HomeMy WebLinkAbout01-06497
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HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
SUZANNE VALLERY, a minor,
II Starboard Drive
Taney town, MD 21787
Plaintiffs
: IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
: NO.:61-L497 Civil Term
v,
CIVIL ACTION LAW
ROBERT PUCKETT and
NEIL MANUFACTURING CO., INC.,
Carrolton Villa Highway
Villa Rica, Georgia 30180.
Defendants
PRAECIPE FOR WRIT OF SUMMONS
TO THE PROTHONOTARY:
Please issue a Writ of Sununons to Defendants, Robert Puckett and Neil Manufacturing
Co., Inc. in the above-captioned matter.
BY:
FER, LLP
Dated:
WRIT OF SUMMONS
To: Robert Puckett and Neil Manufacturing Co., Inc, Defendants
You are notified that the above-named Plaintiffs have commenced an :!Jon against you.
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JAN 0 3 2002 fill
HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
SUZANNE VALLERY, a minor,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
: NO.: 01-6497 Civil Term
v.
CIVIL ACTION LAW
ROBERT PUCKETT and
NEAL MANUFACTURING CO., INC.,
Defendants
ORDER
AND NOW, this /).. day of ~.r..., ,200~ after consideration of the Petition to
Approve Minor's Compromise Settlement, it is hereby ordered and decreed that:
a. The Petition is granted;
b, Settlement between Plaintiffs and Defendant, by and through their insurance company, in
the amount of $6,000.00 is approved;
c. Attorney's fees will be paid to Michael Kaplan, Esq. in accordance with Exhibit D to
Plaintiffs' Petition;
d. The settlement funds (minus attorney's fees) shall be deposited in one or more savings
accounts in the name of the Minor in a bank, building and loan association, savings and loan association or
credit union, deposits in which are insured by a federal governmental agency;
e. No withdrawals will be made from the aforesaid account(s) until the Minor obtains
majority, except as authorized by a prior Order of the Court;
f. Proof of the deposit of settlement funds shall be promptly filed of record;
g. Plaintiffs are authorized and directed to execute a Full and Final Release; and
hoo Plaintiffs are authorized and directed to file a discontinuance of record upon the filing of
Proof of Deposit.
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BY THE COURT:
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Date:
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HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
SUZANNE VALLERY, a minor,
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiffs
: NO.: 01-6497 Civil Term
v.
CIVIL ACTION LAW
ROBERT PUCKETT and
NEAL MANUFACTURING CO., INC.,
Defendants
PETITION TO APPROVE MINOR'S COMPROMISE SETTLEMENT
AND NOW, comes Plaintiffs Harry Vallery and Roseanne Vallery, as parents and natural
guardians of Suzanne Vallery ("Plaintiffs"), and their counsel, Thomas, Thomas & Hafer, LLP,
and file this Petition to Approve Minor's Compromise Settlement and aver the following in
support thereof:
1. Plaintiffs are the parents and natural guardians of minor Suzanne Vallery
("Minor").
2. Plaintiffs and the Minor reside at II Starboard Drive, Taney town, MD 21787.
3. Minor was born on July 20, 1985, and was fourteen (14) years old on the date of
the accident described hereinafter.
4, Defendant Neal Manufacturing Company, Inc., is a corporation with a principal
place of business at Carrolton Villa Highway, Villa Rica, Georgia 30180.
5, Defendant Robert Puckett was an employee of Defendant Neal Manufacturing
Company, Inc. at all times relevant hereto.
6 This Petition is filed as a result of an accident which occurred on or about July 22,
1999, on Market Street in Camp Hill, Cumberland County, Pennsylvania.
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7 At the time of the accident, Defendant Puckett was driving a 1999 Oldsmobile
and headed west bound on Market Street.
8. At the time of the accident, the Minor was a passenger in a vehicle traveling west
bound on Market Street in Camp Hill in front of the Defendant's vehicle.
9. Defendant's vehicle struck the rear of the vehicle in which the Minor was a
passenger.
10. As a result of the accident, the Minor sustained injuries, including, but not limited
to, neck and back injury.
II. Minor has treated with a number of healthcare providers as a result of her injuries.
A copy of Minor's family physician records, Carroll Co. General Hospital records and
orthopedic consultation records are attached hereto, incorporated herein by reference and marked
as Exhibits "A", "BOO, and "COO respectively.
12. At the time of the accident, Defendants were insured by a business automobile
policy issued by Commercial Union Insurance Company, now known as Peerless Insurance.
Said policy was Commercial Union policy number MZAM670383807.
13. Plaintiffs have been and continue to be represented by Michael Kaplan, Esq. of
Kaplan & K,lplan, Attorneys at Law, 200 E. Lexington St., Suite 400 Court Square Building,
Baltimore, Maryland 21201.
14. A copy of Plaintiffs' fee agreement with Attorney Kaplan is attached hereto,
incorporated herein by reference and marked as Exhibit "D".
15. While represented by the aforesaid counsel, Plaintiffs engaged m settlement
discussions with Defendants' insurance carrier.
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16. On behalf of Defendants, Peerless Insurance has offered to compromise this claim
for the sum of six thousand dollars ($6,000.00).
17. Plaintiffs believe that this offer is fair and in the best interest of Minor.
18. Therefore, Plaintiffs request that this Honorable Court approve the proposed
settlement.
19. Plaintiffs understand that any settlement monies left over after attorney's fees are
taken out will be placed in a restricted federally insured account for the benefit of the Minor and
that no withdrawals will be permitted from the account until Minor reaches the age of majority,
unless authorized by Court Order.
20. Plaintiffs understand that proof of deposit of the settlement proceeds will be filed
promptly of record.
21. Additionally, Defendants request that Plaintiffs be authorized and directed to
execute a full and final general release in the form that is attached hereto, incorporated herein by
reference and marked as Exhibit "E"
22. Defendants also request Plaintiffs be authorized and directed to file a
discontinuance of record with the Prothonotary of the Court of Common Pleas of Cumberland
County upon the filing of proof of deposit of the settlement funds,
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WHEREFORE, Plaintiffs Harry Vallery and Roseanne Vallery, as parents and natural guardians
of Suzanne Vallery, pray this Honorable Court enter an order compromising this action;
approving the proposed settleml:nt; authorizing and directing Plaintiffs to execute a full and final
release; and authorizing and directing Plaintiffs to me adiscon~i~ce of record.
BY' ~~
. Harry V llery
~~'
Roseanne Vallery ~
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VERIFICATION
I, Harry Vallery, Parent and Natural Guardian of Suzanne Vallery, hereby state that
the statements made in the foregoing Petition to Approve Compromise Settlement are true and
correct to the best of my knowledge, information and belief. The undersigned understands that the
statements therein are made subject to the penalties of 18 Pa.C.S. ~4904 relating to unsworn
falsification to authorities.
Date: 11-11-01
~~
Harry all~ent and
natural guardian of Suzanne Vallery
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VERIFICATION
I, Roseanne Vallery, Parent and Natural Guardian of Roseanne Vallery, hereby
state that the statements made in the foregoing Petition to Approve Compromise Settlement are
true and correct to the best of my knowledge, information and belief. The undersigned understands
that the statements therein are made subject to the penalties of 18 Pa.C.S. ~4904 relating to
unsworn falsification to authorities.
Date: 1),,-1/ -oj
Roseanne Vallery, as parent and
natural guardian of Suzanne Vallery
., --
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.
III:- 2 2'1999
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SUZANNE VALLERY 7.22.99 .
14 YO gl/1 who was ili. a MVA yesterQaY. She was in the
back seat of a car, unseatbelted. The car was rear.'
ended. She complains of neck and upper back soreness,
Some discomfort in her lower. back. Slight headache, no
dlzziness. No abdominal pain. Examination shows
PERRLA. EOm' s full. TM's NMT: clear. NECK; no
adenopathy, LUNGS; clear. Tendertrap(!zius muscles
bilaterally. NECK; no 'adenopathy, Full range of motion.
No torticolus, Has some mild tenderness around the
scalpula areas anti in the lumbar areas ,.Able to bend
over.
DX: I beleive this is just muscle spasm from MV A,
Tylenol and Motrin. Ice today, heat tomorrow. Retn pm.
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PLAINTIFF'S
EXHIBIT
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Recordex Services, Inc. has been retaine.d by the Medical Record Department of
CARROLL COUNTY GENERAL HOSPITAL
to fulfill requests for copies of medical records. We wish to emphasize that the
increasing demands for patient data pose a rising threat to the confidentiality of the
patient's medical information. Recordex Services strives to take every opportunity
to safeguard patients' right to privacy as outlined in the AHA's Patient Bill of Rights.
Specifically, all patients have the right "to expect that all communications and
records pertaining to their care will be treated as confidential by the hospital and any
other party entitled to review certain information in such records." As one such party,
we ask that all information transmitted herewith be treated with utmost respect and
the dignity such persona! medical information warrants.
. Enclosed are the reproduced medical documents specifically authorized by the
patient or his/her legal representative. Each medical record was carefully reviewed
to assure proper disclosure to you, the requestor. Any re-disclosure without the
express written consent of the person to whom the information pertains is prohibited.
Please be advised that the use of the information for other than the stated purpose
is prohibited. Based upon guidelines provided by the American Health Information
Management Association, the information should also be destroyed after the stated
need has been fulfilled.
If you have any questions, please do not hesitate to contact us at 1-800-525-2922
and one of our Customer Service Representatives will be happy to assist you.
Thank you for your cooperation in maintaining the patient's right to privacy.
I
PLAINTIFF'S
EXHIBIT '
B
17 Lee Boulevard' Suite D . Malvem, PA 19
C.
-525-2922' Fax (610) 640-3844' viww.fyii.com
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SuperiDr commitment. Fxt:eptiorlal care. 9924303408:U~rtil J~;9!1~ 78
200 Memorial Avenue, Westminster, Maryland 21157 V ALLERY ,SUZANNE: I.INDA
EMERGENCY, DEPARTMENT PATIENT CARE ~7~~I1~{.~YIIS'ilf~iD'miml'I'lllIngm
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EYES: . .j. VISJelN ';f'NN 0 D~IA ~ v
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EN'!! 0 .j. H7 0 SO)3l!1HROAT 0 DYSP~IA
RESPIRATORY: 0 ~ ';'poE' 0 ~ING . COtp't . SPUl}Jl'I:
CARDIAC: . EXER1l0~ CHEST PAIN '. PAl;PIT~NS 0 ED~
GI: ' ~.;;~ D1AR~ 0 cONS1)P1\TIONr
NEURO: . H~HE . ~
SKIN: oL.
PSYCH: . DEP~ESSION o~
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ALCOHOL: ,......-~R OCCASSIONAL 0 ABUSES
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.' b1R BP RR' 1" reviewed '
. D~: l2(NfC" ,0 Mild 0 Moderate 0 Severe
Appears: IZf k~,N 0 Chronically ill 0 Elderly and Frail 0 Cachetic
10 Alert, 0 Poorly responsiv~COmalose
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. Scleral Icterus
. Conjunctivae Pale
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R Extemallnspedion . Teeth: Edentulous I Poor repair
TM's clear . AurnJ acuity decreased (Whispered vol~e,
lS!--Pharynx "~,,
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A. NECK, '^-
'Qlnspection . ND
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5. RESPIRATORY
a Breath sounds clear
. Wheezing / Rales I Rhonchi
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6. CARDIOVASCULAR
lSl. Regular -, rhythm
. Irregularly (irregular rt>ythmJ.
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. Gallop (53IS4J1Murmur gr _/6 sys1oUl:/diasloUc
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9. Heart ;3ounds
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DATA REVIEW~:
. OLD RECORDS: DATE: _1_1 _' ANDINGS:'
. MONITOR . PULSE OX: %
. ECG
'. AMBUlANCE RECORDS
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1 ">='"IlWil~.__~~~ ~,"--'-'''''''''''' ~l'lllil.1 ,.. -'jj;"~""~r,,
. Tenderness I Rebound I Guarding
. HeptdmegaJylSplenomegaly/Mass
. Hem.. Pas stool/Mel<:nalGross Blood
. Abnoi'maJ bowel sounds:
in~rease I decrease I absent
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8. PELVIC
o Cervix
o Uterus
o Adnexa
9, SKIN
Warm, Diiy. No Rash
l!,1.NEUROLOGIC
Cranial Nerves II-Xll
Motor Functfol)
Cerebellar Function
Non.focaJ
Gait
1. PSYCHIATRIC
Oriented ~me, place, pelSan' .
, MooQ/AfII>ct . Dep$slon /anxiety I agitation
Memory . Memqry (recent I remote)
~I:tMPHATlC '
,Neck wid Sig Adenopelhy
'" '::(3,:<>in~/dSlg!\denapathy
1 '" MUSCUl.lilSKElETAt:
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, , : oiQitS not llyano11c or lnt1amed
EXlrem. VII/FUII ROM w/o Pain . Confrilctures I crepitalion
\7r Joints stab!e, , '. DISICcIa, tian / Subluxation I Laxitj
6 No LOWBT E>t. Edema:r : PadaJ.Lawer E>t. (__Plus)
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Soft non-lender
t:r No Org!ll)Omegaly
tJ Heme Neg stool
9' Bowel Sounds
4.)
OIS HARGE CONOmoN
nSFACTORY
FAlA
D SERIOUS
o CRmCAI.
MODE' OF DISCHARGE
(] PAIVATE VEHICLE
o AMBULANCE - NO.
.0 TRANSFER FORM
COMPlETED n~E
o HEUCOPTER
WHITE~- MEDICAlAECOAa CANARY. EMERGENJ;" PHYS:CIAN PINK - ~PA~A'TE PHYSICIAN
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EMERGENCY DEPARTMENT
PHYSICIAN'S ORDERS
lABS COMPLETED RADIOLOGY
TIME INmALS
CBC S ,,'- 0 PCXR
0 Bse MTB PROF 0 X-TABLE C-SPINE
COMP MTB PROF 0( pt.. 0 CXR (PNLAT)
0 CARO PROF
0 ABO PAIN PROF 0 KUB
BETAHCG I( '- 0 ABC -+-.
AB 0 CT
0 PT PIT 0 SONO
0 ETOH 0 IVP
0 URINE TOX SCREEN 0
0 CUL11JRE
0 CUL11JRE 0
0 UA 0
MDSI DATE/TIME
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ER PHYSICIANS '1l1IIlll\llfillmm'
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TIME INITIALS
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o EKG
o IV
o Orthostatlcs
o dT .5 1M 101# SITE
o Old records caUed for
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INmAl ORDERS ENTERED
TIME INITIAlS
ENTERED ' COMPLETED
~ TIME INmALS TIME INITIALS
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Wed Sep 01, 1999 03:Q8 pm
Ou~oatient Summary Report
'<('-,'.,!>lame: VALLERY,SUZANNE LINlIA Page: 1
~e\.;:Rec #: 189878
_oc: EMR 08/31/99
'hys-Service: PETROPOULOS,PETER - MElIICAL"
~cC1; #: A9924303408 PCP: FERRA,PETER J
-******************************************************************************
tn: 08/31/99 1848 ----~--------------------~------- Spec: Slood
)ut: 08/31/99 1904 j COMPREHENSIVE METABOLIC FA-NEL I Techs: VEil. T587
:oll Time: 08/31/99 184S-~----------------~~---~---------
lrder Phys: PETROPOULOS,PETER [1\9924303408/1330053J
lesult Name
*5TAT*STAT*5TAT*
Result
iOldium(mEq/U:
"
'~tassium(meq/L);
:Nlorid~(mEq/L):
; liucose(mg/dU:
It:1'!N (rn q IdU: '
: r.,eat i ni ne(mq/dU:
io:ital protein(gm/dU:
Idbumin(gm/dU:
:ailcium(mg/dU:
litirubin, Total(mg/dU:
iSTWILl: '
Itk. Pnos(U/U:
:~~bon DioxideCmEo/L):
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139.
4.0
.105.
139. H
10. L
.6
7.1
3.9
9.4
1.0
19.
107.
20. L
135-145
3.6"'5.0
101-111
65-110
17.0-44.0
0.5-'.4
6.3-8.6
3.7-5.6.
9.2-10.6
0.2-1.3
10- 30
70- 230
22- 31
:n: 08j3i/~~. f8~~ ----~-~---------------
lut: 08/31/99 1852 I cac W DIfFERENTIAL' f
:ott Time: 08/31/99 1845 --~------~~~-~-~~--~~-
)rder Phys: PETROPOULOS,PETER
Spec: Blood
Tech,s: VER T139
(A9924303408/13300S3J
\esul t Name
*STAT*STAT*STAT*
Result
Reference Ran!le
IBC(1 OE9/U:
:BC(1 OE121U:
emoqlobin(gm/dL):
lematocrit(X) :
IC\I(fU:
iCHCoq):
ICHc(gm/dU:
OW C:t,) :
latelets(10E9/L):
PV(ft):
ympn ocyte X(%):
'ononuclear Cells(;():
ranulocytes %C%):
osinoohils ~CO:
10.5
4.16
13.0
37.6
90.3
31.2
34.6
11.1 L
272
6.1 L
15.3 L
4.1
77.5 H
2.5
. '
4.1-10.9
3.89-5.03
11.6-14.9
33.0-43.9
81.6-98.3
25.0-33.0
33.1-35.5
11.9-15.5
150-440
7.4-10.9
20- 47
3.3-9.0
46-74
(Continued on next page)
r. PETROPOULOS,PETER
210 CORPORATE BLVD SUITE 210
OCKVILLE, MD 208504697
VALLERY,SUZANNE LINDA
189878/A9924303408
EMR 08/31/99
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~~~~ ':'~UNTY GENERAL I'IQ.SPIT
Wed Sep 01, 1999 03:08 pm
Outpatient Summary Report
"
, '\..:.J'
'a.,':::./olame: VALLERY, SUZANNE LINDA
1_'--_'"
~"h..Rec #: 189878
_oc: EMR 08/31/99
'hy s~ S erv; ce: PETROPOULOS,P,ETE R - ME OICAL
~cct Ii: A9924303408 , PCP: FERRA,PETER J .
t*****************************************************************************~
[n: 08/31/99 1848 -----.---------------- Spec: Blood
Jut: 08/31/99 1852 I CBC \oj DIFFERENTIAL I Teens: VER 1159
:oll Time: 08/31/99 1845 ---------------~~-~---
Jrder PhyS: PETROPOULOS,PETER
Page:
2
A8
,.,:'...,.. .
+t'+~~~
,esult Name
*STAT*STAT*STAT*
Re su l t
[A9924303408/13300533
Reference Ranqe
(Continued from previous page)
lasophils %(%): ~
.ymph,Aosolute(10E9/L):
lono,Absolute(10E9/L):
,ran,Absolute(10E9/L):
:os,Absolute(10E9/L);
laso,Absolute(10E9/L):
.0.6
1.6
0.4
8.1 H
0.3
0.1
1.0-4.0
<1.61
1.5-7.5
0;"0.60
0-0.20..
._-~~---~--~------------~~--~---~-~~--~~~--~---~--------~-----------~-~---~--~~.
. ,
: n : 0 at 31/9 9 1 B4 8 --~~"'!I---"'--~"',-'~-------~-
lut: 08/31/99 1912 I HCG::QUALITATIVE,S'ERUM I
:o,J..t Time: 08/31199 1845 --------...--~----..--------
lJ(,)r Phys: PETROPOULOS..PETER
Spec: alood
Techs: VER 1586
[A9924303408/13300533
!esult Name
ICG-.ual,Se~um(mIU/ml):
*STAT*STAT*5TAT*
Result
Ref e rence Rance
Negat;v!!
Negative a 25 mIU/ml
. ;', '.' '~','
._------------------------~----~--~------------------~--------------------------
'.
End of Report - 09/01/99 15:09
'~. ~.
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, ,
"
, '
r. PETROPOULOS, PETER
210 CORPORATE BLVD SUITE 210
OCKVILLE, MD 2085046'17
VALLERY,SUZANNE LINDA
189878/Ao924303408
E,~R 08/31/99
(f-07/20/8S)
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200 Memorial A venue
Westminster, Mary/and 21157-5799
/410J876-3000 1410J871-6888
DEPARTMENT OF DIAGNOSTIC IMAGING REPORT
. NAMEJOq,B '
DATElMFI#
ACCT,/SOURCE A9924303408 DIS
PCP: FERRA,PETER J
ORDERING PHYSICIAN PETROPOULOS,PETER
. ElVIR,' ~;~:
, '.'.'.
Chk-in #
324.893
Order
0002
Exam
9236
ER CERVI~ SPINE
HISTORY: MVC, headache.
COMMENT: The odontoid process appears intact. There is
straightening of the normal cervical lordosis. While this may
merely be positional in. nature, it could reflect muscle spasm,
No vertebral swelling is seen. No fracture or'dislocation is
identified. The vertebral bodies and disc spaces are normal
height. The neural foramina are all capacious. The facet joints
all appear to be in proper alignment. Incidental note is made of
a rudimentary cervical rib at C7 on the left.
IMPRESSION: Possible muscle' spasm, No fracture or dislocation
seen,
(.
\""
MBB
Thank. you
. ,(\d ~,
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for your referral,
Harry C Knipp MD
[ES]
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. .
PETROPOULOS, PETER
9210 CORPORATE BLVD
SUITE 210
ROCKVILLE, MD 20850-4697
page :1
Final Report
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r'fCarroll County
V General Hospital
Superior commitment. Fxc<ptianal can:.
200 Menwrtal Avenue, Westminster, Maryland 21157
EMERGENCY DEPARTMENT PATIENT CARE RECORD
GENERAL I EXTREMITIES
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MED .SUZANNE LINDA
07/20/1~t~YSICJANS '
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Location, Severity. TIming, Modifying Factors. Quality. DUl8tion. Context. Associated Signs/Symptoms
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o J:lifsJConjun~
CY~
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o Pharynx
o
:it~.:::,::
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o Carotid Arteries
o Femoral Arteries
o
7. ABDOMEN
o Soil non,tender
o No Organomegaly
o Heme Neg Stool
o Bowel Sounds
,~ :' a; 0
- III a.SKlN
G: 0 Warm, Dry, No Rash
~ 0 Palpation
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J. Pulse/Bruits: ,:
'CarotidLIR
; Femoral L I R
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. HeptomegalylSplenomegaly/Mass
. Heme pos Slool/MelenajGross Blood
. Abnormal bowel sounds:
increase I decrease / absent
9. PELVIC
o Cervix
o Uterus
o Adnexa
10.IlII!:6RO
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D" Gatt
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TREATMENT
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o Immobllize
o CanelCrutchesJWalker
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o SETA HCG
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o CULTURE
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COMPlETEQ
TIME INmAlS OTHER ORDERS
COMPlETED
TIME INITIALS
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ENTERED
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Westminster, Maryland 21157
RESPIRATORY CARE DEPARTMENT
RECORD OF THERAPY
.DIAGNOSIS
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I STAAT DATE . I 0: USE ~ . ";...
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o S~M INoucnON 0 IMPROVE VENTILATION
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DATE -? /'7.., JZ;.., TIMe Pl<., RR '
TREATMerdTYPe/ ,-\0[; -:':;;:"-, <::'-_'- /'CL ~ -.-/'-""...,
TREAntENT TYPE:
TREATMENT GIVEN W1TH~.~ ........- O2 AIR
MOl: n'PE: '
BREA~SOUNCSPRE~' ~
BREATH SOUNDS POST'TX.: .
COMMeNTS pI- ,<:; (' ..J!..u.,.J-l "'Q 1L~
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TREATMENT TY'!'E:
TREATMENT GIVEN WITH:
RFi
TIMe
D,
AIR
MOl: TYPE:
BREATH SOUNDS PRE TX.:
BREATH SOUNDS POST TX.:
COMMENTS
DATE
. TREATMENT,"TYPE: - .
TREATMENT TYPE:
TREATMENT GIVEN Wlni:
MOl: TYPE:
BREATH SOUNDS PRE TX.:
BREATH SOUNDS POST 1X.'
COMMENTS
TIME
RR
0,
AIR
DATE
TREATMENT TYPE:
TREAl"MENT TYPE:
TREATMENT GIVEN WITH:
MOl: TYPE;
BREATH SOUNDS PRE TX.:
BREATH SOUNDS POST TX.:
COMMENTS
'TIME
RR
0,
AIR
-
DATE
TREATMENT TYPE:
TREATM5.NT TtPE:
TREATMENT GIVEN wrf"H:
MOl; TYPE:
BREATH SOUNOS PRE TIt:
BREATH SOUNDS POST TX..:
COMMENTS
TIME
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( DEPARTMENT Of DIAGNOSTIC IMAGING REPORT
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189878
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NAMElOOB
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ACCUISOURCE A9920803237 DIS
PCP: FERRA,PETER J
ORDERING PHYSICIAN LAUGHLlN,JACQUIE CLAIRE
EMR'
Chk-in #
319767
319767
319768
order
0001
0001
0001
Exam
9236
9331
9257
ER CERVIcAL SPINE
ER LUMBAR SPINE WITHOUT OBLIQUES
ER TOE 5TH*R
HISTORY: MVA. Possible fracture.
LUMBAR SPINE
COMMENT: There is a mild to moderate thoracolumbar scoliosis,
convex right in the lumbar area, centered about L4. No fracture
or dislocation is seen, and the lumbar vertebral bodies and disc
spaces are normal height, The pedicles and spinous pr~ces.ses all
, appear, intact.
IMPRESSION: Mild to moderate thoracolumbar scoliosis.
CERVICAL SPINE (5 VIEWS)
t"~:
COMMENT: The vertebral are unremarkable without evidence of
fracture or dislocation. No significant degenerative changes or
foraminal narrowing is identified. Incidental note is made of
rudimentary cervical ribs at C7, bilaterally.
IMPRESSION: Normal ceryicalspi,ne.
, .. .
RIGHT 5TH TOE
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LAUGHLIN I JACQUIE CLAIRE
9210 CORPORATE BLVD,
SUITE 210
ROCKVILLE, MD 20850-4697
Page :1
Final Report
Continued
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, NAMEJDOB V AllERY~ZANNE LINDA
,:*t::':'t,;,": .
DATE/MR' 07/27/991728
189878
"t"... ..
200 Memorial A venue
Westminster, Maryland 21157-5799
(4101876-3000 (4101871-6888
DEPARTMENT OF DIAGNOSTIC IMAGING REPORT
ACCT'ISOURCE A9920803237 DIS
PCP: FERRA,PETER J
OROE"'NG PHYSICIAN LAUGHLlN,JACQUIE CLAIRE
., E~~\}~"i
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Checkin-Exam Code Summary
319767-9236,319767-9331,319768-9257.
HISTORY: Possible fracture, MVC,
COMMENT: There is no fracture, dislocation or radiopaque foreign
body. Mineralization is normal.
SUMMARY: Normal study,
MBB
Thank you for your referral,
Read By: Harry C Knipp MD
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iZANNE LlND,< VALLERY 9924303408 F 08/31n9 08/31/9'~
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'0001 LIBERTY MUTUAL AUTO I PD83021956001
~0001 GREAT WEST LIFE 681 145368965
,ITEMIZED BILL
OF ALL CHARGES
~ilCtP.E!Cl~I~li,: ,1'.1 O:I;7E;1a.l1lrm!!: '''" ,PAQE'I\II,j!i((j.!'
D 1 - E l"lR 0 0/ 0 5/99 1
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UARANTOR HARRY ~I VALLERY o MASTERCARD CARD NO,
NAME 11 STARBOARD DRIVE OVISA
TANEYTOWN I,D 21787 EXPIRATION DATE
AND
ADDRESS SIGNATURE:
L -1 PlEASE DETACH ANIl ~ErIl~H '\'lIIS 1'O!llIOtI '/11TH YOU~ REMlTTANC:
.' " . . .. .0' . . . . , ,"
~/31/99 15'7' I8UPROFEN 600MG TAB 250 1 1 0.09 O~O9
~/31/99 937 DIPHENHYDRAMINE 501-18 INJ 250 2 1 o AO (1,,48
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~/31/S'q 937 DI PHH,iHYDRAM ! NE SOMG IHJ 250 3 1 0.48 0.48
TOTAL PHARMACY 1.05
~/31./99 70:'31 SODIUM CHLOR IDE 0.9% INJ 1000CC 260 5 . 8.80 8.80
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l/31i99 7046 SODIlIM CHL. 0.9'1. IN.! 500CC 260 6 1 8.80 8.80
TOT,;L IV THERAPY 17..60
;/31/99 4038 COi'lPREHENS I VE METABOLIC PANEL 301 1 i 18..00 18,,00
~
TOTAL LAB/CHEN 18..00
~/31/99 802::. HCG,SEMI-QUANT,SERUM 302 1 '1 33..00 33..00
.
TOTAL IMMUNOLOGY 33..00
~/"31 /S""7 6021 CBC W D I FFEREI-H I AL 305 1 1 20..00 20..00
TOTAL HEMATOLOGY 20.00
~/31./9q 92:36 ER CERVICAL SPINE 320 L 1 74 '-00 74.00
.
TQT}iL DX XR.,y 74.00
~/31/99 6 EMER(,HICY l'lEDICAL SCREENING 451 3 1 55.00 55.00
.
TOTAL EMERGENCY MEDICAL SCREENING 55,,00
1/31/99 4 EXTENDED ER BEYOND SCREENING 452 4 " 110.00 110..00
~
TOT,;L ,ER/BEYOND SCREENING 110.00
TOTAL CHARGES
TOTAL PAillEN rS/ADJUSnlENTS
ADDmONAL PATIENT BILLING MAY BE NECESSARY FO~ ANY
CHARGES NOT POSTED WHEN '!HIS BILL IS PREPARED,OR IF ANY
INSURANCE CARRIERS DO NOT PAY ANY AMOUNT OF THE
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200 Memo, Avenue
Westminster; Maryland 21157 - 5799
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JZANNE LINDA VALLERY ~ 07/27/99
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70001 LIBERTY MUTUAL AUTO I PD83021956001
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iUARANTOR
NAM~
AND
ADDRESS
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HARRY J VALLERY
11 STARBOARD DRIVE
TANEYTOI'-iN liD
-,
21787
D MASTERCARD CARD NO.
D VISA EXPIRATION DATE
L
--1
SIGNATURE:
PLEASE DETACH AND RETURN THIS PORTION WITH YOUR REMITTANC
.,
.. . . . . . .. .... . . .. . .-
7/27/99 355 REESE SHOE 270 5 1 10.80 10.80
TOTAL liED-SlIR SUPPLIES 10ft80
7/2'.7/99 9236 ER CERVICAL SPINE 820 1 1 66.00 66.00
7/27/99 9257 ER TOE 5TH 820 1 1 30.00 30..00
7/27/99 9331 ER LUMBAR SPINE .H THOUT OBLl QIJES 320 1 1 4.2.00 42,.00
TOTI"L DX XRAY 138..00
? /27/9\""~ , 4134 AEROSOL SY8TH! SET UP 410 6 1 12.00 12.00
TOTAL , RE SP I RA TORY SVC 12..00
? /2'7/99 . Er1ERGENCY MEDICAL SCREEN I r-.lG 451 :3 1 54..00 54..00
,~
TOTAL EliERGENCY MED I CAL SCPEENING 54..00
7/27/99 1 INTERMEDIATE ER BEYOND SCREENING 452 4 1 27.00 27.00
TOTAL ER/SEYOND SCREENING 27.00
7/27/99 3527 BEDSIDE PULMONARY SCREENING 460 2 1 11. 00 11.00
7/27/99 3531 AERC;::;OL THER~~PY 460 .., 1 11.00 11 ft 00
~ .
TOTAL Pulmonary Functions 22,.00
TOTAL CHARGES 263..80
TOTAL PAYMENTS/ADJUSTMENTS 0..00
I
TOTAL
AMOUNT
DUE
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-"'--' . "".. , '. , PA,IEN, NUMBER
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ADDITIONAL PATIENT BILLING MAY BE NECESSARY FOR A~iY
CHARGES NOT POSTED WHEN THIS BILL IS PREPARED,OR IF ANY
INSURANC~ CARRIERS DO NOT PAY ANY AMOUNT OF THE
AMOUNTS SHOWN,
2t,3 It SO
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V General Hospital
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NAME/DOB
VAlll ,SUZANNE LINDA
07/20/85
DATEIMRI
07/27/991728
189878
200 Memorial A venue
Westmi"ster, Maryland 21157.5799
(4101876.3000 (4101871.6888
DEPARTMENT OF DlA~NOSTlC IMAGING REPORT
ACCTl/SOURC' A9920803237 DIS
PCP: FERRA,PETER J
aRaERlNO PHYSICIAN LAUGHlI/Ij,JACQUIEClAIRE
EMR
Chk-in #,
319767
319767
319768
order
0001
0001
0001
Exam
9236
9331
9257
ER CERVIC~~' SPINE
ER LUMBAR SPINE WITHOUT OBLIQUES
ER TOE 5TH*R
-----~---------------------------------------------------------
HISTORY: MVA. Possible fracture.
I,-UMBAR SPINE
COMMENT: There is a mild to moderate thoracolumbar scoliosis,
convex right in the lumbar area, centered about L4. No fracture
or dislocation is seen, and the lumbar vertebral bodies and disc
, spaces are normal height. The pedicles and spinous processes all
appear intact.
IMPRESSION: Mild to moderate thoracolumbar scoliosis.
CERVICAL SPINE (S VIEWS)
COMMENT: The vertebral are unremarkable without evidence of
fracture or dislocation. No significant degenerative changes or
foraminal narrowing is identified. Incidental note is made of
rudimentary cervical ribs at C7, bilaterally.
IMPRESSION: Normal cervical spine.
RIGHT 5TH TOE
LAUGHLIN,JACQUIE CLAIRE
9210 CORPORATE BLVD.
SUITE 210
ROCKVILLE, MD 20850-4697
Page :1
Final Report Duplicate
Continued
,
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V General Hospital
NAME/DOB
VAL, ,V,SUZANNE UNDA
07/20/85
DA lE/MR'
07/21/99 1728
189878
200 MemoniJl A venue
Westminster, Mary/end 21157-5799
1410/876-3000 1410/871-6888
DEPARTMENT OIi'DI~GNOSTIC IMAGING REPORT
ACm/sOURCE A9920803237 DIS
PCP: FERRA,PETER J
ORDERING PHYSICIAN LAUGHLlN,JACQUIE CLAIRE
EMR
Checkin-Exam Code Summary
319767-9236,319767-9331,319768-9257
HISTORY: Possible fracture, MVC.
COMMENT: There is no fracture, dislocation or radiopaque foreign
body. Mineralization is normal.
SUMMARY: Normal study.
MBB
Thank you for your referral,
Read By: Harry C Knipp MD
[ES]
LAUGHLIN,JACQUIE CLAIRE
9210 CORPORATE BLVD.
SUITE 210
ROCKVILLE, MD 20850-4697
Page :2
Final Report Duplicate
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ADVANCED CENTERS FOR
ORTHOPAEDIC
SUROERY &, SPORTS MEDICINE
Arthur Baitch, M.D., Donald I. Sa/tvftan, M.D" My/e;s D. Brager, M.D.,
Samuel-a. Matz. M.D., DavidA. Silber, M.D. ~ M.D. '
Stacey H. Bern~M.D., Vincent J. RoHo,.fI.' Robert M. Saitvtt ..D..
PATIENT NAME: ,,6,P"<MM 1!rJle.'7 DATE: _0
DiAGNOSIS: {eJ'II,'Cq{ j /lilt--1$a,r f/rCU/'l
PHYSICAL THERAPYIBRACES/ORTHOTICS
PROVIDER:
PRECAUTIONS:
FREQUENCY:~Xperweek _ Daily Other
DURATION: ~ Until next Dr. visit! # of weeks ~ Until program completed_
Evaluate and treat Moist Heat Cold
Electrical Stirn Ultrasound Paratin
_ Massage TENS Jobst
.:... Iontophoresis _ Whirlpool ..:... Crutch Training
_ ROM Exercise Active Exercise _ Passive Exercise
..:... Resistive Exercise ..:.. BacklNeck Rehab Routine _ Cervical Traction
Cervical TIJICIion Lumbar Traction _ 10int Mobjlization
. .' Isokinectics Eva! & Rehab Isokinectics Rehab _ Isokin~cs Test
..:... Spinal Stabilization Prog _ Back School -.:. Cervical Progrnm
...:.. Shoulder Program _ Hip Program _ Elbow Progrnm
_ Knee Program _ Foot/Ankle Program _ Total Joint Progrnm
_ Worle Hardening Progrnm _ Worle Conditioning Prog _ Hand Program
.. Functional Capacity Evaluation _ Crutch Training
- . , J
' , Other ,d-r-uJttl1\11.J Jlffi~ ~ IUd.. [(/:'(>1 jpr,..
ORTHOTICS: _ Heel Flar.... tAedialJliI1C1'llI ...::.. Heel sol~ f\are medialJlateral I
_ Foot Insert with corle post _ Foot Insert, single density _ Foot Insert, dual density
..:... Foot Insert, UCBL _ Foot Insert, tri layer _ Rocker bottom, between sole
, Lift or elevation, beel & sole --- Exteilded Steel sbank
~::~ fooiwear, ladieS in-depth ffo~ns in depth
-;- PIIYSICIAN SIGNATURE: ,Jif/tJ~ ~S4--)- DATE:
116 Slade Avenue Baltimore, Maryland 21208 (410) 484-8088 Fax (410) 653-5668
I ViUage Square Westminster, Maryland 21157 (410) 876-8077 Fax (410) 876-8154
1380 Progress Way Eldersburg, Md. 21784 (410) 549-5780 Fox (410) 549-5913
I
pLAINTIFF'S
EXHIBIT
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ADVANCED CENTERS FOR
ORTHOPAEDIC
SURGERT A SPOftTS MEDICINE
ARTl-lUR 6AllCH, M.D. DONALD I. SALTZMAN. M.D. MYLES D. BRAGER, M.D.
DAVID A. SILI!II!:R. M.D. NOEL S. GRE5SIEUX. M.D. STACEY H. BEANE", M.D.
ROBEJ:fT M. SALTZMAN. M.D. GEORGE H. GRI!:ENSTEIN, M.D. EMI!;RrruS
SAMua. O. M&rz. M.D.
Y1MC~ J. Aou.o. M.D.
OEOPP P'M.1.A. C.I.O.
SPECIALIZING IN FRACTURe: CARE. ARTHROSCOPIC SURQ~. S~1IfTI MEDfCIIC.
SPIN!. SUROERY'. KNEE AND HIP REPt..ACEMENT. HAND SURGERY, ELBOW AND SHOULDCII~.
FOOT AND ANKLE SURGERY', 1'RAu~
VALLERY, SUZANNEL.
SEPTEMBER 24, 1999
ORTHOPAEDIC CONSULTATION
:mSTORY PRESENT llLNESS: Su.zanne is a 14-year-old young lady who was in a motor vehicle
accident on 01/21/99. The specifics of the accident are well documented in her file. Basically she
tontinues to have neck and back discomfort. She initially saw Dr. Medina. She then came under the
ca.re'of. chiropractor, Dr. Greg Lewis, who treated her. She also had physical therapy. She then saw
. Dr.l\.obert Saltzman and requested yet another opinion.
, She cOntinues to complain of pain, Her mother wishes to know why she is not any better. She has been
out ot physical education since the accident occurred.
, PAST MEDICAL IDSTORY: The patient has no known allergies. She currently is on Adviland
Mot.r:itt. She has a history of asthma and stomach ulcers.
. ,PHYSICAL EXAMINATION: On exam today she has discomfort in the cervical region which is
"" outot'proportion to light palpation. she has full cervical motion. She has normal neurovascular exam.
, ". RefleJses are normal She also has some lwDblll:" discomfort and a negative straight leg raising test.
..;:.~::,<q?'~ir.~, .
i reviewed her file.
I'. .c",
RADIOGRAPlllC STUDIES: X-rays were taken of the lumbar spine and the cervical spine at
Carron County General Hospital on 07/27/99. The reports are negative.
IMPRESSION:
Persistent complaints of neck and back discomfort.
DISCUSSION: I have discus$ed the nature of the problem at length. Treatment options were
discussed. I advised her mother that subjective complaints seem to outweigh objective findings on
physical examination, but due to het persistent complaints we will get an MRI scan to further evaluate'
her conditiort. I will see her back after the study.
SAMUEL O. MATZ, MD.
SOMlpIkIWM
,
1'1' L.....o:::.:.~IIII!lI!'!!:!i~~-: -<.04"t1:!:"'" ~,~ ~~
~3tIO~~ WAY, E1.oER58UAG. MD 21 764, (410) 549-5760 (-410) 5<49-5g 1.:3 FlOC
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ADVANCED CENTERS FoR:
, ORTHOPAEDIC
,:~,rt,~. c. ~:_.' SUJIlGE"T " .,.OftTa MI:DIl:I"1:
AmHU" B.\rrcH. M.D. DONALO I. 5AL:l%MAN. M.D. MY~ O. BRAO~R. M.D. SAMU~L o. MAn. M.D.
. DAvID A. SILBER, M.D. NOEL S. GRESSIEUX, M.D. STACEY H. BERHER, M.D. VIMCDff u. ROLLO. M.D.
ROBERT M. SA.LttMAH, M.D. GEORl:?,E H. GA.E~STElN, M.D.. EMERITUS Ge:OP'1r F'AlLL..A. C.E.O.
$PECIAUZING IN FAACTURE: CARE. ARTHROSCOPIC SURGERY. SPORTS MEDICINE,
SPINE. SURGERY, KNEE AND HIP REPl.A.CEMENT, HAND SURGERY', ELBOW AND SHOULDe:R SUROERY,
FoOT ANO ANKLE SuRO~ 11WJ.....
VALLERY, SUZANNEL.
RIP: Samuel Matz, M.D.
DIE: 11116
D :
,ORTHOPAEDIC SPINAL SURGEON'S CONSULTATION
.,,"',-,..,...,;I;::HT!';F COMPLAINT:
'~:,~:; ~\'': ",< .
Neck, upper and lower back pain.
~/;;: mSTORY OF PRESENT ILLNESS: The patient is a 14 year old who Will the
;:i;': ;;.; restrained rear-seat passenger in a minivan that was rear-ended on the above-clptioned
't '};i;date. The mother reports that there was $500.00 worth of damAge to the vehicle.
'. ';'.: Suzanne was initially treated by a cmropractor and then had some physical therapy. She
has had several anti-iutl..mttlatory medications. She reportedly is not at all :.nproved
with persistent complaints about the neck, upper and lower back. She also COiIIpIIiiIII of
some pain and' numbness in her arms and legs. Apparently, she has had 110__
problems in the past. '
PAST MEDICAL mSTORY:
TIlness"s:
Allergies:
Surgeries:
Medications:
GERD, gastritia and utbmB.
None known.
Endoscopy.
Claritin, Bentyl, Advil, and
Albuterol inhaler.
PHYSICAL EXAMINATION: This is a well-developed. obese young lady in 110
, obvious distress. Normal reciprocal, gait. The patient complained of associated
. tenderness throughout the neck, upper, middle and lower back. She was also teoder over
her sacroiliac joints and greater trochanters. She complained about motion throughout the
spine, Cervical and lumbar ranges of motion were full with discomfort at the extremes.
Neuromuscular examination revealed 2/5 deep tendon reflexes bilaterally and symmetric
at the biceps, brachioradialis, triceps, knees and ankles. Long tract signs were absent.
Sitting root tests were only significant for production oflower back pain.
, RADIOGRAPmC STUDIES: I reviewed an:MRI scan of the cervical spine that
"was done at York Imaging Center on I 0/07/99. There is no evidence of any significimt
herniation or stenosis or other structural abnormality.
IMPRESSION: Resolving cervical, thoracic and lumbar strain injuries.
No mdeace ofany radiculopathy.
lie SUoac AWNU~. BALnMORE. Me ala06. (410) 464.6066 (410) 653.5666 FAX
1380 ~ WAY, ELoERSBURO. MD 21764. (4101 549.5780 (4101549-5913 FAX
,,~ SCN~ ~NSTER. MD 2115~, (410) 676.e077 (410) 857-4416 1410) 875.B154 FAX
FbNcN.'r ~. GMDtSTElH. BAneH._ SM:rZ.twt AHO MATZ.. fIlA;
Cr.d _ COuNTY C,ENTER FOR" ORTHOPAEDIC SURGERY AND SPORTS MEDICINE
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PATIENT:
DATE:
2
VALLERY, SUZANNE L.
11/16/99
TREATMENT: ' Continue anti-inflammatory medications, cold therapy and a
swimming exercise program. I expect that over time these injuries will heal uneventfully.
MYLES D. BRAGER, MD.
Dictated but not read unless signed
:MDB/amaIWM
j Peter Ferra, M,D.
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,URSERY ANi) SPORTS MEDICINE
'0 BOX 546.3
IAlTIMORE, Mil 21264-4603
,Hi! 484-8639
:edeial In : 52-U80S75
Itemized Statement
.7/22/99 - 11/19/99
Page~
(e) Medic
Printed: 11/19/99 1:14 PM
)atient
6uarantct~
VALLERY, SUZilJJNE L
11 STARBOARD DRIVE
THr.'EYTGWN, MD
410/756-2%2
PatID:
006781D9-000l PI ML
VALLERY, ROSANNE
11 STARBOARD DRIVE
TANEYTO.'N, MD m87
4101755-2962
AcctID: 0613BB072A
SSN : 061-3B-8072
Dob: 07 /2~f85
21787 Age: 14
Insurance Company
Policy il
B.,oup #
Othel' Info
Holder
Effeotive Dat,I,)
I:PIP C!lRRIER
2:BRSQT WEST LIFE POS
PO BOX 920
LA830-21956.-03 ATTN SULTANA JONES
14536B965 052399 >10.0.
FREDERICK, MD 21705-092.
LIBERTY MUTUAL
VALLERY, HARRY
07/21/99 -
3ervice Date{sJ Patient Nale
Code
Description
"ty/Src Charged
Open Pl'ovider Plac, Cas,li
.B/l.m
VALLERY, SUZANNE L 99243
DiagP: 729.5
DiagS: 724.5
OFFICE CONSULTATION
PAIN IN LIMB
BACK PAIN
1.00
185.00
185.00 SALTZMAN R 47
M/26/99 vALLERY, S'JIPl'lNE L 99213 IlFFlCE SERVICE-EST PT 1.00 B0.00 a0..0 SAl TZAAN R 48
OiagP: M7.1 STRAIN THORACIC SPINE
DiagS: 847.0 STRAIN CERVICAl SPINE
Diag3: 847a2 STRAIN LUt>1BAR SPINE
0Si2.4/9g VALLERY, SUZANNE L S9274 2ND OR 3RD OPINION 1.00 195.00 195.00 MATZ 48
Diage: il47.1 STRAIN THORACIC SPINE
DiagS: 847.0 STRAIN CERVICAl SPINE
Diag3: 847.2 STRAIN LUMBAR SPINE
10/15/99
VALLERY, SUZi1NNE L 01112
DiagP: il47.1
DiagS: 847.0
Diag3: 847.2
CANCELLED/RESCHEDULED APPT
STRAIN THORACIC SPINE
STRAIN CERVICAL SPINE
STRAIN LUMBAR SPINE
1.0'~
0.00
u. MATZ
4-3
Case # : 1 NEC'MBACKlSHLDR
Occurrence: 07/21/99
Consuited :
Accti : 0067809-0001
Adaission :
Discharged:
Total Disability :
Partial Disability:
Thru
Thl'U
InjUl'y/Pregnancy: I
Eaploy. Related: N
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RETAINER AGRERHEB'l'
In consideration of legal services to be rendered by Michael
Lee Kaplan, Attorney at Law, the undersigned client retains said
Attorney to prosecute all claims, including claims under uninsured
motorist and no-fault coverage, including medical payments,
property damages, for client (s) injuries and damages sustained on
or about the VL day of "~ 199j,
The Attorney accepts said employment and is authorized to
effect a settlement or compromise, subject -to the client's
approval, or to institute such legal action or actions, as may be
advisable in the Attorney's judgment in order to enforce client's
rights.
The Attorney's fee shall be a sum equal to thirty-three and
one-third percent (33 1/3\) of any amount recovered, or forty
percent (40%) of any amount recovered after suit and/or arbitration
proceedings have beerr filed. In addition to the fees so stated,
there shall be a reasonable Charge for actual time spent to
process, file and collect any sums due under any existing P.I.P.
coverage, If no recovery is obtained, no fee shall be payable to
Attorney,
If a settlement is made in the case and the client refuses to
accept said settlement, the attorneys shall hold a lien for one-
third (33 1/3%) if the offer is made prior to suit being
instituted, or forty percent (40%) of said offer if suit or
arbitration proceedings have been filed.
Costs may be advanced by Attorney, including investigation and
expert's fees, and said advances shall be deducted from any
recovery and returned to the Attorney at the time of disbursement
of the funds, Associate counsel may be employed at the discretion
and expense of the Attorney. Attorney shall have a lien on said
claim, suit or recovery for said fees and expenses.
In the event the appeal is taken, a new and separate agreement
shall be entered into by the parties as to services and fees.
/-;<'6 -0 I
may withdraw at -any time- Oy giving reasonable
and the client agrees to sign substitution of
event of such withdrawal. ~
(diC//K/V / j' _ - ~lA/
CLIENT
Attorneys
written notice
Attorney in the
DATE
PLAINTIFF'S
EXHIBIT
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FULL AND FINAL RELEASE
For and in consideration of payment to HARRY VALLERY and
ROSEANNE VALLERY, as parents and natural guardians of SUZANNE
VALLERY, of the sum of Six Thousand 00/100 Dollars ($6,000.00), We,
HARRY VALLERY and ROSEANNE VALLERY (hereinafter sometimes referred to
as "Releasors"), do hereby release and forever discharge ROBERT PUCKETT,
NEAL MANUFACTURING COMPANY,
INC., COMMERCIAL UNION
INSURANCE, CGU INSURANCE, ONEBEACON INSURANCE and PEERLESS
INSURANCE, (hereinafter sometimes referred to collectively as "Releasees") their
insurers, employees, agents, and any and all other persons and firms, of and
from any and all actions, causes of action, claims, demands, damages, costs, loss
of services, expenses, compensation, consequential damage, or any other thing
whatsoever including claims not only for personal injuries and damages on
account of or in any way growing out of, any and all known and unknown
personal injuries, debts, and property damage resulting or to result from an
incident involving the Minor Suzanne Vallery that occurred on or about July 22,
1999, on Market Street, Camp Hill, Cumberland County, Pennsylvania.
We hereby acknowledge and assume all risk, chance, or hazard that the
said injuries or damages may be or become permanent, progressive, greater, or
more extensive than is now known, anticipated, or expected, No promise or
inducement which is not herein ex.xessed has been made to us in executing this
pLAIHc1IFF'S
eXHIBIT
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Release. We do not rely upon any statement or representation made by any
person, firm, or corporation, hereby released or any agent, physician, doctor, or
other person representing them or any of them concerning the nature, extent, or
duration of said damages or losses, or the legal liability therefor.
We understand that this settlement is the compromise of a disputed claim
and that the payment is not to be construed as an admission of liability on the
part of the persons, firms, and/or corporations hereby released by whom liability
is expressly denied.
We further certify, state, acknowledge, warrant, and declare that each and
every person, attorney, carrier, entity or association which claims to have a lien
on the proceeds of this settlement arising out of this incident, lawsuit, or
litigation, is aware of this Release and its terms and We understand that said
released parties hereunder are relying expressly upon this unconditional express
warranty in making payment hereunder.
The Releasors accept responsibility for satisfying any liens that have been
asserted against this recovery by any worker's compensation insurance carrier,
healthcare provider or insurer, and hereby discharge the Releasees from any
such responsibility.
In further consideration of the above payment, We for ourselves, our heirs,
next of kin, executors, administrators, successors, or assigns, covenant and
-2-
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agree to indemnify and hold harmless ROBERT PUCKETT, NEAL
MANUFACTURING COMPANY, INC" COMMERCIAL UNION INSURANCE, CGU
INSURANCE, ONEBEACON INSURANCE and PEERLESS INSURANCE, their
agents, employees, insurance carriers, and attorneys, from all claims, demands,
and suits for damages, costs, loss of services, expenses, or compensation which
may arise in the future on account of or in any way growing out of the injuries or
damages we sustained in this incident.
This Release contains the entire agreement between the parties hereto and
the terms of this Release are contractual and not a mere recital.
We certify that we are over eighteen (18) years of age and we further state
that we have carefully read the foregoing Release and we know the contents
thereof and we have signed the same as our free act and intending to be legally
bound thereby.
IN WITNESS WHEREOF, we have hereunto set our hands and seal this
day of
,2001.
WITNESSETH:
HARRY VALLERY
ROSEANNE VALLERY
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COMMONWEALTH OF
COUNTY OF
On this day of , 2001, before me personally
appeared HARRY VALLERY and ROSEANNE VALLERY, known to me to be the
person whose name is subscribed to the within Release, and acknowledged that
he executed the same for the purposes therein contained.
IN WITNESS WHEREOF, I have hereunto set my hand and official seal.
NOTARY PUBLIC
My Commission Expires:
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CERTIFICATE OF SERVICE
I do hereby certify that on this day I served a true and correct copy of the foregoing by
first class mail, postage prepaid, addressed to the following:
Michael Kaplan, Esquire
Kaplan & Kaplan
200 E. Lexington St., S 400
Baltimore, MD 21202
Neil Manufacturing Co., Inc.
Carrolton Villa Highway
Villa Rica, Georgia 30180
Robert Puckett
c/o Neil Manufacturing Co., Inc.
Carrolton Villa Highway
Villa Rica, Georgia 30180
Thomas, Thomas & Hafer, LLP
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Date: I -Z-/'2-1 / C> (
Miche e J. 0, Es
305 N. Front Str
P.O. Box 999
Harrisburg, P A 171 08-0999
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HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
SUZANNE VALLERY, a minor,
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Plaintiffs
v.
ROBERT PUCKETT and
NEAL MANlJ'F ACTURING CO" INC.,
Defendants
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: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYL VANIA
: NO.: 01-6497 Civil Term
: CIVIL ACTION LAW
TO THE PROTHONOTARY:
Please mark the above-captioned case as settled, discontinued and ended.
Date: ID/'"2.- e-f02--
Respectfully submitted,
as, Thomas & Hafer, LLP
by
ic J. orp E
J.D. N .: 71117
305 N. Front Street
P.O. Box 999
Harrisburg, P A 17108-0999
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