [ ] Y Immunlxatiom IITD. [ I N 11 Y Lsat Tetalus: LMP: WWylit: scaldeatlmste {n paruaam) Has pabent been exposed In rite past month to measles, chickenpox or T6~ [ ] N [ ] Y [ ] UNK Are there Advance Dlrechvesa [ ]NIA [ ] N { ] Y Are triples avallattle~ (]NIA [ j N [ ] Y • (Attached E J N I ]?~ Extremity Evaluagkm: 7Haged fo radiology for: ' Yes/No Sa1tlTsmp Warm/Cod alatal Paiass PreaentlAbsen[ fEaerrts Yes/No akin Cater Pink/Lyeridro/Mdtletl Pain (t•ta) ParsaMeW Preeenl/Absent EGthymoela- YeslNo Gplaery rails Nemiel / Delayetl hresrwnkan Visual Acutty O.D. O.S. O.U. --~COrrectitre Lema®a ObJectitre: [ ] AAO x 3 [ J Respitatrons Symmetrical 8 unlabored [ ] Skin temperature & color WNL Vital signs immaMlrxaaon [ ] Cm [ } Badtboerd [ ] C-Collar [ ] Spidlt Mediradans ' [ ]Oxygen [ ] NC [ ]Mask LlAtin ~ [ ] Aarway [ } Nave [ ]Oral [ 1 ~' # { 1 Iv sole Gauge Sae. Past Medicat/Surgloal History: Dear{ktstWn: [ ] Ucgi { ] ER is p~ER Triage assessment oomphsted at by R.N. Data abtalned M.A Adrmssron Called (j Admission [ ] Observation [ ]Old Records Sant [ ]Clothing sheet completed Report Called Admmed to at His Transferted ro at tiN Oiepoauon Home [ j AMA [ OR at [ ] Satksfaotary [ } Impmved [ ] Csdical [ ]Deceased fo morgue at olsdt lhacherge InaVUCrons Olathe H.N. rYv~, t t, LL at Holy Spirit Hospital Camp HIII, PA John R. Dietz Emergency Center ECU Nursing Assessment CHART COPY zot~cu tiros nn aw vntwG uq cs aT) ado^[:9EST CR E[tl ^r:~kk' i~;ei3$G PA 17455 °„~ r 'I7/taa°, 73r3-9427 7C~C` vI^Y M'il ,-, Vttel Slgim Mond« Physwlan Asseae~nt 02 Saturatlon Lung Asaesament EKG Labs PCXRIPort CSpure Sent to RadlWagy Respuakry Treatment Ica Foley Inseruon NG Insertwn Wound Caro Pew 9cele 10.10) Laval of Conacwusneas Siderada Intake 6 Output Patient Education Ink Aola. Dste Tlme AmeuM utlen Catheter She Rats CanttW Sbn A InlYSb' Inmal Signature ~~~ ~: Aata fnltlal mr 5lgnatUr9 ['~"Vlf if t 1 ~J tNJo IMlamatwn Imhal Signature Edema Imhal Signature 2hErythema 26-Ecchymoan Holy Spmt Hoapltal Camp HIII, PA Emergency PaDent Documentation 206 ECV ReNaed 5198 JD, BR, MD CHART COPY 3~Pew t.ontral: 4Hardnea5 t-AVI 6•Warmth 2SISIMesler ' ~' "~ n4 438342 f ~~ •T i~ ~rC~IE M a^1 .On^~''[ST "'t.. ER1~'~'Y 'rC tal~c•~?.:: Pt 17055 r"rl7/I?a5 750-8527 . ^'-17x5 Fr Ga0~1P *'~r ~~^+ Nnl ?~IT100 B~IGEVCY t1RGI CFdV4I DISCHARGE INSTRUCTIONS HOLY SPIRTT HOSPITAL (717) 7G3-2316 ~ (717) 763-2424 " ~ -- - - The esamrrenon and ~~ Yoo >mPo recnved N r7w Bmen3ancy Cveer bare bem rendapd on ® ease mly, sod fb me mi®dM ro 1x a suMnnne fa a an aHwr ro prowEa conrylae nredmai ~ I[ you develop rww pmbraaa a tromphmnam eosreck yaw Physraan or are fbgOW T118 HV57&UCIIONS C1H;'CI~D HQ.OW ~ , Monnsgon. (sallant kdmretlon aheAa InfbmteBpnm feWswana faeP• () Abdpginel pain () Calluricllvllm ';' ~ g ~ () Fever/Pea Fever - () IxArarion () $e¢W8 i) Alcohol resctlon () COPD () FN (1 Nook Saain f) Sara Thma[ I) anerpc reanlun () Comeel ebre9laMoreTgn boar I) PreMUre () Nroseblmd () ~.raaa mtl &rams 1) Asthma (1 croapmrendraa () Haetlacha () rya Makva 1 1 Threatened Mleeamege 1 1 Beck pen f 1 cruxn waking () Heatl MWrr () Padleaw Need Inrury () TcoWiecha {)Bites-HUmaNAnMUUlrceact () Oterthm arrd Vom~tlrrypad VamBltp (1 HYpederrmon () Ped~@rc URI () URI atl CWda f) Bum () Drug/Aloofol a6rxeladdre{m () ImmunveadYfMertus () PIDND (1 UTI erW ~ () Cheel Pain () Fe6nla Camarledm () KMney SCOnee ()Rasa () OMer wouxD DARE ( }May gently wash over wound m z3 hours wrot soap end water a pmowda Do not soak m water ( )Change dreseing ~turae dsaY Redress wah Bakabacm/Naoepodn and arenla dreealrg ( }Keep wound clean, tkY, eoverkid () Tateni»/Dptlane Booster gwen HPRAINH, !TRAINS, BRf118Eli, FRACTUWES ( )Elevate the nyured pert kx,--tleys to reduce awelhng 1 )Appy ne packs IMerrrratelldy for_dgs to retluce avvellmg { }Ave map for support for_deys f) wear aPSnt (} At aY tsflBe kar61 foNOw-up ( )For aolwdy as needed ( )Use sang for support ( )Use crutches (1 As needed, wepM beanng as Ikdereted ( )At elk turrea NO WEiGti1 BEAPoNG ~GGUBAGK V71Yeer carnal coffer for suppM ffr,~^'oaya ( ) Rent, evatl bandkrg, Mang us ectlvky for_kteye (~'FgfpH mare( beet for rNnures ~_amea d~H lrepnrurrg m hours A~ITIONAL 1N9TRUCTIONB - ( )Off wosr/echoc Trwn io C } r.(ght Duff knm Resawlwns ( ) No gym/apose umd ( )Follow naa'uoarnre err Workman's C Foon ( ) Weer eye patch for hours ( ) Ii nose aleed recurs. pinch nose Ormly for 5 rmnutae cammuduery, retain rt Weadm9 nor CdWOlled ( )The prescnhed arskioac pray reduce are eRec6veneea of madvxua+ you are kamendy talking check package inetNChdns ar ansrat with Pharmacret ( )The ntarpreahon M yar x-Rays are pta4mmarr roadlrg Vour fikla will ba rewewetl by a radbloglat You or Your phyemkan oral be corseded s there re e change In the tlregnoas MBDfCATfONB - ( ) Camnue provers madlaetiaa earoepf ~dv8 (PoUproten) a rykmol u needed !or pain. fever b package nmaucrbns br age, wetatr ( )Use rho fclmxng medcinea ara:ording b package Iruitmcaone 1 2 3 ( ) The toHbrmg madranea amy tease dravravrees DO NOT DRIVE OR OPERATE MAGiNiBtY WFOLE TAKING frOLLWYdIP Thre a our raoanmandaaon for fagbw-up If your mekuanoa (HMO) requsae a ptrysicerr refenal br specrelty CoriauBelbn, R IS YWR RE~ONSIBIUTY TO OBTAIN THE NECESSARY APPROVAL , -up wetly () Urgr Censer ( Dxbr ~ramovel I) Coe es soon ae poeeaae fm eppoxtHnerrt ( ) Pldk up your x-Ray4 rran Hse Redfolog)r DePararranr poor [o ~ your fallow-up ~appoY)armnf Ce! 783.2~a fa have M1ana ready { )Sae yen physkaeak or apeu d not mproved m / days ( ) Fdum >o Emergency ~`et1 s you feel ycur condaon eapeaaAy d `I ' L7Ann. (~1~] YoW blood pressure ores ~ have rt rechedretl b'Y Yoe Prerr ( )Teat raeuhe lave Keen gran [c you Take tfran wdh you m the MBrnv-rqr eppomknen{ Tear results given ^f~C RCMP ^EKO OX-RAY COPY ^ BMP ^ RECORDS COPY CHART ^ GLUC ( ) PATIENT VERBAtJgB IA'FANOWQ 1 hereby eearowfodga receipt or elves Inaptreaora arM untlerffiand Htarn I unmkarand Nrei I here has errergancy treatment ~ antl dal.l may be telemed hataw eq M my medical problems are known w rreabd 1 mH arrange Sa b8ow-up mre as I have been ars4uoted Ir is your reapon- aibNiry to noisy r Pnmery Care P of this wad ~~ ~ r 1 I mnustaruE yr t 1.. '~'- x?+a(Y\ , ! 1 1! t~ HOLY 3Pl$IT lI(34PTI'AL EMERGENCY CENTER 503 NORTH Z18°1' STREET CAMP HILL, PA 1?011-128/ (717) ?63-2316 , 1 ()Thomas Aldws. M D 017075E ( )Salvatore glfm0. M D 02.5502E f) Ramesh Amra, M D 016727E ()Olen Daogbuy, D O 05006776E C )Ian Dulan, D O OS 006993E () RoMat Hymck D O OS 0043066 ( ) RrctfeM Lutey, M D 029966E ( ) Philap Magusre, M D 013W3•E ( )Lawrence Paul, M D 039524E ( )Frank Proeopto, M D 003633-E ( )Howard Rudotce, M D 040g62_~ t ( ) Radlmra Shsra®, M D 031265-E _ _ ( )David Spomv, M D 023502-E ( )Alan Tepas, M D 030018•E ( )Blame ThaOoer, M D 057303-L Oavtd 7amosmkan, M D 005636-E . srRAINa, epv~s. FRACTIH~B ) Elevaefta ffie ayurW pen ror_~ye to twee awlW(g ( )Apply roe peeks inlarradardy ior_daya b reduce erreang f) Ace wrap hr a(mport for-.days )weer-apMm {) At a8 woes until fopow-up )For astivM as needed )Use sting for supped ( ] Use auldiac () Aa needed, vrerght bervvrng m tolereted t )AS el sobs ND wExafr eEaRING ~~r~~~~ CX ? V7VYearAceruxeladdar for supper Mr.-~~ )Rant, awed bending. p eaINIIY 1w-,-days d7T7~7ply Irwlel hard for mNluhea~y~„-times dedY iregtming in houre aR1WTI0NAL It~i'RVG710~ ( ) Od work/achool ham to ( ) Lrglrt Duly anal Aea(roeorae ) Ns gymrepoda urM ( ) Fellow nwhrrctwne an worirrnaya Compepeaaan Farm ( )weer aye pareh for harre ( ) d rwss bleed revere, grrd7 mss timty IofS nsntAes oonarerorrsy, reaerr d bbederp m7 eordrNwtl ( ) The prea(albed arM6r0tlF may reduce dta eOar.Mraness of medlcedon you are aarerbY tMlWlg Cheek parJmge inetirrpaorm m tensed Widr Phannewet ( )The tabppreb,lbn of your X-Raye are praWtlhrary reading Your ftlrrre rap be reviewed by a radiddpal You a your phyaaaan rWl be d d eras le a dlahge 1n 07s dagn(aue Atldmlonai inatna8gns aaNrrctiprs 2 3 ( )Tire fdbenng medaar7es may rslrse dror9lneee f)D NOT DRIVE OR OPERATE MAGHWERY WHILE TAKING FOLLOW-UP This w our reoommande6rn tar Follow-up. M your msurer7ce (HMO) ragrdeu ^ pnyekran referrer for epawuy careu8atian, IT IS YOUR RESPONSIBILITY TO 06TAIN THE NECEESARY APPROVAL ~+}FOIaWUp rvdh () Urgr Gaoler amdy Dafor (A~ removal () CeX as soon u paeabla for eppamrsiant ( )Pick up your X-Raya horr7 dle Radobgy Depatrnenl prior to }roar toNOw-up eppomhnem Cell 783.2808 m have Htrna ready )See your phyacmn or aPe'n'alret d trot mtproved wt ( days ettrrrr fo Emergency ~,e~ A you Seel your rordIDan in NIp~ espepaly d ~) ' ~I~1,`~A.n ~( LnFP /i ALrl~1~/j )Your bland pressure was a~l valetl PFsase have d redreclred by your phyawran )Test recaps have bean gNen Io you Take them wph you W th (Ollow-up eppomtinent - Tastreau8agrven ^CBC ~~CMP ^EKG OX-RAY COPY ^BMP ^RECOR05 COPY CNART ^(3Lk1C ( ) PATItM 1~Ap,~a UNCIEfpOFAAIOMiG I herebyr eCglewledga recap{ aF Ulee9 mshdmwrs and underebnd dram. I undermsndlhetl have had emergency treeerrem ggR end dad t amy 6e released bekre ep of my rredtcak ploblame ere laidwn a treated' I vdp arrange br lopow-up Date as 1 Mve been Ineliuchd 0 ie your reapar~ albWey m eddy ya).ir Pdmery Care P~1]i~n of mrs vish ,SIONATLRE ~ ~r HOLY SNJItIT HOSPPPA,L E016RGENCY CENTER 503 NORTH 713T ST86EC CA,R~ HH;I.. PA 17011.7288 (7171 763-2316 C )1Lowes Aidam, MD 0[7(lISK (7 Saivemre Ai(mo, M D 073502E ( )Ramesh Anna, M D O16727H () Gkn Daughby. D O 05006'f766 C 7 Jon Dabm, D O O$ 006991E ( )Howard Rodnuk M D 04086b ( ) Ranjena Seems, M D 031265-E C) Davrd Boomer, M D 62?502-E (> Alan Tep1n, M D 030018-E (> Hlerne ThaOoa, M D 057303-L t) Davrd Zammeman, M D 005636-E 7y-a na.A;r RPFII.L 'rnv>Bs () RudreN Luley, M D dZ99Gg-E ( ) Phdtip Maguve, M D 015063•E ( ) lewreoce Paul, M D 03952-0-L ()Prank Prewpro, M D 003643-E u. vrwan rva w arrwnununipauwa:r ~rv s uurranaua, nfu HtgBCE®PJL Ml1SI' HANp WpTIE °BRAPID N6CdSSARY" OR "saANb M®IGrf.Y 1VBCB93ARy" IPI FHE SPA(2 9af.DW or.AaeL osnasTltimwr P>®LE 778 (5997 i S~(~~ c U`3~~2 ~~I~~~i~ -%.. DAZE _ ADM. 43ATE: 07/182008 GHIEF COMPLAINT. The pahentts a 15 year-old white female who presents with right forearm, right wrist and right hand pam HISTORY OF PRESENT ILLNESS: The patient was mvofved m an motar.vahtde accrderrt. July 17, 2000 She was seen m the Emeigenoy: Department by Dr Arore She how complams of pam in her nghf forearm,. west and hand It hurts more when she pronates and supmates, when she bends her wrist and moves her fingers She has no other spectfiocomplatnts PHY5ICAL EXAMINATION: GONSTITUTIONAL: The patient is a young white female in no salts distress VITAL SIGNS Nurse's notes reviewed Temperature 97 1, Pulse 70 Respiratory rate 16 Blpod pressure 112/83 RIGHT UPPER EXTREMITY The patient has no external srgns.cf Trauma. $ha:ra tender on. palpation over her rightforeamt; wrist and snwff box, the dorsal surface of herhand She-had. decreased range of motwn of tier fingers secondary to-pam; derxeased Hangs: of: mottos other west secondary tQ pain and has paihan pronatfon and awpinatton She is otheiwrse newrovascularly intact ' Pending is an x-ray of the right fnreartn, wrist end hand ARD L RUDNICK, M D HR/jrs DOC #' 89340 D 07/18/2000 T 07/1912000 9.38 P 000358 Camp Hdl, PA 17011 EMERGENCY ROOM REPORT NAME Tyson, Nicole M MRrR' 438392 ROOM ER3 DR HOWARD L, RUDNICK, M D ORIGINAL Holy Spirit Horipltal Department of Radlolagy and Diagnostic Imaging Camp Hill, Pennsylvania 17011 '(717).y83 280D PATIENT: TYSON, NICOLE M DIGTATtON DATE: Jul 18 2000 1 2BP MR#: 438392 TRANSCRIPTION DATE: Jul 18 2000 1 32P SOC SEC: 998-07-1785 ORD DR: RAJANA SHARMA M D PT TYPE• E ADM DATE: 07H8l2000 ARRNAL. DATE: LOCA710N: ER3- HOSP SERVICE: ER3 '"'Final Repolt~"'~ EXAMINATION: RIGHT FOREARM, RIt3HT WRIST AND RIl3HT HAND 18h 73990 -Jul 18 2~0 COMMENTS Indication. Patn after motor vehkla accident ThereJs no fracture or dtsp~cemant The ossiflcaHon cantata are to normal posi0on` The Joints are normal CONCLUSION: Na fracture of the nght forearm,. wrist. or hand DICTATED BY: JERRY CROTEAU M D ! DMR DATE OF EXAM: Jul 18 2000 SIGNED 9Y: JERRY CROTEAU M.D DATErrIME: Jul 18 2000 2.44P ,~ r s goo by .D/DA ~~~ ~ . ___ al3„n-n~al ~Vurs~a-chaci• orders ._ abnormal but no action indkated. File ~~ GG tma~ng Services ConaukaHon Pape 1 1~ I Inkial LaE S X-RSy Ordarr: Gabe/lMee [ ] Acelemnaphea [ ]ESP [ ] Tm Screen ( [Alcohol [ ] Gluwae [ ]Unne TOZ Screen I I Amylase2lpaee I I HOGS [ ] Thnornoolync Labs I I APTT [ ] Liver [ ]Type & gre$a _a 9f urnte [ ] Bkwd CNturoe Prokle [ ]Typo 8 Screen [ 1 RMP [ ] Lyba [ ] WA [ J CBCP [ ] PTP [ ] Unne C & 5 OkidVac [ 1 Monibr ]•. ] AHeY payed N [ ]EKG pelted n I ~I peak Rovs BabrNAttar Reap TY [ ]02 UFNrr ' IJ., RwWrarory rrz [ ]g28wurauon[ Tlme Sssn: DiM AAadlCatiaM (IV's / AtklitbnahOr~s~- [ ] CMP [ ] Sallcylete [ ] Workman s Comp Drug Screen [ ]coat [ ]serum Acetone ~ ] other l 1 Dlgoxm C 1 Tneopnylme [ ] Th roid P hb D l m Tlme ~ ry; N8S/ D6W! LFt/ D¢1.48NS1 DB.9NS infuse at ccThour, DalaRkfle/lrtt y [ I l e m ro Rad Obtain Old raeoFlis, 1 ! AUdObaV 5erlea [ ] KUB [ ]Ankle R L [ ]LIS Spine Cl b R L i dl6l M [ ] c av an a [ ] [ lCerv Sena Letere! [ jNWI ~n~ ~ [ J Cerv Spne Rautlna [ ] Orbit R L - T G~'M1- I 1 Cheel RIn f Part t TPA [ ] PeFna [ I Elbow R L [ ] Pyelognm NP I I Fe0p11 [ ]Femur R ' L [ 1 Rroa R [ ] 9hoWdw R L L ~ ~ ~' Sr'a.{h~ 'r`_ [ ]Finger R L [ ]Skull [ [FOOL R L ~ [ ] Sternum Fwaemr R L ~ [ ]Tyspina L [ ]Tlb/Flb R L ~:/ [ ]Hip R L [ ]NUmerue R L [ ]Tae R ~rM R~ L ~\~ L~ R [ ]Knee L [ ]OThw TnneIGRTRM_ $p~i a/ ~7D0/dllfed: UKrawund [ ]Abdornen [ 1Cr seen or [ f Duplex Doppler [ ] Vq Saen [ [ G^abbddw [ ] on,w [ I Psiwc nmercRrnm. !rte [ ] aea StreP AG t Cunura I 1 Spuwm c a s ' I ] Gwwcal 1 1 Chlemydla [ ] 81001 C & 9 [ I Stool O a P ~ /~ ~l J (~ ( ] GC Cueure BIIIIn9 C1aeaHlwHon: [ ]SlodC Dlfrldlo [ ]WOUndC85 [ 1 LevN i [ ] Fallow uP [ 1 PcaWwd [ I Larel it [ ] case I [ ] Metlksl [ j Lave! III [ ] Medoel Nan-Emergenq [ 1 Level IV I ]Level V Holy Splrh Hospital Camp HIII, PA John R Dlelz Emergency Canter Physrclart Order Sheet 206 EGU REV 1V36 JD BR MD C1iART COPY In SlgnaW In@tklso $Ignatu/e:- R.N Inklals: Slgneture:- R N Initials: 8lgnature: RN • ,3e2 , ~ I ,.., L E .t nUv L~ ST L3] .~.3 ~LyAr11CS~LkG PA iiG... G;/l;/,9d~ :]0-552+ y33-v:-]7d~ $n.AkAA fiA~AkA Tt50v ,"ArZY tlb! Gi/id/CO .-. .,.. r. Pate: a ' Logan Tirl7p Name: „~'~~ A[;<a: /T.a ThsgeTlme !/ , 4 FMD --•'~ ~ Tlme to Exam Room mw -YAmnulaw eks ALS Medwai Commana wne~cnaulcamed T re#urned #rom Tr d x-ra CHIEF COMPLAINT: T-~ 7 D a SL Plaea In[ury ocwrred~ [ 1 Home [ ]industry [ ] Reereadon [ ] MVA I ] txhar .IMM, . .. ~,... MNd irOnl,., Il~em ['I'~emlh~.0. [ ] Raeorda [ ] £Yf1PerYnedk ' Tamp: y / ales: ~'e Respirations: ~~ tUP: G ~ Pulse tht:: AllefgladR6actlons: ~~~ Latex energy [ }rt [ ]v Immunlzatbns UTD: [ ] N [~4 LastTbtanus. LMP: v' Wslgllt aeskfeadmata [N parthtald) Has patent been exposed in the past month to measles, cMdcenpox orTB~ [ }Y [ } UNK Are there Advance Olrechves~ [-)rtDA (I N [ ]Y Ate ooples avadeble# [-]'IAA j 1 N E ]Y (Attached I'1'~[ IY) ExtremltyEv~uatbn: TdagadtorWlola~rior . esloNnpY Yas/Na Slen Warm/Cool OIe1elPWees. Present/Aeeanl Emma Yea/No akln.Cabr Pmkl Cyarroacl Mottled (tAel Panglhealu PreaenllA6aen1- EaGlymoala Yea/No C~Illary reel Normal/Delayed Mhrvanllon Visual AcuEy. 0.D 0.S. O.U..,_Correetlva 6aneas ObJedlve: - (.}•KAO x 3 [ ]&esplrenons SymmetncaF & unlatwred j-pS[tm temperature & color WNL Vital agrrs immoba~zatlon [ ]CID [ ] Badrboanl [ ] C-Gollar [ ] Splmt. MedGa[rons I ]oxygen [ ] NC I ] Mesk L1Mm I ]Agway [ 1 Nasal I 1 Oml [ 1 ET # [ ] tV Soln Gauge Site in' I;# ` o~elF' en La se an' Lae# Dose Past MedlcaUSurgieal Hlatary: Dastlnation: Urgi [ ] ER Intermedfete [ ] ER Triage assessment completed at~by ~f2cuti R.N. Dsta obtalned_~ ' M.A. Admission Called [ ] Adm,eaon [ ! ObservaLOn [ ]Old Records SeM I I Clothing sheet completed Report Caned Admitted EO at Hra fe at by D,spoaltxm Ho a [ AMA [ ] OR at [ ] Satisfactory Imp [ ] Cnhcal [ ] ed argue al~ Discharged aeharga lnstruchons DI a R. at Holy Spirit Hospital Camp Hi11, PA John R. Dietz Emertgency Center ECU Nursing Assessment Tai E6u 111Ba ]p~ qty nnMq MD CS CHART COPY ' tL.E£ a, ,. ,•e5f, ~~, FR3 +EC•d',lt,ac4itG FA ]i(`r.3 I.rill'/.4a~ 1j0•E3S2~ y.l-~;-<<03 .SnARnA RAJAyd liSOq ,w4nY ~`Adl U%/!d/6G ' EMERGENCY CENTER URGI CFNfIs- - PISCAARGE TNSTRUCTiONB HOLY SPIRIT Hga^PITAL (717) 763.2316 .~. (717) 763-2424 .~ ~- ^~ Tkc exasaneren vitl tree~ent you have naxaved m dce P.rmgeacy Canrm have 6mr reriderNi aem emergency beers only, end are m reentlded tv be a auoee{rxo for oe m elfin to pmvr3o 'awaplete tnadreal ~ If yw develop new pobkms m wnrpaamme conucr yam ptyeictan or tke Psergemy Ceorer POI]AW TIffi aYSIR11C170Ng C86CICBD aHIAw ~~a~ ~ kfbrmetbn .fl..a txmuln IrnporfeM Im A6danlnel pan ()COtquncbwtle l) Akohd rBachan () CpPD I s auarg~c reacam () Camml ahresnMorign aodv OAnhma OCroupromncNtls ()Hack pain () CNirJt warimtg () 6aea-HumerJAnimeUlnaect () Diarthee ad Vomihng/Ped Vamding I) Bum (I DrugrAlcohd eouaeleddktlon ()Cheat Pein I )People Cdrvutaron WOUND CARE ( V klay Bendy wash over wouM.ln 24 boon wNt soap and wafer ar parOXide DO not mek m Water ( ) Change dretdng ,amee daily Redreee vdh BecnracmlNeoeparn and stalls dreewng ( )Keep wound okan, dry, covered (} TeWltre/Diplherta Sccaler given STRAINSr.BRUIfWB; FtiACTU Ebvate the itlur'~ pe~r'tor,3,'~Tn recuaa awaking ~~~~ () FeverlPed Fever i) Leceratlon { 1 Flu i } Ntrck Strap ()Fracture () Nmehl9ed () Heatlache () Olfia Meofa ()Head mNry f 1 AeCI®Mc Hid hryttry () Hypenenelon () Pedlakla URI () immunireacnlTetanus () PIWW () KWney 9 () Reeh MEW Cmdinue preeeM madroakarte except . () Sailors 1) sore mmm ~~falna end Skana 1 > Threatened Mlecamege ()Tooataclre ()URI end Cdde () UTI and Pydonephrrlb ()Other Uae Advil (Ibuprofen) a Tylenol u needed for petq lever Mmg to package mdrucfiwre far age, werpM ( )Use ills fodowmg rrtedkrnee acaortling io package Inetructlorm 1 - 2 3 - ( )The fodowmg madldrree may oauae drowelnaea 00 NOT ORNE tM OPERATE MACHINERY WHILE TAKIHG Apply sae pacq,memaaemty rar-~-aaya to rad~ae awelir~ I +-+..u ~ )Ace wrap for support for_ days t vPn y Y .t w ~cr,r ( 1 Wear epsm () At ali hmea undl logow-up ( J Far edNtty a8 needed ( ) uae Bung for atppon ( ) use auk:hea () As needed, ww~t beanng ae lokrafad ( )At 80 times NO WEIQHT BEARING ~~ Is cur racommertdafron for Tallow-up d your maurence (HMO) requires a phyaiaan rafeml for epedalty M,.t.,,aw,,,e rr to vro+te aK~nualRn rrv To rssrnw THE ! <? $'~Z N~~Fr/zE~137C^•L7 ^g ±A ? I~ ! 3'z o A I~? ( )wear eervwel collar for support td -days - ()peat, avoid bending. IAhrg, tdrenuou9 actlNy for_days ( )Apply mood heal Icr minutes 11mee ply hagmnng m houre ADDITIONAL g4STRUCTIONS ( )Orr worWechool from m ( ) tt91tl Duy until peslric6ona ( ) No gym+spat(a Unn( ( ) FoAow matrucdana on Workmen's Can7penee8on Form ( )Wear aye patch for boom ( ) It nose deed rrcurs, perch nose Omlly for s mmulea continuously, return rf bleeding not cordrelk)d ( )The preecnbed ar(nWolk may reduce the eBacWenoae of medication you era currently (slang Cf7eck Package insaucaorq or aer76utl vmh Pharmaolel ( }Toe mterprela6on of your X•Rays are preNminary reatlmg spur films will be rewewed by a radidogiet You or your pnysdcian will Ee conteaed d Mere Is a change to Me dW9r+osrs AddiCwnal Inenurtl,ons ,. NECESSARY Ai. JVAL y~Foflow-up wiM (1.Urgl Cerrter {Y} (army 13aaor () wodrNel in ~~"~ D days for ~lFdtow-up ( ) StMtre removal I 1 Call as soon ac poesd8e for appwnhnam ( ) PICk W your X-Rays hom Me Radidrogy OepadntBrd pool to your tollaw-up appokdmenl call 7832898 ro have films reedy ( )Sea your phyalaen or epeWakst d not enproved In ( )Rehm to Emergency Center d you Teel your corldDron re weraemng, eepedely tl ( ) Your hkwd pressure wee slavered Please have d rechecked by your phy&den . ( )Teel reauna have been gwen to you Take them wdh yai to tae roilow-up appolnhnem Teel reaulre given ^CBC OCMP ^EKG OX-MYC~Y ^ BMP ^ RECOp~ COPY CHART ^aLUC ~( )-ATENT VERBALtaB UNDERSTANDING by aclmowledga racaapt M Drees IrreDuAWne and uMkrerer7d them I uMererettd DIBI 1 have 17td emeryency treahnerd gObt and Mat I may be releaead befots a0 trt my. medloel problems are Mrrown or (reeled I Olltl arrarpa Por rollow-up care as 1 have been beln)cled Nis your reepon- slbAAy to notlfyyQur Primary Gerei N Mla v18it r-, SKANATUgE. ~]~ IY J+ HOLY SP7RAT HOSPITAL EMERGENCY CENTER SQ3 NORTTi ZifiT STREET CAMP HII.L, PA I7011.2?l~ (71717tH-Z31b i () Tbomry Atdous, M D 017075E () RrcharA Luky, M D 029960-E ()David Sprur e M D 823iG2-E! ~ - (7 Salvatore Alfano M D 025502E <) PhtOrp Meguue, M D D15063-E () AIae.Tapbs, M D 030018-H i (7 Ramesh Acura, M D 016727E () Lawrence Paul, M D 039524-L () Elmne Thellnq, M D 057303-L () Gleu Dau9doy, D O 05006776E ()Frank Pmcopm, M D 003643-E )Davin Ztmmumsa M D 00%36-E ()too DuMa. D O OS 006991E r 7 Howard Rudna,k, M D 040862-J,,,,~ m.. Physical Therapy SpOrtsMedkine 101 Erford Road, Camp Hill, PA 17017 • (7t7) 730-0437 • Fax: (717) 730-0450 DISCHARGE SUMMARY DeazDoctor: ~r, w,2~/ Patient's Name: ~ ~ Co le- ~ u ~~n Dx: ~~/k~bo~d snaan,5 Pt's DOB: 79 Last Day Rx: Iola 3 I ~ Date of I/E: l o ~~ (JO Date of D/C: ~ ° I2 ~ ~~ Total Visits: t ~ OBJECTIVE FINDINGS Discharged by: MD Self P.T. Insurance RANGE OF MOTION Patient discharged with functional ROM '~ Patient discharged with linrited functional ROM Patient not tested due to not attending last visit MMT Patient discharged with functional strength ~_ Patient discharged with less than functional strength Patient not tested due to not attending last visit FUNCTIONAL OUTCOMES Patient returned to prior functional levels ~ Patient returned to limited functional levels Patient not tested due to not attending last visits TREATMENT & HOME EXERCISE PROGRAM rv . s ~ ,. COMMENTS xr~rxsot7rX~antunno~ ~M«eae~e~ra OUTPATIENT INFORMATYON HISTORYIQUESTIONNAIRE NAME: ~ r L' o ~t I Y-~ o.tJ FHONE• 7 `-'D - ~' ~ •3. 7 AGE: ~'' HEIGHT: -~ ~ " WEIGHT: ~/~' GENDER !~ RACE. ~,~ Emergency Contact: WAL ~ I Yso~ Relationship: ~"ATL[Ph Phone Number: 7 3a ~ Asa ~ (~l~re~ 7~ ~ -a s ~ - ~ ±:a ~ (tr.~~, Cnffent Living A House ~ Apartment Lives With: ! aws Childr~ {# oral ages): Work Status: Employer: ~(1 ~~ Job Description: Fuii Time Part-Tithe # Hours HiS'~',QRY OF,~RE_Si~T LII~L S: IIiagnoais: ~/~ ?/,re - Date of Onset: 7 I ? va Was it job related? dl a Famt~y Physician: Retetring Physictian: T ,~~ C Sa,y U r s ,H. Next Appaintmem: ~2 G~tek'S Description 7/r 7 Therapy: Currant Medicatiaas: Allergies: (if yes please list of describe allergy) Medication ^ YeS O Food ^ Yes C~l'Na Seasonal E} Yes Q'No A Skin allergies 0 Yes [~'No A Latex ^ Yes (9TTo A Reactions to handling nabberbands, rubber bandies, balloons, or during dental procedures ^ Yes Cl'No Diagnostic procedures and data you had them: MRr: CT scan: x Ray ~~ o v EMG: Mylogram: Other Rehab Potential: l-vnd Patieat Goals: Therapy Goals: Short Term: Treatment Flan/Frequeacy: ~ 3x~,wk ~o~~=ks ~,~5~y,,,, ~~r ~ic~;re ~e-ec1 } ~5P ,~~, xb~ nateT I approve treatn:ept plan and agree with therapy racoamendatioas as outliaed. Date Ir~~ !!t~ ~~ Date To Achieve: gSAI,TS90uTH Rehab CeaterlCentnry Drive 920 Ceatusq Driva Mechanicsburg, PA 17055 (717) 691-3250 OUTPATIE~ TffiSRAPY SYALTTATION RSPORT Patient:•~r" ~/c 7ysa-~ Age: t5 Date: // ~ Physicians !~~ • ~„~/ .Sa..~ vets Admission Dates loa Diagnosis:~°~ascsc+a/ ~al~ l'~y -„~R)sh/rlrr Departments ~~ Date of Onsets 7~~lna 8latorylSubjective Findings: r~ wrt< . ,. ~ MuA;. ~Iis boo . evaluation Fyn When i7ain i.~, Uf~Qfi h.~.r.~ f.2 r-e.~ " nn Se^,~tb~ . ~ ~ ~lYt ~ U(~1~ GilN~- ~ RB uJNC. cTa.in ~L~,58 O-.~5 ° * ~ ~r'3.SC3 b•.3ti° s. yq _._ _ ~~!~: ~-.'~.6_*~~ -GJn.'L _. `M...''jeno~s .DC.in , ~R~1C~Do:~- ~l, ~'] [[rho,-„lx; d s //~++ ~_~fl///L~• ~ C frtri,JLl,f~ j'L.par~ rr non deli. ~~'LfN~ < (n . C,7C diS't~C~CM7on ~~~ / (,~L,_( (~D ~ ) ~ Pf ra~ ,~s-~ ~ ~.y.~L~~s-~- 1 ittitial 8valuatioa Treatm®at s P x ~,,,,~:,., ~' (b US ~ Assasemeat: GEN002 A-A n~ . l ~~z~„ /P~ 5 8~o P c~a~-s hart hcar~achrs ~- h,~a-~a~.~.c" Or~cvr Lt'? oeA Tooo L. SAwsts, M.D. M11RM MiGu1,EK, M.D. m7 Poxw d~wcx Ro~p - CrrNU, PA 17Q1t PA Ln Na pyQg7E 717A75b5B5 ~ 4C NO, p~gp, Nac Q V1 ~ ~ ~ C.(1. /pin's D.,e /O / ~' ~ 00 4 ~ wrid ~~~~ ARN N 5U8971TUTlON PERMIBglg~ IN ORDER FOR A BppIVD,NpM! THE 1'REBCAIBER MUBT HANG BRAND MEDICALLY NECESBAF „~»~»t~Tnaa. Mb/Milm'fwW6~Y0i2 ,. __• ~~ ~_ ~y ~~'Veulology' center, P~ 897 Poplar Church Road Camp Hill, PA 17011 (717) 975-8585 Fax: (717) 975-0670 October 31, 2000 Jennifer E. Weber, D.O. Iron Ridge Family Practice 880 Poplar Church Road -~ Camp Hill, PA 1701 I RE: Nicole M. Tyson Dear Doctor Weber: Maria Michalek, M.D. Todd L. Samuels, M.D. Ravi Dukkipati, M.D. Thank you very much for asking me to evaluate Ms. Nicole Tyson. As you know, she is a IS year old right handed white female who was involved in a motor 'vehicle accident on 7-17-00. She was the front seat passenger of a Ford Taurus which was struck on the passenger side by another car. She had immediate numbness and pain in her right arm and hand. She was evaluated and released from the Holy Spirit Hospital Emergency Room. Currently she continues to complain of tightness in her back and right shoulder. She states that her right arm shakes when she writes. She also complains of headaches. She had no relief with physical therapy - and it was discontinued. She is taking Naproxen 275 mg HS with little relief. She denies-a pre-existent history of pain O VR tremor. She takes Excedrin for her headaches which helps some. ~,,,S~,e~kaaso nt~ter~gm~a~p r~b~,ez She takes no other medications. Family history is significant for a history of rrugrames~r father. On examination the patient is alert and attentive with normal mental status. Speech is fluent and articulate. Pupils are 4 mm and react to 2 mm to light bilaterally. Extraocular movements -are intact and there is no nystagmus. There is no facial weakness. She has full strength in both upper and lower extremities. There is right paraspinal and trapezius muscle spasm and tenderness. There is no tremor. She has full strength. There is no sensory deficit. Deep tendon reflexes are 2-f- thioughout and symmetric. Plantar reflexes are flexor bilaterally. Gait and coordination are normal. Tandem gait is normal. Nicole has myofascial right sided neck and shoulder girdle pain. She has a probable dystonic tremor of her right upper extremity secondary to the myofascial. pain. I have recommended that she resume physical therapy at HealthSouth. She will try Maxalt MLT 10 mg for headaches. I would like to see her again in three weeks in follow up. _~. Page two RE: Nicole M. Tyson Thank you again for referring this patient to us. Sincerely, T¢~t¢.c9 ~ vW~ Todd L. Samuels, M.D. TLS:mk ,,,,; cc: Insurance ,/ ~en~`el; pc. 897 Poplar Church Road Camp Hill, PA 17011 (717) 975-8585 Fax: 017) 975-0670 November 20, 2000 Jennifer E. Weber, D.O. Iron Ridge Family Practice .,_. SSO Poplar Church Road ~I Camp Hill, PA 17011 RE: Nicole Tyson Dear Doctor Weber: _, Maria Michalek, M.D. Todd L. Samuels, M.D. Ravi DuKKipati, M.D. 1 saw Nicole Tyson in the office in follow up today. She has had a good clinical response to physical therapy. Her neck spasms are less. As a result, the dystonic tremor of her right upper extremity has improved as well. She continues to have frequent headaches. She is probably having analgesic rebound headaches related to over-use of Excedrin. -She will discontinue the Excedrin. I have started her on instead on Effexor XR 37.5 mg daily for prophylaxis. She will try Amerge 2.5 mg for breakthrough ,- headaches. She could not tolerate the Maxalt due to sedation. I would like to see her again in three weeks in follow up. Thank you again far allowing me to participate in her care. Sincerely, (~~1r ~ ~. ~(,nTodd L. Samuels, M.D. TLS:mk cc: Insurance 897 Poplar Church Road Camp Hill, PA 17011 (717)975-8585 Fax: (717)975-0670 December I4, 2000 Jennifer E. Weber, D.O. Iron Ridge Family Practice SSO Poplar"Church Road Camp Hill, PA 17011 RE: Nicole Tyson Dear Doctor Weber: lsaw Nicole Tyson in-the office in follow iip today, ,Her headaches ha Iesssevere. S>he is takmgEffexor XR 37:5 rng dailq,for migraine prop] several days she has had some increase in her headaches and'I:haue,the Effexor to XR 75 nig daily. She has withdi•awn.completely from the-E breakthrough headaches. Her. tremor is significantly less. l would like to see her again in two months in follow up. "thank you again for allowing me to participate in her care. Sincerely, ~~~o~~ Todd L. Samuels, M.D. TLS:mk Maria Michalek Todd L. Samuels Ravi Dukkipatl laxis~ Ovier the pa~sc fore increased the edrin. Amer~ae helps here cc: Insurance 897 Poplar Church Road Camp HIII; PA 17011 (717) 975.8585 Fax: (717)975-0670 February 13, 2001 Jennifer E. Weber, D.O. Iron Ridge Family Practice 880 Poplaz Church Road Camp Hill, PA 17011 RE: Nicole Tyson Dear Doctor Weber: Maria Michalek, M.D. Todd L Samuels, M.D. Ravi Dukkipati, M.D. I saw Nicole Tyson in the office in follow up today. Her headaches have resolved. She did have an episode of tremor and spasm involving-.the right arm after bowling thass weekend. She will: try to break into physical activity a little more gradually. In view of her clinical-improvement we will begin to taper off the Effexor. I remain available to see her again on an as-needed basis. Thank you again for allowing me to participate in her care. Sincerely, 18-~QrL~ ~~ Todd L. Samuels, D. TLS:mk :._~. .. 2.~~. LqM ~--~ h .FS~_ ~B~ d.'' Z ~qW~~ ~3~~~ ° l e e m e e o e e e o~oooo$ a '° 9° ~ 9 ~~.ey 1MRa~a~~N~M IIII h ~ e e Na r I~ q q ey e m m m m m m m ^ n C I ~ e e N e S CCC ~~ O O n S S S S 6 5 0 b ~;°a ., a nmmmmmmm»«b °9°~ ~ oooooS,°c $$%8 ao oe F e.°___~ ss s ?i a` o~e__~_-ass ~. m W i~ ~a a~a~'i f+ I e `~~ ti Y ~ ~fF~~p~~~~~€ C~~a 9 ~ ~~~~awm ~~~~ ~~ ~~~~s~~ ~~ ~ry~sass~oo s s- a e~ee~~~~e33 eyes ~ osaos~~:.oe o~=gig ° .~ saaas~see$~ O M O. F ~ o dtl ~e a e e~i -~' ~~ 0 0 M1 F,!n.lfi,n G, ~~ ~i,i ii,~~ ~~A qd Qii ~T ~,TC 'P,~C._uti a' G~,i7.~r fn G AArg i~ W{~Q J~ ~m! i^ a m 8b~s ~ fDbB ba ~ W bi~5 ~ 9 8 ~~ 1 q ,~~~ ~a~~ S $~~ b~ x"98 m4 gb~ o~ b$ re~ a =u~ g m~ 8Qr= J NW~S~ ~fi"pa Cl mm y9~m~y^ g ~Wpe ~ ~ mm Y11.~.1~ 1 '(' •i yl~ FWx F !~ FF•s: ~ $r ~~ wwpQ ~ da >NC}ML ~r~WJ ~ywj~WW ~m N ~~W ~a=6 J~ydNN ~N yyB~.}~~ „$b$$~ myC$y4~~ a'~d m~ p~:iQ ..$ Nlagp LJ ~~ ~m=~ ~ ~8~~~ } ~!~ ~ ~~WJIli m Q~D~ V ~~a~~~ ~~~a~~~a~J@~ ~ ~'m~m" HgM16o~mag=°a~' ~~ Qe.."..m ~M1"®lSF~a~~ ~ e4 y' sbeffi8LL ~sfio~'r~~Wm BS ~Q~~a~'~~~~~~a~;~~s~ ~~ RELEASE OF ALL CLAIMS THIS INDENTURE WITNESSETH that we, Walter and Mary Jo Tyson, individually and on behalf of our minor daughter, Nichole Tyson, in consideration of the sum of Five Thousand Dollars ($5,000.00), receipt whereof is hereby acknowledged, for ourselves and for our heirs, personal representatives and assigns, and those of Nicole Tyson, do hereby release and forever discharge Allstate Insurance Company, Heather Koblish and any other person, firm or corporation charged or chargeable with responsibility or liability, their heirs, representatives and assigns, from any and all claims, demands, damages, costs, expenses, loss of services, actions and causes of action, arising from any act or occurrence up to the present time and particularly on account of all personal injury, disability, property damage, loss or damages of any kind already sustained or that we may hereafter sustain, arising out of an accident which occurred on or about the 17`" day of July, 2000, in the City of Mechanicsburg, Cumberland County, Pennsylvania. To procure payment of the said sum, we hereby declare that we are more than 18 years of age; that no representations about the nature and extent of said injuries, disabilities or damages made by any physician, attorney or agent of any party hereby released, nor any representations regarding the nature and extent of legal liability or financial responsibility of any of the parties hereby released, have induced us to make this settlement. We hereby agree that, as a further consideration and inducement for this compromise settlement, this settlement shall apply to all unknown and unanticipated injuries and damages resulting from said accident, casualty or event, as well as to those now disclosed. We understand that the parties released admit no liability of any sort by reason of said accidents and that said payment and settlement in compromise is made to terminate further controversy respecting all claims for damages that have heretofore asserted or that our personal representatives might hereafter assert because of said accidents. Signed and sealed this day of , 2001. CAUTION -READ BEFORE SIGNING Witness Witness STATE OF PENNSYLVANIA SS COUNTY OF (SEAL) Walter Tyson (SEAL) Mary Jo Tyson On this day of , 2001, before me personally appeared Walter Tyson and Mary Jo Tyson to me known to be the persons who executed the foregoing instrument, acknowledged that they each executed the same as their free act and deed. NOTARY PUBLIC My Commission Expires: VERIFICATION We, Walter Tyson, III and Mary Jo Tyson, parents and natural guardians of the minor, Nicole Tyson, verify that the statements made in the foregoing Petition to Approve the Settlement are true and correct. We understand that false statements herein are made subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. Date: ~a ~ ~?~ Date: ~a''~' ~ o r D2L altet Tyson, III Mary Jo Ty on r~ - - - > z . ' ,_ -=~ ~ ~: r NICOLE TYSON, a minor, by and through her parent and natural guardians, MARY JO and WALTER TYSON, III, Plaintiff, v. HEATHER KOBLISH, Defendant. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA NO. 01-4207 PRAECIPE TO FILE ATTACHED RECEIPT TO THE PROTHONOTARY: Please file the attached receipt from PNC Bank in accordance with the Honorable Judge Hess' Order of February 6, 2002. Date: ~ ~ ~~ Respectfully submitted, NEALON & GOVER, P.C. Brian N. Zulli, E~quir Attorney I.D No. 85 £ 2411 North Front StreE Harrisburg, PA 17110 (717)232-9900 Certificate of Deposit Page 1 of z ~' ~NC]~AN][~ Account Verification ,,,tw PNC Bank National Association NICOLE M TYSON WALTER J TYSON 473 WOODCREST DR MECHANICSBURG PA 17050=6854 Certificate Number Reference Number 31600224031 3600082958 Purchase Date Purchase Amount 3/62/2002 $5,000.00 Maturit Date Term 6/2/2003 15 Month Annual Percentage Yield 2.25 Y, _ Renewal Type Automatic Product Description 15 MONTHS FIXED RATE Pcr Info; matien, Cail 1-877•BANK-PNC Interest Rate Effective Until 2.222 6/02/2003 1k9 i:,'L C'cc!iT ~i;ECK .4°+~,Ot10.0v u='Gil00DCi1.1C'i ti;~~iD? >6,tvupc!-i 3i~ftt"~2~~it?3'. NES:' C'.?: h'ss L'f LATE This deposit or payment is accepted subject to verification and to the rules and regulatiens of this bank. Depositr may riot be available for immediate withdrawal. Receipt should be held until verified with your statement SOUTH CENTRAL PA ~~ cmanrnnnnFtrn as Dlaom cao .o..e. _d3~ c .. n.,.....,... w ____~__. - - en~~ t-~ L"v fr i~,i J ~E; -,n 177 ~ ~'-. _- =7 -_ G=~'~- ; -l , , _ -C: _, ~_ C__ ,. F,J -s: r.A•~+^.ss!v+,~eze;;axmc ujw?~pp*n. _ NICOLE TYSON, a minor, by and through her parent and natural guardians, MARY JO and WALTER TYSON, III, Plaintiff, v. HEATHER KOBLISH, Defendant. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNA NO. 01-4207 PRAECIPE TO DISCONTINUE TO THE PROTHONOTARY: Please mark the above-captioned matter settled, satisfied and discontinued. Respectfully submitted, By: Date: J ~ 4 NEALON & COVER, P.C. Brianl~ Zulli, Esquir Attorney I.D. No. 8 8 2411 North Front Street Harrisburg, PA 17110 (717)232-9900 ~ i ~.. ~~.,, .Uc, Lit' _ r=- ~` `~ C_; - 1~ ~_ _~. 1 '~? f,.,)