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HomeMy WebLinkAbout01-04663POST & SCHELL, P.C. BY: AMY L. CORYER, ESQ. I.D. # 82718 240 GRANDVIEW AVENUE CAMP HILL, PA 17011 (717)731-1970 ARNOLD K. ROOK, LUCINDA J. ROOK and ARON ROOK GRIGINA~ AUG U ~~~ ATTORNEYS FOR PETITIONERS ~ ARNOLD K. ROOK, LUCINDA J. ROOK AND ARON ROOK 1N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Petitioners, v. ALLEN MCELWAIN AND JOANN MCELWAIN, as Parents and Natural Guardians of AZILE MCELWAIN, a Minor CIVIL ACTION -LAW No:OI-~43 ~tu~l~`~~ ORDER APPROVING MINOR'S COMPROMISE FOR DISTRIBUTION AND NOW this ~" day of ~ , 2001, upon Consideration of the Petition for Leave to Settle or Compromise Minor's Action, it is hereby ORDERED that the Minor, Azile McElwain, a minor through her parents and natural guardians, Allen McElwain and Joann McElwain, is authorized to enter into a settlement agreement with the Petitioners, Arnold K. Rook, Lucinda J. Rook and Aron Rook, for the minor child in the gross sum of Twenty-Five Thousand Dollars ($25,000.00), Eight Thousand Dollars ($8,000.00) up front with three guaranteed annual payments of Six Thousand Eighty-Five Dollars ($6,085.00), the first to be paid on May 30, 2002, and the last to be paid on May 30, 2004. c6`C V~ <x . !Y J a" ~'~ kr.' ~~R ~QMLi 4P. ~ ~ ~ ~ :. ~rv j !ba ~~f~ `!, a ~. , ~ e~~Y u" I tfUG -8 ~1 9~ 2? curut;3~hi;;,,.~ ccun,~Y P~NNSYLUANtA e •~ POST & SCHELL, P.C. BY: AMY L. CORYER, ESQ. I.D. # 82718 240 GRANDVIEW AVENUE CAMP HILL, PA 17011 (717)731-1970 ATTORNEYS FOR PETITIONERS ARNOLD K. ROOK, LUCINDA J. ROOK AND ARON ROOK ARNOLD K. ROOK, LUCINDA J. ROOK and ARON ROOK IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Petitioners, v. ALLEN MCELWAIN AND JOANN MCELWAIN, as Parents and Natural Guardians of AZILE MCELWAIN, a Minor CIVIL ACTION -LAW No: of - ti~(a3 C~~u~(.`r~ PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION AND NOW, come the Petitioners, Arnold K. Rook, Lucinda J. Rook and Aron Rook, by and through their attorney, Post & Schell, who file this Petition to compromise action for approval of settlement and aver the following in support thereof: 1. Petitioners, Arnold K. Rook, Lucinda J. Rook and Aron Rook, are adult individuals currently residing at 143 Brick Church Road, Newville, Cumberland County, Pennsylvania, 17241. 2. Respondents, Allen McElwain and Joann McElwain aze adult individuals currently residing at 19 Midland Road, Newville, Cumberland County, Pennsylvania, 17241. 3. Respondents, Allen McElwain and Joann McElwain, are the parents and natural guardian of the Minor, Azile McElwain, who resides with the Respondents at the above-noted address. See Affidavit of Parents attached hereto as Exhibit "A". * 'A ~ 1. 4. This petition is filed as a result of injuries sustained by the Minor child, Azile McElwain, as a result of an automobile accident that occurred on April 14, 2000. 5. The Minor child, Azile McElwain, sustained a splenic laceration and a closed head injury. See copy of medical records attached hereto as Exhibit "B". 6. The Minor child has recovered from said injuries and requires no additional treatment. See Exhibit "A". 7. At the time of the accident, the Minor child was under the majority caze and control of the Respondents. 8. Petitioners' insurance carrier, Nationwide Mutual Insurance Company, has made a careful and diligent inquiry and investigation into the facts surrounding the accident, the responsibility therefore, and the nature, extent and seriousness of the Minor child's injuries. 9. All of the Minor child's medical bills have been paid. 10. The Petitioners' insurance company, Nationwide Mutual Insurance Company, has agreed to compromise this Bodily Injury claim for Twenty-Five Thousand and 00/100 Dollazs ($25,000.00). l=ight Thousand Dollars ($8,000.00) is to be paid up front and Seventeen Thousand Dollazs ($17,000.00) is being paid to purchase a structured settlement which will result in a total payment of Eighteen Thousand Two Hundred Fifty-Five Dollars ($18,255.00), with three guazanteed annual payments of Six Thousand Eighty-Five Dollazs ($6,085.00), the fast to be paid on May 30, 2002, and the last to be paid on May 30, 2004. It is a fair and reasonable resolution under the circumstances. See Exhibit "C". 11. The Respondents, Allen McElwain and Joann McElwain, understand and approve the settlement achieved. See Exhibit "A". 12. The Respondents, Allen McElwain and Joann McElwain, have executed both a Release Agreement and a Uniform Qualified Assignment anti Release, copies of which are attached hereto as Exhibit "D". WHEREFORE, Petitioners pray that an Order be entered approving the Minor's Compromise and ordering that distribution pursuant to the Court's Order. Respectfully submitted, POST & SCHELL, P.C. DATE: R~ 1 ~nl L~'ryu~ ;~ ~io, AMY L. OR ,ESQUIRE Attorney for Petitioners I, Sbarry D. Semans, an employee of Post & Schell, P. C, do hereby certify that on the date listed below, I did serve a true and correct copy of the notice of deposition upon the following person(s) at the following address(es) by sending same via United States mail, first-class, postage prepaid: Allen and Joann McElwain 19 Midland Road Newville, PA 17241 Respectfully submitted, POST & SCHELL, P. C. DATE: cS'~a-~0/ BY ~~~ S~-~!/XQ.yuo Sharry D. emans AFFIDAVIT OF PARENTS In the Commonwealth of Pennsylvania: County of Cumberland: Allen McElwain and Joann McElwain, being duly sworn according to law, depose and state: _ We are the parents and natural guardians of the minor, Azile McElwain. 2. To the best of our knowledge, Azile McElwain has completely recovered from the injuries she sustained in a motor vehicle accident which occurred on or about April 14, 2000. We have reviewed and approved the Petition for Leave to Compromise Action on Behalf of a Minor-and the Order Approving Minor's Compromise for Distribution and concur with the distribution. r ,WAIN MCELWAIN Sworn to and subscribed efore me this s~ day of 2001. Notary Seal NotarialNOtary Public Linda L. Gams, Cumberland County Wesl Pennsboro Twp My Commission Expires Oct. Q: 2003 "`~ ~~;aa!anes Member, PennsyNan_ ts~~'."~~''~ Rn. _ - ~. PennState Geisinger ® Health System EMERGENCY DEPARTMENT NOTE EMERGENCY MEDICINE CENTER P.O. BOX 850 HERSHEY, PA 17033-0850 717 531 8333 TEL PATIENT NAME: MCELWAIN, AZILE PATIENT NUMBER: 361921 DATE OF SERVICE: 04/14/2000 SEX: F DATE OF BIRTH: 05/30/1984 MODE OF ARRIVAL: Life Lion where she was placed in a cervical collar and long board for immobilization. Large bore IV access was obtained and she was placed on supplemental oxygen. HISTORY: A 15-year-old female was the restrained passenger in a motor vehicle accident. She was in a vehicle that t-boned a second vehicle going an unknown amount of speed. There was questionable loss of consciousness and repetitive speech at the scene. Life Lion crew noted some chest and abdominal discomfort. The patient was hemodynamically stable. Trauma alert was paged and the patient arrived to the emergency department hemodynamically stable. Dr. Dillon was present upon arrival and you should see trauma services note for full evaluation and treatment and disposition. DICTATING MD: Christopher J. DeFlitch, M.D. Assistant Director of Emergency CJD/dmd D: 04/14/2000 T: 04/16/2000 07:43 Page 1 of 1 ,~.~,~~ PerlnState Geisinger The Milton S. Hershey ® Medical Center V ._ _ } Health System ' ~ ,_ J+a y Tr;..., sblsZi TRAUMA RESUSCITATION ORDERS - ~ '?'~ : . Dat O de Tim rdered ORDER (Date and Sign All Entries) ircle Orders es ed Signature of Physician or ding to Ord Oxygen: Yes No Airway: Yes No tubate: Yes No FLUID RESUS N: Ringers Lactate: a No Normal Sali ~ e No FFP: Yes N Blood: Packed cells Yes o X-RAYS C-Spine: Lateral P dontoi Swimmers Chest• Pelvis: CT Scans: Cranial Abdomin Chest Neck Other: LAB: ABG CBC Diff Platele Coun Amylase/L Lytes/Renal rotimelPTT Medical Blood ETOH Glucose f Legal Blco TOH CK/MB UA Urine Pregnancy Urine Drug Screen ~ T & C x 3 Units Type & Scree Peritoneal Lavage Fluid MEDICATIONS: Tetanus Toxoid: Tetanus Immune Globulin: ANTIBIOTICS: OTH R MEDI TIONS: GENE L: Cardiac onitor: e o Foley: Yes o NG Tu e Yes Restraints: Yes o EKG: es Chest Tube: :Yes L: Yes o Cervical Collar Yes o Aspen Yes No M.D. Signature: Date: W---' ~ ~ " Original -Medical Record MR 69t 4/96 R UMA RESUSCITATION ORDERS Yellow-Trauma Service Pink - ED ' `~ ~ ~-~ PennState Geisinger 7 ~~~ ~ ®Health System LIFE LION Critical Care Transport The Milton S. Hershey Medical Center ~ ~~ 730/ Airmedical EMS/On-Scene Report ~[~ E,I~u~e~r~ ~ ~,~~ ~i';~~"~`~, t.~~.' ~~,~;_,. ~.,.u~, TCa~sl~: ~~. A ti's. ;~~~~,„: 00-0597-A 04/14/2000 On-Scene N896LL 83 azlie multi trauma Cumberland 15 84 ~ t~10/f Cumberland 361921 Patient Transported Hampden Township 21910 UNIVERSITY HOSPITAL 01351 Hershey Emergency Departrnent Chris De Flitch VI`C~Yt& Gl~.~i '. ~`~'7. ~, ~.?: ..~.:,:~~~ ~~ .~ .s,.,~ z.~:`„x. ,:~3"": c-"...3~',~,r, .x„.i " Ctd~ ~,." ~:~i 18:24 Kurtz, Michael P. Kissinger, Krista Emery,Randy Chadwick, Russ ~t ~,~~s 18:21 P, 018961 ~~ ~ ~~' H, 042639 18:25 ~Y yy ~~ :18:34 ? &~'~~~'~C.~i~. 18:54 P,fi :. , ., : SM~ s'~1~" ~£: ~ , ,....sl" ~i6;`~~~ 3 19:01 82 14 122/68 ~ 4 - Spont 5 -Orient 6 -Obey 't<Y ~ l2,L~.Y~~~~Y~ ~, ~t1~C4Cie, ... €s ~~< 19:03 rS<:: `€~i.~~> .:~:. 19:05 ..~ncidexiELaE;~~. ~<,~.'_,~ .. ..::.~~' W.. ~ :: 1n. _~ilsto. ,:...I, :. ., ...:,,.=,m~afcli ,1'~E, 'esg8rt:;,t EbiS Rendezvous Vehicular Radio 1351 86 ~`. ,. t5"I~~~~~idfi._. >.... ~i l~el~;~?x~ .. A 3, ~i~r f ... ,,:,: , p~$E~; : ~.ss~. s...~~.:.:. fij1~,~,~`¢ ~Y~i. 1h: ,..:.: _ me None None 1. t~ ~ ..'.. ... ~ tIE ,~Qt OISPIJW pl ~ ~ _ m .,:.: :.... ... ,.~. ... - ~°s ~2x ~' ~,, C /" Cr ~ - l `~ 93001829 NIBP TREND 14.04.00 Kurtz, Michael P. /Flight Medic v TINE HR/PR So02 SVS / OIfl - NEflN 0R HH:MM 8PH °L nnHg 0r/TI 18:58 91 10B 124 / 69 B5 OFF 18:49 100 9B 122 / 66 85 OFF LIFE LION ON-SCENE TRANSPORT NOTE PATIENT NAME: MCELWAIN, AZILE PATIENT NUMBER: 0361921 DATE OF SERVICE: 04/14/2000 38X: F DATE OF BIRTH: 05/30/1984 SS #: ATTENDING MD: FLIGHT NUMBER: 00-0597-A DISPATCH INFORMATION: Life Lion was dispatched to Cumberland County to assist Medic 86, West Shore ALS, with a motor vehicle crash with injuries, possibility of two patients being flown. Arrived at the landing zone in Hampden Township to await several minutes for ALS/BLS unit with patient on board. The patient arrived with Paramedic Rick Teats on board and Paramedic Teats gave the following history: 15-year-old, white female passenger, right front seat, seatbelted, negative loss of consciousness. Apparently, this vehicle T-boned another vehicle at an unknown rate of speed. Moderate damage to the vehicle. No entrapment. The patient complains of chest pain and abdominal pain., The patient is able to move all four extremities without any compromise. No visible signs of external trauma, no trauma palpated with the exception of extreme tenderness throughout the chest wall and abdominal wall upon palpation. Past medical history: None. ALLERGIES: The patient is allergic to DURICEF. Weight: Approximately 120 pounds. TREATMENT PRIOR TO ARRIVAL: The patient was fully immobilized, receiving high flow O, nonrebreather mask, cervical collar in place, CID in place, patient secured on a long board with spider straps. The patient had one IV established in the right hand; however, that IV has infiltrated and paramedic Teats is in the process of establishing an additional IV in the left hand. That IV was established by Paramedic Teats, a #18 gauge in the left hand, normal saline at KVO. Physical examination by flight team: Patient presently awake and alert and oriented x 4, anxious. Skin color is pink, warm and dry. Glasgow coma scale currently 15. The patient can recall the entire incident. Pupils are 3 mm, equal, round and reactive to light. No facial head trauma noted. Neck nontender. Chest is tender Page 1 of 2 PATIENT NAME: MCELWAIN, AZILE PATIENT NUMBER: 0361921 throughout the chest wall, no palpable deformities felt, equal chest rise, noted bilateral breath sounds clear in all fields. Abdomen - Tender throughout the entire abdominal wall, however negative distention. The abdomen is soft at this time, no masses noted. Pelvis nontender. Extremities - The patient moves all extremities, normal refill, normal pulses. TREATMENT/PROGRESS: This patient was hotloaded into Life Lion secondary patient area. waited approximately five minutes for patient B, flight 579, to be loaded. In flight vital signs for this patient remained within normal limits. Medical Command Dr. DeFlitch contacted. No further orders given. The patient remained awake, alert and oriented, somewhat anxious in flight, however calmed with reassurance. No other changes. Arrived The Milton S. Hershey Medical Center without incident. IMPRESSION: Motor vehicle crash, status post chest and abdominal trauma. DISPOSITION: This patient was taken to The Milton S. Hershey Medical Center's emergency department for trauma systems evaluation. DICTATED BY: Michael Kurtz, EMT-P ATTENDING MD: Kym A. Salness, M.D. Professor & Director, Center for Emergency Medicine MK/rmh D: 04/15/2000 T: 04/15/2000 15:54 , Page 2 of 2 ~ PerinState Geisinger Health System T , µ, ,~ . ~ ; ~ 7 ~ y ~ ~2\, ~ TRAUMA/RESUSCITAT O FLO SHEET ~ ,\ DATE 1MEPTARRIVEp TIME RESPONSE STAT PAGED AGE ~./ I~ WT~ PRE-HOSPITAL ,M8/MEDIC # IELICOPTER lpl-SCENE d1TERNOSP -OC~. YES` #MIN NO `NTRAPPED YES_ #MIN SELF EXTRICATED YES_ NO '~ C-COLLAR CID/TOWEL ROLL LONGBOARO ED ~ SPLINT ./ UNKNGWN NO ! SEDATED - PARALYTIC AGEN MAST TROUSERS ~~ AAD j RL I ALL _.~~ GCS ~ RR ~- P O~(/ MEC ANISM OF INJURY SPiRATORY MVA _ CAP VER =PICKUP -PASSENGER = ~ TRUCK FRONT VAN BACK UNKNOWN _ )TORCYCLE ~ BICYCLE _ AN D OF PICKUP _ DIVING _ FALL BURN _ DROWNING , FARM BELTED _ EJECTED WINDSHIELD _ DAMAGE AIRBAG _ # Pf ,BROKEN =FRONT rpI1N CARSEAT _ ROLLOVER SPIDERED BACK V MOD NONE X _ BROADSIDED HEAVY UNKNOWN ST WHEEL BENT _ _ R _ L _ HELMET _ NONE _ UNKNOWN _ _ FT _ GSW _ CAVMM _ INDUSTRIAL _ SPORT _ _ STABBING _ PEDESTRIAN _ OTHER _ SPONTANEOUS RATE_ = 02 MASK UMIN_ _ 02 CANNULA VMIN~ ASSISTED RATE _ BVM RATE _ -AIRWAY (ORALMASAL} - ETT (ORAVNASAL) SIZE _ CRICOTHYROIDOTOMY _ TRACH SIZE =LUID RESUSCITATION GAUGE I ShTE,~SOL(~1 Ai Z ,2 f~4~! J~f~ f 3 PMH .~I GL~'iNEDS---~^ IU ALLERGIES LASGOW COMA SCALE A Y PRIMARY SURVEY PER PHYSICIAN S omaneeus 4 4 CHEST ABDOMEN erring is voice 3 RESP LABO BREATH SOUNDS R ART SOUND SO T STABLE sponse To ain 2 2 YES NO PRESENT ~ PRESENT = GI _ D YES 0 UNSTABLE None t ppl~'' _ _ ABSENT _ _ MUFFLED _ ~STENOED WHERE _ _ _ OPEN WOUND st Oriented 5 /-rtS NO CLEAR ~~ GUA RDING SCARS _ BLOOD AT •.rbal Conmsetl 4 WHER IMINISHED _ 60 L SO UNDS _YES NO MEATUS +sponse Ina rc riate words 3 3 CREPIT PARADOXICAL YES NO WHERE Incom rehensibla sounds 2 2 YES NO CHE SYMMETRICAL MOTIO , _ DECREASED _ None 7 _ N _ WHERE ~ YES _ NO _ YES N O est DD¢ seommapd 6 EXTREMITIES SKIN ;HER ECK rotor Localizes ain 5 5 '.asppnse Witheraws in 4 4 MOV MENT SEN ATION PU SES INJ _ INK _ ARM AI. AV PATENT Flexion in 3 3 RA _ PALE _ H07 _YES _ 0 Extension ain 2 2 LA CYANQTIC _ COOL JVD S NO None t 1 RL _ MjyRLEO COLD _ _ 7 A LINE M _ RY MOIS7 A ID YES NO otal gpplythisscpmtoGCG LL _ _ _ ;C6 porrwm of Rauma Smre ~ l ADULT/ EDIATRICREVISEDTR UMAINDEX ".OPEN FRACTURE E-ECCHYMOSIS REVISED TRAUMA SCORE 1 scares T 3 5 B 3: UNBH071WOUN0 c coNNISIaN 3LASGOW 13-15 4 4 Blelal Limbs or Upper Arm, Chest ar Spine Head. Abtlpmen or :DEFORMITY L-LACERATION COMA 9-12 3 Region Skin Only Upper leg Only e~Ar S: STAB WDUND SW-SWELLIND SCALE IGL'$) 6-e ~TOtal Points 4-5 2 1 2 1 Wpuntl Type Minor Open Wountl Singl¢Area of Blunt or2 Bum 3BUrn, Open R, Open Trunk WOUnd G mnk, Multiple BlOpi lBlpi 6. BURN P-PULSE 1. PAIN D-WFAR PULSE from above) 3 0 SHP>1HH antl SBP 80-100 SBP <80 or B. RASH T-TENDERNESS Vital Hlgns HA <100: or Pulse 700-140 Pulse> 150; No PWSe g. CLOSE FRACTURE B-SENSATION Systolic >89mmH 4 4 (Atlulp - RA 25-35 flR>35 or <10 ar Breath "-\ ~~ Blood 76-89mmH 3 SBP>80 SBP 50-80 SBP<50 or ~~ ~~ Pressure 50-75mmH 2 2 Vaal Signs antl HR <120; or Pulse 120450; Pulse>150; No Pulse "~.. 1-49mmH 1 1 (Petliatric) 1D-25 or RR 25-35 RR>35 ar <10 or Breath _ / ~ No Pulse 0 Neurological Not Alert but Opy ResporMS Unlespon5ive ~~y 1~ R¢spnatory 10-29Imla 4 4 Exem Uncooperative Responds to Vpica to Pain < I A' `T'/ ~ ~ x Rafe > 29/min. "" 1 VVV ~ r 1 I ~ / 6-9/min. 2 Petls OnIY 20-30 k9 10-2 <10 kg 111 `'l 1-Slmin. Hope Total Pevisetl Trauma Score 1 0 1 Vehicle Elfecls Age Death of Assoc. Occupant Deformity=30' 4'Shk tl flolloverlElectlon ar Fall>20' 66-80 Years Old T-boneM1aieral Impact -Victim's Slde Over 80 Years Om I' I i~ I / I ~( I -: ~' ~ ~.. Total ~ ~i ~ ~ ~ ~ h ,~pph l~ I ~I ~~ Original • Medical Recortl Yellow • Trauma Service Pink - ED Ir % ` I, "'/0R ED TRAUMA/RESUSCITATION FLOW SHEET ~ ~~ ( ~~~ ~~`~ B S N PU .~ • IL ..r:,~~ PUPIL REACTIVITY N EUROLOGIC EVALUATION VITAL SIGNS I3 =Brisk F =Fixed s =sluggish o =Dilated Time Pupil Pupil Size React Motor Function RA R L L GC Time Cardiac Rhyth 02 Sat T . Warm Lites .H. N = Nonreactive PUPILS MM - ~ • 2 • 3 • 4 • 5 • 6 ~ Z ®B • 9 OD 57 R22653 RN b um E LABS ~ CHART RECORD I ABG/ARTHLB TIME BACK MEDICATIONS X-RAY CBC/PLT CT LYTES/RENAL TI E D G DOSE R UT I IT. Time S GLUCOSE ~tiLQ me aJ~ral PT/PTT AMYLASE/LFT 5 ~, r~f~~4fi~ ~tlontoid CK/MB T Swi rs R PREGNANCY elvis Ef (MEDICAL) ~ Cystogram Extremities R ORUG SCREEN __ LEGAL EDRUG ~wn CT ~'~ LE BLOOD ETON ER ~ Cr ial domen SITE Chest Other Angiogram PREPPED WIT P V D NE-I INE DRAWN BY CRYSTALLOID RINARY FOL ES _ M) + \ ~ IV # TIME SOL'N SIT A T. LEVEL I SIZ FR Pl J _ BLOOD AT MEAT INSERTED BY DASTROINTE NAL RECTAL TONE EM + TONE ^ GOOD ^ DECREASED ~ L ^ABSENT PROSTATE ^ NORMAL ^ ABNORMAL DR ~ ( TOTALS SIZ INS E Y BLOO D PRODUCTS PERIT NEAIIAVAGE _ DONE BY DR PRODUCT UNIT # TIME SITE AMT. INF. INIT. LEVEL I RETURN ^ CLEAR ^ PINK GROSS BLOOD ^ AMOUNT INFUSED CC AMOUNT RETURNED CC FLUID TO LAB YES NO CARDIOTHORACIC RCT SIZE FR CVP R L _ ____ LC7 SIZE FR A-LINE _ R THORACOTOMY CUTDOWN _- L THORACOTOMY BY: TOTALS PERICARDIOCENTESIS DONE BY DR OUTPUT 12 EAD EKG YES NO L NEURDLDGIC I RI NG M IS RCT LCT TOT L __ ICP BOLT INITIAL READING HALO DONE BY DR E NI IRSF'S NOTES ~ vl Support Nurse: L~ I'I /`J~ Documenting Nurse 1~l ABBREVIATIONS MOTOR FUNCTIONS NAME GED ARRIVED BVM =Bag Valve Mas LCT =Left Chest Tube NS =Normal Strength ED DR ET = Endotracheal Tube RCT = Righi Chest Tube W =Weakness TR SURG _ ABD =Abdomen PH =Pre-hospital FP =Flaccid Paralysis PGY 4 RL =Right Leg LOC =Level of Consciousness R =Rigid PGY 2 LL =left Leg PMH =Past Medical History OCB = Decerebrate Posturi g GY 1 RA =Right Arm BH = BairH er ~ -9C Decorticat Pos[u EDS LA = LettArm ~ PEDS _ DISPOSITION TNC ADMITTED TO PORT TO OR TIME OR NOTIFI OR READY OR_ ANESTHESIA ' FAMILYNOTIFIEO ~ BY NEUROSURG RELATIONSHIP ORTHO C-SPINE CLEARED ^ YES 0 DR. X-RAY C-COLLAR ON Q YES ~ NO ASPEN YE S ^ NO CT VALUABLES ^ W/PATIENT ^ SAFE ^ NONE ^ W/FAMILY RT ^ EXPIRED CORONERNOTIFIED@ CHAPLAIN MATERIAL EVIDENCE TO POLICE ^ YES ^ NO CONSULT OFFICER BADGE # CONSULT CONSULT TRANSFERRED TO VIA tr-~l i ~,uu.~tuLG LJGiJiil~'GL The Milton S. Hershey ®Health System Medical Center TRAUMA HISTORY AND PHYSICAL EXAMINATION .:.. _ " _. ~ ~ _~ .. i A. ;i'I i a 5; 7G i .. _ - ._ s3 ,. .. I Date: y I~I(oa Time: '7 =15 Po'+'1 ~Ty~~of Treniua Brief History GMechanism of-Injury) MVC Belted? ^ Yes ^ No ^ Airbag (SYO he({-~, ysen t n ^ Pedestrian ^ MCC ^ Assault my ~" ^ Fall ^ Burn ^ Electrical ^ GSW ^ Stab ^ Other Fietd ReBuScttatt4e, n 'gip- Airway: (~Pn IV's: R.O.S. Field Vitals: P: BP: 'z R: '~j Immohilization: Fluid: Amnesia? ^ Yes No Loss of Consciousness? ^ Yes o Field NOteS: Pritnt;rySurvey TaumaHislgry' .~~ ,K='z,~„~. Airway: Patent ^ 06structed Intubated: ^ OT ^ NT ^ Trach Allergies: NiC Breathing: r~- Breath Sounds: Meds: Circulation: P: w"I BP: IYlt143 RR: 7,b Sat: lcxsfta Disability: Alert ^ Vocal ^ Paintul ^ Unresponsive PMH: Exposure: fiM le Procedures: ^ NG-Tube ^ Urinary Catheter PSH: , ^ A-line: ^ CVP(s): Chest tube: ^ right ^ left Last Meal: ^ DPL: Last Tetanus: Setat~arySuNey 2ndVflals:Temp~" ~ P: P: RR:_ ZSat: Wr ~ HEENT: Head: KCq'T Eyes: PEn2~q Vii`, ~~ ~i ~' Ears: TM's: OFV~ ¢~ L Battle's: i Face: Maxilla: Mandible: i~t(zr.Cf ~-== -- / ~ ,, ~ Nose: (~k•C(- Dentitia: t1Q ! ` ~ Mouth: Dentures: ~ ~ ~~ ~~ ~~~ ~ ~, Neck: Tenderness: Crepitus: Trachea ML I \ Chest Wall: Tenderness: -+- Crepitus: I ~ 1 I I Lungs: ~'T6j'P7 i ~ i / / ) ~ " Back: Tenderness: Crepitus: `~ ~ /I ( , ~ ~ J " Heart: (LRfI~ 1 Abdomen: Distention: BS: Tenderness: ~ ~ I, :~ Rectal: Tone: Heme: Prostate: Pelvis: Stable: ~ Tenderness: Vascular Exam: Radial RighULeft Z,~' IZf' Femoral Z'f'~ Z {~ DP Zi'lZ fi pT Zi'~~ {~ J LEGEND: L -laceration Cfx-closed I fracture Reside g atu Title 12 ( Date u ~ I4 ~~ Time a. .m. :l rnx-Open tree°ra Ab -abrasion C -contusion COPYR , 799 GHS - Orig • Chart 1R 611 Rev. 3198 TRAUMA HISTORY AND PHYSICAL EXAMINATION Copy • Trauma Services T z_ ti~ ,~.~. ~ ,, TRAUMA HISTORY AND PHYSICAL EXAMINATION :f10(IAN CIINCV InnM 1 emity Exam P ~~~ /~ /j ~ ~" 77rq i ~ i 7_'?!'-~ ,- ~ ~y~~~ ~~\ ~ _ ~ ~~~~ _- - i LEGEND' _ j L laceration I I I Cfx closed frecture ~ I ~I, i ~ Ofz open fracture I Ab -abrasion i i ')i I i` S,~ 1 C -contusion ( ~ I~ ~ i ' li I \~1cMry'I' ~I, i' ~~ !ri 1 urologicai, Exam spinal cord miury: Glasgow Coma ScalelPeds Eye Opening Trauma Score nialNerves: 01-' 2-Open to Pain Resp.Rate SBP tOr: 3- Open to CommandNOice ontaneous 0- 0 0- 0 1 _1_g 1 -p_qg T t-d2 al Response t -None 2 ->36 2 - 50-69 1SOry: PlnprlCk - 2-Incbmprehensible/Moansto Pain 3-Inappropriate/Cries to Pain 3 - 25-35 3~0-90 ~q 4- -24 0 Proprioception 4 -Confused /Consolable d/Oriented/Interacts GCS 3'g L 1-5 otor Response 0 - 3-4 _ ~ 1 -None 2 - Decerebrate 1- 5-7 2 - 8-10 3 - Decorticate 4 -Withdraws 3 -11-13 1 r.`i~ i -Localizes Pain 6- eys 5 - ~~ 3 f i Bp .N Total: ~ Total: s/Sio8les~(afuatetl~ PT: Troponin: U/A: (Z~L 14Z PTT: Myoglobin: _ Za'E ., ~ IZ5 ~ T:Bili: 0•'7 CPK: Drug Screen: ~ ''~' ~r o ALT: 3+~f Amylase: U4 a: ALP: ICa: Lt ETOH: ~IIS 3: TEE: BHCG: lays CXR: Pelvis: CT Scans: Head: td: CSpine: Lat Extremities: Abdomen: AP Others: Odontoid Angio: T & L S toes: UiS:. blem List: Attending Note/Rlan: _ .(ti.r 6~L ding Signature/Date/rime / ~ ^ 9 ~ ^^ J I -Chart Copy- Trauma Services s1t Rev.3/ee TRAUMA HISTORY AND PHYSICAL EXAMID TION . PennState Geisinger The Milton S. Hershey - Health System Medical Center - 'c';,'1 HISTORY AND PHYSICAL EXAMINATION - - - ~ ' "a A Z I L E C~~~v= PETER W 712`-2 ':" usl3C' CONTINUED ON REVERSE SIGNATURE tii~E DATE TIME A.M. P.M. MF9 9/71 HISTORY AND PHYSICAL EXAMINATION PAGE . ~1 PennState Geisin er _ g The Milton S. Hershey Medical Center - - - ~- _~ ~ u R; i ®Health System ,;~ y, 301521 ~.:~~- , PROGRESS R O~T c ` r ' `" ' ~ + ~ATE~ I TIME I PRO SS NOTES ~ ^ wPaneNT ^ ouTPaTieNT i NAME-TITLE -t7 ~- .. ~ ---~h'-'-- ' MR&217/91) PROGRESS REPORT ~ ~ ~//„ ~;a«w .. ~ PennState Geisinger The Milton S. Hershey Health System Medical Center PROGRESS REPORT ~c~l-~,~~ . ;,,-2 , ,_ ~~~t40 r~~_ nat. AZI ~ 'l~.~UCtW~~ ~l "Q 2615 ~e.snre,i PROGRESS REPORT ~ PennState Geisinger The Milton S. Hershey ® Health System Medical Center PROGRESS REPORT ~1 ~C~ v F G ... 1 "C_~nAi:~ AZILE Di~~uaa ?EiER W 261;0 Date/Time PROGRESS NOTES: (Include Name, Title) r~ Pk q,-~~.- ~ 1~ ~ ~..~. ..-~L -ZL- a IfP_ ~?"(lca 3 JOB- ~{~- c~ 4cn1T- ~~ ~ ~ it p .s ~ M,J a ' ~ I~.,.,.~.: ~. - ~ }F~GT~ - v.; Il ~-1,~,~,,,, T - -Fry... ~-w "t ..~ d- ~ R t~ `~~'~ -.ti.,,. S. d 2 ' )(}e.- z r . /~' vu 3 MR 5 Rev. 2/95 PROGRESS REPORT „~,.w ~.. . PROGRESS REPORT Date/Time PROGRESS NOTES: (Include Name, Title) a k ~ 1l - .J.-~ ~,~ P,...- 1`` - ~g-its 4D- il~~z _2.8' ~~~- ern F~-.:` ~s n1-,-..~ - G-C.,~._ ~.,~.~ i C ~_ N~o !~ ~~ ~aP INDICATION FOR TRANSFUSION • ENTER INDICATION CODE FROM BACK OF FORM OR OTHER REASON IN THIS SPACE. vv~ -tea v~6is DATE TIME STARTED TIME COMPLETED AMOUNT OIVEN IF LESS THAN AMOUNT ISBUED / ML REACTION ~ VEe, SUBMIT TMNSFUSION REACTION FORM No. 301321 NAME ~~:li~'!Hr i4G `G'.ci,% BIRTH GATE ~Qij~'{]!'~IQ~~ PHYSICIAN jM i~25~, j('j11 k RECIPIENT TYPE ; v[,S?1'IF DONOR TYPE :1-rG9iTIVc KEV TRANSFUSION NO. RccC-iS„ UNIT/POOL/LOT NO. ;YO`_0o~ COMPONENT PpC:'4E~ G[LL`a' CROSSMATCH CuMFr~TIB'tE COMMENTS SEX 2 U Q U (COMPARE TO WRIST BAND) VOLUME _~-~ TECH 'riENiieG~.,. L_`: MR 6 Rev. 2/95 PROGRESS REPORT ..m~..~. MD KEV TRANSFUSION NO. (PROM WRIST BAND) ' ~ PennState Geisinger The Milton S. Hershey ® Health System Medical Center PROGRESS REPORT _~..~, -,~:t, AZiLE 0 Date/Time PROGRESS NOTES: (Include Name, Title) (0 00 ~~ 31 IODm i ~ ~ 269~i a~ C I ~ ? ~~(K(" - -r+~ ~-- „-_- - G3~IS C ~ C~z'- /rri,~ - -~~,-- S„ rya-~~ ~ ~E-c _ r-T - t ~~ o o ~ G-~ c-- ~+~ S rte- ~ , _ , - - S'^/f,Iy c., o[L ~~ 7'/1'!1 ~-~L ~v.~ ~~ r"C/~~ ~ ` t ~- r 1 A ~ d ~ ~ 1 I„`_ 1 L MR 6 Rev. 2/95 Y ~V / ESS R PORT PROGRESS REPORT Date/Time ~ PROGRESS NOTES: ame. Tifla~ N (Include ~ / , ~~r ~ MC QCUQi ~ ~ ~~~ ~ 9.2 -~ Location: ~~- ~ ~ I PASTORAL SERVICES Patient: . f ~~ , QOTime:~~'~G Pastoral VisR Pre-op Death Ministry /~ ~' 1`~ ra Code Other 1 -- .- -. Date: .- Referral Source: Name: ~ re ~'~ - Adm ~ ~~ ~/rl ~ Pt Family MD RN SW C-leyrg~y Other ~ 9 ~''i U/~Q~n ~/ / ,v ~G/ ~' .S'enCC r /n a. /~1~~9 ~0 71/Q Pr Pastoral Care Notes: ~ - . „~ .. ~ m_ rte... ~ ~! /9 ~ 2n ^. ~1irm ~ 02 ,{T~6~tc~, Pb~„e:J 7/~- y7G- 93 rd llar.,-,1aA tTi ~a o-i~~~~ - Pastoral Support: Counseling rayer~ Communion Anointing Baptism Scriptures Other Support Resources: Clergy name & phone: C 1~~ ~ T Onn Other..~i ~~rr /A/~9~ ~iln~/ ~n ~ - ~ - Family:,~~~ttu 2--,e Follow-up: tWill~visit _/ Refer to Other Recom. - ~ """ Chaplai- qtr /~~ 7->/mol~" Length of Time 3~'y/es -s~peNisor _ ". -.. ~ ~.- t}ft7100 Ped S~Ir9 c b~llo/I . oS55 rM 3?` 'rc 35`r P 90-laq 2to6-2$ 13P iz-~-13'~271 Iv vrv rorp~ SIO 12(oO~ Ip10 i Z l cc l <L Ll b hv) gb0 po I V p: I.ICCIKS/° (lbhv) (f5}-pol rDemest~S Pt clo can+tnut~ rnl~-ab I I roved cy'-rrr pulm- crA elm py- soft Nv +er)der erlurvlbll~ ®Bs >< ~- F-1 A E Vv p. r C I c l~. A,IP~~IS v ~ Nd~3 sl s,-'I~F1,5 Ier1~CIgC, N 21.t r0 - S i-cl b l e -Fa l r r) I n C O V11-Yp I L M SO + I2Y10 1) PU t/)'t-S-IGbIC CVS-S+Qb t~ Herne- her Obl Ilzln ~z~), /hcr f-oda~ ~~N I G- t - v)coura z a I n+u. key ~-a d 1G te.-~-:.-~-Za hta ~ zvt-ran used ~. Rer)al f~U- vod ..LOP st-able. iV-aF, VSS ed re5+ ms r~-o a pc •~ ~ s ~ mdq. z dA~.7 , p u ~,~ 01 ~b MR 6 Rev.2195 PROGRESS REPORT l ~24h r1 '' PennState Geisinger The Milton S. Hershey ® Health System Medical Center PROGRESS REPORT ~: S_ ~,°i n~ _;v41~. AZILE 2bt5, Date/Time PRO RES NOTES: (Include Name, Title) ~ _ #€> /~ C (~ ~,1, ,~ ~ , ~' 7 00 ~ adhc / moo- Cn/'~ ~ a ~o~ - lS a,-s - ~ V~ - W 7~ -~ ~~R.._ - ~ ~ C l~ ~ - v / ~-~"` '-- O'~ 7~ ~ ~-- '~ ~_e „Q ~~ //-- 1 ~t s YLa Q it ~S' _f '73 ' /~ 'gyp ~° Lac ~~ wV ` / l_ .. ~ ~ ~ Vi //n ~ ~ ~ ~,/ ~/J ~ o ,n/f1/ ~ ~ V ~ ~ jRJ [JY ~ ~~_ r~ MR 6 Rev. 2195 PROGRESS REPORT PROGRESS REPORT Date/T'me P 0 ESS NOTES: (Include Name, Title) ~ - 1,w - ~~ ~ '~ ~B ~~ ~u.r~rih - Z° C da,~ -#-I }~O~en`~'iCi.~ ~''6,(iedaYr¢ - nod-tom{, irze `t~~~l, O 'uu,~ m ra ~fYavn, -e t' (.ui /l cm-~fi `tD 'rima~.~/~ ~2 - Y b u-{ i zeS m~vrt - reczi ~-i;,Y4 '~ ~/~~~~ d Qs nec~ecL curt. t'P.~zocel~ 6rde,~cf, brc~ hz h ~" ~ eede~C s a et i?f, ambulafiYr ~ - Gtr~~.s-;<, r r-es8i s al '~3 ~Inxi - demons' 7~f92e. i f~~'S Verrbatr~ih Xl 6Vex,ctCfi1~1,"~~' ;reafiYla _ G hQ i es c , 's Ab~7r ~ ~ ~ ` '~ in wIGS.•ci;scursr~C 2'F It,~ ~, o M/~s, i~111 1 G~~~e fa a~r~b~i~o~-. G i i - G ~ S QcfiN reS}~ c,~7 dY1i, mr~'a G GL care canfi ruci n ~ aa?~x~, ~d' f `~ ~ ~ ~ ~ i fi. ~~./hct,B~Zes Gu2d.2rslzivtcG o~ ~ Tar ~~~' ~ ~~, lg1i? Gm t7Yk,ce, than ~ atCC(. ~ r a S ~,~' - ~`~ ~J MR 5 Rev. 2/95 PROGRESS REPORT ' ~ PennState Geisinger ® Health System PROGRESS REPORT The Milton S. Hershey R 4 d 813 ~ f Medical Center T RA IrFiA i 361 92 f ~~ O~S~ZG971 ,, ML~.LxtAtN AZIt,E tt_I.~k PETER M ~2aa-f lies Q5130if99a F 2&tSd3 Date/Time PROGRESS NOTES: (Include Name, Title) ~ Do P~ 5 ~o 7 l©lI ~~ t 6©~ ~M (0 L 7 ,Uf ~7 L G ~~~ 7Je is l tF s V lv S - - - s y G ~ r r7 P " AM 3 ~ ~ ~ S- 15- 37 4- U / m UD P x (, tiT N S C G A P I~ SIP Mv~ rv - - r ~ -' ~~~ MR 6 Rev.2795 PROGRESS REPORT '°~ PennState Geisinper b The Milton S. Hershey ® Health System Medical Center ! PROGRESS REPORT R#d813C1 RAL~Na#361921 „S#2C87] CE~wAIh AZILE ILLC^+ vETER w 7244-t ;"^BS 05/30/tSgd f 26150 ate/Time PROGRESS NOTES: (Include Name, Title) I on 'U ~ lZa`te_. - ~kzile is a I5 ,®. ~uho Ea,~ I.UG1S lhvOlVf~. a GiS ~- /~-S£ ~~ 7h~~crics 'ncli< n.~ird c1-/z ate- ~ ZGi?lG I Yci~7 t CURS ~171/`~~c~ PJCGL drL ~ pv ob~ervct~ien, ~ ,Gdt,' -gym. ' ~ 5 . S ~ 2 ~ . ~o r ~~v 6 P~r~c Pf was fi-,wis~,re~ ~ ~ oar ®n ~` a ~-, s /,-,'ri- be cl~~sf- > ~ Y-~ BRRs or '~ 1~. Nr.~- ~. J en y l~ ~. a ~ cc..e-- h - P X w D {2'Carm~ - mi l a~errti ~e.! b•Cee~n - vital si s stxkl~ 7. u~i/l recGte~k- in .~ G e YI ~U-U/Qa"Gts' OQA. ff2 ~~"LL- GiV aL ~ Y E/2d Y - S>~-lts ba~- - ca>7 ~t ambul~lT>7 ,B s` b'C~ir». ~rx wCo1 • ~3 / - 7 S !.L/ r liY'9'l.~ si o~ xie evb ~ f~vtd.t cfiY, +~ ~t; eve , - •a esa (ved . C ~Ca ' in - R!l ins/nccfians fi ~- rG ~ G ~. £ a rP~n/3 c2 ~7M D ~ Z> C' _ /7/lOVi/7 ~r~5' R/` IqI~~ ( - - ---- I I~ - r, ~ L i~ - ~ - -w ` u.. ~.~Jk~. ~CiU 3-t _ ~r~ Q GLa ? ~-{- c, ..~ ~p V _ ~j G ~ ~ ~ ! L n~ w ,~ • ~ 2 L~_ , Y MR 6 Rev.2195 PROGRESS REPORT PennState Geisinger Health System DISCHARGE SUMMARY Health Information Services M.C. HU?4 P.o. eox sso Hershey. PA 17033-0860 PAT28NT NAME: MCELWAIN, AZILE R PATIENT NUMBER: 0487301 DATE. ADMITTED: 04/14/2000 LOCATION: DATE DISCHARGED: 04/19/2000 SEX: F DATE OF BIRTH: 05/30/1984 ADMISSION DIAGNOSIS: 1. Status post motor vehicle accident. 2. Splenic laceration. DISCHARGE DIAGNOSIS: 1. Status post motor vehicle accident. 2. Splenic laceration. BRIEF HISTORY: This is a 15-year-old female belted passenger status post a motor vehicle accident. The patient with no reported loss of consciousness, no amnesia. The patient originally on admission complained of some chest and abdominal pain. A full trauma work-up was done including CAT scans of her head, chest, abdomen and pelvis which were significant for a grade IV Splenic laceration and a closed head injury. The patient was admitted to the Pediatric Intensive Care Unit where serial hematocrits and examinations were performed. The patient was transfused one unit of packed red blood cells. Serial hematocrits remained stable in the range of 26 to 30. The patient remained on bedrest with bathroom privileges. The patient` was able to tolerate a regular diet and able to void. The remainder of her hospital course was unremarkable and the patient was ~, discharged to home. DISCHARGE MEDICATIONS: 1. Percocet 1-2 tabs p.o. q.4 hours as needed. DISCHARGE INSTRUCTIONS: 1. Diet regular. 2. Activity. The patient is privileges for one week, then patient may return to school, for one week. The patient is the prom. to remain at bedrest with bathroom bed to couch for one week, then the but with no extra curricular activities to have a wheelchair to school and to t~l of 2 PATIENT NAME: MCELWAIN, AZILE R PATIENT NUM88R: 0487301 Call 531-8521 and page the pediatric surgery resident with any questions or concerns. The patient is to follow with the Pediatric Surgery Clinic in three weeks. DICTATING MD: Hoan-Vu Tran Nguyen, M.D. ATTENDING MD: C~_ ~V~ Peter W. Dillon, M.D. /, `~~/ ~1 HVT/bjc D: 04/19/2000 T: 04/20/2000 05:57 c: WP Clerk JAY A. TOWNSEND, M.D. 100 SOUTH HIGH STREET NEWVILLE, PA 17241 Page 2 of 2 ,~ ' ~ PennState Geisinger The Milton S. Hershey ® Health System Medical Center SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA'PATIENT Oo3>~I~LI ~~~ ~ ~ ~ ~ SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA PATIENT DRUG/ALCOHOL: ETOH above .10 Drug Screen No drug and alcohol abuse identified LIVES: Alone With Spouse/significant other With parents ~ /~ N~ _ With friends A'rQ' ~ _ Other ~ ~~ EMPLOYMENT/INCOME: Employed Nn Er.. /-JA~I ti~E Mr J Unemployed Laid off Disability/medical leave Social Security SOCIAL SUPP T: `~ . Family 'rF I,w /V1~yt~IC Friends Neighbors Limited social support available MR 660 5196 Family memffers divided or inconsistent in view of situation Hospital experience limited or family has no experience with serious illness or injury SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA PATIENT MARITAL STATUS: LIVES IN: _ Multi-story home _ One story home _ lstfloorapt. _ Upper floor apt. Mobile home Other MEDICAL COVERAGE: Auto medical limit if known Health insurancethrcughT,~(,~ ' _ No coverage, Medical Assistance application needed Workmen's Compensation INLTIAL FAMILY DYNAMICS OBSERVED: Denial/avoids talking about injuries Minimizing seriousness of injuries Optimistic patient will make full recovery Realistic/verbalizes understanding seriousness of injuries Family decision maker identified: SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA PATIENT OTHER MAJOR STRESSORS WITHIN LAST 12 MONTHS IN PATIENT OR FAMILY MEMBERS' LIVES: POTENTIAL DISCHARGE NEEDS: ' Patient unstable/unable to determine needs at this time. Will reassess in 48 hours. No intervention indicated at this time after patienVfamily assessment. PATIENT/FAMILY MAY REQUIRE: Extended care facility/subacute rehabilitation Acute inpatient rehabilitation _ Outpatient therapy _ Home health care Skilled nursing Physical therapy ~_ Occupational therapy Speech/language therapy _ Substance abuse follow-up financial assistance Home equipment Rehabilitation consult _ Drug/alcohol evaluation Children and Youth Referral _ Domestic Violence Program Referral _ Other `E SOCIAL WORKER'S SIGNATURE: SOCIAL WORKER'S PAGE NUMBER x ~ OI DISCUSSED WITH: A t,SW ATTENDING PHYSICIAN DATE: ~'I/~~O TRAUMA COORDINATOR MR 660 5/96 SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA PATIENT ~~ PennState Geisinger The Milton S. Hershey ® Health System Medical Center TRAUMA SERVICES REHABILITATION ASSESSMENT ~rt,,2 X8730 / 7-~ 36 i9z l ~~-- , ~-e~f~. S~3o%'~l Diagnosis ~ / '^~'(`n",.'~( SPEECH 1. Patient has a swallowing or chewing impairment Y 2. Patient has a communication impairment Y 3. Patient is able to follow commands Q Q. Patient has an impairment of memory and/or concentration Y 6000PATIONALTHERAPY 1. Patient has difficulty completing activities of daily living, such as dressing, bathing, toileting, grooming, feeding Y N 2. Patient is at risk for contractures of the hand Y N 3. Patient has difficulty with fine motor skills Y N PHYSICAL THERAPY 1. Patient has difficulty with mobility activities such as transfers, ambulation Y 2. Patient has decreased strength or endurance Y N 3. Patient has problems with coordination or balance Y N A. Patient has tone or posturing Y N After this screening assessment, it is determined that the patient requires intervention of Physical Therapy Y Occupational Therapy Y N Speech Therapy Y N PATIENT REQUIRES AN ACUTE, SUBACUTE OR OUTPATIENT ABILITATION EVALUATION CONSULT Y REHABILITATION PLACEMENT RECOMMENDATIONS 1. Patient demonstrates adequate safety awareness Y N 2. Patient has complicated wound care needs Y N 3. Patient is incontinent of bowel or bladder Y N 4. Patient has ongoing Respiratory Therapy needs Y N SPINAL CORD INJURY (SCI) TEAM CONSULT Y N ON EMERGENCY DEPARTMENT EVALUATION PATIENT HAD EVIDENCE OF ALCOHOL AND/OR Y N SUBSTANCE USE (IF YES, COMPLETE CAGE CRITERIA) CAGE CRITERIA EVALUATION 1. Nave you ever tried to cut down on your drinking Y N 2. Are you annoyed when people complain about your drinking Y N 3. Do you feel guilty about drinking Y N 4. Have you ever needed an Eye Opener Y N PATIENT REQUIRES DRUG AND ALCOHOL CONSULT Y N Comments: Screen completed by Signature if no rehabilitation or therapy services are required Date White - Metl. Rec. Yellow -Trauma Serv. MR 686 Rev. 5/99 TRAUMA SERVICES REHABILITATION ASSESSMENT Pink - UHRC _~~,~~, PennState Geisinger The Milton S. Hershey ® Health System Medical Center TRAUMA PATIENT RADIOGRAPHIC "WET READS" c '?-'; 1G 'shl"21 E .Y ., _ , -. .:,~~ The following radiographic studies were performed on this trauma patient, with "wet read" preliminary interpretations as indicated: chest ^ Abdomen ^ Elbow - (L) vs. (R) ^ Forearm - (L) vs. (R) Pelvis ~ ^ Hand/Wrist - (L) vs. {R) ^ Hip - (L) vs. (R) Cervical Spine ~O'"~~?~-+b~~'~ ^ Femur - (L) vs. (R) ^ Thoracic Spine ~~~ c~o~rO~J .:. (~ C~S{ ~ ~1~ ^ Knee - (L) vs. (R) ^ FooUAnkle - (L) vs. (R) ^ Shoulder - (L) vs. (R) ^ Humerus - (L) vs. (R) ^ Lumbar Spine ^ Skull Xrays ^ Other Xrays Radiologist's Signature: ~R-.~-~-!--~~--~~ Printed Name: ~~;1~, Beeper#: 1~ ~ Date: `-1, I NOTES: 1. Angiographic/Cardiovascular Interventional Radiologic procedures are documented on other forms. 2. All studies on this patient for whom a "wet read" was provided during the trauma were "checked" in the appropriate boxes. 3. A "minus sign" (`"_") indicates "no significant abnormality." 4. By his or her signature, the Radiologist who interpreted the studies "checked/circled" above indicates that the findings were discussed with the clinical team. MR sob 9/99 TRAUMA PATIENT RADIOGRAPHIC "WET READS" (PRELIMINARY FINDINGS) White-medical Records Yellow - Ratliology - ::.~. ~ 04/18/2000 M.S.-Hershey Medical Center Page: 1 22:53 Hershey; Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWAIN, AZILE F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Acct#: 000000020877 Admit: 04/14/2000 Disch: +~+~~+~~+++++~+~~~~~~~,t+++~~~~~++~ Chemistry ~~~~+~~~+~~+~+~~+~~~~•+++~*t~~~~~++ DATE: 04/14/00 T1ME: 1920 REF RNG UNITS Na 142 135-145 mmol/L K 3.7 3.5-5.0 mmol/L Cret 0.7 0.6-1.1 mg/dL Glu H 125 70-120 mg/dL (a) Ion Ca 1.16 1.13-1.32 mmol/L ~~~+~~++~+.~~~~+~~~+~+~~~t*~~++r~+~~+:r CBC ~~~~+~~+++:r~~~+~:t~+++,r+++:r~x::r :t :try++++ DATE: 04/16/00 04/17/00 04/16/00 [-----04/15/00-----] TIME: n0620 0710 0900 2100 0900 REF RNG UNITS ------ WBC --------------- 6.7 ---------- ---------- -------------------- --------- 4.8-12.0 ---------- K/uL Hgb L 9.5 12-16 g/dL Hct L 27.1 L 28.3 L 26.2 L 25.5 L 27.7 37-47 g RBC L 3.07 4.2-5.4 M/uL MCV 88.3 B2-96 fL MCHC 35.1 32-36 g/dL MCH 30.9 28-33 pg RDW 12.9 12.0-16.4 ~ ---FOOTNOTES--- (a) QA FLAGS MODIFIED BY SEX/AGE UPDATE ON 04/14 AT 2316 CONTINUED Cumulative Summary (Inpatients) Page: 1 361921 MCELWAIN, AZILE 04/18/2000 22:53 04/18/2000 M.S. Hershey Medical Center Page: 2 22:53 Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWAIN,AZILE F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Acct#: 000000020877 Admit: 04/14/2000 Disch: _____________________________________ CBC =_____________________________________ DATE: 04/15/00 [-----04/14/00-----] TIME: 0410 2300 1920 REF RNG UNITS WBC H 16.7 H 25.5 10.5 4.8-12.0 K/uL CAPILLARY Hgb L 9.7 L 8.0 12.2 12-16 g/dL CHECR$D Hct L 28.3 L 24.3 L 35.5 37-47 ~ CHECK$D (b) RBC L 3.23 L 2.80 L 4.10 4.2-5.4 M/uL (b) MCV 87.6 86.8 86.6 82-96 fL MCHC 34.3 32.9 34.4 32-36 g/dL MCH 30.0 28.6 29.8 28-33 pg RDW 13.0 13.0 13.2 12.0-16.4 $ Plts 298 140-340 K/uL MPV 11.9 8.7-12.5 fL *xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Urinalysis xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx DATE: [---------04/14/00---------] TIME: 2130 2045 REF RNG UNITS ---------- Color (u) ---------------- YELLOW --------------------------- YELLOW --- - -------- ----- Appear (u) CLEAR CLEAR Glu (u) NEGATIVE NEGATIVE NEG mg/dL Bili (u) NEGATIVE NEGATIVE NEG Ketones (u) NEGATIVE NEGATIVE NEG mg/dL' SG (u) 1.010 1.015 Hgb (u) * TRACE * 3MALL NEG (b) (b) pH (u) 7.0 7.5 4.5-8.0 units Prot (u) NEGATIVE * 30 NEG mg/dL (b) Urobili (u) 0.2 0.2 0.1-1.0 EU/dL Nitrite (u) NEGATIVE NEGATIVE NEG Leuk Est (u) NEGATIVE NEGATIVE NEG ---FOOTNOTES--- (b) QA FLAGS MODIFIED BY SEX/AGE UPDATE ON 04/14 AT 2316 361921 MCELWAIN,AZILE CONTINUED Cumulative Summary (Inpatients) Page: 2 04/18/2000 22:53 04/18/2000 M.S. Hershey Medical Center Page: 3 22:53 Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWAIN, AZILE F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Acct#: 000000020877 Admit: 04/14/2000 Disch: +*++*+++++++++++++++*+++++*++++++ Urine Micro ++++++++*+++++++++++++++++++++++++ DATE: [---------04/14/00---------] TIME: 2130 2045 REF RNG ----------- IINITS ---- -------- WBC (u) --------------------------------------------- NONE NONE ------------ <5 /HPF RBC (u) 1-4 1-4 <5 /HPF Bact (u) * FEW * MODERATB NONE (c) (c) ++*:*++++++++++++++++*+**++++++++++ Liver/GI ++++**+++++++++++++++++*+**+*++++++ DATE: 04/18/00 04/14/00 TIMH: n0620 1920 REF RNG UNITS - ----- ------ - - ALT ------- - --- ------------ 34 - ----------------- - --------------------- 10-50 U/L T Bili 0.7 0.1-1.0 mg/dL Amylase L 29 44 30-100 U/L +++++++++ ++++++++++++ +++++++++++ Cardiac/Lipid ++*++++++++++++++++++++++++++++++ DATE: 04/14/00 TIMB: 1920 REF RNG IINITS ------- Myoglobin ------ H 133 ------------ ----------- ----------------------------- 0-116 ng/mL (c) Troponin-I 0.4 <2.0 ng/mL ++*+++++++++++++++++++++++++++++++ Toxicology ++++++++++++++++++++++++++++++++++ DATE: 04/14/00 TIMB: 1920 REF RNG UNITS ------ - -- -- -------------------------------------- ------- EtOH med <10 <10 mg/dL ---FOOTNOTES--- (c) QA FLAGS MODIFIED BY SEX/AGE UPDATE ON 04/14 AT 2316 CONTINUED Cumulative Summary (Inpatients) Page: 3 361921 MCELWAIN,AZILE 04/18/2000 22:53 04/18/2000 M.S. Hershey Medical Center Page: 4 22:53 Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWAIN, AZILE F 15Y Loc: 7MB5 (724401) Dr: DILLON, PETER W Acct#: OD0000020877 Admit: 04/14/2000 Disch: .~++v,~*.~+~~,r+r+++,r*+~~.*.~+ Blood Type and AB Screen **~***x~:tx~+++++~.~~~++~+~+ TEST: ABO/Rh Antibody Scr 04/14/00 n 1905 O POSITIVE NEGATIVE +~.•~.~„~•~.+r,+~+++~:.:ta**r+~+ Crossmatches Ordered ****************x++x**~~+*+*+ TEST: Spec Expires R Number Component Type Units Ordered -------------------------------------------------------------------------------- 04/14/00 n 1905 04/17/2000 R22653 RED CELLS 3 **~******~***************~*** Red Cell PxOdUCts ISSUed ***************************** Component Unit Unit Volume Comments ABO/Rh Number 04/15/2000 n0010 PACKED CELLS 0 POS N67586 250 361921 MCELWAIN,AZILE CONTINUED Cumulative Summary (Inpatients) Page: 4 04/18/2000 22:53 04/18/2000 M.S. Hershey Medical Center Page: 5 22:53 Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWRIN, AZILE F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Acct#: 000000020877 Admit: 04/14/2000 Disch: ~,r+r+~++~x~~~~+++~+++~*~+++:r~**~ CANCELLED TESTS *x++~~~~~~+txrr+~**~~~++~:t *:tx *:t+ 04/14/00 1920 CANCELLED: IONIZED CA, NA, & K BLOOD GAS, ARTERIAL HGB AND O2SAT, ART PROTIME WITH INR PTT REASON:NO SPECIMEN RECEIVED 361921 MCELWAIN,AZILE END OF REPORT Cumulative Summary (Inpatients) Page: 5 04/18/2000 22:53 Head CT (peds, unenhanced) Result Type: Head CT (peds, unenhanced) Date of Service: Friday, April 14, 2000 8:45 PM Authorization Status: Final Subject: GT HEAD UNENHANCED-PED * Final Report ~T HEAD UNENHANCED-PED PATIENT NAME: MCELWAIN, AZILE PATIENT MRN: 00361921 ?ATIENT DOB: 30-May-1984 ^~XAM NUMBER: 590A-091400 EXAM: CT HEAD UNENHANCED-PED ORDERING PHYSICIAN: PETER W DILLON Exam: CT HEAD UNENHANCED-PED UNENHANCED CT OF THE HEAD :LINICAL HISTORY: Status post MVA. MCELWAIN, AZILE R - 487301 PROCEDURE: Standard axial unenhanced CT of the head with 8 mm cuts above the tentorium and 9 mm cuts through the posterior fossa :filmed in brain and bone windows. 7~SCUSSION: There are no comparison studies. The brain parenchyma remonstrates normal attenuation characteristics. The ventricles ar.d extraaxial spaces are normal in size and configuration. There is no radiographic evidence of skull fracture. The paranasal sinuses, mastoid air cells and orbits are normal. IMPRESSION: There is no evidence of an acute abnormality in the lead. Dr. Bruno reviewed the images and discussed the interpretation with Ir. Lobell. IICTATED: 16227 3EVIEWED AND SIGNED: MARK E. LOBELL, M.D./MICHAEL A. BRUNO, M.D. ./jor Printed by: LongenecKer, Teresa Printed on: 05/23/2000 9:16 PM Page 1 of 2 (Continued) -_~~. Head CT (peds, unenhanced) Completed Action List: Printed by: Longenecker, Teresa Printed on: 05/23/2000 9:16 PM MCELWAIN, AZILE R - 487301 Page 2 of 2 (End of Report) Thorax CT (peds, unenhanced) Result Type: Thorax CT (peds, unenhanced) Date of Service: Friday, April 14, 2000 8:45 PM Authorization Status: Final Subject: CT THORAX UNENHANCED-PED * Final Report CT THORAX UNENHANCED-PED ?^-.TIENT NAME: MCELWAIN,AZILE 'F~ATIENT MRN: 00361921 2ATIENT DOB: 30-May-1984 IXAM NUMBER: 591A-041400 3X'~1M: CT THORAX UNENHANCED-PED :~RPERING PHYSICIAN: PETER W DILLON Exam: CT THORAX ONENHANCED-PED exam: CT ABDOMEN ENHANCED-PED Exam: CT PELVIS UNENH-PED CT OF THE CHEST, ABDOMEN AND PELVIS CYNICAL HISTORY: Status post MVA. MCELWAIN, AZILE R - 487301 ?ROCEDURE: Axial 8 x 8 mm CT of the chest, abdomen and pelvis was ..erformed after the dynamic administration of intravenous contrast. DISCUSSION: There are no comparison studies. 'HEST: The mediastinal vasculature and structures are all normal in appearance. There are no abnormalities of the lung parenchyma. There is a marked splenic fracture with enhancement of only the most dorsal aspect of the spleen. There is prominent amount of free fluid surrounding the liver through the region of the spleen 2nd throughout the peritoneum consistent with free blood. There is linear lucency in the liver just adjacent to the gallbladder ~ossa which does not appear to be a splenic laceration, its probably an anatomic structure. The liver otherwise enhances normally and is free of definite evidence of laceration. The pancreas is normal in appearance. The kidneys also enhance >trrongly and are also free of abnormality. The bowel is normal in appearance. The remainder of the structures of the abdomen are normal. Note is made of small amount of fluid in the endometrial , Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05/23/2000 9:17 PM (Continued) Thorax CT (peds, unenhanced) MCELWAIN, AZILE R - 487301 .anal, thus the patient is most likely currently menstruating. Caere is a cyst in the left adnexa which is probably an ovarian yst. "he bone windows of the chest, abdomen and pelvis demonstrate no ~.vidence of bony fracture. IMPRESSION: 1. There is a splenic fracture with enhancement of ;nly the dorsal most aspect of the spleen; the anterior fragments are not enhancing. ?. There' is a lot of free fluid in the abdomen which is invariably ~~lood in the peritoneum. There is no definite evidence of liver i_aceration. :he findings were discussed with the clinical team. ~,~r. Bruno reviewed the images and discussed the interpretation with Dr. Lobe11. DICTATED: ZtEVIEWED AND SIGNED: MARK E. LOBELL, M.D./MICHAEL A. BRUNO, M.D. jor Completed Action List: Printed by: Longenecker, Teresa Printed on: 05/23/2000 9:17 PM Page 2 of 2 (End of Report) ~~ . Abd CT (enhanced, peds) Result Type: Abd CT (enhanced, peds) Date of Service: Friday, April 14, 2000 8:45 PM Authorization Status: Final Subject: CT ABDOMEN ENHANCED-PED * Final Report CT ABDOMEN ENHANCED-PED PATIENT NAME: MCELWAIN,AZILE PATIENT MRN: 00361921 PATIENT DOB: 30-May-1984 EXAM NUMBER: 591B-091400 EXAM: CT ABDOMEN ENHANCED-PED ORDERING PHYSICIAN: PETER W DILLON exam: CT THORAX UNENHANCED-PED Exam: CT ABDOMEN ENHANCED-PED exam: CT PELVIS UNENH-PED CT OF THE CHEST, ABDOMEN AND PELVIS CLINICAL HISTORY: Status post MVA. MCELWAIN, AZILE R - 487301 PROCEDURE: Axial 8 x 8 mm CT of the chest, abdomen and pelvis was perfo~:med after the dynamic administration of intravenous contrast. 1I SCU5SION: There are no comparison studies. "'HEST; The mediastinal vasculature and structures are all normal in appearance. There are no abnormalities of the lung parenchyma. There is a marked splenic fracture with enhancement of only the most dorsal aspect of the spleen. There is prominent amount of free fluid surrounding the liver through the region of the spleen and throughout the peritoneum consistent with free blood. There is a linear lucency in the liver just adjacent to the gallbladder fossa which does not appear to be a splenic laceration, its probably an anatomic structure. The liver otherwise enhances normally and is free of definite evidence of laceration. The pancreas is normal in appearance. The kidneys also enhance .strongly and are also free of abnormality. The bowel is normal in appearance. The remainder of the structures of the abdomen are normal. Note is made of small amount of fluid in the endometrial , Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05/23/2000 9:17 PM (Continued) Abd CT (enhanced, peds) MCELWAIN, AZILE R - 487301 ~a na1, thus the patient is most likely currently menstruating. "here is a cyst in the left adnexa which is probably an ovarian cyst. :'he bone windows of the chest, abdomen and pelvis demonstrate no °iidence of bony fracture. £MPRESSION: 1. There is a splenic fracture with enhancement of only the dorsal most aspect of the spleen; the anterior fragments sre not enhancing. ?. There is a lot of free fluid in the abdomen which is invariably blood in the peritoneum. There is no definite evidence of liver Laceration. The findings were discussed with the clinical team. -~. Bruno reviewed the images and discussed the interpretation with C?r. Lobell. DICTATED: REVIEWED AND SIGNED: MARK E. LOBELL, M.D./MICHAEL A. BRONO, M.D. 'lor Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05/23/2000 9:17 PM (End of Report) Pelvis CT (peds, unenhanced) Result Type: Pelvis CT (peds, unenhanced) Date of Service: Friday, April 14, 2000 8:45 PM Authorization Status: Final Subject: CT PELVIS UNENH-PED * Final Report CT PELVIS UNENH-PED 2AT IENT NAME: MCELWAIN, AZILE PP.TIENT MRN: 00361921 PATIENT DOB: 30-May-1984 EXAM NUMBER: 591C-041400 EXAM: CT PELVIS UNENH-PED ORDERING PHYSICIAN: PETER W DILLON Exam: CT THORAX UNENHANCED-PED Exam: CT ABDOMEN ENHANCED-PED Exam: CT PELVIS UNENH-PED CT OF THE CHEST, ABDOMEN AND PELVIS CLINICAL HISTORY: Status post MVA. MCELWAIN, AZILE R - 487301 2ROCEDURE: Axial 8 x B mm CT of the chest, abdomen and pelvis was oerformed after the dynamic administration of intravenous contrast. DISCUSSION: There are no comparison studies. ^HEST: The mediastinal vasculature and structures are all normal in appearance. There are no abnormalities of the lung parenchyma. There is a marked splenic fracture with enhancement of only the most dorsal aspect of the spleen. There is prominent amount of free fluid surrounding the liver through the region of the spleen and throughout the peritoneum consistent with free blood. There is a linear lucency in the liver just adjacent to the gallbladder fossa which does not appear to be a splenic laceration, its probably an anatomic structure. The liver otherwise enhances normally and is free of definite evidence 'of laceration. The oancreas is normal in appearance. The kidneys also enhance strongly and are also free of abnormality. The bowel is normal in appearance. The remainder of the structures of the abdomen are normal. Note is made of small amount of fluid in the endometrial , Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05/23/2000 9:17 PM (Continued) Pelvis CT (peds, unenhanced) MCELWAIN, AZILE R - 487301 canal, thus the patient is most likely currently menstruating. "here is a cyst in the left adnexa which is probably an ovarian cyst. The bone windows of the chest, abdomen and pelvis demonstrate no widence of bony fracture. C~]PRESSION: 1. There is a splenic fracture with enhancement of -aly the dorsal most aspect of the spleen; the anterior fragments are not enhancing. _. There is a lot of free fluid in the abdomen which is invariably ;;lood in the peritoneum. There is no definite evidence of liver t«ceration. :he findings were discussed with the clinical team. Dr. Bruno reviewed the images and discussed the interpretation with Dr. Lobel!. DICTATED: 16227 ~.EVIEWED AND SIGNED: MARK E. LOBELL, M. D./MICHAEL A. BRONO, M.D. _/jor Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05/23!2000 9:17 PM (End of Report) CXR (1-view) Result Type: CXR (1-view) Date of Service: Friday, April 14, 2000 7:30 PM Authorization Status: Final Subject: DX CHEST 1 VIEW - AP ,SUPINE, INSP, * Final Report OX CHEST 7 VIEW - AP ,SUPINE, INSP, ?ATIENT NAME: MCELWAIN, AZILE PATIENT MRN: 00361921 ?ATIENT DOB: 30-May-1984 ^aXAM NUMBER: 588A-041400 EXAM: DX CHEST 1 VIEW - AP SUPINE, INSP, ORDERING PHYSICIAN: KYM A SALNESS Exam: DX CHEST 1 VIEW - AP SUPINE, INSP, Exam: DX PELVIS 1-2 VIEWS - AP SUPINE, CHEST AND PELVIS CLINICAL HISTORY: Multiple trauma. DISCUSSION: MCELWAIN, AZILE R - 487301 CERVICAL SPINE: Multiple open-mouth views were obtained. On the last view the lateral masses are aligned. The dens is intact. The cervical spine is visualized from C1 to T1. There is anatomic alignment. The vertebral body heights are maintained. Prevertebral soft tissues are within normal limits. PELVIS: There are no fractures. There is anatomic alignment. HEST: Calcified right super hilar lymph node is noted. The ~~ardiomediastinal silhouette is within normal limits. The lungs are clear. There is no pneumothorax. There are no fractures. IMPRESSION: Cervical spine, pelvis, chest was within normal limits. Dr. Bruno reviewed the images and discussed the interpretation with :Jr. Haught. Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05/23/2000 9:17 PM (Continued) CXR (1-view) MCELWAIN, AZILE R - 487301 JICTA'PED: 3~VIEWED AND SIGNED: KRISTEN HAUGHT, M. D./MICHAEL A. BRUNO, M. D. /pas Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05/23/2000 9:17 PM (End of Report) G-spine XR (2-3 views) Result Type: C-spine XR (2-3 views) pate of Service: Friday, April 14, 2000 7:30 PM Authorization Status: Final Subject: DX C-SPINE 2-3 VIEWS -LAT, XTAB, AP , * Final Report OX C-SPINE 2-3 VIEWS -LAT, XTAB, AP , PATIENT NAME: MCELWAIN, AZILE PATIENT MRN: 00361921 PATIENT DOB: 30-May-1984 EXAM NUMBER: 588B-041400 EXAM: DX C-SPINE 2-3 VIEWS - LAT, XTAB, AP , ORDERING PHYSICIAN: I(YM A SALNESS Exam: DX C-SPINE 2-3 VIEWS - LAT, XTAB, AP , C-SPINE `L INICAL HISTORY: Motor vehicle accident. DISCUSSION: There are no comparison studies. MCELWAIN, AZILE R - 487301 Four views of the cervical spine are presented for evaluation. There is normal vertebral body height, disc spacing, and alignment of the cervical spine. There is no evidence of a fracture, iislocation, or precervical soft tissue swelling. The cervical spine is evaluated to the level of the T1-T2 level. Visualized portions of the lung on the anterior view demonstrate a calcified lymph node in the upper mediastinum on the right. IMPRESSION: The cervical spine is within normal limits for the patient's age. Cyr. Mosher reviewed the images and discussed the interpretation ~,~ith Dr. Brian. ~7ICTATED: 16874 P.EVIEWED AND SIGNED: PAMELA BRIAN, M.D.ITIMOTHY J. MOBHER, M.D. 1/pas Printed by: Longenecker, Teresa Page 1 oft Printed on: 05/23/2000 9:17 PM (Continued) C-spine XR (2-3 views) Completed Action List: Printed by: Longenecker, Teresa Printed on: 05/23/2000 9:17 PM MCELWAIN, AZILE R - 487301 Page 2 of 2 (End of Report) R~1 PennState Geisinger ® Health System AMBULATORY HEALTH VISIT The Milton S. Hershey NAME: MCELWAIN~ AZILE R Medical Center MD: OILLON PETER W MR#: 487301 008: O6/30I1964 INS: AUTO INSURANCE LOC: PESU OOS#: 748191 MD#: 26160 SEX: F VISIT DATE: 06/10/2000 ^ Health Maintenance I ^ Consultation I ^ Acute Care 1~ Follow-up Referred by/Address: I Medications/Dosage Nursing S. ~~L.; mv~l~~,~-.a~~ y-iti-cam . 2. 3. 4. 5. ~r~ -~ ~~ > ¢~~ Subjective ' 2. li~y1)!' Ou-f~Wil-y ~J SC,L' t7D~. ~-{~r~`i7/'-CCtifyG.GU~-~' r<9u7 ~GfiLP~ti'~~~ 3. ~ 1111 t~0, CQ- L,f:i l ~ ~ ~ a.ar/' ~ C.i/Ytl f ~ /~-/-Luau 4. 9'c(.11J~ (Jc1.v1~ 5. ¢j-f9r''~nd?l'rf-Wd ~, S Vital Signs: BP Pulse N ~-~ Resp: Temp. °C O ^ R ^ Ax ^ Measurements: Weight C,/, Kg % Length ~ (aq cm % Head Circ. cm. % wo~N ~r-,~~-~ i9,~r,Q . t~,o~r.~-ct ctc Assessment/Diagnosis/Plan 2. 3. 4. 5. Next visit: ~ See dictation / Letter to M.D. SIGNATURE ATTENDING 1 ~ J os,xC .:1riuF MR 767 0185 AMBULATORY HEALTH VISIT ' ~' ~ PennState Geisinger The Milton S. Hershey' ® Medical Center NAME: MGELWAIN, AZILE R Health S stem MD: BLEWETT CHRISTOP MDd: 26080 y MRq; 487301 _ 008: OS/30/198d SEX: F INS; AUTO INSURANCE AMBULATORY HEALTH VISIT oosu:Piiez,s VISIT DATE: 05/24/2000 ^ Health Maintenance Consultation I ^ Acute Care I ^ Foliow-up Referred bylAddress: Medications/Dosage Nursing 1. (Lrl ~? 11..1.1'._ ~° {V1V ~ ~~-l ~~'C~ . ~- 2. t1~E-25 I,U. Q 1~SO~.mR~Ji' ~-Cn9.,~ ~-czl.~-~,~ 3. 4. ~-4- to 5 (~ X11 s. Subjective t. 2. 3. 4. 5. Vital Signs: BP Pulse Resp. Temp. °C O ^ R ^ Ax ^ Measurements: Weight ~~ Kg % Length cm % Heed Circ. cm. % Lab Assessment/Diagnosis/Plan 1. 2. 3. 4. 5. Next visit: ^ See dictation / ^ Letter to M.D. SIGNATURE ATTENDING DATE TIME MR 167 0/85 AMBULATORY HEALTH VISIT ~.1 PennState Geisinger ® Health System Section of Pediatric Surgery Department o[Surgery Telephone 717 571-6342 Fax 717 531-4185 V. Dillon, M.D. Sewon Head Robert E. Coley, M.D. Chrhtepher J. elewelt, M.D. Coleen P. Greecheq M.S, R.D. , C.N.S.D. NeomnUPediabic Nutritionist Jaoet H. Shieldr, M.S.N., C.R.N.P., C.S. Clinical Nurse Specialist Smart RaucWlo, M.S.N., R.N. Pediatric Tnsmta Nurse Coordinator AdMohmatlve Stab: , A. Krick Caordinaor Lee A. Naylor Staff Assistant Specializing in the Surgical Care of [nfrnts, Children, and Adolescents [ncluding: Biliary Artesia Neonanl Surgery ECMO Pediatric Trauma and Injury Prevrntron Minimally Invasive Surgery Pediatric 5tvgical Oncology Pediatric Thoracic Surgery Anorecnl Malfonmtrons Inflammatory Bowel Disease Pediatric Weight Management Vascular k Lymphatic Malfotmaaons Hiruhsprnng's Disease Jay Townsend, M.D. 100 S. High Street Newville, PA 17241 RE: MCELWAIN, AZLAZLE Dear Doctor Townsend: Children's Hospital The Milton S. Hershey Medical Center P.O. Box 850, M.C. H113 Hershey, Pennsylvania 17033-0850 May 10, 2000 MSHMC #487301 [ saw Azlazle in the office today for follow-up evaluation. She is now almost a month out from her motor vehicle accident in which she suffered significant splenic laceration. Since her discharge, she has done well. There have been no new medical issues or problems. She has been maintaining a low activity program, but has been going to SCI7001. On physical exam, her weight was 64 kg. Abdomen is soft and nondistended. She had no palpable areas of tenderness or masses. The remainder of her exam was unremarkable. Overall, I am delighted with her progress. We would like to see her back in approximately four weeks at which time we will repeat her CT Scan. [f the spleen is completely healed at that time, which most are, we will release her to all activities. I have released her for swimming activities for some exercise with the limitation that she cannot undertake any type of diving. She is still to be restricted from gym and sports activities. Thank you so much for allowing us to participate in her care. If I can be of any further information or service, please do not hesitate to call. Best wishes. SIHCJJer Pethr . DillonC PWD:asap PennState Geisinger Health System Secdon of Pediatric Surgery Department of Surgery Telephone 717531.8342 Pax 717 531-4185 Pel• "r. Dillon, M.D. Se ead Robert E. Cilley, M.D. Christopher d. 6lewet4 M.D. Coleen P. Greeeher, M.S, R.D. , C.N.B.D. NeonataVPediatric Nutritionist Janet H. Bhlelds, M.B.N., C.R.N.P., C.S. Clinical Nurse Specialist Susan Rxucidb, MS.N., R.N. Pediatric Trauma Nurse Coordinator Administrative Staff: Marcia A. Krick get 'oordinator Dr. Jay Townsend Graham Medical Center 100 South High Street Newville, PA 17241 RE: MCELWAIN, Azalie Dear Dr. Townsend: Children's Hospital The Milton S. Hershey Medical Center P.O. Box 850, M.C. H113 Hershey, Pennsylvania 17033-0850 May 24, 2000 MSHMC #487301 I saw Azalie in the Pediatric Surgery Clinic on 5/24. This youngster is now about six weeks ouYfrom her MVA with a splenic laceration. My partner Bob Cilley saw her two weeks ago. She was doing quite well, however, this morning she woke up with some new left upper quadrant pain. On exam there is no distension and there is a minimal amount of tenderness in the left upper quadrant. Although we are scheduled to repeat a CT scan in two weeks I just went ahead and got a CT scan on Azalie today. It shows excellent healing of the spleen without cyst formation. There is no free fluid seen in the pelvis. [ am pleased that Azalie is resolving her symptoms. I plan to restrict her activity for two more weeks and then she is free to return to full activities. We will be happy to see her back on a PRN basis. I have instructed her to contact us with any further episodes of pain. It is a pleasure to participate in Azalie's care. Please contact me with any questions or concerns. Lee A• Naylor StaffASSislant Specializing in the Surgical Care of InfanLS, Children, and Adolescents Including: ciliary Atresia Neonatal Surgery ECMO Pediatric Tramma and Injury Prevendon Minimally Invasive Surgery PediaMc Surgical Oncology Pedialdc Thoracic Surgery Anaredal Malfomwdons 1n0ammaWry Bowel Disease Pediatric Weight Management Vascular &. Lymphatic Malfomutions Hirschspmng's Disease CJB:asap Sincer//elIly, ~ ,,~ Christopher J. Blewett, M.D. ! UN l~5 Gl~b1 1 J. ~ 3.5 Fk h-bb Today's Date: Name: Date of Birth: May 8, 2001 Azile McElwain May 30, 1984 Plan #1 Annual Benefits: $6,085 per year, guaranteed payable for 3 years. First payment is 05-30-2002 (age 18). Last payment is 05-30-2004 (age 20). This is 3 guaranteed annual payments, and then payments stop. TOTAL STRUCTURE AMOUNT: ~115b4..5bb77. IU y7.'17.~/~/31"17b5 !'.1~L/b4 Female *HT Age: 16 Guaranteed Amount: Cost:, $18,255 $17,000 $18,255 $17,000 This proposal is effective through MAY 10, 2001. This is the date that the funds for the structure must be at the annuity company or this proposal will expire. This is an illustration, not a contract. -,:,~w~ RELEASE AND SETTLEMENT AGREEMENT This Release and Settlement Agreement ("Agreement") is made and entered into among Azile McElwain, a minor, by her parents and natural guardians, Allen McElwain and Joann McElwain and AI1en McElwain and Joann McElwain, individually; Arnold K. Rook and Lucinda Rook, individually and as husband and wife, Aron Rock; and Nationwide Mutual Insurance Company ("the Parties"). The "Claimant" shall colletively mean Azile McElwain, a minor, by her parents and natural guardians, Allen McElwain and Joann McElwain and Allen McElwain and Joann McElwain, individually, their respective heirs, executors, administrators, personal representatives, successors and assigns; the "Insured" shall collectively mean Arnold K. Rook and Lucinda Rook, individually and as husband and wife, and Aron Rook; and the "Insurance Company" shall mean Nationwide Mutual Insurance Company. I. RECITALS A. On or about April 14, 2000, at or near Route 11, Carlisle, Cumberland County, Pennsylvania, Azile McElwain claims to have sustained physical injuries as a result of the alleged conduct of the Insured (the "Incident"). In connection with the Incident, the Claimant has asserted a claim against the Insured based upon tort or tort type claims. B. The Insurance Company and the Insured have entered into a liability insurance contract which provided that the Insurance Company shall defend the Insured against any claim or suit for damages arising from the Incident, has authority to settle any such claim or suit on behalf of and as agent for the Insured, and shall insure the Insured for such liability subject to the limits set 4 forth in the contract. -..,r~ __ C. The Parties desire to enter into this Agreement to provide, among other things, for considerations in full settlement and discharge of all claims and actions of the Claimant for damages which allegedly arose out of or due to the Incident, on the terms and conditions set forth in this Agreement. NOW, THEREFORE, it is agreed as follows: II. RELEASE A. Release and Discharge. In consideration of the cash payment(s) referred to in Paragraph IILA. and the promise to make the periodic payments referred to in Paragraph IILB. ("Periodic Payments"), the Claimant hereby completely releases and forever discharges the Insured, the Insurance Company, and any and all other persons, firms, or corporations from any and all past, present, or future claims, demands, actions, damages, costs, expenses, loss of services, and causes of action of any kind or character, whether based on tort, contract, or other theory of recovery, whether known or unlrnown, which have arisen in the past or which may arise in the future, whether directly or indirectly, caused by, connected with or resulting from the Incident. This release and discharge shall be a fully binding and complete settlement among all Parties to this Agreement, and their heirs, assigns, and successors. The Claimant acknowledges and agrees that this release and dischazge is a general release. The Claimant expressly waives and assumes the risk of any and all claims for damages and expenses which exist as of this date, but of which the Claimant does not know or suspect to exist, whether through i~orance, oversight, enor, negligence, or otherwise, and which, if known, would materially affect the Claimant's decision to enter into this Agreement. The Claimant further agrees that the Claimant has accepted the considerations set forth in Paragraphs III. A. and B. as a complete compromise of matters involving disputed issues of law and fact. The Claimant assumes the risk that the facts or law may be other than the Claimant believes. It is understood and agreed to by the Parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Insured, by whom liability is expressly denied. B. Injuries Known and Unknown. The Claimant fully understands that the Claimant may have suffered personal injuries that are unknown to the Claimant at present and that unknown complicafions of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Claimant acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insured and the Insurance Company from any claims for, or consequences arising from, the injuries which allegedly azose from the Incident; and the Claimant hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. C. Parties Released. This release and dischazge shall also apply to the Insured's and the Insurance Company's past, present, and future officers, directors, stockholders, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, reinsurers, partners, predecessors and successors in interest, heirs, executors, personal representatives, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. III. PAYMENTS TO CLAIMANT, PAYEE AND/OR BENEFICIARY A. Payment at Settlement (and Amounts Previously Paid)_ The Insurance Company and the Insured have agreed to pay Eight Thousand Dollars ($8,000) up front to the Claimant and haue already paid Two Thousand Nine Hundred Thirty Nine Dollars and 02/100 ($2,939.02) to the Claimant for lost wages and out of pocket expenses, receipt of which is acknowledged. In addition, the Insurance Company agrees to pay the Health America lien for approximately Two Thousand Dollars ($2,000), receipt of which is acknowledged. These payments include, but are not limited to, all out of pocket expenses, attorney fees, all medical liens, except Health America, all rights of recovery, all medical subrogation claims, all worker compensation subrogation claims, known and unlrnown, and claims for general damages. B. Periodic Payments. The Insurance Company, on behalf of the Insured, agrees to pay or cause to be paid the following Periodic Payments: (1) To Azile McElwain ("Payee"), the sum of Six Thousand Eighty Five Dollars ($6,085) to be paid annually on or about the thirtieth (30th) day of May each year beginning on or about May 30, 2002, guaranteed to be paid for a period of three (3) years, with the last payment to be made on or about May 30, 2004. (2) Should Azile McElwain die before May 30, 2004, then any remaining guaranteed Periodic Payments set forth in Subpazagraph III.B.(1) shall instead be paid,' subject to the provisions of Subpazagraph III.B.(3) below, as they become due, to the estate of Azile McElain ("Beneficiary"), with the last guaranteed Periodic Payment to be made on or about May 30, 2004. (3) The Payee shall have the right, after reaching the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the Annuity Contract. The change will be effective when approved by both the owner of the Annuity Contract and the Annuity Issuer. Any change in the Beneficiary shall not in any way affect or alter any of a the provisions of this Agreement. IV. ASSIGNMENT AND FUNDING OF PERIODIC PAYMENT OBLIGATION A. Ass_gnment of Obligation. The Parties understand and agree that the Insurance Company may assign its duties and obligations to make such future Periodic Payments to ("Assignee") pursuant to a "Qualified Assignment and Release," within the meaning of Section 130(c) of the Internal Revenue Code of 1986, as amended, attached as Exhibit A. Such assignment is accepted by the Claimant without right of rejection and in full discharge and release of the duties and obligations of the Insurance Company and all Parties released by this Agreement with respect to such Periodic Payments. Upon such assignment, it is understood and agreed by and between the Parties that the Assignee shall make said Periodic Payments directly to the respective Payee and/or Beneficiary designated in Subparagraphs III.B.(1) and (2), and that the Payee shall submit any request to change the Beneficiary directly to the Assignee. THE PARTIES EXPRESSLY UNDERSTAND AND AGREE THAT, WITH THE INSURANCE COMPANY'S ASSIGNMENT OF THE DUTIES AND OBLIGATIONS TO MAKE SUCH PERIODIC PAYMENTS TO HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO PURSUANT TO THIS AGREEMENT, ALL OF THE DUTIES AND RESPONSIBILITIES OTHERWISE IMPOSED UPON THE INSURANCE COMPANY BY THIS AGREEMENT WITH RESPECT TO SUCH PERIODIC PAYMENTS SHALL CEASE, AND INSTEAD SUCH OBLIGATION SHALL BE BINDING SOLELY UPON HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO. THE PARTIES FURTHER UNDERSTAND AND AGREE THAT WHEN THE ASSIGNMENT IS MADE, THE INSURANCE COMPANY SHALL BE RELEASED FROM ALL OBLIGATIONS TO MAKE SUCH PERIODIC PAYMENTS AND HARTFORD COMPREHENSNE EMPLOYEE BENEFIT SERVICE CO 5 SHALL AT ALL TIMES BE DIRECTLY AND SOLELY RESPONSIBLE FOR, AND SHALL RECENE CREDIT FOR, THE PERIODIC PAYMENTS, AND THAT WHEN THE ASSIGNMENT IS MADE, HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO ASSUMES THE DUTIES AND RESPONSIBILITIES OF THE INSURANCE COMPANY WITH RESPECT TO SUCH PERIODIC PAYMENTS. B. Annuity Funding The Parties understand and agree that the Assignee may fund its obligation to make the Periodic Payments by purchasing an annuity contract (the "Annuity Contract") from (the "Annuity Issuer"). If such Annuity Contract is purchased, the Assignee shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, the Assignee may direct the Annuity Issuer to make all the Periodic Payments directly to the respective Payees and/or Beneficiaries designated in Paragraph III.B. Each Payee and Beneficiary designated in Paragraph IILB. shall be responsible for maintaining his/her current mailing address with the Annuity Issuer. The obligation assumed by the Assignee to make each Periodic Payment shall be fully discharged upon the mailing of a valid check or electronic funds transfer in the amount of such payment on or before the due date to the last address on record for the Payee or Beneficiary with the Annuity Issuer. If the Payee or Beneficiary notifies the Assignee that any check or electronic funds transfer was not received, the Assignee shall direct the Annuity Issuer to initiate a stop payment action and, upon confirmation that such check was not previously negotiated or electronic funds transfer deposited, shall have the Annuity Issuer process a replacement payment. C. Status of Claimant, Payees, and Beneficiaries The Claimant, each Payee and each Beneficiary, as applicable, shall at all times remain a general creditor of the Assignee and shall have no rights~in the Annuity Contract nor in any other assets of the Assignee. The Assignee shall not be required to set aside sufficient assets or secure its obligation to the Claimant, each Payee, or each Beneficiary, in any manner whatsoever. V. NO HANGES IN PERIODIC PAYMENTS The Claimant acknowledged and agrees that all, some, or any part of the Periodic Payments cannot be accelerated, commuted, transferred, deferred, increased or decreased by the Claimant or by any Payee or Beneficiary and that the Claimant or any Payee or Beneficiary shall not have the power to sell, mortgage, encumber, or otherwise anticipate all, some, or any part of the Periodic Payments by assignment or otherwise. VI. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Claimant, the Insured, and the Insurance Company with regard to the matters set forth in it. There are no other understandings or agreements, verbal or otherwise, in relation to the Agreement, between the Parties except as expressly set forth in it. This Agreement is intended to conform with the requirements of Internal Revenue Code Sections 104(a)(2) and 130. All provisions of this Agreement should be construed in a manner so as to effectuate that intent. VII. READING OF AGREEMENT In entering into this Agreement, the Claimant represents that the Claimant has completely read all of its terms and that such terms are fully understood and voluntarily accepted by the Claimant. VIII. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents, and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. IX. DRAFTING OF DOCUMENT AND RELIANCE BY CL IMANT s+ This Agreement has been negotiated by the respective Parties. The Parties to this Agreement contemplate and intend that all payments set forth in Secion III constitute damages received on account of personal injuries or sickness, arising from the Incident, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. However, the Claimant warrants, represents, and agrees that the Claimant is not relying on the advice of the Insured, the Insurance Company, anyone associated with them, including their attorneys and the insurance broker placing the Annuity Contract, as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Claimant hereby releases and holds harmless the Insured, the Insurance Company, and any and all counsel or consultants for the Insured and the Insurance Company from any claim, cause of action, or other rights of any kind which the Claimant may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Claimant. The parties signing this Agreement, and each of them, warrant and represent that no promise, inducement or agreement not expressed in this Agreement has been made to them and that this Agreeement constitutes the entire agreement between the Parties and that the terms of this Agreeement are contractual and not mere recitals. The Claimant represents and agrees that the Claimant has read the Agreement and fully understands it, and is aware of the propriety and legal effect of executing it, and neither the Agreement nor the compromise and settlement recited in it were induced by fraud, coercion, compulsion or mistake, nor is this Agrement nor the compromise and settlement made in reliance upon any statement or representation of any of the Parties released by this Agreement, or their representatives, agents or attorneys. X. WARRANTY OF CAPACITY TO EXECUTE AGREEMENT r The Claimant represents and warrants that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Agreement, and that the Claimant has the sole right and exclusive authority to execute this Agreement and receive the sums specified in it and that the Claimant has not sold, assigned, transfened, conveyed or otherwide disposed of any of the claims, demands, obligations or causes of action referred to in this Agreement. XI. COURT APPROVAL The Parties agree that the Claimant will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. XII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. Dated: ~~ ~a -c7 -~_~z_6 Dated: ' ~ ~ r~ Allen McElwain, ' 'vid and natural of Joa Mc~lwain, indisidua~ly and as parent natural guardian of Azile McElwain, a nor, Claimant a Duly Authorized Representative for Nationwide Mutual Insurance Company and as parent ~~ w' f Un Exhibit A "Claimant" "Assignor" "Assignee" "Annuity Issuer" "Effective Date" Qualified Assignment and Release Azile McElwain, a minor, by her parents and natural guardians, Allen McElwain and 3oann McElwain Nationwide Mutual Insurance Company This Agreement is made and entered into by and between the parties hereto as of the Effective Date with reference to the following facts: A. Claimant has executed a settlement agreement or release dated ~; Flu a~ ~/ 2001 (the "Settlement Agreement") that provides for the Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No. 1 (the "Periodic Payments"); and 3. The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant has no rights against the Assignee greater than a general creditor. None of the Periodic Payments may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or encumbered. 4. The obligation assumed by Assignee with B. The parties desire to effect a "qualified respect to any required payment shall be assignment" within the meaning and discharged upon the mailing on or before subject to the conditions of Section the due date of a valid check in the 130(c) of the Internal Revenue Code of amount specified to the address of 1986 (the "Code"). record. NOW, THEREFORE, in consideration of the 5. This Agreement shall be governed by and foregoing and other good and valuable interpreted in accordance with the laws consideration, the parties agree as follows: of the Commonwealth of Pennsylvania. The Assignor hereby assigns and the 6. Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. 2. The Periodic Payments constitute damages on account of personal injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104(a)(2) and 130(c) of the Code. The Assignee may fund the Periodic Payments by purchasing a "qualified funding asset" within the meaning of Section 130(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder ,i ~~ x directly to the payee(s) specified in 70. This Agreement shall be binding upon th Addendum No. 1. Such direction of respective representatives, heirs, payments shall be solely for the successors and assigns of the Assignee's convenience and shall not Claimant, the Assignor and the Assignee provide the Claimant or any payee with any and upon any person or entity that may assert rights of ownership or control over the "qualified any right hereunder or to any of the funding asset" or against the Annuity Issuer. 11. The Claimant hereby accepts Assignee's assumptio of all liability for the Periodic Payments and 8. Assignee's liability to make the Periodic hereby releases the Assignor from all liability Payments shall continue without diminution for the Periodic Payments. regardless of any bankruptcy or insolvency of -- the Assignor. - 9. In the event the Settlement Agreement is declared terminated by a court of law or in the event that Section 130(c) of the Code has not been satisfied, this Agreement shall terminate. The Assignee shall then assign ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Periodic Payments shall terminate. j~1 Periodic Payments. Assignor:Nationwide Mutual Insurance Com an Authorized Representative i Claim r Allen cE 8m, as pa nt a natural guardian of Azile McElwain, a mino Claimant: Joanne Mc ain, as parent and natural guardian of Azile McEI in, a minor Approved as to Form and Content: Claimants Attorney Assignee: Hartford Comprehensive Employee Benefit Service Co - Authorized Representative e 3 f~ Addendum No. 1 Description of Periodic Payments The following Periodic Payments: (1) To Azile McElwain ("Payee"), the sum of Six Thousand Eighty Five Dollars ($6,085) to be paid annually on or about the thirtieth (30th) day of May each year beginning on or•about May 30, 2002, guaranteed to be paid for a period of three (3) years, with the last payment to be made on or about May 30, 2004. (2) Should Azile McElwain die before May 30, 2004, then any remaining guaranteed Periodic Payments set forth in paragraph (1) shall instead be paid, subject to the provisions of paragraph (3) below, as they become due, to the estate of Azile McElwain ("Beneficiary"), with the last guaranteed Periodic Payment to be made on or about May 30, 2004. (3) The Payee shall have the right, after reaching the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the Annuity Contract. The change will be effective when approved by both the owner of the Annuity Contract and the Annuity Issuer. Any change in the Beneficiary shall not in any way affect or alter any of the provisions of this Agreement. Initials Claimant: Assi nor' Assignee: Claimant• ~ ~" `\. a C7 ~-~ /~ J ~ 'fl Q {~ _ T TJ Ci; ~ -._ ~_ ~ ~ ~ a ~ o ~ ~ r- ~~ r :~ ~ ~~ ~ ~ ~' ~ ~ ~ =- :: : a , ~ ti