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HomeMy WebLinkAbout07-7450Milovanovich & Espinosa, LLC Nina Milovanovich, Esquire Attorney ID #: 75545 129 E. Orange Street, Suite 2 Lancaster, PA 17602 (717) 293-1400 FAX: (717) 293-8038 Attorneys for Plaintiffs SEHUDIN DERVISEVIC, as Administrator of the Estate of SAHA DERVISEVIC 530 24d Street Carlisle, PA 17013 Plaintiff V. : IN THE COURT COMMON PLEAS OF : CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant PETITION FOR APPROVAL OF SETTLEMENT OF WRONGFUL DEATH AND SURVIVAL CLAIMS AND NOW, comes the Petitioner, Sejfudin Dervisevic, individually and in his capacity as the Administrator of the Estate of Saha Dervisevic, deceased, by and through his attorneys, Nina Milovanovich, Esquire and Milovanovich & Espinosa, LLC, and files the following Petition to Approve Settlement of Wrongful Death and Survival Actions, and states as follows: 1. Petitioner is Sejf idin Dervisevic, who was appointed Administrator of the Estate of Saha Dervisevic, deceased, by the Register of Wills of the Cumberland County Court on October 19, 2006. (A copy of the Letter of Administration is attached as "Exhibit A"). 2. There has been no previous assignment of any issues to a Judge before this Honorable Court. 3. Decedent, Saha Dervisevic, was 60-years old. She was as a resident of Carlisle, Cumberland County, Pennsylvania. 4. She was not married at the time of her death, and died intestate, survived by 3 children as follows: a. Lutvo Dervisevic (son, not a minor) b. Sejfudin Dervisevic (son, not a minor) C. Lutvij a Cehaj is (daughter, not a minor) 5. On September 24, 2006, the decedent was a passenger in a Chrysler Town-Country van, operated by her son Lutvo Dervisevic. At the time of the accident, the vehicle was in a southbound middle lane on I-81. There were six other family members in the van, in addition to the decedent. 6. Suddenly, the van had a flat tire. The driver slowed down, and turned on the blinkers, in order to try to move from the middle lane into the right lane, and ultimately onto a shoulder, to change the tire. 7. David A. Schriml operated his vehicle in a careless manner, and hit the van in which the decedent was a passenger from behind, causing the van to be pushed over onto the grass divider that divided the southbound and northbound lanes of I-81. 8. As a result of the incident all seven persons in the van suffered injuries. The other passengers, including one minor and five adults, suffered injuries of different gravity, some of them permanent and disabling. 9. The decedent was transported by ambulance to the Wilson Memorial Hospital, where she was admitted. (A true and correct copy of the medical records from the Hospital is attached hereto, marked as "Exhibit B" and incorporated by reference.) 2 10. As the result of the accident, the decedent sustained extensive bruises of left chest, flank and thigh, fractures of left ribs (6 through 10), and contusion injuries to her heart and lungs. 11. After she was brought to the hospital, she was evaluated throughout that evening and it was felt that she was in stable condition and could be discharged. However, because of the severe pain and lack of mobility, the family requested that she be admitted to the hospital and she was transferred from the Emergency Room to a ward early the next morning. Throughout that day, she complained of pain in her left side, but did not seem to have edema or undue difficulty breathing. However, by 8:30 that evening, she was noted to have severe dyspnea and diaphoresis. A troponin taken just before that showed a level of 3.53, which raised the question of whether she had cardiac bruising and an onset of failure. The suddenness of her deterioration also suggested the possibility of pulmonary embolus. She was transferred to the ICU. During that evening and the next day, vigorous attempts were made to support her breathing and blood pressure. She was given large quantities of fluid and received IV Levophed. She also was intubated. However, in the evening of her second hospital day, she developed congestive failure with pulmonary edema and pleural effusions. A massive thromboembolism to both lungs developed. She went into cardiac arrest and could not be resuscitated. (A true and correct copies of the preliminary autopsy report, final autopsy report and certificate of death are attached hereto, marked as "Exhibit C" and incorporated by reference.) 12. The Petitioner retained the undersigned counsel to represent him and the Estate, and to obtain recovery through settlement or jury award, as well as to prepare and present this Petition for Court approval. 3 13. The Petitioner executed a contingent Fee Agreement providing for payment of one-third (1/3) of the settlement proceeds for attorneys fees. (A true and correct copy of the said Fee Agreement is attached hereto, marked as "Exhibit D" and incorporated by reference.) 14. The above referenced Fee Agreement provides that, in addition to the attorneys' fees, the attorneys should be fully reimbursed for all costs associated with the handling of the claim. 15. The undersigned attorney performed a comprehensive investigation of the accident, obtained all relevant medical and other pertinent documentation, and opened the Estate. 16. The undersigned retained an arbitrator, in order to have the arbitrator evaluate the claim and render an opinion as to the fair and reasonable apportionment of the available insurance limits and apportionment of the wrongful death and survival claims. The arbitrator performed a comprehensive review of all relevant information, and opined that $250,000.00 represents a fair and reasonable settlement of the wrongful death and survival claims. (A true and correct copy of the arbitrator's evaluation is attached hereto, marked as "Exhibit E" and incorporated by reference). 17. The undersigned has engaged in extensive negotiations with the insurance companies providing coverage for the losses resulting from the accident (including the UIM carrier), and has negotiated a settlement in the amount of $250,000.00. 18. In exchange for the combined total payment of $250,000.00 dollars, upon the Court's approval of this Petition, the Petitioner will execute a General Release of all claims against the defendant and all insurance companies providing coverage for the accident. 19. Counsel for the Petitioner is of the professional opinion that the proposed settlement is fair and reasonable. The amount of the settlement is within the range of a reasonably 4 anticipated jury award for this case. Furthermore, this amount comports with the evaluation of the independent arbitrator. 20. Petitioner is of the opinion that the proposed settlement is fair and reasonable. 21. The Petitioner and counsel entered into a Fee Agreement for counsel's work in regard to opening the estate and all subsequent work pertaining to the administration of the estate and preparation of the appropriate documents and tax returns. (A copy of the said Fee Agreement is attached hereto, marked as "Exhibit F" and incorporated by reference). 22. Plaintiffs counsel requests approval of the attorneys' fees in regard to the work on the personal injury (wrongful death and survival claims) in the amount of $83,333.33, which represents one-third (1/3) of the total settlement proceeds, as per the Fee Agreement. 23. Plaintiffs counsel has incurred $1,034.55 in expenses, for which the reimbursement is being sought. (A true and correct copy of the ledger documenting the costs is attached hereto, marked as "Exhibit G" and incorporated by reference). 24. In addition to the above referenced itemized costs, it is anticipated that Milovanovich & Espinosa will incur further costs at least in the amount of $100.00, for additional postage, facsimile and reproduction charges, mileage, long distance telephone charges, etc. 25. Plaintiff's counsel requests approval of attorneys' fees in the amount of $6,508.78 for the work in regard to opening the Estate and estate administration, which fee represents 4% of the amount to be transferred to the Estate. 26. The total sum of the settlement proceeds available for allocation and distribution to the intestate heirs and wrongful death beneficiaries of Saha Dervisevic, after reimbursement of counsel's fees and costs, is $156,210.84. 5 27. At the time of her death, Saha Dervisevic was not married, and was survived by her 3 children, Lutvo Dervisevic, Sejfudin Dervisevic and Lutvija Cehajic, all of whom are adults. 28. Under Pennsylvania law, damages potentially recoverable by the Estate of Saha Dervisevic in a survival action are her loss of earnings or earning capacity and her conscious pain and suffering. 42 Pa.S.C.A. § 8302; Smail v. Flock 407 Pa. 148, 180 A.2d 59 (1962); Skoda v. West Penn Power Co., 411 Pa. 323, 191 A.2d 822 (1963). 29. At the time of her death, Saha Dervisevic, was 60 years old. She was receiving Supplemental Security Income (SSI) benefits, because of high blood pressure and degenerative disc and joint disease. Although the decedent received SSI, the Petitioner did not intend to present a claim for lost earnings or loss of future earning capacity on behalf of the estate at trial, if this claim had to be litigated. 30. All medical expenses for the treatment related to the injuries sustained in the accident were paid in full by the PIP carrier. There are no outstanding medical bills for the treatment related to the accident. (A true and correct copy of the PIP printout showing payments of medical bills is attached hereto, marked as "Exhibit H" and incorporated by reference). 31. Expenses for the decedent's funeral were $3,075.00. (A true and correct copy of the funeral bill is attached hereto, marked as "Exhibit I" and incorporated by reference). Funeral expenses are recoverable in the wrongful death action pursuant to the Wrongful Death Act, 42 Pa.S.C.A. § 8302(c). 32. At the time of her death, and ever since she came to the USA from Bosnia in the fall of 2000, the decedent lived with her son, Sejfudin, in his apartment. The decedent 6 contributed to the expenses incurred for maintaining the home from her SSI. Petitioners anticipated that the decedent would have continued to pay her share of these expenses had she lived. 33. During the course of her lifetime and despite her disability, the decedent provided substantial support and services to her children and grandchildren, including providing her adult children with significant child care services for their children (decedent's grandchildren), guidance and tutelage to her adult children and grandchildren, and financial assistance to her adult children and grandchildren, all of which the Petitioner anticipated would have continued had she lived. 34. Petitioner and various members of the decedent's family, including her adult children and her grandchildren, have suffered substantial losses as a result of the death of Saha Dervisevic. Under Pennsylvania law, the losses suffered by her children are compensable pursuant to the Wrongful Death Act, 42 Pa.S.C.A. § 8302; Hodge v. Loveland, 456 Pa. Super. 188, 690 A.2d 243 (1997). 35. Petitioner proposes allocating 25% of the net settlement proceeds to the survival action, and 75% of the net settlement proceeds to the wrongful death action brought on behalf of her statutory beneficiaries. 36. Under all of the circumstances, particularly the evidence concerning damages and the likely awards that would have been made by the jury in the survival and wrongful death actions, the allocation of 75% of the net recovery to the wrongful death action and 25% to the survival action is fair and reasonable. 37. Petitioner's counsel has requested and received approval of the allocation between the Wrongful Death Action and Survival Action from the Department of Revenue. (A true 7 and correct copy of the letter from the Department of Revenue is attached hereto, marked as "Exhibit F and incorporated by reference). 38. Mrs. Dervisevic died intestate and therefore the proceeds of the survival action brought by plaintiff on behalf of her estate are distributable pursuant to the Pennsylvania's Intestate Succession Act, 20 Pa.S.C.A. § 2101, et seq. 39. Pursuant to the Intestate Succession Act, since the decedent was not survived by a spouse, the proceeds of the survival action pass to her issues in equal shares. 20 Pa.S.C.A. § 2103(1). 40. Petitioners have calculated the amount of the Pennsylvania inheritance tax due on the full amount of the net settlement proceeds they propose allocating to the survival action. The applicable tax rate is 4.5% and the tax due on the full amount of the survival action proceeds is $2,812.50 ($62,500 x 0.045 = $2,812.50). Petitioner proposes holding that amount in escrow pending preparation of an inheritance tax return and payment of the tax due and owing. To the extent credits, deductions or exclusions reduce the amount of tax due, the difference will be distributed pro rata to Mrs. Dervisevic's intestate heirs, in the same proportion as the survival action proceeds are distributed. 41. Pursuant to the Wrongful Death Act and Pennsylvania law, proceeds of the wrongful death action pass to designated statutory beneficiaries, in this case the decedent's three children, Lutvo Dervisevic, Sejfudin Dervisevic, and Lutvija Cehajic in equal shares as funds would pass to those individuals under the Intestate Succession Act. 42 Pa.S.C.A. § 8301(b); Hodge v. Loveland, 456 Pa. Super. 188, 690 A.2d 243 (1997). 42. To the best of Petitioners' knowledge, the Department of Public Welfare has no claim or lien against Petitioner, the Estate of Saha Dervisevic, or any of the wrongful death 8 beneficiaries listed herein. (A copy of the letter from DPW indicating that they have no liens against decedent's estate is attached hereto, marked as "Exhibit K" and incorporated by reference). 43. Neither the Petitioner nor his counsel are aware of the existence of any other outstanding claims against decedent's Estate. 44. Pursuant to Senate Bill 1205, a lien search has been performed on decedent and beneficiaries, Lutvo Dervisevic, Sejfudin Dervisevic and Lutvija Cehajic regarding child support. (A true and correct copy of the results regarding such search is attached hereto, marked as "Exhibit L" and incorporated by reference. The social security numbers have been redacted). 45. The proposed distribution of the proceeds of the survival action and the wrongful death action to the decedent's heirs and beneficiaries as set forth herein is in accordance with applicable Pennsylvania law. 46. The settlement reached with all insurance carriers, the reimbursement of costs and payment of attorney's fees to plaintiffs' counsel, the allocation of the settlement proceeds to the survival action and to the wrongful death action, and the distribution of the settlement proceeds to the decedent's intestate heirs and statutory beneficiaries as set forth herein, are fair and reasonable under the circumstances and are in accordance with applicable Pennsylvania law. 47. All involved parties have reviewed and concur with this petition. WHEREFORE, your Petitioner, Sejfudin Dervisevic, Administrator of the Estate of Saha Dervisevic, deceased, respectfully requests your Honorable Court to enter an Order approving 9 said settlement of wrongful death and survival claims, directing the distribution of the proceeds in accordance with the averments of this petition. (717) 293-1400 Counsel for the Petitioner 10 Lancaster, PA 17602 VERIFICATION I, Sejfudin Dervisevic, Administrator of the Estate of Saha Dervisevic, hereby verify that the statements contained in this Petition for Approval of Settlement of Wrongful Death and Survival Claims, are true and correct, to the best of my knowledge, information and belief. I understand that false statements herein are subject to the penalties of 18 Pa.C.S.A. §4904 relating to unsworn falsification to authorities. 10`007 ?? J'!nx ??' Sejfud' Dervisevic, Administrator of the Estate of Saha Dervisevic Date CERTIFICATE OF SERVICE The undersigned hereby certifies that on this day a true and correct copy of Petition for Approval of Settlement of Wrongful Death and Survival Claims was served upon all interested parties via postage prepaid first class United States mail addressed as follows: Mary Altman Encompass Ins. Co. 333 Glen Street P.O. Box 5000 Glen Falls, NY 12801 Lisa Staff Allstate Ins. Co. P.O. Box 1064 Buffalo, NY 14240 By: 12. /to /,9w T Date Lancaster, PA 17602 (717) 293-1400 Attorney ID #: 75545 Attorneys for Plaintiffs A STATE OF PENNSYLVANIA SHORT CERTIFICATE COUNTY OF CUMBERLAND I, GLENDA FARNER STRASBAUGH Register for the Probate of Wills and Granting Letters of Administration in and for CUMBERLAND County, do hereby certify that on the 19th day of October, Two Thousand and Six, Letters of ADMINISTRATION in common form were granted by the Register of said County, on the estate of SAHA DERVISEVIC late of CARLISLE BOROUGH (First, Middle, Last) in said county, deceased, to SEIFUDIN DERVISEVIC (First, Middle, Last) and that same has not since been revoked. IN TESTIMONY WHEREOF, I have hereunto set my hand and affixed the seal of said office at CARLISLE, PENNSYLVANIA, this 19th day of October Two Thousand and Six. File No. 2006-00919 PA File No. 21- 06- 0919 Date of Death 912612006 S. S. # 164-80-1745 NOT VALID WITHOUT ORIGINAL SIGNATURE AND IMPRESSED SEAL el Unfi et iHardth Se? United Health Services Hospitals United Health Services Hospitals Inpatient Coding Summary Patient Name DERVISEVIC, SARA Sex Female Birth Date 011/0111946 Age fill MR Number 4848158 Billing Number 3006248036 Admit Date Discharge Date LOS Newborn Weight Financial Class Disposition 09124106 04:23 PM 09!26106 09:34 PM 2 N D8N Attending Physician CHISDAK, MICHAEL MD Coder Kathy Fairbrother Patient Type I Hosp Service ENC MDC Code / Text 004 DISEASES & DISORDERS OF THE RESPIRATORY SYSTEM DRG Code / Text 882 RESPIRATORY SYSTEM DIAGNOSIS W MV c96 HRS DRG Weight Average LOS Geornet is Mean LOS 4.6893 14.0000 Admit Diagnosis 80700 CLOSED FRACTURE, UNSPECIFIED RIB(S) Primary Diagnosis 86121 CONTUSION OF LUNG WITHOUT OPEN WOUND INTO THORAX Secondary Diagnosis 8074 FLAIL CHEST 86101 CONTUSION OF HEART WITHOUT OPEN WOUND INTO THORN( 51881 ACUTE RESPIRATORY FAILURE 5180 PULMONARY COLLAPSE (ATELECTASIS) 4275 CARDIAC ARREST 4150 ACUTE COR PULMONALE 9584 TRAUMATIC SHOCK 2752 ACIDOSIS E8121 MOTOR VEHICLE TRAFFIC ACCIDENT (COLLISION), PASSENGER (OTHER THAN MOTORCYCLE) 4019 ESSENTIAL HYPERTENSION, UNSPECIFIED BENIGN OR MALIGNANT 30000 ANXIETY STATE, UNSPECIFIED 2724 UNSPECIFIED HYPERLIPIDEMA 42731 ATRIAL FIBRILLATION Pr+ocedum Provider Date 9671 CONTINUOUS MECHANICAL VENTILATION FOR LESS THAN 96 CHISDAK, MICHAEL MD 09/26/06 9604 INSERTION OF ENDOTRACHEAL TUBE ALTSCHUL£R, ROBERT F MD 09/26/06 9960 CARDIOPULMONARY RESUSCITATION CHISDAK, MICHAEL MD 09/26/06 MR number: 4848158 Billing number. 5006246036 Patient name: DERVISEVIG, SAHA Admit date: 09124/06 04:23 PM Discharge date: 09126/06 09:34 PM Date printed: 10/21200610:51 PM UHS_Abst2Fm.doc 02/20106 TemPlate: Abst2fm3oc.doc Confidential Pag UNITED HEALTH SERVICES HOSPITALS Johnson City, NY HISTORY & PHYSICAL REPORT NAME: DERVISEVIC, SAHA MEDICAL RECORD #: 4848158 DATE OF BIRTH: 01/01/1946 LOCATION: ST3 B349A / DATE OF ADMISSION: 09/24/2006 RMS ADM #: 5006246036 0925 HISTORY OF PRESENT ILLNESS: Patient is a 60-year-old female who was involved in a motor accident in a van with other members of her family. This patient sustained some chest trauma. She was initially going to be sent home from the Emergency Room, but it became apparent that she was not able to go due to pain. PAST MEDICAL HISTORY: 1. High blood pressure. 2. Known atrial arrhythmia. 3. High cholesterol. 4. Anxiety disorder. PAST SURGICAL HISTORY: None. MEDICATIONS: 1. Norvasc 10 mg every day. 2. Lorazepam as needed for anxiety. 3. Lipitor 20 mg daily. 4. Lisinopril 40 mg daily. ALLERGIES; BYO K1VOWN DRUG ALLERGIES. REVIEW OF SYSTEMS: Cardiopulmonary: Difficult to obtain, but essentially she has no prior respiratory symptoms. She has cardiovascular disease as mentioned above. Gastrointestinal: No symptoms. Genitourinary: No symptoms. GYN: No symptoms. Neurologic: No symptoms. Musculoskeletal: Some occasional back pain. Page 1 of 3 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY HISTORY & PHYSICAL REPORT NAME: DERVISEVIC, SAHA PHYSICAL EXAMINATION: MEDICAL RECORD #: 4848158 General: This is a fig-year-old female who is lying on the stretcher, complaining of some left- sided chest pain. She otherwise seems to be comfortable. Vital Signs: Vital signs were stable in the Emergency Room. HEENT: Normocephalic, atraumatic. She has no obvious trauma to her face or scalp. Extraocular motions are intact. Neck: Supple. Normal range of motion. No bony abnormalities. No palpable abnormalities. Thyroid is normal. Supraclavicular and infraclavicular fossa are benign. Clavicles and shoulders: Clavicles are benign and both shoulders are benign. Lungs: Clear bilaterally. Y Heart: Irregular rate and rhythm; but normal S1, S2. Thorax: Sternum is benign. Her left lateral chest is tender in the inferior aspect of the chest wall with some ecchymosis. Her right chest is benign. Abdomen: Soft with positive bowel sounds. Nontender and nondistended. Groins: Benign. Pelvis: Benign. Extremities: Upper extremities are benign. Wrists and elbows are benign. Lower extremities show edema to the knees; otherwise with intact distal pulses. No obvious bony abnormalities. RADIOLOGIC DATA: CT scan of the chest and abdomen show rib fractures, but no evidence of any intraabdominal or intrathoracic injuries. Plain x-rays of the ribs demonstrate rib fractures in the lower several ribs on the left side. No evidence of pneumothorax. IMPRESSION: This is a fig-year-old female who sustained a chest contusion with multiple rib fractures. She will require admission to the hospital for observation for possible development of pulmonary contusion. Page 2 of 3 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY HISTORY & PHYSICAL REPORT NAME: DERVISEVIC, SAHA PLAN: 1. Supplemental oxygen. 2. Pain management. 3. IV fluids. 4. Repeat chest x-ray in the MEDICAL RECORD #: 4848158 Dictated by MICHAEL ARONIS - KSM D09125/2006 0102 T09/25/2006 0930 Page3of3 ,n ?:'?. ; UNITED HEALTH SERVICES HOSPITALS Johnson City, New York REPORT OF OPERATION NAME: DERVISEVIC, SAHA MEDICAL RECORD #: 4848158 DATE OF BIRTH: 01/01/1946 DATE OF OPERATION: 09/26/2006 SURGEON: Julia Miller, MD DATE OF ADMISSION: September 24, 2005. ATTENDING PHYSICIAN: Michael Aronis, MD. INDICATIONS: The patient with acute respiratory failure who self-extubated requires emergent reintubation. PROCEDURE: Endotracheal intubation. DESCRIPTION OF PROCEDURE: The patient was prernedicated with 5 mg of IV Versed and 50 mcg of IV fentanyl and a #3 Miller laryngoscope was used to visualize her vocal cords and 0.5 endotracheal tube was passed without difficulty and secured in place, 23 cm at the left. Good bilateral breath sounds were heard. The patient's saturation had been low prior to extubation and reintubation and came back up to her baseline, which was in the mid to high 80s. Dictated by Julia er, MD D: 09/25/2006 09:07 T: 09/28/2006 04:39 1 d'? hs: 178250 / 40112 / 39123 cc: Julia Miller, MD Michael Aronis, MD Page 1 of 1 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF CONSULTATION NAME: DERVISEVIC, SAHA MEDICAL RECORD #: 4848158 DATE OF BIRTH: 0 1/01 /1946 DATE OF ADMISSION: 09124/2006 DATE OF CONSULTATION: 09/26/2006 CONSULTING PHYSICIAN: John DiMenna, MD ATTENDING PHYSICIAN: Michael Aronis, MD REQUESTING PHYSICIAN: Julia Miller, MD CHIEF COMPLAINT: Hypotension. LOCATION: ICU BICU09., 0926 RMS ADM #: 5006246036 HISTORY OF PRESENT ILLNESS: I was called by the house staff to evaluate this patient with chest trauma after a motor vehicle accident. She apparently became hypotensive along with hypoxemia just after midnight and improved with fluid resuscitation. She was involved in a motor vehicle accident resulting in numerous rib fractures on the left. She apparently did not lose consciousness. She has apparently had a history of hypertension and some described arrhythmia. She was on prior to admission: 1. Norvasc 10 2. Lipitor 20 3. Lisinopril20 4. Lorazepam ALLERGIES: NONE KNOWN. SOCIAL HISTORY: She is a nonsmoker. FAMILY HISTORY: Another family member is hospitalized because of the accident. There is no family history of coronary disease. HOSPITAL COURSE: Most of the history is obtained through reviewing the chart and speaking with a granddaughter who is here to act as interpreter. So far she has been treated with analgesics and has had CT scans/x-rays showing multiple rib fractures. No pneumothorax, no significant brain injury. Page 1 of 3 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF CONSULTATION NAME: DERVISEVIC, SAHA MEDICAL RECORD M 4848158 PHYSICAL EXAMINATION: Blood pressure currently 109158, heart rate 100, regular. An elderly lady who is lying flat and appears uncomfortable. She has a washcloth on her forehead. HEENT: No evident facial trauma. Neck: No JVD, no carotid bruit, good upstroke. Heart: PMI not palpable. No pericardial rub. There is a faint apical murmur. No S3. Lungs: Clear. Abdomen: Nontender. Extremities: Numerous varicosities, mild ankle edema. No major traumatic findings. RADIOLOGY/LABORATORY DATA: EKG shows sinus tachycardia with nonspecific ST and T abnormalities. Chest x-ray has been reviewed and shows cardiomegaly. STAT bedside echo shows prominent right ventricular enlargement and hypokinesis, mild tricuspid and pulmonic valve insufficiency. No evident pulmonary hypertension. No pericardial effusion. Aortic root appears to be okay. CT scan of the chest also shows no evident aortic disruption. White count was elevated at 20.9, down to 13.9, hematocrit 39.3, down to 32.2, glucose 192 to 200, BUN 27, creatinine 1.4. Troponin elevated at 3.5. IMPRESSION: 1. 1 believe she probably has a right ventricular contusion resulting in hypotension, sinus tachycardia and elevated troponin. 2. History of hypertension with left ventricular hypertrophy. 3. Multiple rib fractures and probable lung contusion. Page 2 of 3 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY REPORT OF CONSULTATION NAME: DERVISEVIC, SAHA MEDICAL RECORD #: 4848458 PLAN: 1. 1 agree with ICU observation for arrhythmia and anti-arrhythmic medications as needed. 2. Repeat troponin will be done to assess the degree of myocardial injury. 3. Fluid resuscitation has helped with hypotension and should be continued, especially along with analgesics which may lower blood pressure. 4. I have explained the findings and plans to the patient's granddaughter who translated them. Dictated by JOHN D DIMENt SPM D09/26/2006 0306 T09/26/2006 0751 cc: Dr. M. Aronis Dr. J. Miller Page 3 of 3 iJUfNrdHaatth savices unite ,Health Services 40, Hospitals C 4W V ? InNai HospiW Visit ? Wpstisnt Consuft Note ? Pn"* Risk Assessment: Requesting M.D. indication: Cormrltant Notified: Date: T nw pate: q/a4L - Time: Chief Complaint and HPI: (IocatioNquaMWduratiorAmkWseverity/contexU Medications mod factors/associated signs and symptoms) GO ??? ?e.vn? w c..?xc 1 ?V G?Yc?SC /U rr?q Q c _ i m Vo I H VII s l -rdc"- 4r suski nRd n ")Q C-fy Z.o razc Pa on pr 6 a lower r; in -F-x. pt. c,Zs on A&'ay / -1 'fi3r ao rrn © ak l Arid C! e_g +0 Go > > t.N-)C'., P U 4? °n ' ' - ? % ?„? p p re ? ?•f U rY+q 6 d Lxl l -e-brec&f-,t+' g &Z -664S C o?r? up 4* l &- 1 1 o w 40' s - P4. Cuer4.r,+1 `t ca+Vditw 4o l 16 ow.tl a P 7p/[lo - ? Unable to obtain (indicate reason ? NKDA ANergies: REVIEW OF SYSTEMS ? All other systems negative Unable to obtain (indicate reason): WNt_ tents - P Of WN Comments - positive or Deninent rmoatives pertinent neg" Constitutional Integumntary Eyes Musculoskeletal EarsM t Neurologic Respiratory Psychiatric Cardiovascular Endocrinolo* Gastrointes" Hematologic Genitourinary Immunologic Past Msd/Su rg Hx: H-rn) 141fer ft pidtmock Arms i e-+-,, Family fix: ? non-contributory Sochd Hx: ? non-contributory ? Occupation ? MaiW Status ? Tobacco ? Alcotx*Substance use ? Outside records reviewed (placed in chart) ? See Lab Report - Date: ? See Radiology Report - Date: (Attending reviewed above data: M., 77 i s 91XI 4 G a 3 , y 2tao ?• 2 --T'ro oan r n page t D?.t v 5e vi c, 1?k AdmissiordConsult Form 59"709 mv. 1. Utd$odI*WthSKrWcet United Health Services Hospitals 2. MULTI-SYSTEM EXAMINATION • Elaborate abnormal findings* 43 0." Constitutional: T: P: _l 15^ r. at BP: 3 13 S*m , ht.: O sWstand 0 See Vital Sign Flow Sheet Eyes. P62- L Abdominal/Rectal/Genital: S W •:&? t A j d t A Risk s+t i i for Con aulft ta ENT: Lymphatic: Cardiac Risk ? MI within 6 months Neck: Extremities: w/U L O C wave on EKG ? Age over 70 years Respiratory: ?j Uat k t#-S Sian WAX ? Significant vahruiar Dx ? EKG other than Sinus Breast exam done by: M D Neuro: C?k.- M,5Fo?d5 }-o VentriculaF o ? Elec lyte ?Py imbalances El . . C D ? t'nwrd 5 Angina a Pap Smear. [I To be completed by hospital personnel Cardiovascular: „t,,??.?,`, ??d i ? , "°`" " Ply Risk ? t?ssry © Completed within 3 years ? Not feasible [3 Refused ? Other: ? r'vb-3, 0 MVtm Vir,S ? Smoking w/in 8 weeks ? Productive cough 3. MEDICAL DECISION MAKING: ? Diffuse ronchi/wheezes Assessment and Plan: (possible Dx/treatment options additional testingltherapeutic intervention) ? Suspected severe COPD ? Abdominallthoracic surge be rer.? ioc f Cud, u t ?q OTHER rn 2 - Co n 4 t ? V i d s r rro n e f?,? i1 U v ? History of bleeding ? Hypertension 3 - 3+r -* CAP, ? DVT prophylaxis ? Endocarditis prophylaxis © Thyroid disease ? Adrenal insufficiency ? Renal insufficiency 12 Az ? Hepatic insuffk*mcy t wre/wint: ? CA/Chemotherapy MS R2 R3 Fellow/Attending: ? 1 uppressed ATTENDING SUPPLEMENT: ? Alcohot/drug use ? Carotid stenosis (Mm. 7 element from 3 components, fustory, exam and medical decision making) ? Decreased nutritional state ? Bedridden ? Diabetes ? Pregnancy 0 Other risk factors (specify) ? See additional progress notes Counseling and/or Coordination of Care (min.): Total Attending unit/floor time (min.): Attending signatvrelprint: Date: ?0 r L? C C raae if 5BW709 rev. 1.05 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY DISCHARGE SUMMARY NAME: DERVISEVIC, SAHA MEDICAL RECORD #: 4848158 DATE OF BIRTH: 01/01/1946 LOCATION: ICU BICU09 1827 DATE OF ADMISSION: 09/24/2006 RMS ADM M 5006246036 DATE OF DISCHARGE: 09/26/2006 SUMMARY: The patient was involved in a motor vehicle accident with several members of her family. She was initially evaluated by the Emergency Room staff and the plan was to have her discharged from the ER. I was asked to evaluate the patient after she was unable to be discharged from the ER and on my evaluation, she appeared to be and needed to be admitted to the hospital for observation to rule out a cardiac contusion and undiagnosed traumas. The patient speaks English very poorly, but fortunately her granddaughter was present who could translate well for us. The patient complained of generalized aches and pains and was certainly not ready to be discharged. History and physical well outlined in the chart. The patient initially did fairly well with pain management and had a negative workup. There was no evidence of any ectopy in the first 24 hours. The patient was able to be advanced to a diet. On the second hospital day, she acutely decompensated, went into respiratory arrest, was coded unsuccessfully, and definitive diagnosis was thought to be pulmonary embolus. The patient's death note is in the chart from the physicians who attended to her at the time of her death. DISPOSITION: The body was released to the family for burial arrangements. Dictated by MICHAEL ARONIS MD SMB D10124/2006 1402 l b# p T10127/2006 1019 cc: Unsigned Report TMS report is neat filial until signed by PhYsieisn Page 1 of 1 United 44 ' 4 '*I IS a Health Services Hospitals C.1 - x; c t ???ai ?i Cc!L#':E P Release of Deceased F A ! lot x I authorize United Health Services Hospitals, Inc. to transfer the body of _a n ?d 4)eu Al r C NAME OF DECEASED who expired on at 3 a.m. / p.m. to J 'yy/ NAME AND ADDAVI WITNESS f p WITNESS (Necessary if telephone rahbase) DATE TIME Of FUNE HOME f?3- A M f _ i ; ?.3 I SIGNATURE OF PIEPRESPIRITATIVE TO DECEASED fl 7yC7 RELATIONSHIP OF REPRESENTATIVE (Spouse. Legal Guardian, Najd of DURING THIS ADMISSION PATIENT BEEN IN TYPE OF ISOLATION: IS(xATION? ?YES CANDIDATE FOR ANATOMICAL GIFTS IAO ORGAN PROCUREMENT AGENCY CALLED AT: (800.803.0667) SPOKE WITR AUTOPSY CRITERIA MET: OYES VINO i 7013 t 7 f !o - `i' / ATE AND TIMEFUNERAL DV- L?-.4 L 3?3.0 w m IF YES, CHECK CRITERION AND APPROACH FAMILY FOR CONSE!(T (MD PREFERRED) A. Expiraffam whie!r require nod icadan and autopsy request of the Coroner. B. EsPirai ons which squire autopsy by request of the V :11rng: MsdICAMxgicaf ?tion ? Cases which met Coroners criteria, but ware declined t ;y the Comer. O Unanticipated des fAt during or within 48 hours tok"V erxgary, irnrasive treatment andlor kwasWe dtagnoatic prncedrrre O Death of unknown etiology . ? Deaths during anesthesia or induction of anesthesia. p Patients who die in die samV of suspected or oonfinnsd sepsis who O Deaths associated with therapeutic misadventure: etiology andibr source d infection are undetermined. ? Patient who carry a diagnosis of cancer with unknown pdrnsry. ? Invasive diewXWX procedures ? Deaths not readily explained by the patient's condition at the time of h O kuwpmorisle or erronoaia nwdications O Famiy concems Q Deaths associated with omission of appropriate therapy ? Deaths when famiy members haw sWeaeed sicgniiiicsnt dissadw O Diagnostic procedures or teens with patient's care. O Dnig therapy ? Ruls out psnetie disaae& / Atzhiem O Forensic INerest 008 / Pediatric / Neonate! ? Natural deaths 04180e11lansous ? DOA at hospital ? Death due to pose be oca pational hazard OOcpxs within 24 hours of admission 0Death due to possUe erMtora hail hazard ? Deaths accompanied by unuwd c immistances ? Death of clinical trial patient O Deaths due to. or postrbiy due to. Inpatient traurne (i.e. Iraehrre sustained O Transplant Issue (i.e. a suspected Illness having a bearing on recipie by fal out of bal). donors of transpient ory.ns) AUTOPSY REQUEST MADE: Q=EMO // REQUESTED BY: = DING OFAb UTOP Y A S TO OF PERFORMED: 01N0 CONSENT: OYES ONO 010Th ER COMMENT: THE BODY OF THE ABOVE NAMED DECEASED, WrM T"E FOLLOWING PERSONAL IITEMS WAS RECEIVED BY ME ON THIS DATE PERSONAL PROPERTY TO MORGUE PERSONAL PROPERTY TO FUNERAL ESTABLISHMENT t 6 NURSE PREPARINGi BODY F TRANSFER CUR /TRANSPORTATION AIDE U RAL EC SECURITY AT10 RADIATION ALERT: ? YES VNO LICEPME NlA1A13ER AT TE I TIME OF RELEASE FUNERAL ESTABLIShWt 5106184PS rev 7.113 PART I - MEDICAL RECORDS PART 2 - QUALITY IMPROVEMENT PART 3 - MORGUE PART 4 - FUNERAL DIRECTOR UnftedHedlth Servim United Health Services Hospitals DERVJSEVIC, SAHA Emergency Deppartmen 500-624.6036 MR#: 4SU158 Physician/Provider DOB: 01/01/1946 F 60Y Order ADM DATE: 04/24/2006 17:47 MD Page (rev 05/21104) OOT Circle or check affirmatives, backslash 6) negatives bb oratory adin? arin? • CMP • CPK Cultures • Urine ? Wound ? Blood X • Throat • Rapid Strep • Amylase Blood • Lipase • O Nag • Hepatic P rofile • Type + Cross • Serum Acetone • FFP X • ESR • CRP • Type + Screen • T4 ? TSH Drug Levels • Monospot • ETOH • Ouant HOG • Digoxin • Urinalysis • Dilantin • Urine HOG • ASA - • Urine Tox Screen • Acetaminophen • Dip Urine • Theophyline • FS Gkicose Laboratory Psrmis • Cardiac (EKG, Troponin, BMP, CBC, PT/PTT, Did Records, CXR, Port or 2 View) • Abdomen (CBC, BMP, Lipase, Hepatic Profile, Dip Urine, Urine HOG) • CSF (Cell Count/W, Gram Stain, C and S, Glucose, Protein) • STD (DNA Chlam/GC, VDRL, Cervical Swab C and S, Urine HCG) Radiology All reque , tJde clinical indicators + Chest Pain • SOB rauma/Pain ? NN • Pain • LOC a WA he Portabl PA/LA omplete (Pneumott?orax) Abdomen • View • 3 View Spine e Cervical Thoracic • LS a Coccyx • Portable c a ? Contrast: & No BUN/Creat • Brain ace "• Spine: Cervical Thoracic Lumbo-Sacrz m ? Abdomen Ultrasound • Abdomen • Testicular • Pelvic: Trans ABDO Trans VAG ¦ HCG Venous Doppler • Leg: Left Flight Bilateral RN Orders • Cardiac Monitor 02via Pulse Ox • Saline Lock + Straight Cath • Bag for urine • Foley • NGT + IV IV 0 May be off monitor for testing/transport ? Yes ? No L Repeat: BP HR RR Temp • Consult: CPEP Detox Physical Therapy LSD Medication Orders • KG Holter Monitor • Echocardiogram Order Time Medication o"'°" melMir'ai espiratory Qs GEC • Albuterol 2.5 mg/Atrovent 0.5 mg X - :2- Z7V • Albuterol 2.5 mg X • Vaponephrine: ` 0.25 mU3cc NS < 6 mos. Z 0.50 ml/3cc NS > S mos. Rio odx,,:?a O(A4 avow • ABG Room Air 02 via • Peak Flow X1 Pre/Post ? Old Records G+IF?.I.TI IP'ff Resident /MLP Physician: 1 1' 4 ? b Y Patient: DERVISEVIC, SAHA MRN: 4848158 Encou n to r# : 5006246036 PCP: OOT 60y, F Clinical Report - Physicians Wilson Memorial Regional Medical Center Emergency Department 33-57 Harrison Street, Johnson City, Ny 13790 Phone: 607.763.6611 Fax: 607.763.6411 Registration Date/Time: 09/24/2006 17:43 Time Seen: 1750. Arrived- By ambulance. Historian -family. History limited by a language barrier. HISTORY OF PRESENT ILLNESS Chief Complaint- MOTOR VEHICLE COLLISION. Location of injuries- chest. The accident occurred just prior to arrival. The patient complains of moderate pain. No blow to the head, neck pain or loss of consciousness. Not dazed. Mechanism details- Cannot recall if wearing restraints. Patient was seated on the right side of the back seat. Impact was on the rear of the vehicle. The accident involved two vehicles and a moderate impact velocity and resulted in moderate damage to the patient's vehicle. Patient was ambulatory at the scene. REVIEW OF SYSTEMS The patient has had chest pain. No numbness, loss of vision, difficulty breathing, headache or nausea. No abdominal pain, laceration or vomiting. All systems otherwise negative, except as recorded above. PAST HISTORY Heart disease. Medications: See nurses notes. Allergies: See nurses notes. SOCIAL HISTORY Nonsmoker. No alcohol use. ADDITIONAL NOTES The nursing notes have been reviewed. PHYSICAL EXAM Appearance: Patient on a backboard. C-collar in place. Alert. Oriented X3. No acute distress. Vital Signs: Have been reviewed - Head: Head non-tender. No swelling of head. Eyes: EOM intact. ENT: No dental injury. Neck: Painless ROM. Non-tender. CVS: Abnormal rhythm. 216 systolic murmur. Respiratory: Chest wall injury: moderate tenderness located in the middle and left chest. No swelling. No laceration. No abrasion. No ecchymosis. No deformity. No splinting present. Abdomen: Abdomen soft and nontender. Back: No back tenderness. ROM normal. Skin; Skin intact. Normal skin color. Skin warm. 17 Extremities: Normal inspection. Extremities atraumatic. No lower extremity edema. Neuro: Oriented X 3. No motor deficit. LABS, X-RAYS, AND EKG EKG: Atrial fibrillation (ventricular rate ; 100 - 11 s). X-Rays: Chest X-ray. Chest X-ray: Moderately widened mediastinum versus patient Chest CT: Note (rib fractures 5th, 6th, 7th, 8th; small bilateral dependent effusions uand dependa presen parenchymal lung changes). p nt CT Abdomen: No acute disease. CBC: WBC 20.9 - Chemistries: Basic Metabolic Panel (Chem 8) - normal except as follows. Glucose - 195. PROGRESS AND PROCEDURES E.D. Course: 18:06. Fentanyi 75 mcg IV 22:50. Pt is offered admission for pain management and respiratory toilet support. Her family after discussing treatment plan w/ her, decide to take her home and seek admission at her local hospital in Carlisle, PA if her pain cannot be adequately controlled at home. Disposition: Condition: stable and improved. Discharged home in stable condition. CLINICAL IMPRESSION Multiple rib fractures . Atrial fibrillation . INSTRUCTIONS Use incentive spirometer every hour while awake. Prescription Medications: Ibuprofen 600mg tablets: take 1 tablet orally every 8 hours as needed for pain. Dispense 30. No refills. Percocet 5 mg/325 mg: take 1-2 tablets orally every 6 hours as needed for pain. Dispense twenty-five (25) No refill. Generic substitute OK. Fallow-up: Follow up with Doctor own doctor in Carlisle, PA-- bring labs, EKG, CT report to appointment in two days. (Electronically signed by Theodore Petkov, MD 09/24/2006 22:59) Addenda for DERVISEVIC, SAHA MRN:4848158 VisitlD: 5006246038 Date: 09/24/2006 9/24/2006 23:47 when placing pt in we she became diaphoretic dizzy, also pt has been fasting all day due to a religious holiday. m ealrpak gin' dr.petkov aware.morphine 4mg sc rt. deltoid. MIearoniaW signed Amy Stone R.N.. 912442008 23:47) Patient: DERVISEVIC, SAHA MRN: 4848158 Encounter#: 5006246036 PCP: OOT 60y, F Clinical Report - Nurses Wilson Memorial Regional Medical Center Emergency Department 33-57 Harrison Street, Johnson City, Ny 13790 Phone: 607.763.6611 Fax: 607.763.6411 Registration Date/Time: 09/24/2006 17:43 MVC chest pain TRIAGE Initial Assessment Triage time 1740. Acuity: LEVEL 2. SP: 97172. HR: 118. RR: 30. 02 saturation: 89 % room air. Alert. Weight = 200 lbs. (estimated). Height = 65 in (estimated). --1746 Marne King, R.N. Medications Medication history unknown. --1746 Marne King, R.N. Allergies Allergy history unknown. --1746 Marne King, R.N. History Chief Complaint: MOTOR VEHICLE COLLISION. Location of injuries (chest pain/rib pain). Pain level at this time described as moderate - PAST HX: Unknown. Tetanus status: unknown. Immunizations: status is unknown. Arrived by EMS and arrived (broome). Historian: none. Primary physician ( unknown). --1746 Marne King, R.N. PHYSICAL ASSESSMENT To room via stretcher. Appears in pain. The patient is alert, appears uncomfortable, shows no apparent trauma and has normal color for race. The patient is pale and well hydrated, appears restless and flat affect and is cooperative. The patient is obese, exhibits normal mobility, appearance is consistent with stated age and is well developed and well dressed. Chest wall: moderate tenderness. Moderately decreased breath sounds bilaterally. Normal sinus rhythm noted. Abdomen soft and nontender. Extremities exhibit normal ROM. Neuro-vascular status intact to the extremity. --1748 Marne King, R.N. NURSING PROGRESS NOTES Progress Two patient identifiers checked. Oxygen increased to 3 liters by nasal cannula. C-collar applied. Patient placed on backboard. Cardiac monitor, pulse oximeter and NISP monitor placed on patient. Call light placed in reach. Side rails up x 2. Bed placed in lowest position. Brakes of bed on. Patient ready for evaluation - ED physician notified. --1748 Marne King, R.N. FENTANYL 75 slow IVP. IV patency established. IV site checked: no pain, redness, or swelling. IV flushed thoroughly pre- and post-medication administration. . --1808 Marne King, R.N. Blood samples drawn by lab per protocol and sent to lab. --1842 Marne King, R.N. IV started prior to arrival: #1 site, right hand. --1842 Marne King, R.N. Patient transported to radiology by stretcher with tech. --1854 Marne King, R.N. Visit# 5006140;(12h AT-- Cll:-, ( report from xray. patient possibly had a vagel response apon sitting up for 2 view xray, trendeleburg anc fluids opened up.). --1923 Marne King, R. N. BP: 115 / 53. HR: 65. Patient returned from radiology by stretcher with tech. --1943 Marne King, R.N. BP: 109161. HR: 118. RR: 28. Temp: 97.8 oral. 02 saturation: 95 % on 02 (at 2 liters/minute). --2018 Marne King, R.N. Late entry - patient doesnt speak english, younger family members attempting to translate for patient. patient transported to CT. --2059 Marne King, R.N. Patient reports current pain (patients family interperted that the patients pain is the same, not getting worse or better). Overall patient status is the same - the patient states feels same. --2131 Marne King, R.N. Late entry - 2120. Patient returned from CT by stretcher with tech. --2131 Marne King, R.N. IV / 180 Flowsheet IV fluid started - #2 bag NS 1000 mL. Rate - wide open. --2131 Marne King, R.N. DISPOSITION 1 DISCHARGE BP: 110 / 51. HR: 121. RR: 24. Temp: 97.8 oral. 02 saturation: 93 % room air. Patient reports pain level on departure as 4/10. Condition at departure: unchanged. Discontinued: IV site (IV catheter intact). Fall risk assessment completed. No fall risk identified. No learning barriers present. Discharge instructions reviewed with the patient. Reviewed warnings. Reviewed medication. Treatments reviewed. Reviewed referrals. Patient verbalized understanding. Written instructions provided in English. The patient was discharged home and accompanied by family. The patient left the Emergency Department in wheelchair and via private vehicle. Family member driving. Patient has no belongings. Departure time: 23:25. --2325 Marne King, R.N. Locked/Released at 09/24/2006 23:25 by Marne King, R.N. DE VI EVIC SARA 3 of 3 09/24/2006 17:43 MR# 4848158 Visi # 50062464 6 P sici n Clinical R rt ? 9/25/2006 0:35 At time of discharge pt vecame diaphoretic with sitting and had increased pain at site of her broken ribs; due to her long drive (3 hours) to her home in PA, family reconsidered and requested that she be admitted. Dr. Aronis (trauma) contacts and will see pt in ED and facilitate in-patient care in terms of pain control and further stabilization. (Electronically signed Theodore Pelkov MD - 9!25/2008 4:35) 9/25/2006 0:50 0015 attempted to get pt oob to wc. family uncooperative stating pt was unable to get up. pt sat at bedside. by 109/62 pulse 90. sat 1000/6 ra. resp 24. no diaphoresis . no paleness. states no pain. drank juice and ate pretzies. returned to bed with assist. pt normally walks ad lib. family at bedside. dr.petkov aware. discussed admission with family (EIedronicaky signed Amy Stone R-N. - 9/25!2006 0:50) 9/25/2006 0:50 late entry 0030 papers out for admission (Electronically signed Amy Slone R.N. - 9/25/2006 0:S0) 9/26/20061:57 taxed report recieved by becky m . reviewed report sheet. by 116/68, hr 102, rr 20 o2 sat 99% resp reg and easy. denies dizziness at this time {Electronically signed Amy Stone R.N. - "..02" 1:57) Genera! Discharge Instructions Wilson Memorial Regional Medical Center - Emergency Department 33-57 Harrison Street, Johnson City, Ny 13790 Phone: 607.763.6611 Fax: 607.763.6411 09/24/2006 -------------------------- Patient Name: DERVISEVIC, SAHA MRN: 4848158 Encounter#:5006246036 Thank you for visiting the Wilson Memorial Regional Medical Center-Emergency Department. You have been evaluated today by Theodore Petkov, MD for the following conditions): Multiple rib fractures . Atrial fibrillation . INSTRUCTIONS Use incentive spirometer every hour while awake. Prescription Medications: Ibuprofen 600mg tablets: take 1 tablet orally every 8 hours as needed for pain. Dispense 30. No refills. Percocet 5 mg/325 mg: take 1-2 tablets orally every 6 hours as needed for pain. Dispense twenty-five (25; No refill. Generic substitute OK. Follow-up: Follow up with Doctor own doctor in Carlisle, PA-- bring labs, EKG, CT report to appointment in two days. Note: If x-rays were taken they will be reviewed by a radiologist. You will be notified of any new findings that may affect your care. Although not common, it is possible that a fracture can be present that cannot be seen on the initial set of x-rays. A fracture such as this can often be seen after some time has passed or a different type of imaging, such as bone scan, CT, or other devices are used. You have been given the following additional information: RIB FRACTURE MEDICATION: PERCOCET Patient Signature (Date/Time) General Discharge Instructions Wilson Memorial Regional Medical Center - Emergency Department 33-57 Harrison Street, Johnson City, Ny 13790 Phone: 607.763.6611 Fax. 607.763.6411 0=4/2006 Patient Name: DERVISEVIC, SAHA Thank you for visiting the Wilson Memorial Regional Medical Center-Emergency Department. You have been evaluated today by Theodore Petkov, MD for the following condition(s): Multiple rib fractures. Atrial fibrillation . INSTRUCTIONS Use incentive spirometer every hour while awake. Prescription Medications: Ibuprofen 600mg tablets: take 1 tablet orally every 8 hours as needed for pain. Dispense 30. No refills. Percocet 5 mg/325 mg: take 1-2 tablets orally every 6 hours as needed for pain. Dispense twenty-five (25) No refill. Generic substitute OK. Follow-up: Follow up with Doctor own doctor in Carlisle, PA-- bring labs, EKG, CT report to appointment in two days. Note: If x-rays were taken they will be reviewed by a radiologist. You will be notified of any new findings that may affect your care. Although not common, it is possible that a fracture can be present that cannot be seen on the initial set of x-rays. A fracture such as this can often be seen after some time has passed or a different type of imaging, such as bone scan, CT, or other devices are used. ADDITIONAL INFORMATION RIB FRACTURE A fracture is the medical term for a broken bone. Rib fractures do not require a cast like other bones. They will heal by themselves in 3-4 weeks. The first two weeks will be the most painful because breathing, twitching and bending may cause the broken ends to move slightly. Home Care: 1) Rest. You should not be doing any heavy lifting or strenuous exertion during this time. 2) You may take Tylenol (acetaminophen) or ibuprofen (Advil, Motrin) for pain unless another medicine was prescribed. 3) If you were given a Rib Belt to wear, it will reduce pain by limiting the motion of your chest wall. If worn continuously, this limited motion can sometimes cause other problems from reduced airflow into your lungs. You can avoid these problems by taking four very deep breaths at least four times a day (exhale through pursed lips as if you are blowing up a balloon). If possible, blow up a balloon or rubber glove. This exercise may cause some pain at your fracture site. This pain is normal. Follow up with your doctor during the next week or as advised. Rarely, a broken rib will cause complications within the first few days that will not be evident during your initial exam (such as, collapsed Exitwriter Instructions 2 of 2 ?vvv i ?? ?v1tc 4t34ZS 158 Visi lung, bleeding around the lung, pneumonia). [Note: If x-rays were taken, they will be reviewed by a radiologist. You will be notified of any new findin s that may aff ect your care.] g Return Promptly or contact your doctor if any of the following occur: -- Shortness of breath -- increasing chest pain with breathing Dizziness, weakness or fainting -- New or worsening abdominal pain MEDICATION: PERCOCET Percocet (generic: oxycodone and acetaminophen; other brand names: Tylox, Endocet, Roxicet, Oxycet ) is a narcotic pain medicine. Be sure to take it only as directed. Directions For Use: If this medicine makes your stomach upset, take it with food. Pain medicine should be taken only if needec at the times prescribed. If you are not having pain, do not take the medicine unless you are advised to do so by your doctor. What to Watch For Possible Side Effects: Dizziness, drowsiness --> (Take a smaller dose: break the pill in half or take it less often). Constipation --> (Drink lots of liquids, use small doses of a mild laxative like Milk of Magnesia as needed). Nausea, vomiting --> (Take the medicine with food). Difficulty passing urine --> (Stop the medicine and contact your doctor). Allergic Reaction: Rash, itching, swelling, trouble breathing or swallowing --> (Contact your doctor or return to this facility promptly). Important ***••+.+t. Medical Conditions: Before starting this medicine, be sure your doctor knows if you have any of the following conditions: -- Prostate enlargement, liver disease, chronic alcoholism -- Pregnancy or breast feeding Drug Interactions: -- Barbiturates, Tegretol (carbamazepine), Dilantin (phenytoin), Rdampin -- Cournadin (warfarin) -- Retrovir (AZT or zidovudine) Warnings: -- Do not Drive, ride a bicycle or operate dangerous equipment while taking this medicine until you know how it will affect you. -- This drug may cause increased side effects when taken with alcohol, muscle relaxant, sedative, tricyclic antidepressants, MAO-inhibitor or another pain medicine. -- Prolonged use of this medicine can be Habit Forming and may lead to Addiction. UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT RADIOLOGY CURR LOC: ICU-BI0009 ORD NO: 90002 NAME: DERVISEVIC SAHA REQST LOC: EMD PT CLASS: E MRM , 4848158 INFO. AT TIME DERVISEVIC, SAHA DOB: 01/01/1946 AGE: 60Y OF THE EXAM DOB 01/01/1946 MR#4848158 ADM# 5006246036 FC S ORDERING: THEODORE PETKOV MD ATTENDING: PHYSICIAN 000000 UNLISTED WMHER 33-57 HARRISON ST JOHNSON CITY, NY 13790 13790 COPIED: PROCEDURE: CHEST. V VIEW X-RAY ORD#:90802 EXAM DATE: 09/24/2006 19:33 ACC#:4783230 -REPORT: Clinical Indication: Trauma. Supine AP chest radiograph is obtained. We have no previous studies for comparison, The patient appears large. Cardiac size is enlarged. The pulmonary vascularity is prominent. There is an increase in the interstitium. There is no pneumothorax or pleural effusion although the current study is obtained in the supine projection limiting assessment for a pneumothorax. -IMPRESSION: Cardiomegaly. There may be mild pulmonary vascular congestion although in part this may be accounted for by a limited depth of inspiration and projection. Suspect underlying interstitial lung disease. No pneumothorax. READING RADIOLOGIST: ELECTRONIC SIGNATURE: ANDREA ROTHE MD ANDREA ROTHE MD ORDERED BY: THEODORE PETKOV MD TRANSCRIBED: by DMT on 09125/2006 11:05 ADM# 5006246036 ......... .?-- --- - DATE OF DICTATION: 09/24/2006 19:34 BEADING RADIOLOGIST: DATE OF TRANSCRIPTION: 09/25/2006 11:05 ELECTRONICALLY SIGNED BY: TRANSCRIPTIONIST: OUT SIGNED ON: Con aiitq fi?otTce ?rtfornat+orI in 1his3iwnmen`tTfaxmi Fnv e6-en ?`fo y0y_1iram recwifi ca regulations and stale laws prohibit you from making funkier disGosura of such Information without the sperJfic wrftte, or as otherwise permitted by such reytAations- A general authorization for the release of medical or other lnformatN information is not the intonded mclpiero- you are hereby notified that a?wntyy use, dissemination. disc ImAon or re duo this information in am. please immediately notify us at 6()7.7le and /alum Oft doewnenVrax to United H RNM*Ml Medical Center. 3357 Harrison Johnson City, NY 13790 via U.S. Postal Service. Thank You. Printed : Sep 26 2006 9:20AM _-- ANDREA ROTHE MO ANDREA ROTHE MD _ 09/26/2006 09:20 er+bali?proier?ed?federa-T awn `sta`re of ws? Feuer'--Tor mserd of the parson to whom the information pertains t NOT sufficient for this Purpose. If the reader of this d this rnrorm;l "on is strictly wahibrted. ir you racaived h Sonritxa. RadioWy Department, Wilson Memonal Page 1 of 1 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT RADIOLOGY CURR LOC: ST3-8349A ORD NO: 90003 REOST LOC: EMD PT CLASS: E NAME: DERVISEVIC, SAHA INFO. AT TIME DERVISEVIC, SAHA MR#: 4$48'15$ OF THE EXAM 008 01/01/1946 MR# 4848158 DOB: 0146 AGE: 60Y ADM# 50006246624$036 fC S ORDERING: THEODORE PETKOV MD ATTENDING: WMHER 33-57 HARRISON ST UMA 30 MICHAEL AR HARRISOSO MD JOHNSON CITY, NY 13T90 N S455 JOHNSON CITY, NY 13790 COPIED: PROCEDURE: LEFT -RIBS, UNILATERAL. X-RAY EXAM DATE: 09/24/2006 20:46 ACC#: #: 478 4783003 3233 -REPORT: History of trauma. Examination of the left ribs show fracture of the 6t', 7t', 8th, 9th and possibly 10'h ribs on the left side. Mild displacement of the fracture fragment is seen. No evidence of pneumothorax or hemothorax is identified at this time. No definite contusion in the left lung is seen at this time. -IMPRESSION: Multiple rib fractures on the left side. READING RADIOLOGIST: CHANGA S NATARAJAN MD ORDERED BY: THEODORE PETKOV MD TRANSCRIBED: by KMC on 09/25/2006 13:59 ELECTRONIC SIGNATURE: CHANGA S NATARAJAN MD ADM# 5006246036 DATE OF DICTATION: 09/25/2006 09:12 DATE OF TRANSCRIPTION: 09/25/2006 13:59 READING RADIOLOGIST: -- CHANGA S NATARAJAN MD TRANSCRIPTIONIST: KMC ELECTRONICALLY SIGNED BY. CHANGA S NATARA IAN MD SIGNED ON: '°" Md U061 Tfiein, +a tionn?re-doaumerif/ raf+x iiay' relatioM ne and slats laws prohbtl you from ?y?' yu fiave-been tom raoo?3s w?i oon-i rrali ecie? ?ede?aTer??TawsB 1654 or ai ONlenwiSe permitted t7y such reputations. A?yenere authorization for 11 a "'fom?ation wlUaut tt?e specific writisn Consent of?a person 10 +vhorn the . aT intom?affon is not Mee intended redpisnt, you ors release of medical or other information is NOT suficient far >his u stfOrrrratlon penar+s this inlorrrsltlcn ? era. please Immediately n hereby notified that any use. dissernN?dion, distribution or reproduction Of this inbrmation is p use' It tlr roeder of trtis R ?d Madlnl Center 33-37 Harrison St, Joh_n?s_onuClly, N 13 o viaW U.S P lostal S?eivdice? Tl a?aYO?u, United lisa?th Services. ' ??Olted. if you received Printed :Sep 25 2006 4:54PM - __ __ _.__._._ - ?O? ? tNtison Wkmonal Pape i of 1 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER r IMAGING SERVICES REPORT C.T. SCAN CURR LOC: ICU-BI0009 REQS7 LOC: EMD ORD NO: 90005 NAME: DERVISEVIC SAHA INFO. AT TIME DERVISEVIC SAHA PT CLASS: E MR#: , 4848158 , OF THE EXAM DOB 01/01/1946 1yR#ggg815g DOB: ADI1A# 01/01/194fi AGE: 60Y 5006246036 FC N ORDERING: THEODORE PETKOV MD ATTENDING: WMHER 33-57 HARRISON ST MICHAEL AROMS; MD JOHNSON CITY, NY 13790 UMA 30 HARWSON S455 JOHNSON CITY, NY 13790 COPIED: PROCEDURE: CT THORAX, !CONTRAST EXAM DATE: 09/24/2006 21:31 ORD#:3 ACC#: 478383317 17 -REPORT: INDICATIONS: 60 -year-old involved in MVA. No oral contrast was ingested. 100 cc Visipaque was injected. Axial images are provided through chest, abdomen and pelvis and coronal reconstructed images derived. CT abdomen and pelvis are dictated separately. The lungs appear to be at fairly low volumes. There are small bilateral pleural effusions and most dependent atelectasis, infiltrates or perhaps contusions, this is without particular focality. Lungs are mildly hazy elsewhere either atelectasis or, perhaps related to the low lung volumes. There is no pneumothorax. There is small density along the right wall of the trachea extending into the origin of the right main bronchus presumably mucous. No endobronchial abnormalities are seen otherwise. There is no evidence for aortic injury or mediastinal bleeding. There are bilateral hilar and mediastinal nodes particularly subcarinal which are mostly calcified. Multiple nodules are seen in the thyroid, likely a multinodular goiter, this could be further assessed with ultrasound. Multiple bilateral rib fractures are seen, left more than right, some of the deformities may be chronic related to previous trauma. -IMPRESSION: Bilateral rib fractures. No pneumothorax. Small effusions and mostly bilateral lower lobe atelectasis/pneumoniarinfiltrates. Calcified nodes compatible with granulomatous disease. Multinodular thyroid. READING RADIOLOGIST: ELECTRONIC SIGNATURE: ANDREW M GOLDSCHMIDT MD ANDREW M GOLDSCHMIDT MD ORDERED BY: THEODORE PETKOV MD ADM# 5006246036 TRANSCRIBED: by KMC on 0912812006 14:52 DATE OF DICTATION: 49/27/2006 14:47 READING RADIOLOGIST: ANDREW M GOLDSCHMIDT MD DATE OF TRANSCRIPTION: 09/2&200614:52 ELECTRONICALLY SIGNED BY. TRANSCRIPTIONIST: KMC SIGNED ON: ANDREW M GOIDSCHMIOT MD ?Y =' in 'aeon iinn-in icunenflraic may fjave -"?4 ?--- 09/28/200616:36 - YOU rogutatiorrs and state laws prohibit you from making Itxfher disclosura of such Wonnation wftm to ?pg?y?„?°Qn i1y ? to in es OJMwisO Perm itted by such regulations. A general authorization for the release of medical or other WomTkow is NOT a? sulliciem M awtwm the intom?stion Pertains intprmation ation i s not the intended r you ors hereby r1olfRed that any use, dfuentination, distribution or Purpose- it on warder of this for iMOrmaflon in error, plus == i repraduclion of this informailon is stri this ProMblisd. K you received IN? _ ately rroUfy us at 807-763 tS104 and return this documenNfax to Unged Health cgY Services. RadiobDy peparen?k Wilsor? Memorial R Cenfe?• 3357 Flarrisan t Johnson Wl+ 13790 via U.S. Postal Service. Thank You. Printed : Sep 28 2006 4:37PM ?51.-?.-....._ -----_ . - Page 1 011 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT r?1 ton r r%^_ C.T. SCAN °- "'u-tHL;UOg ORD NO: 90005 REQST LOC: EMD PT CLASS: E INFO. AT TIME DERVISEVIC, SAHA OF THE EXAM DOD 01/01/1946 MR# 4848158 nRnr orur_. NAME: DERVISEVIC, SAHA MR#: 4848156 DOB: 01/01/1946 AGE: 60Y ADM# 5006246036 FC N THEODORE PETKOV MD ATTENDING: WMHER 33-57 HARRISON ST MICHAEL ARONIS MD JOHNSON CITY, NY 13790 U? 30 HARR 137- JOHNSON CITY. , N NY 13790 COPIED: PROCEDURE: C A D EN E VI / NT ST EXAM DATE: 09/24/2006 21:32 -REPORT: History of trauma. ORD#:90003 ACC#: 4783315 There are bilateral flank hematomas. There are marked degenerative changes in the lumbar spine including vacuum disc deformity and possible protrusion of the disc at 1-5-S T where there is a gas bubble within the canal here. I would recommend MR to better evaluate this. The kidneys, liver, spleen and surrounding tissues are within normal limits. There is no free intraperitoneal fluid nor localized hematoma. There are no fractures seen below the diaphragm. -IMPRESSION: No acute intraabdominal pathology. READING RADIOLOGIST. MICHAEL R STONE MD ORDERED BY: THEODORE PETKOV MD TRANSCRIBED: by DLW on 09/26/2006 14:34 -...... ....__..... __...-. DATE OF DICTATION: 09/25120M 16:47 DATE OF TRANSCRIPTION: 09/26/2006 14:34 TRANSCRIPTIONIST: DLW C-ai W Aye. T`iaTnfoirima?on in $1?s3ocixry'?j ds Mato or a oU Wn W° c you from making funk by? regulations. A general information is ttte intended recipient, you are heretsy n Information in error, Obese imrriately notify us al Regional Medical Center, 33-57 Hankon_ St dohr?son CAM Printed : Sep 26 2006 9:46PM ELECTRONIC SIGNATURE: MICHAEL R STONE MD ADM# 5006246036 READING RADIOLOGIST: ELECTRONICALLY SIGNED BY: SIGNED ON: -f -C0 e of such infarmakm without the aperjfic "to an for the rdsase of madiml or other informatkc any use. dissemination, dsolhution or reproduce 144 and retum this documentAaz to t)nited Fk -`na -US- Postal Service. Thank You. MICHAEL R STONE MD MICHAEL R STONE MD 05V2612006 21:46 tonserR cflha ••• revere' Pew to whom the i is NOT lysuRkl6m d6m for this purpose. WMnedw M the roader of pertains tly prohibited. Ngyou received wt of this Informati tion is stricep?tment, Memorial rNh Services. Radiology D Page Iof I C _ _ 1 - - - ET -- 1 = 71 ZZIC 1 ,: _ _ - _ ---_ -- - --' .. - - =. ............... a f v, [ _ -- - -- - - - - - ?P - - tip - _; ---_ :i - _ - - - - - .:::.. -r- - -- _ - 'j a• rJ'O':, _ _ is _ - =_ -- _ - - - - - j - - - :i: - - _ --i - _ - - -' P -- i' - - : - ' 77, ??•- ice- - _- T" -- 77- ;m ?r UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT CURR Lac: REQST LOC: INFO. AT TIME OF THE EXAM ICU-810009 / ORD NO: 90007 ST3 PT CLASS: E DERVISEVIC, SAHA DOS 01101/1946 MR# 4848158 DRDE9ijun. RADIOLOGY NAME: DERVISEVIC, SAHA MR#: 4848158 DOB: 01/01/1946 AGE: 60Y ADM# 5006246036 FC S MICHAEL ARONIS MID UMA 30 HARRISON S455 JOHNSON CITY, NY 13790 COPIED, PROCEDURE: E-ST. 1 VIEW X-RAY EXAM DATE: 09/25/2406 09:34 -REPORT: ORD#:90007 ACC#: 4783747 Examination of the chest done in AP upright view at bedside shows cardiom al , Bilateral basal atelectasis is seen at this time. No pneumothorax is identified. small effusion on the left side cannot be excluded. READING RADIOLOGIST: CHANGA S NATARAJAN MD ORDERED BY: MICHAEL ARONIS MD TRANSCRIBED: by JAK on 09/26/2006 06:40 ELECTRONIC SIGNATURE: CHANGA S NATARAJAN MD ADM# 5006246036 GATE OF DICTA710N: - ----- • -----.. _.._._._.._.. _ _ DATE OF TRANSCRIPTION: 09/09/26/2006 06:40 READING RADIOLOGIST: ` ?- CHANGA S - A S N ELECTRONICALLY SIGNED BY: ATARAJAN MD TRANSCRIPTIONIST: JAK SIGNED ON: CHANGA S NATARAJAN MD Tcs-T?e=' `'a is documental may FliaveerT discl5W- o ?? state levee maki fort yo-„-?'?^; .+,1, can?da?i?alF yt-p?o?d-lj, 0912&2006 09:23 by 9uctr reprriatbns. A diatloe of such ir?omration without the speCiflc written consent ofpthe Inbrmetign k not t nt? n? ' 9er al autho?iyatton for the rabase a( rr l a other inbrtru6p? is NOT sufficie?i?t tl pe-dains IRegional lrs in(gtmelion in ennr, Plasee ee are hereby notified that 8ny use. digsernination. dlstri6ution or roprodudion at tltis infom?atian !sOi° ft the reader of this Iriedical_Center. 3357 Hartig ?Jotruon at 807-7d3-614 and velum fftie doaaner?vfax to Unifod Health Services, tY WofWCited. If You received Prlrlted :Sep 2t3 2006 9:23AM .. ? LNY 13790 uia U.S. F?astel Service. Thank You. _^ __?. ?? ?Pa. Wilson IlAernor;? ATTENDING: MICHAEL ARONIS MD LIMA 30 HARRISON S455 JOHNSON CITY, NY 13790 Pape 1 of 1 UNITED HEALTH SERVICES HOSPITALS , WILSON MEMORIAL REGIONAL MEDICAL CENTER ? IMAGING SERVICES REPORT RADIOLOGY CURR LOC: ICU-BI0009 ORD NO: 90010 NAME: DERVISEVIC, SAHA REQST LOC: ST3 PT CLASS: I MR#: 4848958 INFO. AT TIME DERMSEVIC, SAHA DOB: 01/01/1946 OF THE EXAM DOB 01101/1946 MR# 4848158 AGE: 60Y ADM# 5006246036 FC S ORDERING' ATTENDING: MICHAEL ARONIS MD MICHAEL ARONIS MD LIMA 30 HARRISON S455 UMA 30 HARRISON S455 JOHNSON CITY, NY 13790 JOHNSON CITY, NY 13790 COPIED: PROCEDURE: C14EST, I VIEW X-RAY 9 EXAM DATE: 09125/2006-20:03 ACC#: 47 O 47844869 869 -REPORT: There are nondisplaced left rib fractures. There is no pneumothorax. There is no fluid collection. The mediastinum is stable. There is vascular congestion. READING RADIOLOGIST: ELECTRONIC SIGNATURE: MICHAEL R STONE MD MICHAEL R STONE MD ORDERED BY: MICHAEL ARONIS MD ADM# 5006246436 TRANSCRIBED: by DLW on D9/26t20o6 94:35 DATE OF DICTATION: 0925/2006 20:17 '- - - -- _ READING RADIOLOGIST; DATE OF TRANSCRIPTION: 09/26@00614:35 ELECTRONICALLY SIGNED 8Y: MICHAEL R STONE MD TRANSCRIPTIONIST: DLW SIGNED ON: MICHAEL R STONE MO Con?enUafity F)-ii T e n _.-_._...twnin fws--d0-CUam_ fax m _ 09/26/2006 . 21.46 regulations and stab laws Prohibit aY-_b?en d"n-16 ypu' orb"records w t con otheirwise you from making further dbcbsure of such information without the I? ?? a^ s Feaera-T U=ld ' int. yy such regulations. A general authorization for the release of medical or otheir written consent of the person to whom the intbrrnatlon pertairwt iofo?r etion Is dad redp %, are ^larrnatipn 1s NOT suf ci" br this this iMarmation in error, rn Yo hereby notified that any use. dissemination, distribtrtion or reproduction of this Wanna m is strictly prohibited. if y?rie oiwd i notify us at 607-783 8104 and nAm this dorameMlfax Hard U_S.Postposes al to United Health Services, Radiology De"nment, Wbbn Afemof•al R_al Medical Cellar. 57 son St Y J, ohnson Citv?NY 13790 via Servk:e. ttarrc You. _ Printed: Sep 26 2006 9:46PM T Page 1 of 1 71 Z --_ - _ - - _ a°- - - -----F_ - _ -- _ ell - • - - _ _- - f7 7 L. L. 7:t =F-_ _ I - r- - j rz .0 A: 77. Ld 7:1 =. .. ,? a - -- --.- --- - + 77 Z v N r - j: _ - - - - - - --- - - - -- - op n00nfrj _. -777 Q ----.:?.. __ - f- - - -...: .7': 77 Q a C~ LA .77= - - f - itr -?........ 'ZU 777 :a - - _ - r..... - _ _i_: _ •? -- -- - -- --- - - - - .... . .. x .a - - t- •?.-'__*_-_ _'?_-- '--?_. -- -- ---------- r ?L. - -- _ ---- _ -- - - - - _? __ --_-- i -- 77 -H L 77 J?: 77 r ? ? ~ .?;?.? i - - - - _ '__' - - _ - : _?-_ - - :1: -. :-t_- Vii' :- - _ •t r. 7 3 t - - - _ -- - -- ---- - - ----- ..? _ . - - - L, 177? w 40 0.t ? G 042 - t i__ CO Co 7- Z- ?L?i r, -- - - -- - _ -;???. - :jam-_ 1...:7. _ :1-`::: - :... - •,- -'-} -r --{ UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT RADIOLOGY cuRR Lac: oRD nlo: 90011 C REOST URB LOC: ICU NAME: DERVISEVIC, SAHA INFO. AT TIME DERViSEVIC, SAHAPT CLASS. 1 MR#: 484$1'5$ DOB: 01/01/1946 OF THE EXAM DOB 01101/9946 MR# 4848158 ADM # 5 50062 00624660303 AGE: 60Y 6 FC N ORDERING: REGINA FRANTS MD ATTENDING: UMA BOt RIVERSIDE DR MICHAEL ARONIS MD JOHNSON CITY, NY 13790 UMA 30 HARRISON S455 JOHNSON CITY, NY 13790 COPIED: PROCEDURE: CHEST, 1 E -RAY EXAM DATE: 09/26/2006 01:33 ORD#;90041 ACC#: 4785074 -REPORT: See prior and subsequent dictations. There is cardiomegaly and clear lun s basically. g READING RADIOLOGIST: MARVIN GUTER MD ORDERED BY: REGINA FRANTS MD TRANSCRF13ED: by KMC on 09/26/2006 17:00 DATE OF DICTATION: 09/26/2006 07:47 DATE OF TRANSCRIPTION: 09/26 oe 17:00 READING RADIOLOGIST: TR_ANSCRIP710NIST• KMC ELECTRONICALLY SIGNED BY: C°r'r a?iif'sJity° ea^Tfi?eIn is _-% SIGNED ON: rogdaGona and state laws prohibit You kom ma Y? you?m reams-wadi a`an a as otltorv pemul? bY:uch repugtlons p krttter disdosuro of such infomwtion without the spedtic vwitfen iMorrrratton is nol the irttanded rtxipiN?t y,q? am ?'? authorization for the release of medical or other iniotatation Is NOT wftia this information in error, plows imrnscliab? ?? nodfled that arty use, diseernination, distriwtfon or niproduclion d this irdOrn ?5 Y ?tY ua st 807-7eKi.6t04 aid repxn tltis eopntenyCax ro Unked Flsaror 3ervkxs, ? R?qe '?al AAOdlcal Gnbr 7 Harrison Sf. Johnson City NY 13790 vie U.S. Poattal Servka Thank You. Pnnted :Sep 27 2006 8:18AM _ _ ELECTRONIC SIGNATURE: MARVIN GUTER MD ADM# 5006246036 MIARVIN GUTER MD MARVIN CUTER MO 09/27/2006 08:17 Yto whom n the im Pwain r this ptrposp. H the?readerr & this Y PrdtibltW M ypu received b9Y ?aparfrnent. Wison Memorial Pape 1 of 1 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT RADIOLOGY"' CURR LOC: ORD NO: 90012 NAME: DERVISEVIC, SAHA REQST LOC: ICU PT CLASS: I MR#: 4848158 INFO. AT TIME DERVISEVIC, SAHA DOB: 01/01/1946 OF THE EXAM DOB 01/01/1946 MR#4848158 AGE: 60Y ADM# 5006246836 FC S ORDERING: ATTENDING- REGINA FRANTS MD MICHAEL ARONIS MD LIMA 601 RIVERSIDE DR UMA 30 HARRISON 5455 JOHNSON CITY, NY 13790 JOHNSON CITY, NY 13790 COPIED: PROCEDURE: C?HESST,1 VIE X-RAY EXAM DATE: 09/26/2006 07:48 ORD#:90012 ACC#: 4785144 -REPORT: The patient is now intubated with endotracheal tube tip 4.6 cm above the canna. The lungs are basically clear perhaps with some minimal volume loss at the left base. The stomach is distended. There is no nasogastric tube. The heart is enlarged. -IMPRESSION: The patient is now intubated. Otherwise there is little change from yesterday. READING RADIOLOGIST: ELECTRONIC SIGNATURE: MARVIN GUTER MD MARVIN GUTER MD ORDERED BY: REGINA FRANTS MD ADM# 5006246036 TRANSCRIBED: by KMC On 09/26/2006 16:59 ---..... .....-- DATE OF DICTATION: 09/26/2006 07:53 READING RADIOLOGIST: D DATE OF TRANSCRIPTION: 09/261200616:59 MARVIN GUTER MD TRANSCRIPTIONIST: ELECTRONICALLY 9iK3NED BY: MARVIN GUTER MD KMC SIGN ED ON: 09/27/2006 08:17 '+?e?? 'r?ormaian Tn -document7faz may Retie use-n-Mi lam you rt onrecoFd regulations s con?enbs"Ti ?? and state laws preftbit you from making further drectosure of such information ttio speafic written consent of tt?ftlw _l al and-eteie?'F-eaeraf or as otherwise perm;gad bbyy ?? regr?atlons. A general auttgrizatian to the roleaso of rrtsdical or other iniorrr?slion is Nt?T surticien?t ? ?I ?? ? Information peAav?s inforrnatiott is nOt ttte irttendsd recipient, yo,r are hereby notified that arty use, dissemination distrilrrrtion a reproduction of Mi4 kMorrr?atian u •YProhibi eud?jl reader of This this Mtfotmetion in error, please immediately notify us at ti07-7ts3-81oW arW Tatum Ihia dpcurttsntlFSU to United Health Services. Radio you r?soeived _ anal Medical Center. 3_3-57 Harrison St. JoMgon City NY 13790 via U.S. Paste Service. Tharrc You. iOOS` DeWrtmeM. wflson Memaal Pape 1 or f UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT CURR LOC: ICU-BI0009 ORD NO: 90016 NAME: DERVISEVIC, SAHA REQST LOC: ICU PT CLASS: I MRS: 4848158 INFO. AT TIME DERVISEVIC, SAHA DOB: 01/01/1946 AGE: 60Y OF THE EXAM DOB 0"1/1946 MR# 4848158 ADM# 5006246036 FC N ORDERING: ATTENDING: REGINA FRANTS MD MICHAEL ARONIS MD UMA 601 RIVERSIDE DR UMA 30 HARRISON 5455 JOHNSON CITY, NY 13790 JOHNSON CITY, NY 13790 COPIED. PROCEDURE: CHEST. 1 VIEW X-RAY EXAM DATE: D9/26/2006 09:29 ORD#:90016 ACCM 4785272 -REPORT: AP semi-erect view was taken portably at 09:19 hours and compared to a similar study earlier on the same day. There is an endotracheal tube in place whose tip is 3.7 cm above the carina. The heart is enlarged. There is a subclavian central line on the left. This terminates in the superior vena Cava. The lung fields are grossly clear. The pleural surfaces are unremarkable. -IMPRESSION: Since the previous study earlier on the same day, a left subclavian central venous line has been inserted. No other significant changes are noted. READING RADIOLOGIST: ELECTRONIC SIGNATURE: DAVID N LISI MD DAVID N LIST MD ORDERED BY: REGINA FRANTS MD ADM# 5006246036 TRANSCRIBED: by JRO on 09129/2006 18:53 ._ ....... ...... ...... _....._._.......- DATE OF DICTATION: 09/29/2006 07:50 READING RADIOLOGIST: DAVID N USI MD DATE OF TRANSCRIPTION: 091291200618:53 ELECTRONICALLY SIGNED BY: DAVID N USI MD TRANSCRIPTIONIST: JRO SIGNED ON: WW 091301200614:30 itiy box rn iRls ao`ciiinenUtaz may have i o you tnom feoo „n eral a fiats ntgulatlons and state laws W~ YOU from making f vdw disdosurs of such information without ft specific written consent person to whom the Infomwtion pertaats or as othw a permiced by such regulations. A general authonzation for the release of rrre6cal or other information is NOT suftent for this purpose. M the rstader of tttle irtfanealicn ie not tM intatdsd rsdpient. you are hereby notified that any use. dissemination. distribution or reproduction of this information is strictly protrbited. If you roceived this information in error, please immedre{sly notify us at 807-76"104 and return this document%K to United Health Servim. Radk*W Department, Wilson Memorial Recional Medical CsrNert33S7._Fianison St. Jofnson City NY 13790 via U.S. Postal Service. Thank You. Printed : Sep 30 2006 2:30PM Page 1 of 1 RADIOLOGY '/T' L UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT VASCULAR LAB- , CURR LOC: - ORD NO: 90015 NAME: DERVISEVIC, SAHA REQST LOC: ICU PT CLASS: I MRM 4848158 INFO. AT TIME DERVISEVIC, SARA DOB: 01/01/1946 AGE: 60Y OF THE EXAM DOB 01101/1946 MR# 4848158 ADM# 5006246036 FC N ORDERING: ATTENDING: MICHAEL ARONIS MD MICHAEL ARONIS MD LIMA 30 HARRISON S455 UMA 30 HARRISON S455 JOHNSON CITY, NY 13790 JOHNSON CITY. NY 13790 COPIED: PROCEDURE: BILAT LOWER EXTREMITIES-VENOUS EXAM DATE: 09126/200612:25 -REPORT: ELECTRONIC SIGNATURE: EDWARD D. SANTELLI MD TECHNIQUE: Real-time images and Color Flow Doppler Venous Ultrasound of the Right and Left Legs were performed. FINDINGS: There was good visualization of the right and left common femoral veins, origin of deep right and left femoral veins, right and left greater saphenous veins, right and left femoral veins, right and left popliteal veins, right and left anterior and posterior tibial veins, and right and left peroneal veins. There is no evidence of deep venous thrombosis, reflux or other abnormalities. -IMPRESSION: A negative color flow Doppler venous ultrasound of the right and left leg. Left greater saphenous vein is thrombosed at the origin level. READING RADIOLOGIST: EDWARD D. SANTELLI MD ORDERED BY: MICHAEL ARONIS MD TRANSCRIBED: by JAK on 09/27/2006 10:55 DATE OF DICTATION: 0912612006 13:12 DATE OF TRANSCRIPTION: 09/2712006 10:55 TRANSCRIPTIONIST: JAK ' in Uft doeumme Itax ma'?y ,hays E reWlations and state laws prohibit you from snaking further disdoswe of or as Otherwise penmiped by such regulations. A general authorisation R intorrrraffion is not the intended to you are hereby nofrfied that any ttris infom+stion in error. ?e kil notify us at 607-704104 Regwnal Medics{ Center, 7 Harrison St, Johnson City. NY 13790 via Printed : Sep 27 2006 2.29PM ADM# 5006246036 READING RADIOLOGIST: ELECTRONICALLY SIGNED BY. SIGNED ON: the relesse of medical or or 10 ORD#:90015 ACC#: 4785263 EDWARD D. SANTELLI MD EDWARD D. SANTELLI MD 09127/200614:28 consort bf the person-to whom the VftwMon pert i is NOT suffk isnt for this purpose. If the reader of in of this inforawtion is allxly pmhrb W. If you teas oth Services, Radiology De wtmnt. Wilson Mem Pape 1 Of 1 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT RADIOLOGY -- - CURR LOC: - ORD NO, 90017 NAME: DERVISEVIC, SAHA REQST LOC: ICU PT CLASS: I MR#: 4848158 INFO, AT TIME DERVISEVIC, SAHA DOB: 01/01/1946 AGE: 60Y OF THE EXAM DOB 01/01/1946 MR# 4848158 ADM# 5006246036 FC N ORDERING: ATTENDING: REGINA FRANTS MD MICHAEL ARONIS MD UMA 601 RIVERSIDE DR UMA 30 HARRISON S455 JOHNSON CITY, NY 13790 JOHNSON CITY, NY 13790 COPIED: PROCEDURE: CHEST. 1 VIEW X-RAY ORD#:90017 EXAM DATE: 09/26/200612:40 ACC#:4785839 -REPORT: History of nasogastric tube placement. The nasogastric tube is seen extending into the stomach. The tip of the endotracheal tube is 4.4 cm above the carina. Left subclavian venous line has its tip in the superior vena Cava. Left lower lobe atelectasis appears worse and new infiltrate in the right lung base is evident, since the film taken earlier today at 09:19. The current film is obtained at 12:32 p.m. The heart is enlarged. -IMPRESSION: Worsening bibasilar atelectasis/infiltrates. Nasogastric tube placement. READING RADIOLOGIST: ALAN WAGNER MD ELECTRONIC SIGNATURE: ALAN WAGNER MD ORDERED BY: REGINA FRANTS MD TRANSCRIBED: by DMT on 09/27/2006 10:56 ADM# 5006246036 DATE OF DICTATION: 0912612006 12:52 READING RADIOLOGIST: DATE OF TRANSCRIPTION: 09/27/200610:58 ELECTRONICALLY SIGNED BY: TRANSCRIPTIONIST: DMT SIGNED ON: ALAN WAGNER MD ALAN WAGNER MD 09/27!200614:13 a.?w m-lay 1-p-m. [ 1w ¦HOrri-muon in un cocuawmaz may nave peen cisdosed to you from recordzvvW -Acientle ty a reQUlitiOna end itatb tetra prOhd?t ypu 6om making fUAher disclosure of SULtI infor1T18bOn 1MIt10u1 file epeCdiC tivriltarl Grorlsent the person to Mitlorn It10 or as otherwise perntitt? by axh rapulatlons. A general auC?ori?tk?r+ for the roles d medir?l or other i?ortnation is NOT sulfitient for tltis puMoe& inforrnatkxt is not the i redpient .you Oro hereby nol?ed tl?at any use. disteminstion. disMbution or ropnodugion of Mtia iMarrnstion is sVictly prohll this information in error, ? im y notify us at 60T-783-6104 and re? file aoamenvfax to United Health Services. Radiology Departrnei _Regionel (<Aedir?ll CantM. Hannan SI. JOixltion Ci?l (,, NY 13790 vla..U S. ?petit Service. Thank Ygu. _._..-r--...._.__ Printed :Sep 27 2006 2:13PM K ii Page 1 of 1 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER L IMAGING SERVICES REPORT RADIOLOGY CURR LOC: ORD NO: 90019 NAME: DERVISEVIC, SAHA REOST LOC: ICU PT CLASS: I INFO. AT TIME DERViSEVIC, SAHA ?R?: 484$158 OF THE EXAM DOB 01/0111948 Mll4848158 DOB: 01/01/19-46 AGE: 60Y ADM# 5006246036 EC N ORDERING: ATTENDING : MICHAEL ARONIS MD MICHAEL ARONIS MD UMA 30 HARRISON 5455 UMA 30 HARRISON S455 JOHNSON CITY, NY 13790 JOHNSON CITY, NY 13790 COPIED: PROCEDURE: C ST 1 VI W X-RAY EXAM DATE: 09/26/200617:04 ACC#: OROI 47862B62 8 98 -REPORT: Portable chest obtained semi-erect 09/26/06 compared with chest from earlier the same day at 12:33 hours. We are asked to check endotracheal tube placement in this patient. Endotracheal tube in place, tip projecting approximately 4.5 crT1 above the carina. There is a left central catheter in place, tip projects in the expected location of the SVC as it did earlier. Since the prior examination there is increasing volume loss on the right with new airspace density at the right lung base consistent with atelectasis. The cardiac and mediastinal silhouettes are stable. Left lung unchanged in appearance. READING RADIOLOGIST: ELECTRONIC SIGNATURE: VINCENT R MONTONE MD VINCENT R MONTONE MD ORDERED BY: MICHAEL ARONIS MD ADM# 5006246036 TRANSCRIBED: by JRO on 09/27/2006 17:41 DATE OF DICTATION: 09/26/2008 17:43 READING RADIOLOGIST: D DATE OF TRANSCRIPTION: 09/27/200817:41 ELECTRONICALLY SIGNED BY: VINCENT R MONTONE MD TRANSCRtPMNIST: JRO VINCENT R MON70NE MD SIGNED ON: 0° i ao 09V2 OOS 08:24 aimax "maye? isa6iii ill 116 fft rooordseer?fi" or as 0ow"M Pi? such regu ie s making further disdosune Of such Intamebw without the specific wriNa? coneent ends ?edirsl by eytions. A general authorization kx ttte release of medical a otlter person m whom the irr?orrrtatlon pertains informstlon ? rtot ? +MerMled recipient, you an3 hereby notified that an use. ??n ? NOT sufltGartt for thts purpose. H tFte roeder of this tltis intorrRatiOn in error. p? Irrtrrretlietely rtpti/y us pt 1107-78.9-e104 end rem Wrn?ittis?doc?v?menUf?an to lJ?IUt?Sereiv'itpsRed? ? ?p Y Wohlbitd. M f?ou received Reflionsl Medieel Center, 33.67 Hanieon St. Johnson City. NY_13790 via l1 S_ Poste! Service. Thank You. ?y ?L Win Alernoripl Printed :Sep 28 2006 8:24AN1 .. _.._...__ _ _ Page 1 of 1 UNITED HEALTH SERVICES HOSPITALS WILSON MEMORIAL REGIONAL MEDICAL CENTER IMAGING SERVICES REPORT RADIOLOGY `%0%0. ORD NO: 90020 REOST LOC: ICU PT CLASS: I INFO. AT TIME DERVISEVIC, SARA OF THE EXAM DOB 01/01/1946 MR# 4848158 NAME: DERVISEVIC, SAHA MR#: 4848158 DOB: 01/0111946 AGE: 60Y ATTENDING: ADM# 5006246036 FC N ORDERING: MICHAEL ARONtS MD UMA 30 HARRISON S455 MICHAEL ARONIS MD JOHNSON CITY, NY 13790 UMA 30 HARRISON 5455 JOHNSON CITY, NY 13790 COPIED: PROCEDURE: CHEST, 1 VIEW X-RAY EXAM DATE: 09/26/2006 21:11 ORD#:90020 ACC#: 4786541 -REPORT: The study is performed after cardiopulmonary resuscitation. There is a central venous catheter in the superior vena Cava. Nasogastric tube is positioned within the stomach. There is an endotracheal tube in place whose tip is approximately 2.4 cm above the canna. The heart is mildly enlarged. The lung bases are better aerated than on the study earlier on the same day. There is some residual subsegmental atelectasis at each lung base. The upper lung fields are clear. IMPRESSION: Bibasilar subsegmental atelectasis which is radiographically improved when compared to the radiograph earlier on the same day. No other significant changes are noted. READING RADIOLOGIST: DAVID N LIST MD ORDERED BY: MICHAEL ARONIS MD TRANSCRIBED: by JRO on 09/27/2006 21:20 DATE OF DICTATION: 0912612006 21:60 DATE OF TRANSCRIPTION; 09/27/200621:20 TRANSCRIPTIONIST; JRO You Srenter. 33-57 Her Printed : Sep 28 2006 8:25AM are ELECTRONIC SIGNATURE: DAVID N LISI MD ADM# 5006246036 READING RADIOLOGIST: -? DAVID N LIST MD ELECTRONICALLY SIGNED 8Y: SIGNED ON: DAVID N LISI MD 09/28/2006 08:24 lave n 'G y 7?m rid un of such information wifhoul the ? p? '6-,Tidle?ai end a'`-Fa?arat Neon lur the rebase Of medical Or aq wnlten consent ofthe person'to whom the information partew?s N '?Y4 use, dissami?atlon, di:bibutlon or MOnrwtlon is NOT sulfi?orlt tOr lhia puipost. H the reader d this -610and n3turn thla documenf/fax to UnNedul?Seiv tenon irs strlcnY Drofifbitad. if you n?oeivad f0 a l?l S. Postal Service. Ttmnk You_ ioloDY ?Parhrtent, Wllson Memorial Pays ? of t UNITED HEALTH SERVICES HOSPITALS Johnson City, NY ECHOCARDIOGRAPHY REPORT NAME: DERVISEVIC, SAHA MEDICAL RECORD M 4848158 DATE OF BIRTH: 01/01/1946 PHYSICIAN: Michael Aronis, MD DIAGNOSIS: DATE: 09/26/2006 LOCATION: 0928 RMS ADM #: 5006246036 TECHNICIAN: M Mode and 2D Study Normal; Cardiac Doppler Study Normals Left Ventricular Mitrat Valve Diastolic Dimension 3.5-5.6 Peak Flow Velocity 0.6-1.3m/sec Systolic Dimension Mean Flow Velocity Ejection Fraction >45% Peak Pressure Grad Post Wall Thickness 0.7-1.1 cm Mean Pressure Grad Septal Thickness 0.7-1.1 cm Pressure Half Time 4.0-6.0 sq.cm Right Ventricular Diastolic Dimension 0.7-2.3 cm Aortic Valve Left Atrial Size 1.9-4.0 cm Peak Flow Velocity 1.0-1.7 m/sec Mitral Valve Mean Flow Velocity E-F Slope >3.5 cm Peak Pressure Grad Max ALMV Excursion Mean Pressure Grad Annular Calcification Aortic Valve Area 2.5-4.5 sq.cm Aortic Valve Pulmonary Valve 0.6-0.9 m/sec Systolic Opening .1.5-2.6 cm Tricuspid Valve 0.3-0.7 m/sec Aortic Root Size 2.0-3.7 cm Prosthesis: AV Calcification Aortic Thrombus Mitral Vegetation Pericardial Effusion INTERPRETATION: Echocardiography is performed in one and two dimension with Doppler study. I read the echo an hour after it arrived in my box. 1. The patient's left ventricular chamber size is normal, with normal wall motion. There is concentric left ventricular hypertrophy. 2. Right ventricular dimension is enlarged. Page 1 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY ECHOCARDIOGRAPHY REPORT NAME: DERVISEVIC, SAHA MEDICAL RECORD #: 4848158 3. Left atrium is normal. 4. Mitral valve shows no mitral stenosis or prolapse. 5. Aortic root is normal. Aortic valve opening is preserved, with no aortic clots or vegetation noted. 6. No pericardial effusion noted. Color flow Doppler shows mild tricuspid regurgitation. No significant aortic insufficiency or mitral regurgitation is noted. Pulsed Doppler shows no pulmonary hypertension, or aortic stenosis. SUMMARY: Echocardiography is performed at bedside, but is of adequate quality. The patient has concentric left ventricular hypertrophy, with good contractility. There is right ventricular enlargement and mild tricuspid regurgitation. Dictated by RICHARD A RYDER M D KDP D09/28/2006 1017 709/28/2006 1100 cc: Cardiopulmonary Lab Dr. Aron is Page 2 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY ECHOCARDIOGRAPHY REPORT NAME: DERVISEVIC, SAHA DATE OF BIRTH: 01/01/1946 rIr MEDICAL RECORD #: 4848158 LOCATION: ICU BI0009 0926 PHYSICIAN: Charles Campbell, MD DIAGNOSIS: DATE: 09/26/06 RMS ADM M 5006246036 TECHNICIAN: M Mode and 2D Study Normals Cardiac Doppler Study Normals Left Ventricular Mitral Valve Diastolic Dimension 3.5-5.6 Peak Flow Velocity 0.6-1.3m/sec Systolic Dimension Mean Flow Velocity Ejection Fraction >45% Peak Pressure Grad Post Wall Thickness 0.7-1.1 cm Mean Pressure Grad Septal Thickness 0.7-11 cm Pressure Half Time 4.0-6.0 sq.cm Right Ventricular Diastolic Dimension 0.7-2.3 cm Aortic Valve Left Atrial Size 1.9-4.0 cm Peak Flow Velocity 1.0-1.7 m/sec Mitral Valve Mean Flow Velocity E-F Slope >3.5 cm Peak Pressure Grad Max ALMV Excursion Mean Pressure Grad Annular Calcification Aortic Valve Area 2.5-4.5 sq.cm Aortic Valve Pulmonary Valve 0.6-0.9 m/sec Systolic Opening 1.5-2.6 cm Tricuspid Valve 0.3-0.7 m/sec Aortic Root Size 2.0-3.7 cm Prosthesis: AV Calcification Aortic Thrombus Mitral Vegetation Pericardial Effusion INDICATIONS: Status post motor vehicle accident with multiple rib fractures on the left and difficulty with mechanical ventilation. Apparently respiratory/cardiac arrest status post resuscitation. Assess ventricular function and rule out evidence of pericardial tamponade. INTERPRETATION: An exceptionally limited 2D M-mode color and Doppler study was performed at bedside in my presence. The parastemal and apical views are rather poor due Page 1 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY ECHOCARDIOGRAPHY REPORT NAME: DERViSEVIC, SAHA MEDICAL RECORD #: 484$158 to the mechanical ventilation. In all views, the left ventricle appears small and dynamic. There are no obvious segmental wall motion abnormalities. There is mild left ventricular hypertrophy. The left ventricular ejection fraction grossly appears on the order of about 65- 70%. However the right ventricle is markedly dilated as is the right atrium. There appears to be mild tricuspid insufficiency on the color Doppler exam. Views of interrogation were exceptionally limited. Pulse and continuous wave Doppler exams could only be performed from the subcostal views which were of course significantly off axis. Tricuspid insufficiency peak velocities appeared to me visually to be close to 3 mps but were recorded at about 2.3 to 2.4 mps. This would correlate with mild pulmonary hypertension. I do feel however this is somewhat of an underestimation as the angle of interrogation is considerably off axis. The tricuspid and mitral valves appear grossly unremarkable. I do not see evidence of a "flail" mitral valve. There does appear to be trace to mild mitral insufficiency but this is seen only in intermittent apical views in between ventilator cycling. CONCLUSION: 'l . Exceptionally limited transthoracic echocardiogram. 2. No obvious evidence of pericardial effusion. The right ventricle and right atrium are dilated and hypokinetic. Mild tricuspid insufficiency is identified and pulmonary artery pressures are in the range of 35-40 mmHg by measurement I think it is modestly higher however as the angle of interrogation is significantly off axis. 3. Dynamic left ventricular systolic function with relatively small left ventricular cavity size and dynamic segmental wall motion. 4. Probably trace to mild mitral insufficiency. 5. Also noted is lack of inspiratory fall in the IVC calib with mechanical ventilation. 6. No obvious sign of left ventricular dysfunction. h ventricular dysfunction is less likely to be on the basis of contusion given the locat' n of her rib fractures being anterolateral and no reported eviden rn I re. Dictated by CHARLES RANA L M REH D09/26/2006 2026 T09/26/2006 2328 cc: Cardiopulmonary Lab Page 2 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY ECHOCARDIOGRAPHY REPORT NAME: DERVISEVIC, SAHA DATE OF BIRTH: 01/01/1946 MEDICAL RECORD #: 4848158 LOCATION: ICU BI0009? 0926 PHYSICIAN: John DiMenna, MD DIAGNOSIS: DATE: 09126/2006 RMS ADM #: 5006246036 TECHNICIAN: M Mode and 213 Study Normals Cardiac Doppler Study Normals Left Ventricular Mitral Valve Diastolic Dimension 4 3.5-5.6 Peak Flow Velocity 0.6-1.3m/sec Systolic Dimension 2.4 Mean Flow Velocity Ejection Fraction 0.70 >45% Peak Pressure Grad Post Wall Thickness 1.4 0.7-1.1 cm Mean Pressure Grad Septal Thickness 1.4 0.7-1.1 cm Pressure Half Time 4.0-6.0 sq.cm - Right Ventricular Diastolic Dimension 2.7 0.7-2.3 cm Aortic Valve Left Atrial Size 3.2 1.9-4.0 cm Peak Flow Velocity 1.0-1.7 m/sec Mitral Valve Mean Flow Velocity E-F Slope >3.5 cm Peak Pressure Grad Max ALMV Excursion Mean Pressure Grad Annular Calcification Aortic Valve Area 2.5-4.5 sq.cm Aortic Valve Pulmonary Valve 0.6-0.9 m/sec Systolic Opening 2.8 1.5-2.6 cm Tricuspid Valve 0.3-0.7 m/sec Aortic Root Size 3.4 2.0-3.7 cm Prosthesis: AV Calcification Aortic Thrombus Mitral Vegetation Pericardial Effusion INTERPRETATION: This study was done emergently at the bedside in the ICU because of hypotension and chest injuries. Two dimensional and M-mode images were adequate to show normal and vigorous left ventricular wall motion. There is concentric LV hypertrophy. The right ventricle is enlarged. There is diffuse hypokinesis of the right ventricle. The aortic valve has three leaflets which open well. The tricuspid valve is normal. The pulmonic valve was seen with some difficulty. No significant abnormalities seen. The mitral valve is Page 1 of 2 UNITED HEALTH SERVICES HOSPITALS Johnson City, NY ECHOCARDIOGRAPHY REPORT NAME: DERVISEVIC, SAHA MEDICAL RECORD #: 4848158 normal. No pericardial effusion is seen. At the apex of the right ventricle, an echodensity is present, which I believe is a moderator band. No obvious intracardiac thrombus or vegetation is seen. Color, PW and CW Doppler examinations were also reviewed. Mild pulmonic and tricuspid valve insufficiency are seen on the color study. Tricuspid velocity suggests a right ventricular systolic pressure of approximately 34 mm/Hg, assuming a right atrial pressure of 10. Mitral inflow is normal and biphasic. Aortic flow is normal. The aortic root is normal. CONCLUSION: 1. Concentric left ventricular hypertrophy with normal 2. Normal valves. 3. No effusion. 4. 5 ejection fraction. Right ventricular enlargement and hypokinesis, consistent with injury (right ventricular myocardial contusion). Mild pulmonic and tricuspid valve insufficiency. Dictated by JOHN D DIMENNA MD r JCF D09/26/2006 0231 T09/26/2006 0758 cc: Cardiopulmonary Lab i possible traumatic Page 2 of 2 Q Y C u Z x ri 1 f Lir _J X i-' Q z C M z 8 r r x a rN C V Elm- y 1r a rs -U CL; Ca O ?? ? ?' ^ ?t• ? ,sr C7 ra ?? Q3a ? N OG O? A!2 C r Q ? k J ' V ? •p F i-+ a as aa. d aar 71 ?.;. > a a z„ a x ?? ES Q d O ua y. U ?Q a4 c F l? :.f - _ - • - - : i.. :?-__ - ::.:.-- -- -- - - ---- - '1:-- -- -i- ...T':_`--- ?? ?-----?--;fir: oil :?= -.? -177 -- T_ :1t --- .77 77 -7 7' ct - _ -,?^_-- - _ ale= -_ -:-=:.:?:.:__ _-_,. .i. - :: -- • .!: - - ?-.- _ - - _ -- -- - f-=? - - - -- - - - - - - 77 WSW. i - - :t _ z:- ;-. -: -- 7.1 i _ I i .7 7' - -+ -- - - - s -1 t -_ ___ - :ice ?? - _ „ •, _ - _ 74 -74 r'""?"?_. ?:a=::: •-- - ?_.:?.. •?'=::r-- -.:: '"."' --?--=-yam fry !? [- -? -- • ? . - - -- : ?. "_- . ?- _ _ ?-`-??- • ? _ - - - -- - _-- -- .t-. -Iwo 7=: ••--'•-- 40 CL to 14 Ll PC ? ? ? ??. - - ?-?.-.-= Vii: '??_ -- '.`??. ??•-- _ _''-= • ? of C N Q r'i ? + ??.- _ - _ - -•-,. ^^ _ .: - ?: ? ?i=:; ;."+' ?.L'^I: =i'. 4n No w a x u es L- 2 i ?_' `-ice _ = -:-•- ::.]: -:_;; --:x?:3-_: co d E - - _- _ _-?-_ - _ _ - - - __ - - - - - - T - u__ - -w - --? _ : _- -?--- - _.:tZ-*:-l- ? =? __ ?' :rte _ _- _ ?2.? - -- _-- ?-;.. 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L_ 7 717 '7.- 71 7:: tr 711 - par- 77 ?- RADIOMETER ABL800 FLEX ABL820 ABL820 PATIENT REPORT 07:35 PM 9/2W006 Syringe - S 85u1 Sample #I 9 Identifications 976 Patent ID 93252105 Patient Lest Name DERV1sEVIC Patlent First Name SARA Sample type Not specMed Semple alte T 98.6 °F FO,(I) 1000% Sex Unknown Note NRB Blood Gas Values PH 7.327 FCO: 3t.6 mmHg [ - j P0: 71.4 mmHg Oximetry Values ctHb 10.3 g/dL [ _ ] FO,Hb 90.1 % ] FCOHb -0.4 % [ _ FMetHb [ 1.1 % FHHh 9.2 % Temperature Correc ted Values pH(T )c 7.327 pCO,(T )c 31.6 mmHg p0,(T Ic 71.4 mmHg -xygen Status ctO,c 13.1 Vor/o [ - 1 Pic 32.57 mmHg Acid Base Status cHCO,-(P)c 16.1 mmol/L ABEc -8.5 mmouL ( j Notes C CsirAllaled va luers) 0293 Warrvwj HbF deteCted at-ld Compensated fa Printed _ 7 37:32PM '- - i C)Fi-09-5 i Lk%Vvd United Wilson 33-57 HarrieonSGreet RJahnsed' Ctr. Health Services Ja on City, NY 13 790 9mohan S. Sidhu M.D. Laboratory Director Hospitals LOCATION: ICU BED #; BICU09 MEDICAL RECORD #: 4848158 ATTN. M.D.: ARQNIS, MICHAEL PATIENT: D8RVY88'VIC, SARA ADMIT: 09/24/06 DISC: 09/27/06 SEX. F DOB' 01/01/1946 PATIENT #: 5006246036 CMMSTRY RESULTS COLLECTED 93252242 09/25/06 21:07 93252131 M1 09/25/06 20 93240613 M2 :00 09/24/06 18:41 REFERENCE RANGE GENERAL CHEMISTRY RESULTS SODIUM ruM ? :13 6 P O M ' 6 4. + 139 135-148 MMOL/L CHLORIDE ? 3.04 3.8 13.5-5.3 MMOL/L CARBON DIOXIDE ? 23 106 +98-107 MMOL/L ANION GAP 14 l 22 +21-32 MMiOL/L GLUCOSE ? 200 $ ! 15 19-17 gUN 127 192 H 165-105 MG/DL CREATININB 1.4 i 21 +7-23 MG/DL CALCIUM 17.8 L I ? Y•3 10.7-1.5 MG/DL TROPONIN I 8.6 18.5-10.0 MG/DL fu: CALLED tropi 3.53 T to t 6055 on 09/251200r, at 21:44 by D4919. M3 f NG/ML mat $R 26 x3: Refer*nce Ranges: Normal ........... 0.40 Ischemic disease 0.40 - 1.49 COnsi;tent with ANN >1.49 fCCy for Abnormal COl%Mn: H=High. L?Low, MR-Critical High, LL=Critical LOW DISCHARGE REPORT 125 of 160 FRIATIM 09/2912006 17:40 Page : 6 of 1 B Wted United Wilson Mem. Reg. Med. Ctr. 33-57 Harrison Street, Johnson City, NY 13790 Health Services Jagmohan S. Sidhu M.D. Laboratory Director Hospitals - LOCATION: ICU BED #: gICU09 MEDICAL RECORD #: 4848258 ATTN. M.D.: ARONIS, MICHAEL PATIENT: DB?tVI38VIC. SARA ADMIT: 09/24/06 DISC: 09/27/06 PATIENT SEX: F #: 500062 06 01/01/1946 46036 :RZ ATOLOOY RROULTS COLLNCTBD 93260415 09/26/06 03:55 93252242 09/25/06 21 93240613 M1 : 07 09/24/06 18:41 REFERENCE RANGE HEMATOLOGY RESULTS NBC RBC i 14730 3 .7 L 13.9 B + 20.9 HE 14.0-10.5 K/UL HEMOGLOBIN , 10.2 L 3.81 L 4.70 14.10-5.40 M/UL HF%MATOCI2IT 130.9 L ? 10.6 ? 32 2 L + 12.9 +12.2-15.5 GM' 'DL MCV + 83.6 . $4 5 L ? 39.3 35.0-47.0 $ MCH 27.7 . 27 8 53.5 178.0-100.0 FL 14CHC ? 33.2 . ? 32 9 ' 27.5 26.0-32.0 PG RDW j 15.5 H . + 16 7 1 32.9 32.0-35.0 G/DL PLATELET COUNT ? 179 . H 1 15.9 H +12.0-14.0 $ MPV 8 5 j 176 I 266 1150-450 K/UL TOTAL CELLS COUNT . 100 8.1 100 j 8.0 17.4-10.4 FL SEGMENTED NEUT ? 67 78 100 ? CELLS BAND ? 18 H ' $ ? 83 H 140-75 $ LYMPHOCYTE 5 L 3 5 + 10-12 $ REACTIVE LYMP 1 11 f L s L + 120 20-4 2 $ i MONOCYTE 9 la-5 $ EOSINOPHILE , 0 18 16 12-11 $ BASOPHILE ' 0 , 0 10-10 $ RBC MORPHOLOGY ? SEE BELOW ? SEE BELOW NORMAL 10-2 $ PLATELET ESTIMAT( ADEQUATE ADEQUATE , ADEQUATE MORPHOLOGY ### M2 ### M3 I MORPHOLOGY ANISO 1+ ' ### M4 MORPHOLOGY I POIK 1 + ### M5 4ORPHOLOGY ### ### M6 ml; CALLED wbC called to dr on 09/24 /2006 at 19:07 by X49211. ER 16 X21 MORPHOLOGY result: ECHINOC1TES 2.. x3s MORPHOLOGY result: MICROCYTOSIS 1+ 741: MORPHOLOGY result: ACAIMOCYTzS 1+ xS: MORPHOLOGY result: OVALCYTES 2+ K6. MORPHOLOGY result. OVALCYTES 1+ aey for AbAormal Column: Ii=high, L:Low, HH=Critical Higb, LL:Critical Lov DISCHARGE REPORT 121 of 360 PRIXM 09/29/2006 17:48 Page : 2 of 8 meted United Wilson Mein. Reg. Med. Ctr. Health Sert-ices 3357 Harrison Street, Johnson Cit NY 13 Jagmohan Hospitals S. Sidhu M.D. y, 750 Laboratory Director LOCATION: ICU BED #• BICU09 MEDICAL RECORD #: 4848158 ATTN. M.D.: A?RONIS, MICHAEL PATIENT: DSRVISEVIC, 8?18A ADMIT': 09/24/06 DISC: 09/27/06 SEX. F D 01/01/1946 PATIENT #: 500624 6036 93260280 CHEMISTRY RESULTS COLLECTED 09/26/06 12:00 93260383 09/26/06 03:55 93260279 09/26/06 03 :50 REFERENCE RANGE GENERAL CHEMISTRY RESULTS soDZVM POTASSIUM ' 135 I 4 9 ? 1135-148 r'II?'tOL,?L CHLORIDE ? . 105 ? 13.5-5.3 MMOL!L CARSON DIOXIDE + 19 198-107 A'MOL/L ANION GAP I L 16 121-32 P8?i0L/L GLUCOSE 186 8 9-17 3UN 28 ! ' 16-1 5 DL O CREATININE H 1 4 7 -23 MG DL CALCIUM . 7.9 L ? I0.7-1.5 Ma/DL TROPONIN I 2.72 T M1 18.5-10.0 MG/DL mlI 4.13 T Ml I NG/ML Reference Ranges: Normal ........... 0.40 Ischemic diseago 0.40 - 1.49 Consistent with A1lI X1.49 Key for Abnormal Colu= : H`xigh. LsLov, RK-Critical xi9tLLB Critical Lpr DISCHARGE REPORT 134 Of 360 PRINTED 09/39/2006 17:48 Page : 5 of a Lk*od UnitedW Wilson Mem. Reg. Med. Ctr. Health Services 33-57 Harrison Street, Johnson City, NY 13790 Hos Jagmohan S. Sidhu M.D. Laboratory Director ?,it??ls -LOCATION: ICU BED #: BICU09 MEDICAL RECORD #: 4848158 ATTN. M.D.: ARONIS, MICHAEL PATIENT: DERVISBVIC, SAGA ADMIT: 09/24/06 DISC: 09/27/06 SEX: F DOB: 01/01/1946 PATIENT 5006246036 BLOOD 93260662 QUES (URSH) R. RIGOTTI ND, DIRECTOR COLLBCTSD 09/26/06 10:00 93260384 09/26/06 0 93252105 5 :00 0 9/25/06 19 :30 REFERENCE RANGL PH (RESPIR.ATORY)j 7.11 L M1 7 32 PAC02 CARBON DIO' 53.8 B . L M2 + 7.33 L M3 7.35-7 55 PA02 ART. OXYGEN J 53 L , 29.8 M4 61 L 31 " 6 L . 1 3 5.0 -4 5.0 I?y?;G HC03 BICARBONATE 16.2 L ? 14 9 L ? 71 L 180-100 I?iG 02 SATURATION f 72.5 L . 8 L 16.1 L 122.0- MEQ/L CARBOXYHEMOGIABI1 0.3 5 M5 r' 90.1 L 100 1920- $ METHEMOGLOBIN 1.7 g 0 8 MS -0.4 L . 9 1 W M5 ?0.0- $ >'IODB ? A/C ? 1'8 8 ? 1..1 . FI02 ? 100 0 NRBNC ? ? ### M6 . TIDAL VOLUME ' 580 100 f .0 100.0 RESPIRATORY RATE 18 ML PEEP 10 VD (MEC) ' 25CC i CM BASE EXCESS 12 6 . DRAW SITE ? X j -8.5 , MEQ/L Mls DR FUMOTS NOTIFIAM LB I X22 RX notified N3* RN R"I=R AWARa x4: DR FRANTS NOTIFIED m5= Reference r"OS: cat Loy o.l-fit Normal Nonsmoker N--1 Steoker - 15i High 15.1-25% CritiCal High >25% Toxic N6s MODE result: HON-kMREATHE<R Rey for Abnormal Column: H=High, L:Loy. Uf[.Critical Ki h. LL= 4 Critical I,ow DISCHARGE REPORT 127 of 360 "INTEa 09/29/2006 17:4e Page : 8 of a United U - nited Wilson Mem. Reg. Med. Ctr. 33-57 Harrison Street, Johnson City, NY 13790 Health Services Jagmohan S. Sidhu N.D. Laboratory Director Hospitals LOCATION: .ICU BED #: BICU09 PMEDICAL RECORD #-. ATIENT: DERVISZWC84S1ARK ATTN- M.D. . ARONIS, MICHAEL SEX: F DOB: 01/01/1946 ADMIT: 09/24/06 DISC: 09/27/06 PATIENT #: 5006246036 OTOLOGY RESULTS 93261870 COLLECTED 09/26/06 18:40 REFERENCE RANGE HEMATOLOGY RESULTS WBC 18.4 H 14.0-10.5 K/UL RDC 3.17 L 14.10-5.40 M/UL HEMOGLOBIN 8.9 L 112.2-15.5 GM/DL HEMATOCRIT 1 27.7 L 135.0-47.0 MCV 1 87.4 178.0-100.0 FL MCi 1 28.1 126.0-32.0 PG 4CiC 1 32.1 132.0-36.0 G/DL RDW 1 17.4 H 111.0-14.0 V PLATELET COUNT ( 125 L 1150-450 K/UL MPV 1 8.2 17.4-10.4 FL TOTAL CELLS COUN1 100 1 CELLS SEA NEUT ' 81 g 140-75 $ BAND 10-12 % LYMPHOCYTE 1 10 L 120-42 # REACTIVE LYMP 1 1 10-5 t MONOCYTE 1 3 12-11 $ EOSINOPHILE 10-10 % BASOPHILE 1 0 10-2 } RBC MORPHOLOGY 1 SHE BELOW PLATELET ESTIMAT 1 ### M1 1 MORPHOLOGY 1 ANISO 1+ 1 MORPHOLOGY 1 ### M2 1 MORPHOLOGY 1 ### M3 1 its PLATELET ESTIMATE result: SL.DSCRRASE - H2s MORPHOLOGY result: OVJU CYTLS 1+ K3s MORPHOLOGY result: ECHINOCYTES 1+ Key for Abnormal Column: H•Aigh, L.Lor, HH-Critical High, LL.Critical Lox DISCHARGE REPORT 120 Of 360 PRIWM 09/29/Zo06 17:48 Page : 1 Of 8 united United Wilson Mem. Reg. Med. Ctr. 33-57 Harrison Street, Johnson City, NY 23790 Health Services Jagmohan S. Sidhu M.D. Laboratory Director Hospitals --LOCATION: ICU BED BICU09 MEDICAL, RECORD #: 4848158 ATTN. M.D.: ARQNIS, MICHAEL PATIENT: D]MVISEVZC, sjkRA ADMIT: 09/24/06 DISC: 09/27/06 PATIENT Ste' F #: 500062 06 02/01/1946 46036 COAGULATIOti 93261893 M1 93261103 COLLaCTBD 09/26/06 18:40 09/26/06 17:30 REPERENCI, RANGE PROTHROMBIN TIMSl 16.6 H INR 1.38 M2 APTT >150 BE M3 135 RH M4 M1= CALLED read back by 2710 on 09/26/2006 at 20:07 by H4107. Sts LESS "TRUSS THERAPEUTIC RANGE: 2.00 TO 3.00 MORE INTENSE THYRA?SUTIC RANGE: 2.50 TO 3.50 Note: The INR is intended to be used only for Patients.on cow•adin type anticoagulants at stable dosing levels 1938 THER"EUTIC LEVEL FOR UNMACTI0VATED HEPARIN IS 2.0 TO 2.5 TIKES THE MEAN NORMAL. LZVELS 13211,W TWAT ImnrcATB INSUFFICIENT ANTICOAGULANT U42 THERAP$UTIC LSVRL FOR UNFRACTIONATSD HXPARI11 IS 2.0 TO 2.3 TIKES THE IRAN NORMAL. LEVELS BHT,= THAT nWICATs INSUFFICIENT ANTICOAGULANT Phoned to 02720 19.0-13.5 SEC 1 122-36 SEC Key tar Abnotsal Colym; H=High, L•L,ow, UH-Critical High, Lb critical Low DISCHARGE REPORT 122 of 360 PItINTgD 09/2912006 17:49 Page : 3 of $ Wtod United Wilson Mem. Re 33-57 Harrison Street, Reg. Med. Ctr. Health Services Jagmohan Johnson City, NY 137.90 Sidhu M.I}. Laboratory Director Hospitals LOCATION: ICU BED gTCUO.9 MEDICAL RECORD #: 4848158 ATTN. M.D.: ARpNTS, MICHAEL, PATIENT; bBRVI$BVIC, SAE[A ADMIT: 09/24/06 DISC: 09/27/06 PATIENT Ste' F 50006206 O1/01/I946 46036 93261871 M1 CMISTRY SSSULTS COLLECTED 09126106 18:40 93261870 0 9/26/06 18 :40 REFERENCE RANGE GENERAL CHEMISTRY R ESULTS SODIUM POTASSIUM ' i 53? +135-148 MMOL/L CHLORIDE H 13.5-5.3 MMOL/L CARBON DIOXIDE 109 H 198-107 MMOL/L ANION GAP 14 L 121-32 MMOL/L GLUCOSE I ? 20 $ -3.7 191 3? 3 1UN 224 a 165-105 MG/DL CREATI NINE 29 S 17-23 MG/DL CALCIUM I ? 2'0 B 10.7-1.5 MG/DL TROPONIN I 3.42 T M2 6.9 L 8.5-10.0 MG/DL Hlz CALLED prev elev On -09/26/2006 at 19:30 b U28 Y D4819, IG/ML Reference Ranges; Normal ........... 0.40 Iscl?emic disease 0.40 - 1.49 Coneistent with AMI x1.49 Key for Abnormal Column, H-High. L-L*w, RK-critical High, LLeCritical Low DISCHARGE REPORT 123 of 360 PRINTED 09/29/2006 17:4a Page : 4 of 8 United United - Wilson Mem. Reg. Med. Ctr. 33-57 Harrison Street, Johnson City, NY 13790 Health Services Jagmohan S. Sidhu M.D. Hospitals Laboratory Director LOCATION: ICU BED gICtJOg MEDICAL RECORD #: 4848158 ATTN. M.D.; ARONIS, MICHAEL, PATIENT: DSRVISEVIC, SARA ADMIT: 09/24/06 DISC: 09/27/06 Ste' F DOB: 01/01/1946 PATIEN'T' #: 5006246036 BLOOD 93262106 GIBES (URSH) R. RXGOTTY mn, DIRECTOR COLLBCTS'D 09/26/06 20:45 93261299 09/26/06 15 :15 RERBR.@ICE RANGE PH (RESPIRATORY)1 PAC02 CARBON DI01 6.85 64 6 LL M1 7.02 LL M2 17.35-7.55 PA02 ART. oXyGEN1 . 66 H M3 1 53.9 H 135.0-45.0 P+II?;G HCO3 $ICARBONATEl 10.6 L L ( 74 L 180-100 1 HG 02 SATURATION 1 79.5 L 1 13.2 L 123.0-24.0 MSQ/L CARBOXYHEMOGLOBII 0 0 1 9 L 192.0-100.0 METHEMOGLOBIN 1 . 2.0 it M4 00.1 1 M4 10.0-9.1 RODE 1 BAGGING 1 1.9 1 A/C 8 FZ02 FLUSH z 0 1 100 TIDAL VOLUME 1 . 1 RESPIRATORY RATE1 1 580 1 PEEP 1 1 24 BASE EXCESS 1 -21 4 1 12 1 CM DRAW SITE 1 . RR 1 -16.8 1 lygQ/L MIS Dr. Campbell Aware 1 r.R 1 li2z rn notified in wu < 7.35 M38 Dr. Campbell aware K4: Reference ranges: <0% 0.1-40 0_1-9} 9.1-151r 15.1-25, >25U Low Normal Nonaeoke, Normal Smoker High t Critical High Toxic xey for llbpormal Coll,_. H-High L.LOK. KH-Critical iilgh. LL.Critieal Low DISCHARGE REPORT 126 of 360 PRINTW 09/29/2006 17:49 Page : 7 of 8 C7 U rI • UnltsdHiWth Seroicxs T UWted Health SerWcies ? t t ?attt ?a4114/04 Hmpitals Admission History t pro ST totttcir * z :? -Shaded areas may require folow Ir --if c 14 yrs of age also complete APL 1 T=. . " if AS& iNAW MIdu, - ? - ht: Jam.- / S /, t to be called: J Care py; Alzheimer °Yes Seizure Diabetes dyes Blegdi /B ? ottfng ?Y es OYea ? Blood T DYes Transfusion Reactions Blood Pressure Oyes X! O+ Ronal Faikxe Stroke es es Heart Disease Y es Respiratory Disease DYes Mitral Valve Prolapse ? Y Q YeS Other comment Patient oriented to room and nurse cal system Z-5 loe AV Shull Site Chicken Pox Measl s OUnsura 66 EWO e ?Unsure Yes OUM" DY mho Rubella OUnsure DYes Hepatitis Tuberculosis OUnan DYes o ° unsure ° b Sexually Transmitted pYe: Diseases: Speci fy MRSA DYes No VRE E es No Reefferrrral to Infection ConD d Nurse: Y QNc Mastector Melt Might Bnaca*ts Applied OY63; p NIA Pacemaker DYes Cardiac °Yes Abdominal Orthopedic OYee Dyes Nro es DY Anesthesia Reaction DYes If yes, describe below Otter, describe below been exposed to any Corrtrnunicabte Diseases in the -- -- Past 4 weeks. If yes and NOT' here. what is indicated on the form Patient has written Advance DlrectIves? DYes If Yes: Place a (quate?. COPY on Medical Record. Document actions on Kardex 1. If No: Proceed to Kardex I for further action. Who would you give the health care provider (MD. etc) consenUpenjimion to dhKX= Ycur firtdrnQe with? "I would you like hospital Personnel 10 share medical information with? _ J PATIENTS RIGHTS Petienta Righta have been given and explained to '•s Aye ONO If no, explain Lemming needs: DYes ?No 109 rn y m 00 S u? ?Brought in Medication: ?Sent to Phamy?y Latex Iodine Contrast Tape Adhesive Environment Other O Sent Home Food: ( 1X01 /1446 i 09/Z4106 / c .L if i S. " I c"Ji f t No .?t 390 ST CQLLEOf P ti: Ct,2L 1 Ut !t 17013 .:.7 C ??40v??0 S 57?7111S47a ?"-:_ r= PCP; OOT Have YM smoked cigarettes or cigars, even one Puff- or used an other Patierrt<18 years old ? Y tabacca ?'?? In ft Past 12 months? pYes ?lo carealver smoked or used tobacco Products in the past 12 months? Dyes ?No ON/A Amount: How If yes, both of the fokw*V Should occur, iOReferral to discharge planner for discussion with patient rega ? with wition information and courisetkm about tobacco cessationrd"ng tobacco cessation program. Recroadonal druDyes Frequency: How long: AJcohof Use, 074"34 t: `" - Diniormadoon given to patient How kxV: Havel ever received Treatment? Oyes XNo Cage Questtonnalrs: (If yes, automatic rofarral) C. Have you ever felt that you should cut down on your drinking? A. Have PeoPle annoyed you by aiticizkV your drinking? 0. Have you ever felt bad or guilty about your drk*hg? E. Have YOU ever had a drink in the 1 0 a.rrL to stead nerves or be rid of a t Hearing I Otmpaired / Hearing Aid O HVi(h Patient Vision ONormal sadin lasses OContactLenses OPmsthesis Speech ONormal ?DifWWtto Understand anguage Barrier ILiege f above completed by an LPN) Signah e/Satus: Oyes Oyes ? Yes Deaf ?Rt O Lt [380th DWhh Patient OBlind Used.ThC'% 1? 29- OUnable to 1. Are you currently in pain? '>ji,es ONo (If no go to question 7) 2. On a s Qe2of alo3with 0p4mg no pain sensation and IQ belm the newt intense pain [35 )dB- Q6 137 09 10 rrrtaghaiWe) how would you score your pain? 3. Wen h did the pain start? Location?93 4. Describe your pain: How does it feel? Mull C7Throbbing OBurning OConstant ennitterM Other. 6. Are you currently taking any medication for pain? ?Yes DNo if yes, list medicatf 6. Is the pain medication effective? DYes ONo ?See Mad List 7. Describe any previous or ongoing k*ances of pain: 8. What methods of pain control have n I to t; 9. What is your personal pain goal? 4 1 Have you had a tetanus shot In the last 10 years? Yes ONo Learning Needs: ?Yes ONO Special Dkt/Re s/Supptement ?NIA r Appetite: rmal Oincre ODeareased ODecreased Testa Caps: Ey" ?No MeaJ$ Per Day Dentures: ? ore Bonding: ? es o WIM artial OFull Lower DPartial DFult pW+th Permanen=_ Bridges es No Yes t0 any of the following, obtain a nutrition consult. 1. Unintentional weigh kws of 10 tbs. in last 6 months? ?Yes 4. is the patient at risk for not managing oral secretions L3 yes 2. Does Patient appear to be underweight? Dyes o and/or swat dii? 3 Chewhg or oral problems that make it difficrrll to eat? O Yes 3• Does the Patient e a pressure sore? OYes If s 4 is Yes, or if uired the into rdisci Iin Care Plan Ike Swapowi Screen (refer to the Swal lowind 1? r- r -I LJ 4C7 h -- 4'b 0 3b cF-rl??y?c •sAk ??4$1S8_ ?!r'fg46 r ti ! s , ? ! C,1 04/?4/06 car 3t Q S7 COLLEGE P CAtl?LF 17013 Bladder EWA O y ?t y lncp? QToul TOtai QDysuds ?Retwdm ONocturta ' OU AssisNve ODaytime ONighttime ?Occasional ONone ?Intttrrrritterd Caawnerization ?Y: Type * Of BMs/pay Ap nce Sett [Yes OtVo Bov -L Dale of Iasi BM Laxatives: DYes AS 0 OConshpation ?Diarrhea Olntontinent Enemas:OY t]Pattexn Change Care - XNo: fowel Sounds ve; • • If the first box and any additional boxes are checked which interfered with Mobility orADL's, Physical Therapy or Occupational Therapy Referral. Pie consult with Physician to request a PHY I ?OOB Attempted unless contraindicated with noted decrease in function as Compared to functional level prior to current illness ?New onset weakness/paralysis ONew onset balance/coordnation deficits ?Equoywnt evaluation jj A ProWwns: ?insomnia ONightmares Oorthopnea ?Self care attempted unless contraindicated with noted decrease in function as compared to functional level prior to illness. ?New onset weakress/paralyms ?New alteration in cognative/visuat status ONeed for energy conservation techniques DEquipment Evaluation ElSleep Apnea ?Pairr OOther. S FEMALE: O WA Is there any chance that you might be PreWant? Oyes O?ina yes. t ooted prm Menstruation Date LMP: L arY Care P?KW- Birth Control Oyes ONo Menopause a ONo Irregular am: hh Sett l3reat Exam: DNo ng OYes Vagl Dischar a es Do ou an corcems? OYes g Last Pap Smear. SSpecify: Exa m: PSA Test: ?Yes [No Monthly Testicular Exam: OYea ?No Do you have any concerns? Oyes ?No Specify: Life Changes: [Nona DChanges in Relationship ?Job Changes Onnandal OBirth of a Child ?Move 000W: tic Injury O Death of Farruly/Sgnficsnt Other What do you do to cope with stress or anWT-?-.'l C _ What calms yo u in a stressful or angry situation? O Music OWalking D T alkin9lwith whom? Is there anything we can do to help you with any fears or concerns? Yes 64 Currently under the care of a Mental Health Professional? ayes ki& teary Ust Medications: Name: []See medication List Suspicion of Abuse or Neglect Immediate Referral to Case Management. Under age 1S immediate referral to UHSH Child Abuse Liaison ant- fndudes Child or Adult Abuse Referral to Case Manap . OYes r::::: Retierral Lfahmm OY r: i:. SIX T i If yes. aubrrtalfc referral f. I)o you currently receive tronte care services, or would you like to receive lame care? ayes Agency, if known: 2. Is the admission diagnosis respiratory in nature? Dyes 3. Is the patient on oxygen or respiratory treatments at Oyes Contact Person / Guardian - Relationship - Phone * P i 1 Support System OSPouse / Significant Other ?'Fa-m yarn' UFamy in the separate residence ONone OLivee atone Information obtained from: ?Patiwd source: Reliability: Gopd QPoor l3Wn_comrnw*zWe the same residence 1d duves alone l3NeW11XVIs / friends ? Family not present ?i,res with: lpp?adent / or Family Educated about the purpose and dangers of bedrals. Fiecalth OPost Op Misease process Oluledicatiom OWound care dOther: Spada) Needs / Barriers to Learning CJRead iness to learn assessed Anxiety Rtt QYes Comment: Method the patient learns teat (check all that apply) nation Marrionstratim, ?Printed Material l3&Aio-Visual NOTE: Information from this section must be entered on leschng record Comment: Does the patient present with any, of the following: -kil NonnPlanca ?Yes o SYrM0Pe / per diagnosis Oyes Confusion DYes o Weakness Flistory of felts DYes dY o Inability to use call bell ClYes No Decreased Mobility ?Yes o l Based on the above assess t is patient fall prone?, MAW Is Patient at risk for bedrail entrapment? ADDITIONAL COMMENTS Patient Valuables Inventory Form Completed 'ATUS: A'A Jt ' I f 4--) TIME: C 4 J C United A09 zi 9po&t ZI60 j 100 f-kealth Sen•ices stop :*Ujv 9 ?£totby , ovb Hospitals bHys os-?ZS'oos PRIORITY .31A-3SJAUao j h S ED Admissions: Bed Request/Report Sheet d'a to C ine Monitor ?rl WNo Admit Serviee of Dr. i Coverts Yes/ No Reason fora ission/dia psis: Assigned bed `J U T lme_je?D Vit4l Signs: BP Medical Altered Mental Status NOTES: A t-?D ?P ?02 l/min Sat )? e?J Lung Sounds: NOTES: Supplemental 0? -0 via CardV onitor: ytf known): ???KG.?/ No NOTES: Bowel Sounds: NOTES: Foley: Yes J Void: Yes NOTES: Nausea/vomiting: Intake: PO IV Blood Mods in ER Abnormal/Pending Pain Assessrnent Labs/Tests Consults Notified ?- site 1) -? N ? Desc. 2) Y / N ale (o- la) 3) Y / N Transfer RN (sign) Transfer Dare Time fazed to door-`/ 3801330ila rev pB.b?.pG Uriginaf in Medical Rc x?rd Copy la registration I ? edH6th SErms PRESCRIBER'S ORDER Ft AUTHORIZATION IS GIVEN TO THE PHARMACY TO DISPENSE A GENERIC ANb THERAPEUTIC EQUIVALENT DRUG WHEN A BRAT NAME IS ORDERED UNLESS THE PRESCRIBER SPECIFICALLY REQUESTS THAT THIS BRAND HE USED BY CIRCLING THE NAME DATE TIM WRI N AL IE 3: i CHECK EACH ORDER f h s ?, RAMS IB50 4 r-? L ,_• "' w ?. 04 ul / W -.y C ,tia - r Y. N 2 ? Q s i y r rw `FI } f%b r% a-- ' El TELEPHONE ORDER READ BACK PRE8CA18ER AND VERIFIED. w O l/7 PPRE NOTED S S NATURE ? 00 CRt8 ER'S SIGNATURE DATE TIME r• DATE TIIrIE WRI EN i ALLERGIES: CHECK( ) EACH ORDER AS T ?SCRIBEC !( Z 3 o!oo 4 cr+ y T t., a -c ? U C-1- i H V ' 1 • f ya wr w ns ... Ar ro a x `mom-??ca a0 r V .. y V M 00 71M - -E-DA CHECK ( ) EACH ORDER AS offC "t -0 $;--, GC` /4.7 45L12e-l TELEPHONE ORDER READ BACK TO PRf:dbWpfR AND VERIFIED. RSE'3 b TU v4 - j 0 DATE .ERGIES: 44 /,; /m BACK TO PR W ER AND VERIFIED. !A AAt, ro?.n ?••c?cs f .'I 9 ?. (/? 4+ Q •:: r . M Q LA 39 a -? ?- p? cs 1 ' ?. a. • ?!r c? a vs C r? ?} w C 1 ?j r er- ? ' ' Q V. ? r7 QO A V- w A4 -A ?V 1 Y Y_ 00 I UhiftdHadtlI Sep, jci._,q ..a. PRESCRIBER'S ORDER F( AUTHORIZATION IS GIVEN TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EaUrVAL-ENTDRUp MEN-4,g NAME IS ORDERED UNLESS THE PRESCRIBER SPECIFICALLY REQUESTS THAT THIS BRAND BE USED BY CIRCLING TH AM TI EN ALLERGIES: s CHECK ) v EACH ORDEFI I r• AS iI TRANSCRIBED C/, 1 I i I I I TIME t s I _ PRESCRIBERS fG3?NAnRff !DATE IME WRITT N CHECK ( ) EACH ORDER AS I I r' TIME PRE; CHECK ( )"' EACH ORDER AS TRANSCRIBED 0 TELEPNONE ORDER READ BACK TO CV 4 3t '__! PN44Af.DE# READ BACK 1O PRESCRIBER AND VERIFIED. TEL pff6NE ORDER READ BACK TO PRESCMaER AND VERIFIED. r Y A ._ LJ .rte y r .., ? s. o rr S W na n, 306 cA Qis ... 'O dv y /y u o Ln I ? a 2 1 Y. ? e,'? ` 'h fti c: z ~" ? x ri rs x . . 0_ s!- W s ' .r' D f p -a ? M Q ti trI Q I.II! P 00 • .. .'rte Y_? '/ .,. . r• • I - ' ?7 l .. ? N 1 Y T t, r :r. C? .G c ?• . w M ? t.r Ln CA CA -r -r : • s .ii ?C w cr r! _ x ? 1r ?1 V, H o V r g5 O r r` x X L.EJ ? N r.e ? ? , i - alp _ • CIE I•Mp10 4111. V y N .U ? W Q L? 'i 00 S T349AW, Unite dHealthSen-kes United Health Services Hospitals PHYSICIAN'S ORDER Admission Protocol Date: lTime: 1 This patient meets medical necessity criteria per InterQual Guidelines. Cane Management will continue to follow and assist with services as needed: 61 Admit as Inpatient: Effective f ?V Q Order placed in NurseVu: Initials This patient does not meet medical necessity criteria for inpatient care per Interoial Guidelines at the present time. Care Management will continue to follow, assist with services as needed and reassess within 24 hours. U lace in ? eat E Nurse Care Manage r• Physician's Signature: 1 Nurse>s Signature: 44 YISrYIC RiSR j t? :':J 1/ 1446 . 5+it doe"Is F 09/24/06 C'?e So? CN?ft 0 E C A -LISLE Sf COL L Ef; F p P T ?-p'"O"O S 570? i 854 7? 13 . Surgery Order placed in NurseVu: Effective initials 0 Date A Time: Date & Time: Date & Time: ?fl L? -4* ;X: . 5801533 rev 07.26.06 C- AUTHORIZATION IS aryl TD THE PHARMACY TO DIVENSE A GENERIC AND TH PRESCRIBEWS ORDER F1 NAME IS ORDERED UNLESS THE PRESCRIBER SPECIFICALLY REQUESTS THAT THIS BRAND THERAPEUTIC EOUNALEN7 DRUG WHEN A BR/ DATE TIME WRITTEN ALL BE USED BY CIgCLM1G THE HAM ES: CHECK { ) y EACH ORDER IL- V C% ry +,% To r> ? AS P1 c:Mb tw 4? ^ti TRANSCRMED T n -1 C) '„ *. a - 1 T1? n f?y?r 4' x C., •K lY C7 R/t a a. x ?` h W Ci r ? 00 g x V V ,? TELAMOM A L? OHDER READ MACK TO NIESCRIM AND VEIMM ?" ~+ NOTED RSE'S NA IA Q ul O? 00 OR _ ER S $ NATURE AT • )ATE TI WRI N ALLERGIES: 0-10L., CHECK ( ) EACH ORDER AS TRANSCRISF.D Y r-- b :' . fir .- - . Z57YELEP"OW ORDER READ BACK TO RRESCPAWn AND TI TED Nl/ SE s SIG NA E ?e.....,r..... .. _ _.. Q&L&JOYALLF, f-4 CHECK ( ) EACH ORDER AS r r*n??o-?tru,.? ??n°ZWM QTaA READ BACK TO PAW AND VERIFIED. m C; 30 &4 ?.s 9 V ''t a? Cx ? .p Q r- at U K G 4f - ... r c?? a w L 4m -? - a n es x C i w +F y? ? ar } ii O a ` I '" -4 N 0o w r ? d I - ? I n C: 1r f "a f! .? Ir{ ;; r r ca •o fLa C3 U ?+7 Q + d no, ? w ? • 4 IY y ?i • Q, Q' y r iJ1 o _Q ? ,. w o to ,?? co 1. ' Hr?Ith Senrices PRESCRIBER'S ORDER PI • • ¦• •?,?.., I wn m vrcv cry I U Y" E PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EWJrvALENT NAIVE IS ORDERED UNLESS THE PRESCRIBER SPECMALLY REOUESTS THAT THIS BRAND BE USED BY CIRCLM E NAM ATE TIME WRTT A CHECK( ) EACH OFIDER AS TRANSCRIBED ? ULWHOFE ORM READ BACK TO PRESC? AND VERIFIED, PFU R 5 gUNATURE Q1TE C - DA E TIME WRITTEN aE (? 2 CHECK( ) EACH ORDER AS TRANSCRIBED i C. I r% hr I - [j TEI. NGW OMl1ER READ LACK TO PRESCRIBER ANI VERIRED. CHECK( ) EACH ORDER AS TRANSCRIBED ? rMJPHOW OROER AMD BACK TO PRESCMWR AND VWWW0. a a z 10i Q ) 2 hes ?soe? ^?av 1a rro?,o ? • o r` ar O : W 4 -Lg - rr you -u?tw C ?OO,ro. ,per C hx d 4 r r- La C? p DO Ab _ % x v .f ps 00 ? r}-- 00 MR* -0ti 4 rp" Lo o cri 4 ys rv (i;?t? c ?T cr e- 4 `,? ? 71r "'r sy o N p Ln P pp ?r a M,.b w o ea ..Qr" atps Q Los .S M ?Oates 0 am Ci d Poo* ... " tip /? ?It a ... M ct # M A Q 41b %% V ?I N W [? w q V'I gAn l e ff-ladsh Services PRESCRIBER'S ORDER F+ • w • r••••,?.I Rm 10 ulvrr' TD THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EQWVALENT DRUG WHEN A BRL NAME IS ORDERED UNLESS THE PRESCRIBER SPECIFICALLY REQUESTS THAT THIS BRAND BI: USED BY CIRCLWQ THE NASA ATE ITIMEWRITTEN AL A! CHECK{ } EACH ORDER AS TRANSCRIBED D TEL4 HO ORDER RiAD sAm To Pmaomn AND warm. PRES IBER' I W ?""-? DAT CHECK( EACH ORDER AS TRANSCRIBED D TELZPMONE OFAM READ BACK TO PRESCRIBER AND VMNWD. '-' nME NOTED NUR M NATURE 053n jo.Z- rr ,t 3 EACH ORDER AS TRANSCRIBED TELEPHONE ORM READ BACK TO PRESCMER AND VERIFIM R3 r1 ? n sr. p '4 .. Qr- 6:4 49 W u •• ...• Wo Q us :L? '? M i ro C r- W* ... ww I :z 4b Ol es LA > g > ?- 4" ! •*t Q O y v N 00 w o Ln a 00 `s o rt n s p C7 Ct ? '•v •ef ? •n ?? ?' t• C? \ ?D tf' • O r` ?e q t ? Q CJNi UN\y t~ o- .? a o ... .D t = O to J6 'gAQ'h .1: y a z 4 >r c a ? t? ? IAJ o r r n ?+ s tT ? s ^? o .r h A ob 00 Timt : ; .. ,. {. • . , . 70AS1raa ROIrN ??.n? 'q to?O\ ? 1.r ar o c C? !- u « - ..,. -.rv... t h .» 16 0 '? - ... 014 n .a N Q ? • A a yr. u c r- ?. •w s. td ! LC T• s _ v to o o ?. ?? .,. Ln u P 00 . ' 1?lnitedHdth Semis PRESCRIBER'S ORDER F TION IS GIVEN TO THE PHARMACY TO DisPENSE A GENERIC AND THERAi+ UM EGMALENT ORW WHEN DERED UNLESS THE pRES R SPECIFICALfrY REQUESTS THAT THIS BRAND BE USED BY CIR? THE A BFL WRITT N S; NAM • 041 MEKO EACH ORDER Ol7,wsO 0 TRANSCRIBED Xso? h o No ti -0 ` on ?vvwO\? g?a^' ,os a I SAC( TO rncJ4 A J J' ?" PCHEW EACH ORDER AS TRANSCRIBED ? i r- -- TAME NOTED R PRESCRIBER IGNATME DA IJTIW EN ili agiw. CHECK ( } EACH ORDER ' AS TRANSCRIBED MAY 7 TELEPHONE OMER READ BAOK TO PRESCRUM AND VE FRn AND VERIFIED. v READ BACK TO PRESCRIBER AND XERMMM M p w ?{ O lrri r. 00 f... w Ln AE GG *Vdn •• soO r`7 c7 N. - - ....w ? r'" r. U yR G?+••4t?...? rcz C L3 r Q w /? -4 a ? IF a Nx x . ? o w C to O ?' ?+. s t a n a a y.? w +ra ? a ov We 0ell .wlb Oco m p w N W~ f" *am *%M Ln • • a +•- als o co r c3 p r io 2 a, w O y??•+ Or s N d •,? lot s W +°. ?r t V -4?nle a v o ?Q v K Od to w a 4fp Mw y Y` tf 1 L Hezlfh Seniii; PRESCRIBER'S ORDER FI AUTHORIZATION IS GIVEN TO THE PHARMACY TO DISP NAME !S ORDERED ENSE A GENERIC AND UNLESS THE PRESCRIBER SPECIFICALLY ? R ATE TIME W REQUESTS THAT T R AND USED BY CIIRCCUNG RITTE AL $; THE NAM CHECK ( ) 'bGh s EACH ORDER h c: w o AS TRANSCRIBED ------------ ?1 Pew .. ?;, r .?r p .- w .,. ! nr *•? ca s r r- w 'D c rw o a g ? N ? A ? TELEP?1 M ORDER REM SACK TO PRUgOQR AND VERF" _ 8 TIME NOTED . NURSE'S NATURE P Ir?1...• . ;„, ; PRESC IB E j Mesh D T"m %= // E710 r OATS TTEN .. , CHECK ( ) =1 a r ..v EACH ORDER AS TRANSCRIBED « r s. c] n o ?QCw YL ? g ; X o. , ? z ro N C C r ` TE ? 4EPIIONE READ sAac TO PRESdiISER Amu YERrP1ED. Lid O V P TW N U S S NATURE O PRE ISER'S SIGNATURE DA ATE IME WS g. l7C?ry nsG? CHECK r? r-. s ?v • ? _. ,.R EACH ORDER C? s -r" AS t.??.. TRANSCRIBED N C. ., .: N ' to S r G7. _, w C:.v g 'a an c.> N i ? _ u? h cr =A Qom . CA Q 9 v !" ? a o r W N ? W as a• ? v v ap 4? CIO a UPI il OjnM READ TO PRESCRIEER AND VElII?IED. O? 00 u T IME NOT ' R PR BER'S SIGNATURE _n n?TC, s' C C. Is UWtodHadth Serzias ' C.- AU I MURI7.ATION IS NAME IS ORDEFIED DATE IME WRITTEN GIVEN TO THE PHARMACY TO DISPENSE A GENERIC AND TH UNLESS THE PRESCRIBER SPECIMALLY REQUESTS THAT , CHECK( } EACH ORDER TRANSCRIBED 1?L! ETW f TELE *wm BACK TO PMSYNER AND VERMED. TIME nV NJffjE IGNATUR I PFIESCRWWS $IGNATURE DA TMAE _ 4 I --- - _ w m A JlAld r CHECK ( ) EACH ORDER AS TRANSCRIBED TELEPr w OTMNV sAcm TO PRESCrdiWR AND VEPINgM T1ME N N SN3NATU PRESCR R'S mr,,NA nau t , PRESCRIBER'S ORDER Fl ERAPEUTIC EOtlIYALENT DFdM WHEN A BRI THIS BRAND BE uSEO By CNNXM THE NAM Vn<"> "n a.pQ rl C. s nln ?...? i .a t << V! 'L y 1 {A W } r ti cr • CA g Q W .. W w a , x ? y. E ?. V V IV 00 L G J? ??.. %A O a- pQ G7 r >s Q +t ( NOUN y? N wow Q ? ? ? N O X aD 4 %J ?A N W Q O • F'? r ? Ln 00 i [kWtodfla*h Servk6 PRESCRIBER'S ORDER F1 Au I nullIZA I ig" IS GIVEN TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EOUIVALENT DRUG WHEN A BR/ NAME IS ORDERED UNLESS THE PRESCRIBER SPECIFICALLY REQUESTS THAT TM BRAND BE USED BY CIRCLING THE NAM •T f '? EACH ORDER AS t TRANSCRIBED ?. 9J ?f? w^- r 3u Vj:Q l %&4 ANC., S }bn,- ar PIN- 60 - 0 P ?T Z6 - tl J ' ?t 'L?rJ c r.-ts 1 -ids - •1r b u I E1r- 7 I cdJ awl A x ? h.r,.r ?_ a, by 2`? u••?i aTf LEPMDNA MR M WJAR,PACK TO PRESCMBER AND VERIMM 41 P A7UR DATE E DATE ITIME WRI V3 3,::1 CHECK( ) EACH ORDER AS TRANSCRIBED ?L,_ 4tir'3 c^e c??r-+n =p -> as Fv,..r l1W- Q c- 2 x S'?o x t -•- f?C3G •? -2- 1r,.t..rj TELE410M ORDet BEAD BACK TO PRESCF K AND MFORM DATE TIME CHECK( ) EACH ORDER AS RIBED a t /(f Q??? ?? ^ / dt? o+Awm or TO PREfClgBER Alp Y[MRED. van LM wo0 Lil Q tp '? ?A 1 iA C) cr o ¢? x s cr a a C? -+• s? r- r Lri x v V '?? ?, cr IIv `J N 00 'G 1 A ti ?? w o Ln a? 00 rc ew ? 44 im a CA it w-• UA -c w Q' `R L C3 --" "mm r M 4p low 00 - -c •i po W o w l•-- ftk Ln to 40 • 14 a { vor,_,1,.ov f'10 i.N 'DIP is• Qi d?" ZOO r. "?.. •u A N .L 1 /1 10 o r• x 4J M *++ 4w jo I" 00 O Q dab I.- W O a Oro p B NA M D ,? DATE TNE i u»taxecrlfh Sertices PRESCRIBER'S ORDER R AUTHORIZATION IS G NAME IS ORDERED U DATE TIME WR N ?Pp N'A IVEN TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EQUIP NLESS THE PRESCRIBER SPECIFICALLY REQUESTS THAT THIS BRAND BE ALLERTI : CHECK( ) EACH ORDE#1 TRANSCRIBED . $\lC C _I_^ p TELIPHOIR ONWI HEAD WK TO MWICANIN AMID VERIFIED. TIME T u E'8 31 `?rncx+rn?na ?ntnniurs? CHECK ( ) EACH ORDER AS CHECX ( ) EACH ORDER AS TRANSCRIBED ALENT DRUG WHEN A BRA USED BY CIRCLING THE NAAR h+O ?,v ? ? O y ti La J •?3 !- d V? \ y Q ? d mow} "? ? w h i + N mob 1 o 00 w %.4 -4 'r 00 '.? o In a? 00 uA l t: TIME BACK TO PRESCFLMM AND VEWIED. V 40 M •? t.% s. •v ?, ?c.:ptiaacati, fir' .tas CAL`+fA ?y \N -? (.a .., 4M s s a?w O" A . "J w br C N ' .C LA A. ` ?+ N 00 M p ? 00 ,6 r _I I l 1 _ READ WK TO PEER AND VERIFIED. I CIO ci an b .. M .. Qr aG?s c a-?,?...... _. d d N {A \ C ca to C2 O sn s?... cc d 0 a. H C t7 r I.a co ? o %A a -C -+ •r1 ^s OO Q G A I+? 00 f UhitedHealth Scenia4 PRESCRIBER'S ORDER R AUTHORIZATION IS GIVEN TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EQUIVALENT DRUG WHEN A BRIT NAME IS ORDERED UNLESS THE PFIESCRIBER SPE M TIME WRI C ALLY REQUESTS THAT THIS BRAND BE USED BY CIRCLING TH A , E NAN CHECK 'o p } n a f? Q ^? EACH ORDER am, r? t=% v n ?. - el TRANSCRIBED y p •C G cr c.- rn x ... 11. H O? 1j)lti?-- a ?f ?G . or w-mow E`-Ccr ip 30 TELEPHONE REM BAC Y K To PRESCMM AND YERIRW. O TNAE NOTED E'S NA URE 00 .; PRE _ . DA. / ? TIME ? EACH ORDER AS TRANSCRIBED rtfn??=?` v O +-• 'A w i C Or LA , . r. C> n CA CA c rr ?. c ? tR se ? .? r , f"1 ?? to C r P" w r L - -? o r r x ,. Q v ,a s ?c s. ••, c? p OQ ?4%j 00 Q TELEPHONE OPAWR TO PRESCWWk ANO VEWMIX /.? o y ? !-? a Ln NURSE 81Q RE pCD ? 00 N'A TE ? g ME . TE ITNEWWRITTEN CHECK () b c7 i f n s p ri EACH ORDER h 0 N -- ^? AS fi r. ? Wob .. TRANSCRIBEQ G r x 0 d4 c?tr?,• cw c / al 9f c . . Am - Uy --+ O O vj/r r i Pt? J w ? Q raw v Q .? ro ? ao s. ra ?O ? l 00 5 v V N i? TELEPHONE READ sACK TO PRA AND VEipF1E0. j TIME N -44 1 U SIGNATU - co PRESCRIBERS SIGNATURE ;'¦ Tf t< ;' 70 1 . I 11--? [A at &1h Serf 1UPS I PRESCRIBER'S ORDER FI AUTHORIZATION W GWW TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EGINIVALENT DRUG WHEN A BR/ NAME IS ORDERED UNLESS THE PRESCRIBER SPECIMALLY REQUEStB THAT THIS BRAND BE USED BY CIRCLING THE NAM DATE TIME WRITTEN ALLEAQIES: CHECK ( ) DATE EACH OHDER TRANSCRIBED TIME -.? PAP "T Ff TA ft-CWN .?. C7 c, !Nat fe ? C><) < d. Refusal -- r) • n ted ?? iff IWM SAM D [7 No ROW: DATE 7AS 1CK( EACH TRAN.r ? El mo4ma own E DATE TI b1E WRITTEN ALLERIOIEB: CHECK ( ) EACH ORDER AS TRANSCRMSED 0* BACK PSBR AM VWW4W. ? No WAPr WM ANMEWAMS ? TRAPNONE 0NM READ SACK TQ rRESCINIBER ARD VRMMD. ? NO UNAPPROVED ABSRavlwnons t7l L F r 1 -1 ST34gA.*" iAl?itadHe?Ith sertacec 0 0 SOOb24bO3b United xv f MAN W 4 0 4 R f S$ Health Services e''6«"'RO"' .'o` m IV d1'?. a f u v I S I Y 1 C , S A 4 A Hospitals (mm-ml mmmuli 0 1 J 0 1 I 1 9 4 6 F 0 9/ 2 4/ 0 6 Asti1S. MICHAEL HD HI,IR31NO UWARTMEN r: 7 4 30D ST C 8 L L F f P INTERNAL NURSING TRANSFER SUMMARY C A v t i S L E P A 17 013 } 0000000u0 S 5702185470 twx na ^ ?r . 1. ADMITTING DIAGNOSIS: f? lY"mro F- :•>:, II. TRANSFER DUAGNOSIS: V 111. REASON FOR TRANSFER: V N. BRIEF NARRAME OF PATIENT'S HX AND COURSE WHILE IN UNIT: e- n t i 5 h f P lh?ltl fl c, w""s Mr. am ???„ ?t h• Yet ??., n ? t 1 C?'I\ ? O??lP 0?, ,j_)-A [4 rw0 )A. C d 1 '0.X Co LI X Q Tti Y- L 1?y ?-p,n .?LZ'! V?.ri ?? +f1C1G:J ? ? ?30.? S ? '? ? ' ? 1 f . Ye 6(paw 4, a j o 4 qL1 i %h)s V PATIENT TFEACHINQ INITIATED: OwIt ae pre and postop teaching. Tatum plans. f0rVuxwf V nerds) W. STATUS OF PATENT UPON TRANSFER. Vii. PATIENT AWARE OF DIAGNOSIS: IF NO, EXPLAIN: VIU. FAWLY IIMIVOLVEMENT: (aware of trwwW, problems WW Aad, dam*ParXias ==V mambas) DC PHYSICIAN NOTIFIED OF TRANSFER @ TO TRANSFERRED VIA - Zoc. R K iN?IM7t? tlnalt"Health Services United Health Services Hospitals Nursing Department Intake and Output Record (bedside) Date: Q i Lam. N4`f4IttE .? TIME P.Q. AMOUNT IV SECTION URINE 0001 - 0700 TOTAL 0700 - 1500 v 1 TOTAL 1500 - 2400 TOTAL -FILL 112 ' FROM THE TOP TRAY MUG = 200 m1 ICE CREAM = 90 ml SOUP / BOWL =180 ml SHERBERT = 320 ml CUPS: WATER ICE =120 at SMALL JUICE - 120 ml SODA CAN - 355 ml STYROFOAM = 240 ml 8 07- MILKSHAKE = 240 ml PLASTIC GRADUATED = 300 rnl 6 oz. EGGNOG = 180 ml MEDICINE = 30 ml 1/2 POPSICLE - 45 ml 8 oz. MILK CARTON = 240 ml 4 oz- MILK = 120 ml INSTANT BREAKFAST = 240 ml OUTPUT FOLEY I FORCE FLUIDS TO: FLUID RESTRICTIONS: 5202215 rev ' thdfedHeulth Services United Health Services KARDEX I Hospitals '):'1 0 b2460 36 4 94 $!, S8 DF"'YISFYIC SA4A 01 - !-0 l / 194b F 09/24/06 A?^k I S. nICIIAf L PO `14 3'3 ST COLLE ll P CA?'L I SLI PA 17013 Assessment Admission deferral Nealed Follow Up Referral t Comments Cardiopulmonary ? Yes N!o ? Yes ? No ? Yes ? Yes Case Manage? ? Yes ANO ? Yes ? No ? Yes ? Yes Chaplain ? Yes Nb ? Yes ? No ? Yes ? Yes Infection Cgntrol RN ? Yes No ? Yes ? No ? Yes ? Yes Food & Nutrition ? Yes No ? Yes ? No ? Yes ? Yes Physical Therapy ? Yes ?(N0 ? Yes ? No ? Yes ? Yes Occupational Therapy (need order) ? Yes No [] Yes ? No 4Yes ? Yes Speech Language Pathology (need order) ? Yes VNo ? Y? ? No ? Yes ? Yes Child Abuse Liaison ? Yes No ? Yes ? No ? Yes ? Yes W OC ? wound ? Ostomy ? Incontinence ? Yes No ? Yes ? No ?Yes ? Yes Learning Need: Learning Need: Learning Need: Advance Directives Initials Date/Follow-up Date If Patient Has Advance Directives: Family notified to bring in (reminder dates) COPY Placed on Medical Record If Patient Does Not Have Advance Directives: Education to Patient ' Form Completed/Copy on Medical Record Copy to Patient Pain Management on Admission initials Date Patient's Personal Pain Goal: tn be r Dm. 'A? i) Patient/FamiN Teaching Booklet Distributed and Reviewed Patient's rights to effective Pain Management Teaching Explained to Patient/Family History of Patient's Stay (optional) Recopied: 000001 rev UnitedHealth Services United Health Services Hospitals ; . SO()b 4 b 0 3 b 4R4R15$ KARDEXI PrIDYISEVIC ?SAWA 10".11-1111146 F 04/24/06 HICHAIL K0 c?4 340 ST COILE"ot P ROOM #: qpE; y DOCTOR/CONSULTANTS: ADMISSION ST t1e t ? Mod Observat , 7 'fat 0 CONDITION: ? FAA '? JOUS ? CRITICAL FAMILY/S.O. PHONE ADMITTING DX/ OTHER DX / DATE. RESUSCITATE: SURGERY / PROCEDURE DATE: ALLERGIES: ISOLATION: ? AFB-Airborne ? Airborne ? Contact ? VRE ? C-DM ? Immunosuppressed ? Droplet ? MRSA ? VRSA Pulse/Resp/BP Temperature 0z Saturation DIET / TUBE FEEDINGS: ? FEED ? ASSIST Neurochecks / - u 1&0 Every Shift very 4 hr WEIGHT CHEMSTRIP DRAIN / TUBE S At Your Request Program: ? Yes ? Assist ? No FLUID RESTRICTION: Schedules: ? Positioning ? Ambulation ? Splint ? ROM ? OO TREATMENT(S) / MISCELLANEOUS RESPIRATORY L4 L Mobility Protocols: ? 1 ? 2 ? 3 ? 4 ? Fell Alert ? Bedrail entrapment risk El IV ? SALINE LOCK 3 N UY~r mMSen*es KAADEX tl l nC=L 2ybn 3b xi. United f V 4 Q 4 R 15 8 Health Services V 1 S f V 1 C . SA C1?,Ii 1 ?46 F 49/24/06 Hospitals A:.:+ 1 KJC4AIL MD j ? ?4 3"'? ST COLL[rf P to L I SLE PA 17013 S 70 2 1 854 70 DATE O / SNFI-AL TESTS / SINGLE ORDERS ORDEF9NG ply ORDER NUMBER GATE COMPLETED MtlTt Q 77- 4 ?3d tlNt"Healfh Serurc N United Health Services Hospitals Expected points of discussion: > Prior days goals reviewed (follow through documented) > Mobility > Pain F ?.;Cba4bO36 _ > aev urea ,9 4 R 1 S $ > Advop i? . SAN A > Exi¢c tsc Of f ar MD 09/24/06 > *Pa %E ti > tDe' C a t i. I: C f P i 'b?tGga as t E t' Ph 17013 P^p, r.?fa S `- 702 1 854 70 > Key process points > Restraints > Nutrition Diagnosis: S P m ,, (a Discharge Plan: " DATE MQB INTERDISCIPLINARY CASE CONFERENCE NRS ?" RT PT/o sLP aror c e OTHEF A Ck NH5 = Nurse RPH = Registered Pharmacist RT - RespiratoryTherapist PT =Physical Therapist OT = Occupational therapist SLP - Speech Language Pathologist D/DT = Dieticiarv iet Technician CM = Case Manager NM- Nurse Manager MOB = Mohikty 5300027 ini 3.05 OTHER = Any other guest to Case Conference UrdtedHealth Services United Health Services Hospitals SOCb?4603h KARDEX t I)["*YISEVIC *$ANA 01 .'.1, 1114!1. C nei?IN iAa [A PdHeaM Serf s dmvm? Unite Heath Sa vices ?. Ho*tals DATE ORDEI INITIAL l ,o{ i It KARDEX 11 TESTS/SWCLE ORDERS 5TA7 t S? f:_ -Tr4 r1tle.r fo Ire( Prr 1?? ren C J ??*e/+Y? ?/1? ?1 AI ?i ?7 A? ?M /W? •/ A R )n n(d« A Vvy -4,k CL "7 j ? (? dl ?C I h r• ?. `ffhf ? ? ??? rn `' : nrw? rM? Ca?^b24b03h f y ?/ /? Dr 511 Vy IC *51tsA L' l/ 0 1 1 1 44b i OW24/06 1r S. M1C H1ft 190 3,-: 5Y COLL111C P C"L I SL F P1 17013 00')00j'133 S 5707185.470 ' PCP: OAT OFRID EF&*N*G PARTY OMER OATE ! ! M Gs? r re J C 5300019 {Rc,. tlfniAedHeulfh Servkvs Lht3ed Health Services Hospitals KARDEX II SOOb24643 b,y158 DF-?V I SEV IC .SA'tA t o1/U1/1946 f 09/24/06 A0141 S, mICHAEI MD I" c24 yQD ST COLLEGE ° CAg41SLI PA 17013 S 5702 1 854 70 000000000 DATE IN?OIALREO! TESTS/ SINGLE ORDERS j. ORiXRING PARTY NUUMDBER COMPETED WMAL 1 n ( 11 j P r L If}LL frnj fa 'Y 5300019 (Rev. 9199) urn aN lhs-,? 570b2403b United 4 R 4 R! S 8? r. of 9vls??I c sxNS _ Health Services c 1 r J i! 1 446 f 09/24/06 H o s p i t a l s "'? ;'? I S • K I c H fi E L no ''2s 3?D ST COLLFG1 F, CA CL I SLf PA 17013 Integrated Progress Recoj%g"300000 s 5 702 2 85470 cr: OOT DAIT/ TIME f FOCUS DATA n_ A-ACTION R=RESPONSE J e o?-Cil° k'-' 5207794 rev 5/04 United Health Services Hospitals Integrated Progress Record DATE?FO T IME D=DATA l/z9 l ? 4, ct,k (_ RUC f C1 . 14 84 09124164 ! 6:3111 S. !ttcatf1 00 D St C??l [ K; r A =ACTION R=RESPONSE ?? Sr U? f. LL ?i r ?? (9r1 Z U v ta, 1?G d b(]ra r? nt?n J? p Dr. r F? 7F"r ariS i-o 1-Ly 5207794 rev 510• r unmodHealth &nviees United HeAffi Services Hospitals Integrated Progress Record SOOb246^3 bR4SI58 P,f"1YiSt..v1r , 54"A C I r 01 1 1'446 f 09124/06 4"x.41 S. P..IC14AFL 110 ?4 3- 3 ST COILfrst P ?- C8-LISLE PA 170!) C-':JO•:-•;0 S 570218:470 PrF , i_';T Az?A I C._42 C C'i- r p r ,L jjroro `` ib r ? C? ? . 1 3? r _ C vV.JL/ Y? r I VbZU r iV4 reV WU4 ` United .?-_. ??#l? 4??:t,? ?' Heath SMiees !14 310 ? t 1, Hospitus ? ,? ? pip Integrated Progress Record - DAT'A •=,.-.::..=- ?r?. :'fir' '':"?: `:`-?-? '? ? #= " -:? AC ITON .. R?RFSPONSE 1.4 Ooy?m rvD ?. 4uK3 v - r "-4 L ey , 2?Le C (5/o 10"- 5207794 rev 5104 UnitedHealth Sm ice5 United Health Sen dces Hospitals Integrated Progress Record DATE/ FOCUS I=DATA TIME yam. c C 71 sDCb24bO3b or "YISfVIC SS `A 01/.01,r 1946 F 09/24/06;,:.. wIC'-'AFL MO ;.'. T CALEhf P CA I SLf PA 17013 001001,.;;•.? S 5702185470 41, PCp . ;T A=ACTION R=RESPONSE 0 t; ("sl m VA 2 arc. UT c Out M _ /V ' f I /' iI6?YtJY? I n eZ /17 t- .,_U f v l C! 0C 7L- Y/ 40 V 7 -' 1000 u ;o I - u U .. L o/ 4?062 -S jr k-z d= ?t -6& q Ke 114"ja-,p -w ? 2? -s o 1 L) 6 tJ 1/1 I A.. .d/I/ / n I Qa? /3s ice- ?L,a.6-la?ses e S?¢?794 re: 510k unh*dHimith SM'Ices ......... --- United Health Services Hospit& 5UUb(fIbU."tl 4?4FIS 3... p A ;. RE YISfYiC 5A "A F 09/24/06.?' A !&1C4Af1. MD c' 14 3 %LLIP CA- -L 1 SL E PA 17013 C:;GOOOO; Q S "•732185470 P C P. O :; T 3 j'L .1"d C 1 - 5207794 rev S O Integrated Progress Record UnitedNrdth Se-rcea United Health Services Hospitals Integrated Progress Record SoOb24bo3b ?5S SFVIC ,Sa4k ....:•.. at j ill1946 F 09/24/06 ..?• $T CCLLEvE P C4.L 1 Stf P? 17013 r g 5702 1 854 70 jx P "P : Cam? t'. _.1 i `• i 1 520; . -, rev 5 04 UmUdHesdr h Ser>ia? S?ob246a36 United y1R4?IS 8 Health Seri.-ices DE p v I S E V I C , g e -*k H itals 41/01/1146 F U9l24/46 0f;?t4i S, r1 ? C? Afl . ?s4 3".1 ?T Integrated Progress Record " CA r L I SL E CC-L.Lf P° "?' 3 .; oauaooocOQ S ; T: 2 1 8S4 ; cp: W DATE/ FOCUS TIME D=DA TA A=ACTION R=RESP ONSE 20 ('A?b?r J?,? ('SUt?f(L i of 'mac.jfi lvt to iL• f(?' -'C.; ti sl i C, 9?+ S 'Pc /? S -k-k l,i; f v 1 V 2"Gt w ? ' /art i_ i c.1 f0, 1 c ?l E AA 16 5207794 re 50 unltedt-stntrt? ??z??:e?. United Health Services Hospitals Integrated Progress Record DA1 U ? T1R1F. SOQb24bO 3 y 1R4 q 15? Of =•YISEVIC 09/ 24/06 o s t a4ti '• T y"L`t ?:?a i = r CA;'LISLI PA 17013 0 ;;va0J 185470 ?. PCP OOT ?b C C? A 1 All, vio?llrllf- C HS ?f-/ .F G4 revs 5104 v' .•• -)J t-;hey bU 3b - 1MItedHoWth Semk& t' ?. ^fpY tSEYIC 4 R 4 S I S 8 . A. jSAm& United t fC ? i ? 9? f, 09/24/06 H e a l t h S e r v i c e s ICHAEL KQ 52 3'0 ST C O L L E G E Hospitals [C! A L I S t f P PA 170f3 i y`„V].?J?.,/0 S P, c 5702185470 Integrated Progress Record • V - DATE/ FOCUS IME D=DATA A=ACTION R=RESPONSE z!? v /??I /`' r/mar Tsc e -? 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R--?i L E _ aN [ CD C3 ?0 d O /1 S"'„r U} .T_ -•.v?,[ \J: I x •,? -?- - {--- -- _ ?. ?9 - N tr3 in (D r• ao rn d r- r r I W Q Z ' U), f i U W ? M W a +? o 9/25106 7:00 to Plan of Care Page. 9/26/06 7:00 United Health Services Hospitals ST3 Room: B349A 4848158 DERVISEVIC, SARA. GENERAL MED PATIENT EDUCATION RECORD Care Path 01D# GENERAL MEDICAL PA TIENT CARE PA TH DA Y # GENERAL IVIED KEY PROCESS POINTS CORE b1EASURE - PRE-PRINTED PHYSICIAN ORDERS UTILIZED, prophylactic antibiotic recieved within one hour prior to surgical procQdure. CORE MEASURE - ASSESS FOR PN(JEMONIA AND INFLUENZA VACCINES. GENERAL MED D1-3 EXPECTED PATIENT OUTCOMES GUIDELINE STABLE HEMODYNAMIC STATUS PATIENT'S PAIN CONTROLLED PATIENT WILL ACHIEVE OPTIMAL MOBILITY PATIENT ADEQUATELY NOURISHED (75% or>) PATIENT'S 02 SATURATION > 92%. PATIENT'S SKIN INTEGRITY MAINTAINED GENERAL MED D1-3 NURSING CARE PLAN GUIDELINE I . Assess nutritional status (Nutrition consult, pre-albumin) 2. Assess Activity Level(Mobility Protocol) 3. Assess & Monitor Treatments (Braden score, wound care, dressings, line site) 4. Monitor Tests (Lab, radiology etc.) 5. Monitor Medications (Appropriateness, dosage, frequency) 6. Consults (Completed, communication of plan) 7. Discharge Planning (Plan initiated, follow-up, needs .identified) GENERAL MED CO-MORBID CONDITIONS #1 ADD APPROPRIATE UOCs D1-4 Expected Patient Outcomes 02 SATURATION > 92% D7 NURSING CARE PLAN GUIDELINES - Nursina Diasfnosls D2 NURSING CARE PLAN GUIDELINES - Nursina Diagnosis 1. Impaired physical mobility related to neuromuscular and perceptual or cognic.ive impairments resulting in paralysis and immobility and causing motor activity deficits, loss of muscle strength and mass. 2. Self Care deficit. D1 Nursinst Interventions Printed at: 9/25/2006 , 4:05:29AM United Health Services Hospitals Plan of Care Page: 2 9/25/06 7:00 to 9126/06 7:00 United Health Services Hospitals ST3 Room: B349A 4848158 DERVISEVIC, SAHA . D1 Nursing Interventions 1. Observe for signsisymptoms of increased ICP. 2. Assess for evidence of tissue perfusion. 3. Auscultate chest for breath sounds every 4h. 4. Monitor Coma Scale. 5. Consult with PT/OT/Speech/Cognitive. 6. Assess for signs and symptoms of bleeding. 7. Monitor anticoagulation status. 8. Aspiration precautions. 9. Smoking cessation. 10. Fall Precautions. D2 Nursing Interventions 1. Mobility Protocol 12 3 or 4. 2. Assess functional ability and extent of impairment; record and monitor changes and improvements. 3. Provide pictures of common objects to which patient can point if necessary. 4. Continue BP monitoring. 5. Fingerstick glucose,if ordered. 6. !V access, if ordered. 7. Continue to reinforce educational material and disease process with patient and family. ADVANCED DIRECTIVES - Nursing Responsibility 1. Advance Directives will be adressed with all patients upon 2. If pt has Advanced Directives, the box on the admission history will checked, a copy will be placed on pt's medical record, and the nurse will fill in the appropriate boxes on Kardexl. 3. If pt has Advance Directives but does not have them with them, get a specific quote fron the pt as to the content of the Advance Directives and record on the admission history. 4. If pt does not have Advance Directives, check the appropriate box on the admission history, provide pt education, assist pt in completion of form, place copy on medical record, and give copy to the pt. Complete Kardex 1. BEHAV HEALTH - ANXIETY, MILD: PATIENT I. 2. 3. 4. 5. 6. 7 Approach the patient in a calm, speak slowly and simply. Repeat Provide calm, quiet environment. Assess level of anxiety. reassuring manner. instructions as needed- 24hr A sheet admission. Adm Hx Kardex Mod Roe Aden Hx Med Rec Adm Hx Kardex'i 24hr A sheet 24hr A sheet teaching record Document signs of increasing anxiety. Identify factors that increase anxiety. Assist the patient to identify strategies elimates stressors. Spend time talking with the pt. $, Tell zhe patient when you will return. g, Assist the patient to identify the kind of support needed to reduce or teaching record Printed at: 912512006. 4:05:29AM United Health Services Hospitals 9/25/06 7:00 to Plan of Care 9/26/06 7:00 United Health Services Hospitals ST3 Room: B349A 4M I58 DERVISEVIC, SARA. BEHAV HEALTH - ANXIETY. MILD: PATIENT to be given by the family. 10. Administer sedation/antianxiety agents as needed as ordered. BEHAV HEALTH - ANXIETY: FAMILY med admin record Pt and family received teaching when appropriate. 1. Approach the family in a calm, reassuring manner. Speak slowly and simply. Repeat instructions as needed. 2. Document signs of increasing anxiety in the family. 3. 5ocument family's perception of patient's problems. Encourage the family to ventilate concerns. 4. Provide emotional support to family during all conttea actsing record with them. Answer their questions. Provide realistic progress reports about patient's condition. Suggest resources to meet their needs. 5. Consult Social Service if necessary. 6. Patient and family teaching when appropriate. teaching record LANGUAGE BARRIER Pt will be able to communicate with staff effectively 1. -.. Assess patient's language deficit 2. If family or friend with patient, ask to write key words on white board to help with communication between staff and patient 3.Use communication board 4. Call operator to get list of interperters at UHS and their phone numbers 5. Obtain AT&T interperter phone line from operator DIABETES Services are arranged for discharge. Pt able to secure necessary supplies & equipment. 1. Weigh patient and document. 24hr A sheet 2. A 1 C on all patients with primary/secondary DM per physician order. Kardexll 3. 1. If Al C <6.5% assess, review, reinforce. 2. If A1C > 6.5% assess, formulate plan, inipate teaching, consult Diabetes Management Center. teaching rec. 4. Assess need for monitor teaching daily. teaching record 5. Assess need for medication teaching daily. 6. Assess need for mealplan teaching & consult Food & Nutrition consult, as needed. 7. Assess need for PHN, Meals on Wheels, etc. 8. Assess need for support in securing necessary supplies or equipment DIABETES: TEACHING KardexI, SMS Page: Printed at: 9/25/2006 , 4:05:29AM United Health Services Hospitals 9125/06 7:00 to Plan of Care 9/26/06 7:00 United Health Services Hospitals ST3 Room: B349A 4848158 DERVISEVIC, SARA. DIABETES: TEACHING 1. Explain the significance of Al C. teaching record 2. Nutritional consult/Diabetes Management Ctr for meal planning. Kardexll 3. Teach self-monitoring to patient/family. teaching record 4. Teach medications and side effects to pt/family. teaching record 5. Educate pt/family to the availability of resources. teaching rec. 6. Information given for out-pt education classes. teaching record 7. Provide literature for resources post-discharge. teaching record 8. Provide phone number for Diabetes Management Center for follow-up as needed. Nrsg disc sheet MOBILITY PROTOCOL P1 Mobility/Function assessment completed. Appropriate level of mobility designated. PT/OT referral completed if needed. Necessary changes are made in :Mobility Protocol level. Patient mobilized per protocol. Patient has intact skin. Patient experiences no loss of range of motion. 1. Mobility/Function assessed on history & pt is determined to be independent once. 24hr A sheet 2. Mobility protocol Level 1 initiated once. 3. Encourage patient to be mobile on unit daily. 4. Reassess Mobility Protocol every shift & as needed. 5. Consult with physician once. Kardexll NPO AND CLEAR LIQUID FOR 5 DAYS Pt tolerates medical nutrition therapy. GOAL: Has adequate nutrition absorption to meet needs. 1. Assess and make dietary consult on day 5 if diet cannot be pro9 ressed. 2. Monitor intake and tolerance every meal. 24hr A sheet 3. Evaluate lab values & report abnormal values daily. 24hr A sheet OXYGEN THERAPY: NASAL CANNULA The patient's blood gases are within normal limits for the patient. Has moist mucous membranes. 1. Nasal cannula in place with no irritation/necrosis to nares or behind the ears. 2. Adainister oxygen at a rate of 2 -4L/min. 3. Correct functioning of 02 delivery system maintained. 24hr A shee 4. Observe for signs/sx of hypoxia q 4h & prn. Report significant changes to the physician. 24hr A sheet 5. Monitor ABG's and/or SaO2 results. Report all significant changes to the physician. 24hr A sheet 6. Encourage fluids, unless contraindicated. 7. Monitor I&O as ordered. 8. Document s/sx of acute increase in arterial C02_ 24hr A sheet 9. Oral hygiene as needed when patient awake. 24hr A sheet Printed at: 912512006, 4:05:29AM United Health Services Hospitals Page: 4 9/25/06 7:00 to 9/26/06 7:00 Plan of Care United Health Services Hospitals Room. B349A 4848158 ST3 PAIN DERVISEVIC, SARA AT ALL TIMES , the Pt will report Pain ?o?, the MD was notified. Level of 4 or below. it 1- I. Assess for pain using pain scale every 2. Offex "as needed" 8 hours, as needed. 3, pain medication. Evaluate the patient's response 1/2 medication is given. hour after Pain Level 24hr A sheet Reported Pain Length of pain episodes Moaning on crying Facial expressions of pain Restlessness Pacing Narrowed focus Muscle Tension Loss of appetite Respiratory Rate Apical heart rate Radial pulse rate Blood pressure Perspiration Overall Rating: Pain level PERIPHERAL IV: INITIATION The IV device is patent. The IV device is secure The patient's, peripheral, IV is complications initiated without . The IV is running at the prescribed rate. The IV device is in an appropriate vein. 1. Explain procedure to family and provide 2. privacy. Check physician's order. 2• Prepare the infusion set and tubing. 3. Check solution 4. Check infusion bag 5. Insert infusion set into the infusion bag. 5. Don gloves. Perform veni uncture per poli. 7. Attach to prescribed fluids and administercvia infusion pump. 8. Document on 24 hour assessment sheet. g' Change site q 72 hours or obtain order to leave in place >72. hrs. PERIPHERAL IV: MAINTENANCE 1. 3. 5. Printed at: 9/25/2006. 4.05:29AM United Health Services Hospitals inspect insertion site every 1h & document Running IV bag/tubing is labeled; monitored every per 'h ur.24 24hr A sheet Change bag every 24h. Do not flush occluded lines. 24hr h sheet Flush between incompatible medications with 2ml N Se24hr A sheet page: 9125/06 7:00 to Plan of Care 9/26/06 7:00 United Health Services Hospitals ST3 Room: B349A 4848158 DERVISEVIC, SAHA. SELF CARE Patient appears clean and does not have an odor. Patient's teeth and mucous membranes are free from debris and odor. The patient's skin is not excessively dry. If skin is dry, lotion has been applied. Skin on entire body is intact. Absence of reddened areas on any area of the body. The bed linens are comfortable for the patient. After evening care, the patient states s/he feels relaxed and is ready for sleep. Patient's hair is clean and neatly combed. Mamie patient is shaven according to his request. Female patient's legs and axiliae are shaven according to her request- 1. Document patient's usual hygiene habits on admission. Ns A Hx 2. Plan for the day discussed with the patient/famity. Encourage pttfamily to ask questions. white board 3. Discharge planning reviewed. Additional needs or problems identified and discussed with patient. Referrals/Consults made as needed. Inter Case Conf sticker 4. Document v. s . per order & as needed. Report deviations. 24hz sheet 5. Provide supplies & assist with hygiene in a.m.,as needed. 24hr A Sheet 6. Place personal items within the patient's reach. 7. Change or straighten bed linens as needed. 2 4hr A sheet 8. Implement standard precautions. TELEMETRY MONITORING The patient does not experience any life-threatening rhythm changes. If experienced, appropriate measures were taken and the physician notified immediately. 1. Place on telemetry. Obtain a strip every shift and as needed. Report all significant, or life--threatening changes to the physician. 24hr A sheet CARDIAC MONITORING The patient is not experiencing an arrhythmia. The patient is not experiencing any skin irritation. 1. Monitor cardiac rhythms. Report significant changes to the physician. Change electrodes prn. 24 hr A sheet 2. Obtain rhythm strip every shift & as needed & report significant changes to the physician. 24hr A sheet APPROVALS within last 24 hours: Date Name 9/25106 3:58 Rebecca. Ciotti RN Page: fi Printed at: 9/25/2006, 4:05:29AM United Health Services Hospitals 9/26/06 7:00 to Plan of Care Page: 9/27/06 7:00 United Health Services Hospitals ICU ` Room: BI0009 4848158 Care Path 01D# DERVISEVIC, SARA. =IVcrrAI. MEDICAL PATIENT CARE PATIO DAY # GENERAL MED KEY PROCESS POINTS CORE MASURE - PRE-PRINTED PHYSICIAN ORDERS UTILIZED, prophylactic antibiotic recieved within one hour prior to surgical procedure. CORE 24EASURE -,ASSESS FOR PNUEMONLA AND INMUENZA VACCINES. GENERAL IVIED D1-3 EXPECTED PATIENT OUTCOMES GUIDELINE STABLE HEMODYNAMIC STATUS PATIENT'S PAIN CONTROLLED PATIENT WILL ACHIEVE OPTIMAL MOBILITY PATIENT ADEQUATELY NOURISHED (75% or>) PATIENTS 02 SATURATION > 92°/n. PATIENT'S SKIN INTEGRITY MAINTAINED GENERAL IVIED D1-3 NURSING CARE PLAN GUIDELINE 1. Assess nutritional status (Nutrition consult, pre-albumin) 2. Assess Activity Level(Mobility Protocol) 3. Assess & Monitor Treatments (Braden score, wound care, dressings, line site 4. Monitor Tests (Lab, radiology etc.) 5. Monitor Medications (Appropriateness, dosage, frequency) 6. Consults (Completed, communication of plan) 7. Discharge Planning (Plan initiated, follow--up, needs identified) GENERAL MED CO-MORBID CONDITIONS #1 ADD APPROPRIATE UOCs D1-4 Expected Patient Outcomes 02 SATURATION > 92€ D2 NURSING CARE PLAN GUIDELINES - Nursing Diagnosis 1. Impaired physical mobility related to neuromuscular and perceptual or cognitiv- impairments resulting in paralysis and immobility and causing motor activity deficits, loss of muscle strength and mass. 2. Self care deficit. D3-4 NURSING CARE PLAN GUIDELINES - Nursina Diagnosis D2 Nursinq Interventions 1 • Mobility Protocol 12 3 or 4. 2. Assess for signs and symptoms of bleeding. 3. Monitor anticoagulation status. Printed at 9/26/2006, 4:16.51AM United Health Services Hospitals Plan of Care Page: 2 9i26/06 7:00 to 9/27/06 7:00 United Health Services Hospitals ICU Room: BI0009 4848158 DERVISEVIC, SAHA . D2 Nursina Interventions 4. Assess functional ability and extent of impairment; record and monitor changes and improvements. 5. Provide pictures of common objects to which patient can point if necessary. 6. Continue BP monitoring. 7. Fingerstick glucose,if ordered. 8. IV access, if ordered. 9. Continue to reinforce educational material and disease process with patient and family. D3 Nursing Interventions 1. Complete 24 hour assessment form 2_ Reinforce and encourage all activities achieved with Medical Rehab dept. ADVANCED DIRECTIVES - Nursina Resaonsibility 1. Advance Directives will be adressed with all patients upon 2. If pt has Advanced Directives, the box on the admission history will checked, a copy will be placed on pt's medical record, and the nurse will fill in the appropriate boxes on Kardexl. 3. IF pt has Advance Directives but does not have them with them, get a specific quote fron the pt as to the content of the Advance Directives and record on the actnission history. 4. If pt does not have Advance Directives, check the appropriate box on the admission history, provide pt education, assist pt i.r. completion of form, place copy on medical record, and give copy to the pt. Complete Kardex 1. BEHAV HEALTH -'ANXIETY, MILD: PATIENT 1 2. 3. 4. 5. 6. 7. Approach the patient in a calm, speak slowly and simply. Repeat Provide calm, quiet environment. Assess level of anxiety. reassuring manner. instructions as needed. 24hr A sheet admission. Adm Rx Kardex Med Rec Adrn Hx Mad Ree Adm Hx Kardexl 24hr A sheet 24hr A sheet teaching record Document signs of increasing anxiety. identify factors that increase anxiety. Assist the patient to identify strategies eii:nates stressors. Spend time talking with the pt. 8. Tell the patient when you will return. 9. Assist the patient to identify the kind of support needed to be given by. the family. 10. Administer sedation/antianxiety agents as needed med admire record as ordered. BEHAV HEALTH - ANXIETY: FAMILY Pt and fam'_ly received teaching when appropriate. 1. Approach the family in a calm, reassuring manner. Speak slowly and simply. Repeat instructions as needed. 2. Document signs of increasing anxiety in the family. to reduce or teaching record Printed at 9/26/2006, 4:16:51 AM United Health Services Hospitals 9/26/06 7:00 to Plan of Care 9/27/06 7:00 United Health Services Hospitals ICU Room: BI0009 4848158 DERVISEVIC, SAHA. BEHAV HEALTH - ANXIETY: FAMILY 3. Document family,s perception of patient's problems. Encourage the family to ventilate concerns. 4. Provide emotional su teaching record with them. Answer theirtquto family estions. dProvidelrealisticS progress reports about patient's condition. Suggest resources to meet their needs. 5. Consult Social Service if necessary. 6. ?atiet and family teaching when appropriate. teaching record LANGUAGE BARRIER Pt will be able to communicate with staff effectively 1. 1. Assess patient's language deficit 2. If family or friend with patient, ask to write key words on white board to help with communication between staff and patient 3.Use communication board 4. Call operator to get list of interperters at UHS and their phone numbers 5. Obtain AT&T interperter phone line from operator DIABETES Services are arranged for discharge. Pt able to secure necessary supplies & equipment. 1. Weigh patient and document. 24hr A sheet 2. A1C on all patients with primary/secondary DM per physician order. Kardexll 3. 1. If A 1 C <6.5% assess, review, reinforce. 2. If Al C > 6.5% assess. formulate plan, initiate teaching, consult Diabetes Management Center, teaching rec. 4. Assess need for monitor teaching daily. teaching record 5. Assess need for medication teaching daily. 6. Assess need for mealplan teaching & consult Food & Nutrition consult, as needed. 7. Assess need for PHN, Meals on Wheels, etc. 8. Assess need for support in securing necessary supplies or equipment. DIABETES: TEACHING 1. Explain the significance of A1C. teaching record 2. Nutritional consult/Diabetes Management Ctr for meal planning. Kardexll 3. Teach self-monitoring to patient/family. teaching record 4. Teach medications and side effects to pt/family. teaching record 5. Educate pt/family to the availability of resources. teaching rec. 6. Information given for out pt education classes. teaching record 7. Provide literature for resources post-discharge. teaching record 8. Provide phone number for Diabetes Management Center for follow-up as needed. Nrsg disc sheet Printed at: 9/2612006, 4:16:51AM United Health Services Hospitals KardexI, sm-s Page: 9/26/06 1:00 to 9/27/06 7'00 Plan of Care United Health Services Hospitals ICU Page: 4 Room: BICU09 4848158 DERVISEVIC, SARA. MOBILITY PROTOCOL P1 Mobility/Function assessment completed. Appropriate level of mobility designated. PT/OT referral completed if needed. Necessary changes are made in Mobility Protocol level. Patient mobilized per protocol. Patient has intact skin. Patient experiences no loss of range of motion. 1. Mobility/Function assessed on history & pt is determined to be independent once. 24hr A sheet 2. Mobility protocol Level l initiated once. 3. Encourage patient to be mobile on unit daily. 4. Reassess Mobility Protocol every shift & as needed. 5. Consult with physician once. Kardexll NPO AND CLEAR LIQUID FOR 5 DAYS Pt tolerates medical nutrition therapy. GOAD: Has adequate nutrition absorption to sweet needs. 1. Assess and make dietary consult on day 5 if diet cannot be progressed. 2. Monitor intake and tolerance every meal. 24hr A sheet 3. Evaluate lab values & report abnormal values daily. 24hr A sheet OXYGEN THERAPY: NASAL CANNULA The patient's blood gases are within normal limits for the paticnL. Has :Hoist mucous membranes. 1. Nasal cannula in place with no irritation/necrosis to nases or behind the ears. 2. Adalnister oxygen at a rate of 2 -4L/min. 3. Correct functioning of 02 delivery system maintained. 24hr A shee 4. Observe for signs/sx of hypoxia q 4h & prn. Report significant changes to the physician. 24hr A sheet 5. Monitor ABG's and/or Sa02 results. Report all significant changes to the physician. 24hr A sheet 6. Encourage fl::yds, unless contraindicated. 7. Monitor I&0 as ordered. 8. Document s/sx of acute increase in arterial C02. 24hr A sheet 9. Oral hygiene as needed when patient awake. 24hr A sheet PAIN AT ALL TIMES , the Pt will report pain level of 4 or below. If not, the MD was notified. 1. 1. Assess for pain using pain scale every 8 hours, as needed. 2. Offer "as needed" pain medication. 3. Evaluate the patient's response 1/2 hour after medication is given. 24hr A sheet Pain Level Reported Pain Length of pain episodes Printed at: 9/26/2006 , 4:16.51AM United Health Services Hospitals 9/26/06 7:00 to Plan of Care Page: 9/27/06 7:00 United Health Services Hospitals ICU Room: BICU09 4848138 Pain Level Moaning on crying Facial expressions of pain Restlessness Pacing Narrowed focus Muscle Tension Loss of appetite Respiratory Rate Apical heart rate Radial pulse rate Blood pressure Perspiration Overall Rating: Pain level DERVISEVIC, SAHA. PERIPHERAL IV: INITIATION The IV device is patent- The IV device is secure. The patients peripheral IV is initiated without complications. The IV is running at the prescribed rate. The IV device is in an appropriate vein. 1. Explain procedure to family and provide privacy. 2. 1. Check physician's order. 2. Prepare the infusion set and tubing. 3. Check solution 4. Check infusion bag Insert infusion set into the infusion bag. 6. Don gloves. Perform venipuncture per policy. 7- Attach to prescribed fluids and administer via infusion pump. 8. Document on 24 hour assessment sheet. 9. Change site q 72 hours or obtain order to leave in place >72 hrs. PERIPHERAL IV: MAINTENANCE 1. inspect insertion site every 1h & document per policy. 24hr a sheet 2. Running IV bag/tubing is labeled; monitored every hour. 24hr A sheet 3. Change bag every 24h. 24hr A sheet 4. Do not flush occluded lines. 24hr A sheet 5. Flush between incompatible medications with 2ml N/S. 24hr A sheet CRITICAL CARE - DAILY CARE 1. No signs of infection or infiltration at IV site. 2. Lung sounds are clear, if signs of congestion, physician was notified. 3. Tubing, IV bags changed according to protocol. 4. IV site dressing changed according to protocol. Printed at: 9/26/2006, 4:16:51AM United Health Services Hospitals Plan of Care Page. 6 9126/06 7:00 to 9/27106 7:00 United Health Services Hospitals ICU Room: BICU09 4848158 DERVISEVIC, SAHA. CRITICAL CARE - DAILY CARE 1. . CARDIAC ASSESSMENT - HEART SOUNDS 24hr Sheet Auscultate the mitral or apical area. identify if rhythm is regular or irregular. Listen for extra heart.and document Compare ap-cal and radial pulses. 2_ SKIN/INTEGUMENT ASSESSMENT Note the color of the skin and nailbeds. Note the skin's moisture, temperature, mobility and turgor. Note any evidence of bleeding or bruisinq and any lesions. Note capillary refill time. Observe oral mucosa. Braden scale documented every 24h. 3. co-nplete the braden scale on admission and daily. if the patient's score is < 16, c the patient is assessed to be at risk for developing pressure ulcers, refer to uhs policy cp # 25 for prevention and treatment protocols. 4. CARDIOVASCULAR ASSESSMENT - DISTAL PULSES Palpate radial and pedal (or post tibial) pulses bilaterally. Note their strength and regularity. 5. EDEMA ASSESSMENT Check for pitting edema in patient's extremities. Press one or two fingers on the edematous area over a bony prominence. If the indentation remains Eor 15 seconds or more, record the degree of pitting edema according to the depth of indentation. 6. RESPIRATORY ASSESSMENT Observe respiratory pattern, note rate and rhythm of breathing. Auscultate posi:erior chest; if ventilated also listen anteriorly. Listen for quality and intensity of the breath sounds; adventitious or other abnormal sounds. 7. Describe color and consistency of sputum. 8. ABDOMINAL ASSESSMENT Inspect the contour of the abdomen. Auscultate in all four quadrants. Identify areas of resistance or tenderness. 9. NEUROLOGICAL ASSESSMENT, LOC Assess level of consciousness, awareness and ability: orientation, memory, speecg, commands/behaviors. 10. NEUROLOGICAL ASSESSMENT, MOTOR Assess extremities for sensation and strength bilaterally, compare side to side. document strength as weak/mod/ strong pertinent to each individual patient. 11. Neurological assessment, eye Assess eye for double vision, photophobia (irritation to eyes aggravated by light), ptosis (drooping of eyelid), pupil size, shape and reaction to "sight/equality. 12. DOCUMENT ON Critical Care Assessment Sheet: Vital signs (BP,P,R)at minimum every 4h. Temperature every 4H, or more frequently if elevated. Cardiac rhythm changes- Oxyger. concentration and mode. I/O monitored with summary documented every shift. Reposition and skin assessed. Care provided as needed. Deep breathe and cough (if appropriate) surgical patients every 2 hours. Splint thoracic or abdominal incisions. Printed at 9/26/2006, 4:16:51AM United Health Services Hospitals 9/26106 7:00 to Plan of Care 9/27/06 7:00 United Health Services Hospitals ICU Room: BI0009 4MI58 DERVISEVIC, SAHA. CRITICAL CARE - DAILY CARE Other documentation as appropriate. 13. Evaluate for implementation of Fall Alert Protocol every 8 ours 14. Spiritual/emotional support offered to patient/family. Explanation of care provided. Safety features of applicable equipment explained to patient/family. Questions answered and teaching reinforced. Restful environment when able. Treatments grouped together when possible. 15. Continually reassess throughout shift for for fall risk status. 16. Or. admission to CCU attach the patient to a continuous cardiac monitor with the alarms set. Obtain a complete head _o toe baseline assessment. 24hr Sheet 17. Assist patient with ADL'S as needed. 18. Determine need for case manager/discharge planning consult and need for other services. Incorporate teaching/discharge planning into daily care with patient and/or family. 19. Refer to JCC Number 960, 961, 962 CRITICAL CARE - ADULT RESPIRATORY DISTRESS SYNDROME (ARDS) Page: 1. Provide pulmonary toilet (TCDB, suction). 2. Assess for cyanosis. 3. Molitor input and output. Document effects of fluid administration and diuresis. 4. Monitor aerosol treatments and watch for side effects. 5. Monitor P.BG's and PFT's. 6. Note signs and symptoms of deceased cardiac output-elevated pulse, decreased bloc pressure, change in level of conscienceness, decrease urinary output. 7. Assess for signs and symptoms of fluid overload and edema. 8. Monitor hourly and daily fluid total intake and output. 9. Monitor Mean arterial pressure, pulmonary arterial pressure, cardiac outpu-,:, an--; pulmonary arterial wedge pressure if ordered. 10. Administer IV fluids as indicated. 11. Monitor/replace electrolytes. 12. Monitor hemodynamic status. 13. Note findings related to decreased perfusion. 14. Note changes in loss of conscienceness. 15. Monitor EKG's and note dysrhythmias. 16. Assess bowel sounds, abdominal girth, nausea and vomiting, constipation and coca: blood. 17. Monitor hourly urine output. Note specific gravity if ordered. 18. Assess GI function. 19. Provide to-cal parenteral nutrition tube feedings as ordered. Follow protoco_s. 20. Suction only when necessary. Use intermittent suct°_on. 21. Monitor for GI bleed and ileus. 22. Monitor for renal failure. 23. Monitor skin and follow wound care protocol. 24. Monitor drug levels and coagulation studies. Printed at. 9/26/2W6. 4:16:51AM United Health Services Hospitals 9/26/06 7:00 to Plan of Care Page: 9127/06 7:00 United Health Services Hospitals ICU Room: BI0009 4848158 DERVISEVIC, SARA. INDWELLING URINARY CATHETER: CARE 1. Patient/family taught measures to maintain paiency of unnary catheter. 24hr A sheet APPROVALS within last 24 hours: Date Name 9/26106 2:03 Shyrlie . Bockus RN 9/25106 22:19 Jennifer. Cornell RN 9125106 10:58 Luann. Roberts GN 8 Printed at: 9126/2006. 4:16:51 AM United Health Services Hospitals r °p '4 • .fib `; x u° r fL "' s .n o t0; `Q ? Q G pet.VQ If j ci +f d 0 4 m k f QO O $ Z r o z ! OC QQ...s.. ~ Q .w - :! •t....... n m VF N? N Y N O b l/y a ?. c? $ • r w - e. ? as D4K u? 2 LL w W F q O q _ , N ?Yy C 5 _ U) '9c A- W R V O L rf.' 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U Q .f S f'r O n 7 f` CO .D --' LA -- I 4 C, C> G: N M1 M1 ? 1 7 O' ?` M T ? ._ t.. L T• J J 4 ah a N H .t O su ? N ? O T r w O r ;v ,..a 6 c. J o O N\ir? HO a C „ate .r0 co mw u0 r 7 tlr 9 O , ? a w C _ UN h W L yy O ?`/ ??yp " F A F C O [I 7 M ENE-, I 4 . I I i 1 ? 1 b ? R 014-ftlb- ,nwr ,nauw ?a„ra, r UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ,ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 -FROM: 09/24/06- 00:01 TO 09/26/06 24:00 M A R PERMANENT CHART COPY ORDER INFORMATION - ---? --------------------------- -- - -------------------- 019/24 ? 09/25 ? 09/26 ( ------------------------------------- -------------------------------- ROUTINE ORDERS ------------- HEPARIN SODIUM 1120 JG2710 HEPARIN SODIUM HIST 8000. UNI IV ONCE ONCE ROUTINE 8000 UNI/1.6 ML VIAL SMS RX00026 09/26 12:00 TO 09/26 12:00 - METOPROLOL-TARTRATE ----------- - ----------- ---------?-- *0745 JG2710 LOPRESSOR *2157 JG2710 12.5 MG PO j Q12H ROUTINE 12.5 MG/0.25 TAB TAB HOLD FOR BPS<90 SMS RX00013 09/26 09:00 TO 10/25 21:00 SIMVASTATIN 2320 RK6055 *2157 JG2710 ZOCOR 40. MG PO QHS ROUTINE 40 MG/1 TAB TAB SMS RX00005 09/25 22:00 TO 10/24 22:00 MAGNESIUM HYDROXIDE 0917 I,R0435 0745 JG2710 -- MILK OF MAGNESIA 30. ML PO QD ROUTINE 30 ML/30 ML SUSP SMS RX00004 09/25 09:00 TO 10/24 09:00 ---------------------------------------------------------- SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C * - NOT AM PERMANENT CHART COPY 102:55 09/27/06 FROM @00L,OCMARDFI ***'k******?k*******tk*******************?k*lr?k*****#?k*#**iir'k?k?lrnir#*ilr*#**ir*******ak+{ UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 FROM:-09/24/06- 0001 TO 09/26/06 =24.00 M A R PERMANENT CHART COPY -----ORDER-INFORMATION------------I---09/24----J---09/25--------09/26`---?-- AMLODIPINE *0909 LR0435 NORVASC 10. MG PO QD ROUTINE 10 MG/1 TAB TAB SMS RX00006 09/25 09:00 TO 10/24 09:00 DISCONTINUED: 09/25 09:43 **** DI ORDER *** LISINOPRIL PRINIVIL/ZESTRIL 40. MG PO - Q D0 0 MG/2 TAB 4 TAB SMS RX00007 09/25 09:00 TO 10/24 09:00 DISCONTINUED: 09/25 09:43 PANTOPRAZOLE PROTONIX 40. MG IV 4D ROUTINE 40 MG/1 VIAL VIAL RECONSTITUTE WITH 10 ML NS ADMIN IV OVER AT LEAST 2 MIN. ADMIN IV OVER AT LEAST 2 MIN. SMS RX00008 ADMIN OVER 2 MIN IV PUSH.MIX W / 10 ML NORMAL SALINE 09/25 09:00 TO 10/24 09:00 ___`=====z l*Q909 LR0435 **** DI ------------------------ ------ ONE TIME & STAT FENTANYL CITRATE FENTANYL CITRATE 50. MCG IV ONCE ONCE STAT 50 MCG/1 ML SYRING SMS RX00032 09/26 13:56 TO 09/26 13:56 ORDER 0917 LR0435 a = _ = c x = =c = s= 1050 JG2710 0940 JG2710 HIST SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C - * - NOT-ADD - PERMANENT CHART COPY 02:55 09/27/06 FROM Q00L,OCMARDFI UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 - T FROM: 09/24/06 00:01 TO 09/26/06 24:00 M A R. PERMANENT CHART COPY ORDER INFORMATION - --- ----? --- 09/24 ---- ? --- 09/25 ---- i ---09/26 ----?-- FENTANYL - -- -- - -------- - -0840 MS2526- -- SUBLIMAZE HIST 50. MCG IV SITE= IV ONCE ONCE STAT 50 MCG/1 ML INJ SMS RX00024 09/26 09:17 TO 09/26 09:17 MIDAZOLAM HCL 0840 MS2526 VERSED HIST 5. MG IV ONCE ONCE STAT 5 MG/1 ML VIAL SMS RX00025 09/26 09:17 TO 09/26 09:17 ?===cam====?_______________•?____?_ -=?r===c=...=- - - _?________- - - --_____?___ - - -_ LORAZEPAM 0738 MS2526 ATIVAN SITE= IV 2. MG ONCE ONCE STAT 2 MG f l ML SYRING IV FOR INYUBATION SMS RX00019 09/26 07:38 TO 09/26 07:38 FENTANYL CITRATE 0735 MS2526 FENTANYL CITRATE SITE= IV 75. MCG IV ONCE ONCE STAT ?- 75 MCG/1.5 ML SYRING SMS RX00018 09/26 07:35 TO 09/26 07:35 SUCCINYLCHOLINE CHLORIDE 0734 MS2526 QUELICIN FLIPTOP SITE= IV 40. MG IV ONCE ONCE STAT 40 MG/2 ML VIAL SMS RX00017 09/26 07:34 TO 09/26 07:34 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C * - NOT ADr PERMANENT CHART COPY 02:55 09/27/06 FROM Q00L,OCMARDFI *##*?r#*?Ir#*###*#1t*#****k**?*#**#!***#*##**?r*#*7k##k*-k***k*?ie?Elrk***#it*1r*##**l?rUNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 FROM: 09/24/06 -00:01 TO 09/26/06 24:00- M A R PERMANENT CHART COPT ---'----_-~--- - - ------_ ----- ORDER MIbAZOLAM HCL INFORMATION -_ -- ? ? ------~_ 09/24 ---_ + _--___- 09/2_S ~_-- ? -0710 09/26 ' MS2526f-_ VERSED ? I ?HIST I 3. MG IV ONCE ONCE STAT 3 MG/3 ML VIAL 3 MG IV NOW SMS RX00015 09/26 07:32 TO 09/26 07:32 METOPROLOL TARTRATE LOPRESSOR 12.5 MG PO ONCE ONCE STAT 12.5 MG/0.25 TAB TAB SMS RX00011 09/25 23:57 TO 09/25 23:57 2357 MT5815 PRN ORDERS LORAZEPAM ATIVAN 1, MG IV 02H PRN EVERY PRN 1 MG/0.5 ML SPRING AGITATION SMS RX00034 09/26 15:01 TO 10/03 15:01 FENTANYL CITRATE FENTANYL CITRATE 50. MCG IV 02H PRN EVERY PRN 50 MCG/3 ML SPRING PAIN SMS RX00033 09/26 15:00 TO 10/03 15:00 **** NO ADMINISTRATIONS i 1543 JG2710 cx SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C * NOT ADP - - PERMANENT CHART COPY 02:55 09/27/06 FROM @OOL,OCMARDFI UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SARA ICU BICU09 ATN MD: ARONIS, MI CHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 z FROM 09/24/06 00:01 TO 09/26/06 24:00 M A R. PERMANENT CHART COP) ___-_ORDER-INFORMATION----- 09/24 09/25 09 1 I /26 ? FENTANYL CITRATE _-_ ___- ___ ____ ___ 1118 _--- -- JG2710 FENTANYL CITRATE 1305 JG2710 75. MCG IV HIST Q2H PRN EVERY PRN 75 MCG/1.5 ML SYRING PAIN SMS RX00023 09/26 08:32 TO 09/26 15:01 DISCONTINUED: 09/26 15:01 **** DISCONTINUED ORDER *** ------------------------- - LORAZEPAM - ------------- -1050 JG2710 ATIVAN 1355 JG2710 2. MG IV Q2H PRN EVERY PRN 2 MG/1 ML SYRING AGITATION SMS RX00022 09/26 08:31 TO 09/26 15:01 DISCONTINUED: 09/26 15:01 **** DISCONTINUED ORDER *** CODEINE/APAP #3 1338 LR0435 TYLENOL #3 TAB 2. TAB PO Q4H PRN EVERY PRN 2 TAB/2 TAB TAB MILD TO MODERATE PAIN SMS RX00010 09/25 09:43 TO 10/02 09:43 - CODEINE/APAP #3 0917 LR0435 TYLENOL #3 TAB 2. TAB PO 04H PRN EVERY PRN 2 TAB/2 TAB TAB MILD TO MOD PAIN SMS RX00003 09/25 02:39 TO 09/25 09:44 DISCONTINUED: 09/25 09:44 **** DISCONTINUED ORDER *** ---- --------------------------------------------- SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C * NOT ADI, PERMANENT CHART COPY 02:55 09/27/06 FROM COOL, OCMARDFI ***#*ak###**#*k**kt#*-kk?k*ak?r*k#Itlt-k*#*k#*tk**ik#*##**IF***#ik#*9k#*tllr#*9t#*4#tk***It#*It UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ICU BI0009 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR##: 4848158 AGE: 60 SEX: F ADM DATE: 092406 FROM:-09/24/06y-00.01-TO _09/26/06 --24_00-- --M_A-R-}---PERMANENT_CHART_ COPS --------------------- ORDER -INFORMATION------------j09/241_09/25----1-_-09/26 --------------- _---ONDANSETRON HCL ZOFRAN 4. MG IV Q6H PRN EVERY PRN 4 MG/2 ML VIAL FOR NAUSEA SMS RX00009 09/25 02:39 TO 10/25 02:39 - **** NO ADMINISTRATIONS **** MORPHINE SULFATE MORPHINE SULFATE 1. MG IV Q1H PRN. EVERY PRN 1 MG/0.5 ML SYRING SEVERE PAIN SMS RX00002 09/25 02:38 TO 10/02 02:38 JG2710 JENNIFER GUSSE LRO435 LOUANN ROBERTS MT5815 MEGHAN TRUB JC5883 JENNIFER CORNELL ------------------------------- *NIKA 0338 RC6162 1833 JC5883 2318 RK6055 NURSE IDENTIFICATION 0155 RK6055 0459 SB7445 RN RK6055 ROBIN KUPAI RN MS2526 MATTHEW SMIT] RN RC6162 REBECCA CIOT' RN SB7445 SITYRLIE BOCK1 PATIENT ALLERGIES ---- ---------• ---------------------------------------------------------- SEF END OF REPORT FOR LIST OF PATIENT ALLERGIES *CANC* -D/C * - NOT ADD PERMANENT CHART COPY 02:55 09/27/06 FROM Q00L,OCMARDFI UNITED HEALTH SERVICES HOSPITALS MEDICATION ADMINISTRATION REPORT PAGE: 7 NAME: DERVISEVIC SAHA ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR##: 4848158 AGE: 60 SEX: F ADM DATE: 092406 MAR FINAL MAR FINAL DISCHARGE DISCHARGE MAR A R===-=PERMANENT CHART COP: -_FROM--_-- _-----------TO--------------- ----------------------------------- ----------------------------- MAR. -REASON-EFFECT/CHARTING -HISTORY------------ ------------------ METOPROLOL TARTRATE 09/26 0900 0745 09/26 2100 2157 SIMVASTATIN 09/26 2200 2157 ----------- CHARTING REASON AND EFFECT ---- 12.5 MG PO Q12H DAILY JG2710 REASON: HP LOW JG2710 REASON: CPR I PROGRESS 40. MG PO QHS DAILY JG2710 REASON: CPR IN PROGRESS MAGNESIUM HYDROXIDE 09/26 0900 0745 JG2710 _.. ILODIPINE 09/25 0900 0909 LR0435 LISINOPRIL 09/25 0900 0909 LR0435 MIDAZOLAM HCL 09/26 0917 0840 MS2526 LORAZEPAM 09/26 0738 MS2526 FENTANYL CITRATE 09/26 0735 MS2526 SUCCINYLCHOLINE CHLORIDE 09/26 0734 MS2526 3 0. ML PO REASON: PATIENT NPO 10. MG PO REASON: BP 96/68 40. MG PO REASON: BP96/68 5. MG IV REASON: INTUBATION 2. MG REASON: INTUBATION 75. MCG IV REASON: INTUBATIN/AGITATION 40. MG IV REASON: INTUBATION )RPHINE SULFATE 1. MG IV - 09/25 0338 RC6162 REASON: PAIN ------------------------------- CHARTING HISTORY QD DAILY QD DAILY QD DAILY ONCE ONCE ONCE ONCE ONCE ONCE ONCE ONCE Q1H PRN EVERY ------------- HEPARIN SODIUM 09/26 1200 8000. UNI IV ONCE ONCE STATUS EFF TIME OLD 1202 REVISED: 09/26 1209 RTIF NEW 1120 FENTANYL CITRATE 09/26 1356 50. MCG IV ONCE ONCE STATUS EFF TIME OLD 1356 REVISED: 09/26 1357 RTIF NEW 0940 FENTANYL 50. MCG IV ONCE ONCE 09/26 0917 OLD REVISED: 09/26 1240 RTIF NEW *** CONTINUED ON NEXT PAGE *** FOR FENTANYL 50. -------------------- __ ------------------------------------------ SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES I *CANC* - D/C - NOT ADD PERMANENT CHAR 02:55 09/27/06 FROM (COOL, OC MARDF2 * tk'**?t*******k***?ttk****t**#*tk**k?r*#*k**k'*vk***********#***tk#**********#**it*?* UNITED HEALTH SERVICES HOSPITALS PAGE: 8 MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ICU BICU09 ATN MD; ARONIS, MICHAEL MD' PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 ----------=-=--MAR-FINAL- --LIAR FINAL DISCHARGE DISCHARGE --------------------------------- ---__ CHART COP` -FROM: TO M A R PERMANENT --------------`----------- MAR REASON EFFECT/CHARTING HISTORY------------- -------------------- *CONTINUED FROM PREVIOUS PAGE* FOR FENTANYL STATUS EFF TIME 0917 0840 50. MIDAZOLAM HCL 5. MG IV ONCE ONCE 09/26 0917 OLD REVISED: 09/26 1240 RTIF NEW STATUS EFF TIME 0917 0840 MIDAZOLAM HCL 3. MG IV ONCE ONCE 09/26 0732 OLD REVISED: 09/26 1243 RTIF NEW STATUS EFF TIME 0732 0710 FENTANYL CITRATE 75. MCG IV Q2H PRN EVERY 09/26 1355 OLD REVISED: 09/26 1357 RTIF NEW STATUS EFF TIME 0930 1305 09/26 1355 OLD REVISED: 09/26 1355 RTIF NEW STATUS EFF TIME 1355 0930 -------- --------__ - NURSE IDENTIFICATION - - JG2710 JENNIFER GUSSE RN RK6055 ROBIN KUPAI LR0435 LOUANN ROBERTS RN MS2526 MATTHEW SMITI RC6162 REBECCA CIOTTI GN JC5883 JENNIFER CORN] SB7445 - --- SITYRLIE BOCKUS RN RTIF N/A N/A - *NKA ---------- ------------- PATIENT ALLERGIES - ---- -------- ----- SEE END OF REPORT ------------------- FOR LIST OF PATIENT ---------- ALLERGIES ---------------------- I *CANC* - -------- D/C - - - NOT ADD PERMANENT CHAR 02:55 09/27/06 FROM @00L,OCMARDF2 UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SARA ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX:'F ADM DATE: 092406 --FROM: 09/24/06- -00_01-TO-09/26/06_-24_00---I-V-A-R PERMANENT CHART COP'. ---__ORDER-INFORMATION---+-- --? -- -09/24----___09/25----'__09/26----1 ----------------------------- ROUTINE ORDERS ------------- SODIUM CHLORIDE 1000. ML IV Q4 Q4HRS EVERY ROUTINE SMS RX00035 0250.00 004-OOH 09/26 16:15 TO 10/26 16:15 BTL:A VOL:1000 ML IV RATE: 250ML/HR RUN-IN: 4 H SODIUM CHLORIDE 0.9$ 1000. ML DOBUTAMINE~250M 250.~ML^IV Q24 Q24HRS EVERY ROUTINE FINAL CONC = 1MG/ML BRAND NAME = DOBUTREX SMS RX00031 OOO.OOH 09/26 14:15 TO 10/26 14:15 BTL:A VOL: 250 ML IV RATE: OMIT/HR RUN-IN: DOBUTAMINE 250MG/D5W 250. ML -===HEPARIN 25000UN 250 ML IV Q14 014HRS EVERY ROUTINE FINAL CONC 100UNITS/ML SMS RX00027 0018.00 014. 0 OH 09/26 12:15 TO 10/03 12:15 BTL:A VOL: 250 ML IV RATE: 18ML/HR RUN-IN: 14 H HEPARIN 25000UNI/D5W 250. ML *2157 JG2710 *2157 JG2710 it 1543 JG2710 - 1120 JG2710 - HIST ---------------------------------------------------_-------- SEE-END-OF_REPORT -FOR LIST OF PATIENT ALLERGIES I *CANC* D/C - * NOT ADP PERMANENT CHART COPY 02:55 09/27/06 FROM @OOL,OCIVARFI UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ICU PT# 500 BICU09 ATN MD: ARONIS, MI CHAEL MD : 6246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 R---- -FROM 09/24/06 00 01 TO 09/26/06 24 00 -- - . ------------------------ : 1 V A . PERMANENT ART COP' CHART C P' ----_ORDER-INFORMATION--------- -`-1 ---------------------1 09/24 ? 09/25 ? 09 /26 CHLORIDE 1000. ML IV Q1 - -^ ---- --` ---- - 1202 JG2710 01HR EVERY ROUTINE 1231 JG2710 SMS RX00028 1543 JG2710 0999.00 1543 JG2710 001, OOH 09/26 12:00 TO 09/26 18:00 BTL:A VOL:1000 ML IV RATE: 999ML/HR RUN-IN: 1 H SODIUM CHLORIDE 0.9k 1000. ML DISCONTINUED: 09/26 15.47 **** DISCON TINUED ORDER *** SODIUM CHLORIDE 1000 ~ML-IV 04 1050 JG2710 Q4HRS EVERY ROUTINE SMS RX00021 0250.00 004.OOH 09/26 08:45 TO 10/25 14:45 BTL:A VOL:1000 ML IV RATE: 250ML/HR RUN-IN: 4 H SODIUM CHLORIDE 0.9t 1000. ML . DISCONTINUED: 09/26 11:42 **** DISCON TINUED ORDER *** SODIUM CHLORIDE 1000. ML IV Q2 020HRS EVERY ROUTINE SMS RX00016 0500.00 002.OOH 09/26 08:00 TO 09/30 12:00 BTL:A VOL:1000 ML IV RATE: 500ML/HR RUN-IN: 2 H SODIUM CHLORIDE 0.9%- 1000. ML 0745^JG2710 DISCONTINUED: 09/26 08:29 **** DISCONTINUED ORDER' *** SODIUM CHLORIDE 1000. ML IV Q2 *0745 JG2710 Q20HRS EVERY ROUTINE SMS RX00014 0050.00 020.OOH 09/26 00:45 TO 10/26 00:45 BTL:A VOL:1000 ML IV RATE: 50ML/HR RUN-IN: 20 H SODIUM CHLORIDE 0.95 1000. ML DISCONTINUED: 09/26 07:33 **** DISCONTINUED ORDER *** -----------------------------------------.----- SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES *CANC* - D/C - NOT PERMANENT CHART COPY 02:55 09/27/06 FROM @OOL,OCIVARFI UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 - FRAM -09/24/06 -00:01 TO 09/26/06 24.00-=-I-V A R PERMANENT CHART COP' -`---ORDER_INFORMATION____________+ 09/24 ' _09/25----i---09/26----1- -------------------------------- DEXTROSE 5% NAC 1000. ML IV Q1 0338 RC6162 - Q10HRS EVERY ROUTINE 1345 LR0435 SMS RX00001 *2318 RK6055 0100.00 010.00H 09/25 03:00 TO 10/25 03:00 BTL:A VOL:1000 ML IV RATE: 100ML/HR RUN-IN: 10 H DEXTROSE 5$ NACL 0.45V 1000. ML DISCONTINUED: 09/26 00:21 **** DISCONTINUED ORDER *** DEXTROSE 596 WATER - - 500. ML NOREPINEPHRINE BITARTRATE 32. MG DEXTROSE 5$ WAT 500. ML / NORE Q12HRS EVERY ROUTINE FINAL CONC = 64 MCG/ML QUAD STRENGTH QUAD STRENGTH SMS RX00036 OOO.OOH 09/26 18:30 TO 10/26 18:30 BTL:A VOL: 0 ML IV RATE: OML/HR RUN-IN: DRIP RATE: DEXTROSE 5% WATER 250. ML NOREPINEPHRINE BITARTRATE 4. MG DEXTROSE 5% WAT 250. ML / NORE 012HRS EVERY ROUTINE FINAL CQNC = 16MCG/ML BRAND NAME = LE VOPHED BRAND NAME = LEVOPHED SMS RX00030 000-OOH 09/26 14:15 TO 10/26 14:15 BTL:A VOL: 250 ML IV RATE: OML/HR RUN-IN: DRIP RATE: DISCONT *2157-JG2710 1543 JG2710 INUED: 09/26 18.02 **** DISCONTINUED ORDER *** -------'-------------------------------------- --------- SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES 1 *CANC* - D/C - NOT ADD PERMANENT CHART COPY 102:55 09/27/06 FROM @OOL,OCIVARFI ****#*#****##*###*Ir#**•klrkt**?rk***kk?rk*#It*kk****7Ir**1k**•itkit•R*4*##*k*1c#*Ir'k##*tk# UNITED HEALTH SERVICES HOSPITALS PAGE: MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ,ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 FROM: 09/24/06- 00:01 TO 09/26/06 24 00- I V A R - PERMANENT CHART COP' -----ORDER-INFORMATION------------I---09/24----+---09/25----'---09/26----?- .DOPAMINE 400MG/D5W 0815 JG2710 500. ML HIST DOPAMINE 400MG/ 500. ML IV Q12 Q12HRS EVERY ROUTINE FINAL CONC = 800MCG/ML TITRATE TO KEEP MAP > 70 SMS RX00020 000.OOH 09/26 08:45 TO 10/26 10:45 BTL:A VOL: 500 ML IV RATE: OML/HR RUN-IN: DRIP RATE: )ISCONTINUED: 09/26 13:54 **** DISCONTINUED ORDER *** JG2710 JENNIFER GUSSE LR0435 LOUANN ROBERTS ------------------------------- *NKA NURSE IDENTIFICATION ------------ RN RC6162 REBECCA CIOT'. RN RK6055 ROBIN KUPAI PATIENT ALLERGIES -------------• --- --------------------------------- I CANC* _ D/C SEE END OF REPORT FOR LIST OF PATIENT ALLERGIES * * - NOT AM PERMANENT CHART COPY 02:55 09/27/06 FROM 000L,OCIVARFI UNITED HEALTH SERVICES HOSPITALS LAST PAGE: 13 MEDICATION ADMINISTRATION REPORT NAME: DERVISEVIC SAHA ICU BICU09 ATN MD: ARONIS, MICHAEL MD PT#: 5006246036 MR#: 4848158 AGE: 60 SEX: F ADM DATE: 092406 MAR FINAL MAR FINAL DISCHARGE DISCHARGE FROM: TO - - ---- I V A R PERMANENT CHART COP' ---------------------------------------------------------------------------- IVAR REASON EFFECT/CHARTING HISTORY --------------------------------------------------------------------------- ------------------------------- CHARTING REASON AND EFFECT ------------ PLLVP 1000. ML IV Q4HRS EVERY BOTTLE ID: A VOLUME: 1000 ML RATE: 250 ML/HR RUN-IN: 4 H 09/26 1615 2157 JG2710 REASON: CPR IN PROGRESS 09/26 2015 2157 JG2710 REASON: CPR IN PROGRESS PLLVP 1000. ML IV Q20HRS EVERY BOTTLE ID: A VOLUME: 1000 ML RATE: 50 ML/HR RUN-IN: 20 H 09/26 0045 0745 JG2710 REASON: NOT NEEDED -_T,LVP 1000. ML IV Q10HRS EVERY _JOTTLE ID: A VOLUME: 1000 ML RATE: 100 ML/HR RUN-IN: 10 H 09/25 2300 2318 RK6055 REASON: MED DISCONTINUED NOREPINEPHRINE BITARTR 500. ML IV Q12HRS EVERY BOTTLE ID: A VOLUME: 0 ML RATE: 0 ML/HR RUN-IN: 09/26 1830 2157 JG2710 REASON: CPR IN PROGRESS ------------------------------- CHARTING HISTORY ------------- PLLVP 250. ML IV Q14HRS EVERY VOLUME: 250 ML RATE: 18 ML/HR RUN IN: 14 H BOTTLE ID: A BOTTLE NI 09/26 1215 OLD REVISED: 09/26 1209 RTIF NEW STATUS EFF TIME 1202 1120 LVP 500. ML IV Q12HRS EVERY VOLUME: 500 ML RATE: 0 ML/HR RUN IN: BOTTLE ID: A BOTTLE NL 09/26 0845 OLD REVISED: 09/26 1241 RTIF NEW STATUS EFF TIME 1050 0815 -------- ---------- ------------- NURSE IDENTIFICATION ------ ------- JG2710 JENNIFER GUSSE RN RC6162 REBECCA CIOT LR0435 LOVANN ROBERTS RN RK6055 ROBIN KUPA RTIF N/A N/A N/A -------- ---------- ------------- PATIENT ALLERGIES ----- -------- * NKA -------- SEE END ---------- OF REPORT -------------------------------------------------- *CANC* FOR LIST OF PATIENT ALLERGIES - ------ - D/C I * - NOT AD PERMANENT CHAR 02:55 09/27/06 FROM 000L,OCIVARF2 uaRttedi * Do Not Remove If Record Is Thinned' United * To-Be Reviewed at Discharge* Health den, ices Hospitals PRESCRIBER ORDER F0FW Medication Assessment and Reconciliation La Q 0 r m 0 D v SOC624603b .?:. DFa1I sfy IC 4R4RISS Of?4tJ19?6 's? NA A Ortt S, MICHAEL A¢4?ttl0; Cott.frr P cant 1 st f PA 17013 OL-1-1000000 S 57021 M ,470 ,P. G-,f AUTHORIZATION IS GNEN TO THE PHARMACY TO DISPENSE A GENERIC AND THERAPEUTIC EQUIVALENT DRUG WHEN A BRAND NAME IS ORDERED UNLESS THE PRESCRIBER REQUESTS THAT THIS BRAND IS USED BY CIRCLING THE NAME TE TIME WRITTEN ALLERGIES C17250 in r Information obtained:[] Patient/Family BottlewUst ? Did Records ? Retal Pharmacy ? MD Office Records ? Other: For Preacriber Use Horne Medlestions DahkTkne For Prescriber Use CHECK A Check butt to EACH OPI" continue nods AS k, hos w T M Order meobw Stop DoWRoutelFrequency (Include HerbaVOver the CountavNih mins) Reason for PRN mads ? Patient takes no medications I n 40 L Last Does Taken XX)= Continue on discharge YES $44 Now NO vos? m d ? 1 t .} 'v d 1 Medication Assessment History Completed b : Date: a (LA Write additional admission medication orders on physicians order and / or pre-printed order forms Per P&T Committee orders for herbals will not be dia nsed. ADMISSION PRESCRIBER'S SIGNATURE T 'TIME ? TELEPHONE ORDER READ BACK TO PRESCRIBER AND VERIFIED. NURSE'S SIGNATURE DATE TIME DISCHARGE PR IBER'S SIGNATURE DATE TIME ? TELEPHONE ORDER READ BACK TO PRESCWI3ER AND VEN19ED. NURSE'S SIGNATURE DATE TIME United Health Services Hospitals Interdisciplinary Discharge Planning Flowsheet Patient Name: SAHA DERVISEVIC Account Number. 5006246036 DOB: 01/01/1946 Age: 60 MR Number: 4848158 Admission Information _ discharge Information _ Encounter Type: Observation Patient Type: Observation Admit Date: 0912412006 Admit Time: 05:47 PM Admit Reason: FRACTURE RIB NOS-CLOSED Admitting Phys: ARONIS, MICHAEL Attending Phys: ARONIS, MICHAEL Unit: ST3 Room/Bed: B3491 A Assessment Information - Status: Completed 09125/2006 Discharge Manager: Homan, Mary Transition Manager: Screening Results Pre-Hospital Resource Utilization 09125/2006 09:27 AM Homan, Mary Findings: No Prior Resource Used Caregiver Issues 0912512006 09:27 AM Homan, Mary Findings: Lives with Family Who are Able to Meet Patient Needs 09125/2006 09:27 AM Homan, Mary Lives with son and daughter-in-law Environmental issues 0912512006 09:27 AM Homan, Mary Findings: No Environmental Issues Noted by Patient and/or Family Financial Issues 09/2512006 09:27 AM Homan, Mary Findings: No Financial Issues Noted by Patient and/or Family Substance Abuse 09125/2006 09:27 AM Homan, Mary Findings: NIA Referral Source 09/25/2006 12:55 AM Jacobs, Sheila Findings: Screening Community f Family Support Available 0912512006 12:55 AM Jacobs, Sheila Findings: Community / Family Support Available Problems Identified Post DC Needs; Onset 09125!2006; Completed 49125/2006 0912512006 09:27 AM Assessment Form (Homan, Mary) Findings: No Discharge Needs Identified Discharge Plan Notes 0912512006 12:57 AM Jacobs, Sheila Pt was brought to ED s/p mva. Pt is from Pennsylvania and was travelling with her 2 sons and their families. Pt speaks Bosnian - a family member is present who has been interpreting. Pt is generally independent - pt is to be admitted. Caremanager to follow. Page 1 of 1 CONFIDENTIALITY STATEMENT: This document rnay contain information that Is confidential and protected by federal and state low_ It Is intended only for the use of the individual b whore it Is addressed. If you are not the intended recipient, you are hereby notified that any d'ia?rv, copying or distribu- tion of the contents of this information or the taking of any action in reliance thereon, is strictly prohibited. If you have received this transmission in error. please notify the sender in mediately, to arrange for the return of the docuRrents. United Health Services Hospitals Interdisciplinary Discharge Planning Flowsheet Patient Name: SAHA AERVISEVIC Account Nui DOB: 0910111946 MR Number: 4848158 Age: 60 Admission Information Discharge Information Encounter Type: Emergency Patient Type: Emergency Admit Date: 09/24/2006 Admit Time: 05:47 PM Attending Phys: GENERIC, DOCTOR# Assessment Information Status: Open 'Discharge Manager: Transition Manager: Screening Results Referral Source 09125/2006 12:55 AM Jacobs, Shelia Findings: Screening Community / Family Support Available 0912512006 12:55 AM Jacobs, Sheila Findings: Community /Family Support Available Discharge Plan Notes 09/2512006 12:57 AM Jacobs, Sheila Pt was brought to ED s/p mva. Pt is from Pennsylvania and was travelling with her 2 sons and their families. Pt speaks Bosnian - a family member is present who has been interpreting. Pt is generally independent - pt is to be admitted. Caremanager to follow. Page 1 of 1 CONFIDENTIALITY STATEMENT: This document may contain information that is confidential and protected by federal and state law. It is intended only for the use of the individual to wtxxn I is addressed. If you are rwt the Intended redpient, you are hereby notified tlat any disclosure, copying or distdbu- tion of the cDnhrft of this information or the taking of any action in reliance thereon, is strictly prohibited. If you have received this transmission in error. please rK*(y the sender irnnadiatety, to arrange for the return of the documents. ,.,_ EMPLOYEE NAME 104NTENSIIVE CARE UNIT W.LENSTEDT. JOAN L 3OCKUS, SITYRLIE 3RADTKE, SANDI J BRADY, CARIANN S CROSS, DANIELLE M DAVENPORT, MICHELE DIETZMAN, BRETF DEL, DAVID C I FRANTZ, CHRISTINA FREEMAN, DONNA SIGNATURE AUTjj.oI` pW4b03`b « g t?C aY I sty IC •Sl?+t ?Ir31j1146 i ?41?4106 flicolit 100" y? SIGNATURE y 4 3' a S? C Q t, t??TI?-S ?Itfl S S?02 1854 7Q 03004000 POT. j t C=4RTEWAN, JACQUELINE: A GASTON. REBECCA GIANNICCHI, TAMMYJo A GRIFFITH, PENNY GUSSE, JENNIFER S HALINSKI, ALEXANDRA HOGAN. EMILY M HOWELL, LISA J NUIZINGA. ALISON J -- 4 . r. 1..?r y ? ?, ` j A.? I ac 2026 1350 9067 ^: 1 0560 rCJ?• ? EMP# 3856 7445 6124 8100 4351 6245 2865 5914 ?-- 8041 5570 0190 2710 3934 4306 1 r.: 2158 5446 ?' ?`? _ x 4936 JEAVONS. CHRISTA M ?. poge V.rxlay. July 24. 2" j j SIGNATURE AUTH OR11-Y IITIALS EMP JURJE EMPLOYEE NAME Si NA U 1844 AZALM, WILLIAM S LOTZBAUGH, RALPH J - 3262 6055 UPARINEN, ROBIN R - - pCKWOOD, EVA X69 /f 5952 .LINER, BOBBY JO A°?; • ` :-x•-- 1618 AAI+ICINI, DEBBRA M ? 1 ``•• ''?.?- ??%???-'? -? •--, ?? __ _ G854 AEANEY, SHEILA A 7961 ??? •\' :?i '?, '??. t` i , AERRILL, KATHIE J - J 1943 MINER. GLORIA - 1 0773 H, TONI A 21 f ~ 5879 gFWMAN, JOHN D l 5612 JAKES. SUSAN 6936 'ER, THERESE F _.. . i r 3745 GUILES, JANETTE L ?''Z 8104 SCHLOTTMAN, KRISTEN L ^2526 SMITt ?, MATTHEW D SWEET, AM ANN TRUE, MEGHAN E TICKER. BRENT VALLESE, GEORGE R ot, 4744 '?'/,', % l ! r. 581 J 1069 .?,? 4264 Nonday. j* 24. 2006 . . - .& Gage SIGNATURE AUTHORITY 5 :UYEE NAME KRISTIrN E SHILO M ,yA, WENDI T SIGNATURE INITIALS EMP# Px k:% NS La k-d5j a ' --?i 5318 t f 2 4364 6694 fi - j ry ivY ? { .... fc, ( Mooch ., July 24.2006 United SIGNATURE AUTHORITY Health Services fimpitals EMPLOYEE NAME SIGNATURE INMALS EMI -.j62WS TOWER 3 • CARD STEP DOWN ABAUNZA, THEODORE E ?.•, z,u?, J?- 216! ALLEN, MILTON 6327 632: BATTAGLINO, KARA LYNN ?? - - _e 592E (y1.{..?I CINA, MARY T 837E -2 al f DAVIS, JUDY L 1 2672 DODD, CHRISTINA 0838 DORVAL, EMILY O plc 3813 FAUCI, SPRING A j- 2885 U GONZALES. KATHERINE C + J??J 2384 GREEK, JAYNE'- /?'LfC?c? Lt?hi 0515 GRISWOLD, JENNIFER L HELLMANN, KAREN HELMER, LAURA HOLLANDT, VALERIE K -./t?' 6Ei60 ? - 4 0205 .11: jn 0130 3948 HOUSE, CHRISTOPHER L ?- 2' 43 HUMMELL, GLORIA 8618 r ?1 Thursday, January 12, 2006 Page ?th Sew Ur'`e SIGNATURE AUTHORITY EMPLOYEE NAME INITIALS E 17 ,. 67 30. r ? .' 63 350 519 c V'.-- 048; ' 695( c^' 2633 SIGNATURE KIRCHMEIER, KIMBERLY K.Y? sa e Px'}?, cn? LAHODA, CHERYL R MASON, EARLESE B MATOLKA, PATRICIA A MCDONALD, SHANNON B MENGES, SALLY B MERRITT, DIANA M NIXON, ENID E PARSONS, TERRY L 7431 PRIBULICK, MARGARET 9400 PUTMAN, DAWN E ' 0126 ROBERTS, LOUANN ?- 0435 "td, -ro RYAN, CHERI L 4176 SEIDEL, JULIEANNJ 2038 STOUT, SHIRLEY A ; _ 5288 SUBIK, JEANNA M 17'.5 SUMMERS, SARAH L l )!? 4432 TRAVER, LINDA L 6791 Thursday. January 17 2006 Page 2 ibutedHu nth :arnco• United SIGNATURE AUTHORITY Health Semites FiDWitalS EMPLOYEE NAME SIGNATURE INITIALS EMPI WALBURGER, ADAM 3469 WARD, SANDY M 3373 ................ 1 ZOPFF, DEANA M 3302 I Thursday, January 12, 2006 Page 2 GlnitedHealth Services CONSENT FOR E /USE OF I agree to tP 158 Rv`S V1G, SAV U Nlt ? 6oY 5 ?20 10 IA946 p912412006 X7:47 ppM ppY ooz HEALTH INFORMATION PATIENTS SIGNATURE' 'Because the patient is a minor (under 18), The below consent is given on the patients behalf by: X WITNESS M/PIIA DATFJT mE AM) DATEMME years of age or, is unable to sign for the following reasol X PARENTREGAL GUARDIAN OR HEALTH CARE AGENT OTHER 1, am presenting myself for care at United He,, Services Inc., and I voluntarily consent to the rendering of such care, including diagnostic procedures and medical tee ment, by authorized agents and employees of the hospital, and by its medical staff, or their designees, as may in their p fessional judgement be deemed necessary or beneficial. I acknowledge that no guarantees have been made to me as to the effect of such examination or treatment on my con tion. CONSENT TO USE PROTECTED HEALTH INFORMATION Our Notice of Privacy Practices provides information about how we may use and disclose protected health informati about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of t notice may change. If we change our notice, you may obtain a revised copy by referring to the United Health Servic Hospitals Privacy Notice. You have the right to request that we restrict how protected health information about you is used or disclosed for tree ment, payment or health care operations. We are not required to agree to this restriction, but if we do, we are bound I our agreement. By signing this form, you consent to our use and disclosure of protected health information about you for treatment, pa ment and health care operations (inclusive of reminder notices) as well as acknowledge the receipt of the United Heat Services, Inc. Privacy Notice. You have the right to revoke this consent, in writing, except where we have already mac disclosures in reliance on your consent. ASSIGNMENT OF INSURANCE BENEFITS I hereby assign and transfer to United Health Services. Inc. and each and all of its affiliates sufficient monies and/or bane fits to which I may be entitled from government agencies, insurance carriers, or others who are financially liable for m hospitalization and medical care to cover the costs of the care and treatment rendered to myself or my dependent. (continued on back) 5213212A rev 02.06 united Hen1 th Services GUARANTEE OF PAYMENT I understand that some hospital and medical services are not covered by insurance. Non-covered services include private room difference, discharge medications and some hospitalizations for cosmetic surgery, dental and sterilization procedures. I understand I must pay for non-covered services. I give my permission for an analysis of my credit to be done if there are substantial balances owed. I hereby guarantee payment of all hospital charges incurred by the patient named on the face of this sheet from date of admission to date of discharge. Charges shall be the hospital's prevailing or posted charges during the time of patient's hospitalization, a list of which is available for the patient's examination. FOR PATIENTS ENTITLED TO MEDICARE BENEFITS I certify that the information given by me in applying for payment under title XVIII of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Social Security Administration and the Centers for Medicare & Medicaid Services or its intermediaries or carriers any information needed for this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician or organization furnishing the services or authorize such physician or organization to submit a claim to medicare for payment to me. BENEFIT QUOTES Insurance benefits quoted to United Health Services, Inc. and each and all of its affiliates providers are not a guarantee of payment. Patients are ultimately responsible to confirm benefits with their own insurance company. INPATIENT HOSPITALIOUTPATIENT INFORMATION BOOKLET As an inpatient I have been given a copy of the Patient information Booklet which explains the Hospital's policy regarding private rooms, personal property, patient's rights and other matters. As an outpatient I have received the Patient's Bill of Rights and Advance Directives. MARKET RESEARCH I authorize United Health Services, Inc. and each and all of its affiliates or representatives on its behalf, to contact me for patient feedback about the service it has provided to me. I understand that my name could be picked for feedback based on my specific medical condition, when United Health Services, Inc. and each and all of its affiliates is seeking to improve the health care of its patients with certain conditions. I also understand that this may involve United Health Services, Inc. and each and all of its affiliates disclosing my name and medical condition to an outside company that is contracted to col- lect the feedback for United Health Services, Inc. and each and all of its affiliates. Any such company would be required to keep my name and condition confidential. I understand that if I do not want to participate in this, I may cross out the above paragraph. 5213212A rev 02.06 ST349AAM &h**/F Irahtt 1T.-z United Health Service: E-lospitals BELONGINGSNALUAI3LES INVENTORY -UHS Hospitals is not responsible for valuables andlor belongings brought by ilid couraaed to send honor their valuables and belongings. 50Cb24603b 4r:'4RIs8 i 0E YY I Srif IC ,SA14i :1l /31 / 1946 F 09/24/06 A'01:I S, MICHAEL K0 c-74 V0 St COLLEGE P CA `L I Slf PA 17013 an- PATIENT BELONGWISN UPON ADMISS1014 STATUS DATE: V SENT HOME KEPT TO SAFE UNIT LOCK-UP Dentures: - Full- pper/Lower artial-Upper/Lower - Sent Home - pt - To Safe _ Unit Lock-Up Eyeglasses _. Sent Home ept - To Safe -: Unit Lock-Up Hearing Aid Right Left Both _ Sent Home Kept - To Safe --'Unit Lock-Up = Ambulation Aids - Type: - Sent Home - Kept - To Safe -Unit Lock-Up Prosthesis - Type: . Sent Horne - Kept - To Safe -Unit Lack-Up - Medications - List C Sent Home Kept - Pharmacy -: Unit Lock-Up Sent Horne - Kept = Pharmacy - Unit Lock-Up --'Sent Horne - Kept - Pharmacy - Unit Lock-Up - Cash (Breakdown) - Sent Home - Kept 7 To Safe - Unit Lode-Up :? Sent Home -" Kept To Safe --Unit Lock-Up - Sent Horne Kept To Safe - Unit Lode-Up J Sent Home - Kept - To Safe . Unit Lock-Up Jewelry (Description) 01V Of 0 -Sent Home pt -To Safe _ Unit Lock-Up Sent Home _ Kept - To Safe :. Unit Lock-Up Clothing S Sent Home pt - To Safe -: Unit Lock-Up '- Sent Home ept - To Safe - Unit Lock-Up Sent Home - Kept To Safe -Unit Lock-Up Sent Home Kept - To Safe - Unit Lock-Up Other -Sent Home Kept . To Safe -Unit Lock-Up Sent Home Kept = To Safe - Unit Lock-Up I have been informed that UHS Hospitals will not be held liable for loss or damage to any or my personal property during my hospitalization. This includes, but is not limited to: clothing, jewelry, eyeglasses, dentures, hearing aids and cash. I have been informed that UHS Hospitals maintains a safe for the safekeeping of cash, jewelry and other valuables. I understand that I may utilize this safe for my belongings. Articles placed in the safe may be claimed by contacting the Security Department through the Switchboard Operator. I understand the hospital is not responsible for items I choose to keep with me during my stay. I verify the above inventory is accurate, and any additional items brought into the hospital are solely my responsibility. Date: ORIGINAL ON CHART COPY TO PATIENT 5220211 rev 04.08 Signature: ke_1 ? C' Date*- ( ati nt or Authorized Representative - Relationship) C United United Health Services Hospitals Jagmohan S. Sidhu, M.D. - Director Department of Laboratory Medicine Wilson Regional Medical Center 33-57 Harrison Street Johnson City NY 13790 Provisional Autopsy Report Name DERVISEVIC, SAHA Case# UAO-06-00107 DOB 01/01/1946 60 Y F MR# XW0000008869 Date/Time of Death 09/26/2006, 21:34 Date/Time of Autopsy 09/2712006, Performed by CLAUDE C. CORNWALL, M.D., PATHOLOGIST Coroner TIMOTHY JONES, D.O. Report Date In Attendance Assistant JAMES COLETTA, Provisional Autopsy Diagnosis 1. Motor vehicle accident - subject was passenger in vehicle hit from behind. Subject sustained injuries to left side. Extensive bruises of left chest, flank and thigh, fractures of left ribs 6 through 10. 2. Contusion injuries to heart and lungs - congestive failure with pulmonary edema and pleural effusions. 3. Massive thromboembolism to both lungs (cause of death). 4. Minor findings: Exogenous obesity with fat apron and stria. Partial edentia, left subclavian triple lumen catheter. CCCrkw 9/28/06 V CLAUDE C. CORNWALL, M.D., PATHOLOGIST Reported: , Report signed elechvnfcaW «Date.tprinted:i08%28.06,'Timepdnted,,?323!P"A page'1 of 1 United He,.lth°Sorvices Hospitals Jagmohan S. Sidhu, M.D. - Director Department of Laboratory Medicine Wilson Regional Medical Center 33-57 Harrison Street Johnson City NY 13790 Autopsy - Final Report Name DERVISEVIC, SAHA Case# UAO-06-00107 DOB 01/01/1946 60 Y F MR# XW0000008869 Date/Time of Death 09/26/2006, 21:34 Date/Time of Autopsy 09/27/2006, Performed by CLAUDE C. CORNWALL, M.D., PATHOLOGIST Coroner TIM JONES, D.O. Report Date 11/13/2006 In Attendance Assistant JAMES COLETTA, Final Diagnosis 1. Motor vehicle accident - subject was passenger in vehicle hit from behind. Subject sustained injuries to left side. Extensive bruises of left chest, flank and thigh, fractures of left ribs 6 through 10. 2. Contusion injuries to heart and lungs - congestive failure with pulmonary edema and pleural effusions. _ 3. Massive thromboembolism to both lungs (cause of death). 4. Minor findings: Exogenous obesity with fat apron and stria. Partial edentia, left ?:• subclavian triple lumen catheter. CCC/bk - -TTN /06- _ __ Clinical Data The deceased was a 60 year old white female who was a passenger in a motor vehicle which ~ experienced a sudden flat tire and somewhat irregular stop on the highway. The vehicle was .... then hit from behind causing injuries to the passengers. The subject experienced severe injuries to the left side and was in severe pain when she was brought to Wilson Emergency Room. She was evaluated through that evening and it was felt that she was in stable condition and might be discharged. However, because of the severe pain and lack of mobility, the family requested that she be admitted to the hospital and she was transferred from the Emergency Room to a ward early the next morning. Through that day, she complained of pain in her left side, but did not seem to have edema or undue difficulty in breathing. However, by 8:30 that evening, she was, noted to have severe dyspnea and diaphoresis. A troponin taken just before that showed a level of 3.53 raising the question of whether she had cardiac bruising and onset of failure. The suddenness of her deterioration also suggested the possibility of pulmonary embolus. She was transferred to the ICU. During that evening and the next day, vigorous attempts were made to support her breathing and blood pressure. She was given large quantities of fluid and received IV Levophed. She also was intubated. However, in the evening of her second hospital day, she went into cardiac arrest and could not be resuscitated. Gross Description External Examination (Limited Autopsy - Autopsy Incision Is restricted to chest only.) Date printed: 11/13/06, Time printed: 8:49 AM page 1 of 4 Unitedf United Health' Services Hospitals Jagmohan S. Sidhu, M.D. - Director Department of Laboratory Medicine Wilson Regional Medical Center 33-57 Harrison Street Johnson City NY 13790 Autopsy - Final Report Name DERVISEVIC, SAHA Case# UAO-06-00107 The subject is an obese white female appearing consistent with the stated age of 60 years. The body appears clean and well kept. The height measures 5 feet 5 inches and the weight is estimated at 260 pounds. There is advanced post-mortem cooling and well-developed rigor mortis. Dependent lividity is present on the back. Traumatic injuries to the left side are apparent with extensive bruising of the left chest, left thigh, and a particularly large, 18 x 3cm, area of bruising in the left flank and lower thorax area. These injuries are consistent with her multiple rib fractures, which are on the left side of the lower chest. She has an endotracheal tube and a left subclavian triple lumen catheter. The skin shows no jaundice or specific lesions. There are no tattoos or specific scars. The lips and nailbeds are very prominently cyanotic. The head is normocephalic and atraumatic. The scalp hair is gray but has been dyed brown. The hair is abundant. The eyes are blue. The pupils are round, regular and equal, about 5mm in diameter. The sclerae are clear. The external ears and nose show no injury. The face, mouth, lips and gums are also free of injury. The teeth appear in poor condition and some are missing. The neck structures are midline and no abnormal masses are present. The thorax has the usual contour. The ecchymoses of the left side have been described. The breasts are large but free of palpable mass. The abdomen is quite protuberant with early fat apron. Extensive stria are present all over the lower abdomen and thighs.. No abdominal scars are seen.- The female genitalia- are free of - - - - lesion. The extremities show no scars, deformities or edema. Her legs are particularly fatty and large. External examination of the back shows no injury or deformity. Internal Examination (Limited to chest) The panniculus adiposis measures 6cm in thickness over the chest. There is abundant fat in the skin. Musculature is appropriately developed. The rib cage shows non-displaced fractures of the left lower aspect involving ribs 6-10. The possibility of other anterior fractures of ribs 4-7 are also noted a -Me left-_side of -ttfe-stemum. The pleural-and pericardial-cavities are free of fibrous adhesions. About 300cc of serosanguinous fluid are present in both pleural cavities. The pericardial cavity has about 30cc of clear serous fluid. The thoracic organs appear normally situated. The domes of the diaphragm appear particularly high, suggesting a large quantity of fluid in the peritoneal cavity. The mediastinum is midline and there are no masses or mediastinal hemorrhages. Heart: The heart weighs 450 grams. It is moderately enlarged but of normal shape. There is modest left ventricular hypertrophy. The right and left ventricular walls measure 0.4 and 1.5cm in thickness respectively. The auricles appear normal. There are no intra-auricular mural thrombi. The valves appear competent. The ring circumferences are: TV - 13.5cm, PV - 9em, MV - 17.5cm, and AV - 8.5cm. The epicardium is smooth and there are no petechial hemorrhages, which might indicate any contusion. The coronary arteries arise normally and follow a normal course. The vessels are of large caliber and there is absolutely no arteriosclerosis. The myocardium is soft and somewhat flabby. The posterior wall of the myocardium has a somewhat irregular blotchy appearance suggesting contusion-type hemorrhages where the heart may have struck the vertebral spine. Sections will be taken of these areas. The endocardium is free of mural thrombi. The papillary muscles, foramen ovate and septum are intact. Lungs: The right and left lungs weigh 950 and 780 grams respectively. They are of normal size, shape and lobar division. The pleura is smooth. The bronchi are free of lesions. The w bronchial lumina contain modest amounts of frothy mucus. In both lungs, the main pulmonary Y"l Date printed: 11/13106, Time printed: 8:49 AM page 2 of 4 C United Hedlth'Services Hospitals Jagmohan S. Sidhu, M.D. - Director Department of Laboratory Medicine Wilson Regional Medical Center 33-57 Harrison Street Johnson City NY 13790 Autopsy - Final Report Name DERVISEVIC, SAHA Case# UAO-06-00107 arterial trunks are occupied by fragments of coiled laminated thromboembolus material. This is more prominent on the left side where the embolic material extends into more distal branches. The size of the embolic fragments indicates formation in the great saphenous vein. The pulmonary parenchyma is dark red, heavy and soggy and abundant edema fluid exudes from all cut surfaces. The great extent of the congestion makes it difficult to evaluate the contusion injuries. There is nothing to suggest a prolonged pulmonary infarct. Focal areas of the lung show very prominent centrilobular anthracosis consistent with exposure to soot-filled air. No infiltrate or true emphysema changes are seen. The hilar lymph nodes are enlarged and anthracotic. Abdominal Organs, Neck Organs and Cranium: These are not examined. CCCr kw 9/28/06 Microscopic Description: Heart (slides 1 thru 5): Sections of left ventricle show a moderate degree of hypertrophic change with enlarged fibers and prominent hyperchromatic nuclei. There is no sign of inflammation or ischemic injury. A very mild degree of fibrosis is noted around intramyocardial blood vessels. Slides 3 and 4 show-regions- of fatty- infiltration of the myocardium -extending- down from--the - - epicardium. The significance of this is not clear. Slides 1 and 2 have portions of coronary arteries included in the section. These arteries show no arteriosclerosis. The classic section (slide 5) shows normal atrium, valve annulus and ventricle. Lungs (slides 6 thru 10): Sections of lungs show very prominent vascular congestion, however, there is very little evidence of bruising or pulmonary hemorrhage. Slide 10 shows massive congestion and outright pulmonary edema consistent with agonal heart failure. The bronchial branches occasionally show mucus but there is no sign of aspiration. The pulmonary parenchyma is well preserved with no emphysema. Scattered small nodules of apparent anthracosilicosis are present however;-there?®ems-lo-be--ri significant-disease-from_this -- The pleural surface shows some mesothelial reaction but no thickening. Thromboembolus material (slides 11 and 12): Multiple sections of the thromboembolus confirm the presence of true thrombosis with multiple lines of fibrin, platelets, white cells and red cells. No tumor or inflammation is seen. The embolic material is clearly of size appropriate for formation in the great saphenous vein. Summary: The deceased was a 60 year old female who was injured in an automobile accident, sustaining numerous rib fractures on the left side which essentially made her bed-ridden. She was brought to the Wilson Emergency Room and then admitted because of her difficulty with pain. On the evening of her admission she suddenly began having severe dyspnea and diaphoresis. The possibility of myocardial infarct or pulmonary embolus was entertained. She was given vigorous supported care that evening and the next day, however, on the second hospital day she went into refractory cardiac arrest. Autopsy confirmed the presence of a massive thromboembolism extending into both lungs. The embolus was laminated and coiled and present in multiple fragments, probably consistent with several embolic events which terminated in the massive saddle embolus. The lungs showed massive congestion and focal outright pulmonary edema. No contusion injury of lungs or heart was discovered on microscopic section. In addition there was no sign of myocardial infarct. The autopsy was limited to examination of heart and lungs. A mild degree of cardiac hypertrophy was noted. There was also a mild degree of scattered anthracosilicotic nodularity of the lungs. These latter conditions played no role in her fatal course. Date printed: 11/13/06, Time printed: 8:49 AM page 3 of 4 United Health" Services Hospitals Jagmohan S. Sidhu, M.D. - Director Department of Laboratory Medicine Wilson Regional Medical Center 33-57 Harrison Street Johnson City NY 13790 Autopsy - Final Report Name DERVISEVIC, SAHA Case# UAO-06-00107 CCC/bk 11/10/06 t'', CLAUDE C. CORNWALL, M.D., PATHOLOGIST Reported: 11/13/2006, 08:40 Report signed electronically Date printed: 11/13/06, Time printed: 8:49 AM page 4 of 4 DOH-1961 (102005) DIET T NEW YORK STATE (j DEPARTMENT OF HEALTH SIDENCE R NUMBER CERT IFICATE 'OF DEATH STATE FILE NlMItBER E MIDDLE LAST 2. SEX: 3A. DATE OF DEATH: 38. HOUR: - MALE FEAULE MDNTH DAY NCHS a Dervisevic S ?1 X32 9 26 1,2006 ' 9:34 P. m EATH: HOSPITAL HOSPITAL HOSPITAL NURSING PRIVATE HOSPI OTHER IFFACIURDATEADMITTED: ODA ER OUTPATIENT INPATIENT HOME RESIDENCE FACILITY (Spaelty)I Y YEAH Cl 1:1 11 91 11 0 El El 09 124 12006 4C CUTY: (If not / 6*, ois,t AVress) 40 LOCALM: (Cheat one and specfry) 4E COUNTY OF DEATH: FACUTY: CITY VILLAGE TOWN n Memorial Hospital ? X1 ? Johnson City Broome 4G 4F. MEDICAL RECORD NO, 14 . WAS DECEDENT TRANSFERRED FROM ANOTHER INSTITUTION? (Ryes, vocity afifutfon name, city or town, -oly&W slam) 4848158 NO YES XJ O 5, DATE OF BIRTH. 6A_ AGE IN 16a, if UNDER 1 YEAR y 6C. IF UNDER 1 DAY 17A. CITY AND STATE BIRTH: (#not USA, Country and 178. IF AGE BIRTH UNDER 1 YEAR, NAME OF HOSPITAL OF YEARS F raOerrA' DAY YEAR : : I m l I hours ? 10 11 1945 60yra. ' Bosnia U p 8. SERVED IN U. S. ARMEO 9. DECEDENT OF HISPANIC ORIGIN? trier Ar be= uw but describe *Ww mw Avedewr it r 10. DECEDBrrS RACE: aisc* am ornm race to whNan dmbg c mi&wl* rNaMrwho ee: O O RCES? A-y)aas) FO NO YES AXI No, not Spanshhl spardr p 8 ? Yes, Magian, Me>ocan Mnerican, Chum A ® Wfat tadasw B ? Black or African American C ? Asian Indian D ? Chinese N r/O [ 0 ? 1 C ? Yes, ham Rican D ? Yes Cuban E ? Fl w F ? Japanese G ? Korean H ? Vfehwnese E ? Yaa, Odrer Span*0*vWLatjna (Seedy) J ? fgtive HaYraBan K ? GuaeYriaA or Chamaro M ? $amorr W 1.? DECE091 13MLS+ATIMI:r?AIM'rmraWbWdoWft rhphesWwor**ds0oawrpbb a9wOwNdo*. ,1 S K, pisde 2?9tlr12th grade;md,plortu 3?High srhpol graduate or GED N El Atnaitan Indian or Alatta ltaEve ,sr 4 ? somato8ege cram, bW nrr delew 5 ? Assowro's degree 6 ? Bachelor"s degree P ? Other Asian (aperYfy) A ? Dtfmr P8018C IBlaI1dM-(saz'rM). . p, ? ? dapr Doctorate/ProfessipWl Masixes 3 F1 degree I* $ S El od Otl a {speaYy) CCn d i2 SOCIAL SECURITY NUMeEP.: 13, MARITAL STATUS: 14. SURVIVING SPOUSE: EaW am if Q 164 -$ 0- 1 7 4 5 NEVER MARRIED MARRIED WIDOWED DIVORCED SERIAATEO ? 1 ? 2 XX ? 4 ? 5 ffeaw at sq. a 1, d If=*agspousers matdrn none. Q 1OCCUN: (ra xtaAn refired) 158. KIND OF BUSINESS OR INDUSTRY: 15C. NAME AND LOCALITY OF COMPANY OR FIRM: U t Homemaker Own Home 16A KEkYN:£ 168. Coun or AapionlProvmca 16C. LOCALITY: (Check om and spadty) 16F ff CITY OR VILLAGE, IS RESIDENCE C 4 ar ountry if at USA: CITY VILLAGE TOWN I_ WITHINCITYORVNlAGELIMFTS? dn0t) Pa. Cumberland p: ? ? Carlisle 4AM ?NO tFNO,SPECIFYTOWN; - w 160. STREET AND NUMBER OF RESIDENCE: 116E. ZIP CODE: 530 2nd Street 17013- 17. NAME OF FIRST MI LAST 18. MAIDEN NAME FIRST M1 LAST FATHER: OF MOTHER: -- Bajro Ba'ric Malca Korkotovic 19A NAME OF INFORMANT: r 19B. MAILING ADDRESS: (dude no code) 1 7 0 5 5 - 31.- Savit Sisic 010 Lenker St-Birch Bld w Mechanicsburg, Pa.. 211k 1A BURIAL 2 ° CREMUM 3 t3 11111 4 HOLD 5 ° D ?TIDN 1208. PLACE OF BURIAL, CREAIATI ON, REMOVAL OR OTHER WSPOSI ION. 120C. LOCATION: (Cry or town antl slate) 3, MOM DAY 6°ENTOAIIINFNT 9 29 2d0 r Shellsville Cemetery :Grantville, Pa. 31 21K NAME AND ADDRESS OF FINiERAL HOME: t 218. REGISTRATION NUMBER; Cable-:Reber Funeral Home 208 pion St-Middletown a. 22K NAME OF FUNERAL DIRECTOR: i 22 IGNATU EOF FUNERAL DIRECT : 1 22C. REGISTRATONUMIER: Joseph L. Hubik 01900 23A. ISSUEP E OF REGi i 238 D?AHTE FI 4 PAWL ? OR BY: r 2?A H A YEAR as dgqd1z ? (J dkIA00 Y)f d6d?o ITEMS R033 CO B BY CEgTIFYiNG PHYSICIAN -- OR -- CO#tONER/ RONER'S PIMICI OR MEDICAL EXAMINER 25A. CERTIFICATION: To the best of my knowledge, death occurred at the time, date and place and due to ftte causes stated. OCOD CarttWs Name: License ft: Sip>tatwa PC T^w T' ?7`a,1-i?- 'MOM ©6 CANCER CertMer s Title: 0 ? Attend ft Physician 0 ? Physician dcmp on behalf of Attending Physician ros: 1 2 ? Medical Bxaminer I Deputy Medical Examiner ?r s ?Lll3 O 25B. It coroner is not a physician, enter Coroners Plrysiraan's name b ttle: l cru4.: soft_._ a" oft YM 25C. If certifier is not aRending physician, ender Atten?ng Physician's name li title: Uoeose No.: Adddnau? NA. Afmnft physkdan Mow Yea Nom rea 26B. Deceased lest Sean Wl" 29C. ProarwAved Off Year attended deceased: I Tp try atleridirp pMsician: Dead ON ?o AT AI 27. MANNER OF DEATH: UNDETERMINED PENDING NATURAL CAUSE (DENT HOMICIDE SUICIDE CIRCUMSTANCES INVESTIGATION 28. WAS CASE REFERRED TO CORONER OR MEDICAL EXAMINER? 29A AUTOPSY? 29B IF YES, WERE FINDINGS USED TO DETERMINE NO YES REFUSED t CAUSE OF DEATH? ?1 ?3 ?4 ?5 ?6 0©No 1 ?0 2 I 00 No LI&O CONFIDENTIAL SEE INSTRUCTION SHEET FOR COMPLETING CAUSE OF DEATH CONFIDENTIAL 3D. DEATH WAS CAUSED BY: (BITER ONLY ONE CAUSE PER LINE FOR (A), (B); AND (C).) APPRDaaNiE NRERVK eErWEN OW AM DEA,H ?..... PART I. IMMEDIATE CAUSE: (A) OUE TO OR AS A CONSEQUENCE OF: r (8) o DUE TO OR AS A CONSEQUENCE OF: & r (C) PART It. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DATH BUT NOT RELATED TO CAUSE GIVEN IN PART I (A) DID TOBACCO USE CONTRIBUTE TO DEATH? 10 YES 2 ? PROBABLY 3 ? 31A IF t UDAY RY, DATE_ HOUR: 31 Y C r town d 31 DESCR tlE HOW INJURY 3I 31E. INJURY AT AioaTH 3s N OYES %?? ?3e ? fJ j r EGG r r y m ?u ? 1 ??? M o ` 41111151FTfV4l1 1 SPECIFY 32 DECEDENT 33A IFFEDkAtE: OF DELIVERY. o , ? DdrorlDDr+la 2 eager 3 ? Pedoti4ian I ;HOSPITAL N1. NO _ YES - C? "a PeP wtaAn I># year , n PW& at Gras of deem 2 u Not prgewa, bW MOW Mate 42 days of cicala faONiH IMY_ YBA DI CONTINGENT FEE AGREEMENT I/We hereby retain and appoint MILOVANOVICH AND ESPINOSA, LLC, to act as my/our attorn eys to institute and maintain any claims, law suits, or other such legal proceedings that in the Judgment are necessary in connection with my claim for damages sustained from a •¢ on year against: C+ and any person, firm, or corporation who may be responsible for my claim for damages, or to obtainA"/, -? an amicable settlement. ` Co ,-e I/We agree not to settle or adjust the above claim or any Proceedings which arise out of the ' ' above claim without having first consulted with the above office and having obtained their written consent. I/We hereby covenant and agree that out of the sum recovered from any source on account of said accident, first the expenses of suit, costs, disbursements and expenses in the investigation and trial of the case shall be reimbursed to said attorneys. Said expenses shall include but not be limited to filing fees, service costs, copying costs, court reporter's costs, investigation costs, witness fees, fees for medical records, doctors' reports, expert witness expenses, or any similar costs or expenses. Thereafter, in consideration of the services rendered by the above attorneys I/We hereby covenant and agree to pay to the attorneys for their professional services rendered 33-1/3% percent of any sum recovered from any source on account of said accident. If the case proceeds to trial, however, I/We agree to pay 35% of any sum recovered. The swearing of the jury, if a jury trial, or calling of witnesses, or the introduction of evidence, if a trial or arbitration without a jury, shall constitute the dividing line between settlement before and during or after trial. In the event that there is no recovery obtained on this claim, the attorneys will make no charges for time or services. However, any costs or expenses which the attorneys may have advanced on behalf of the claim will be paid by me. All medical bills incurred as a result of the accident, even if previously paid or advanced by the said attorney, shall be chargeable to my share exclusively, unless otherwise paid by insurance. If my/our case is appealed by any party to any appeals court and a recovery is obtained after such an appeal is filed, my/our attorneys will receive 40% of any sum recovered. The remainder of the net recovery will go to me/us, upon deduction of reimbursable costs advanced by my/our attorneys. Recovery means all sums of money received on my behalf as a result of my claim by way of settlement, award or verdict. 'This Contingent Fee Agreement applies to all proceedings up to and including a verdict or decision at trial or arbitration in the Court of Common Pleas. If, in the discretion of the attorney, further post-trial proceedings, including appeals, are warranted, a new fee arrangement may be required by said attorney. This Contingent Fee Agreement does not apply to any law suit which may be filed against my/our own insurance company for non-payment of medical, work loss or other such first party benefits. If after settlement or trial against the primary Defendant(s), I/we wish to pursue an uninsured or underinsured motorist claim or an uninsured or underinsured motorist arbitration against my own insurance company, the said attorney reserves the right to withdraw if he believes that such uninsured or underinsured motorist claim or arbitration would be unwarranted under the circumstances. However, if the said attorney continues to represent me then he shall be entitled to a fee of 40 percent of the recovery from any settlement or award of the arbitrators. If I/We terminate this agreement before any recovery is obtained, I specifically agree that my attorneys shall be entitled to reasonable compensation for all work done and costs incurred in connection with my claim up to the point of termination. I/We agree that reasonable compensation for my attorneys shall be $ 135.00 per hour, $ 65.00 per hour for their paralegal, and $35.00 per hour for their legal assistant/secretary, or such higher rates as shall constitute their standard billing rates at the time that the work is performed. If the court awards counsel fees to be paid by the defendant or if defendants agree to pay counsel fees, the attorneys shall be entitled to the court awarded fees, in addition to our agreed upon contingent fee, except that the amount owed as a contingent fee shall be reduced by the amount awarded by the court. I/We hereby represent that no other attorney has been retained to represent me or the injured person in this case. IN WITNESS WH?REOF, I hereunto set my hand and seal this day of • , 200 , and acknowledge that I/We have received a duplicate copy of this ,j2o? / Ag WITNESS: By E DANIEL C. HERR RICHARD C. Low 7. MICHAEL SALADIK TAMARA E. SHOWALTER HERR & Low, P.C. ATTORNEYS AT LAW 234 NORTH DUKE STREET P.O. BOX 1533 LANCASTER, PENNSYLVANIA 17608-1533 (717) 397-7544 FAX: (717) 397-8227 WEB SITE: HERRLOW.COM October 29, 2007 Nina G. Milovanovich, Esquire Milovanovich & Espinosa, LLC 129 East Orange Street Second Floor Lancaster, PA 17602 RE: Dervisevic Family - Motor Vehicle Accident on 9/24/06 Dear Attorney Milovanovich: BRANCH OFFICE 7 NORTH DECATUR STREET STRASBURG, PA 17579 (717) 687-9376 You have asked me to review the underlying facts in the above referenced matter, in order to render an opinion with regard to the value of the claims by the members of the Dervisevic family injured in the accident and the allocation of the available insurance funds among those claims. In order to arrive at this opinion, I have reviewed: 1. your letter of September 21, 2007, which summarized the injuries, treatment and prognosis of the seven members of the family who were involved in the accident; 2. medical records of Saha Dervisevic; 3. medical records of Sadika Dervisevic; 4. medical records of Sejfudin Dervisevic; 5. medical records of Adelisa Dervisevic; 6. medical records of Lutvo Dervisevic; Nina G. Milovanovich, Esquire October 29, 2007 Page Two 7. medical records of Tarik Dervisevic; 8. medical records of Zekira Dervisevic; 9. summary of the wage loss of Lutvo; 10. the Police Accident Report; and 11. the insurance policies applicable to the various claims. As you know, the evaluation of personal injury claims is a matter of judgment, not science. For the purpose of this review, it may be helpful to know I have been engaged in the practice of law for twenty-seven years and have spent that entire time in the settlement and trial of cases, primarily personal injury matters. I began my practice with Dickie, McCamey & Chilcote, a Pittsburgh defense firm and have spent the last twenty-four in my firm in Lancaster, Pennsylvania. In addition, I have experience evaluating cases in the arbitration of motor vehicle claims, having served as a neutral arbitrator dozens of times and as a plaintiff's arbitrator slightly fewer times. I have an active mediation practice and have over 250 hours of experience mediating litigated and non-litigated disputes. Since 20011 have served as the Chair of the Lancaster Bar Association Alternative Dispute Resolution Committee and am currently the President-elect of the Lancaster Bar Association. On the basis of my experience, the following opinions are expressed within a reasonable degree of professional certainty. What follows is my response to your specific questions. 1. Do the claims of Lutvo Zekira and Tarik Dervisevic surpass the threshold of New York law? Having reviewed the applicable statutory provisions, I am of the opinion that their claims do not exceed the threshold necessary under New York law for the recovery of damages as a result of a motor vehicle accident. I base this upon my review of their medical records and my review of statutory New York law, specifically the New York State Insurance Laws, Section 5102(d). 2. Evaluation and apportionment of the remaining claims. Questions 2 through 4 concerned whether the apportionment of the various policies as proposed by the carriers were fair and equitable. Based upon my review of the above cited material, my opinion as to the relative apportionment of these policies differs somewhat, but not greatly, from that proposed by the various carriers. I will explain my evaluation of each of the claims below. The values which I have set forth are based on the relative value of the claims and the available insurance policies. The policies available are as follows: (1) A policy covering the tortfeasor, issued by Allstate with limits of 250,000/500,000 dollars; (2) A policy covering the liability attributable to Lutvo Dervisevic, Nina Milovanovich October 29, 2007 Page Three issued by Encompass Insurance having limits of 50,0001100,000; (3) An underinsured motorist policy issued by Met Life to Sejfudin (covering Sejfudin, Sadika, Tarik and Saha) with policy limits of 25,000/50,000. Saha Dervisevic Mrs. Dervisevic, the mother of Lutvo and Sejfudin, was injured in the accident and died two days later from a "massive thromboembolism to both lungs." (Provisional autopsy report, 9/28/06). There is no question that her death was a result of the injuries she received in the auto accident. Saha Dervisevic received multiple contusions and fractures of her ribs and contusion to her heart as a result of the automobile accident. When first admitted to the hospital, she did not appear to be gravely hurt and was going to be discharged, until she developed pain in her chest. She was then admitted. Unfortunately, her condition continued to deteriorate and she died on September 26, 2006, two days after the accident. Her claim consists of two parts: a claim under the survival act and a wrongful death claim. The survival claim encompasses her pain and suffering prior to her death, and the loss of income earning capacity over her lifetime and claims for medical and funeral expenses, if recoverable. The wrongful death claim is a claim by her three children for their loss of her care, guidance and society over her remaining lifetime. In my opinion, her total claim has a value of $250,000.00. Seventy thousand dollars of that I would allocate to the survival claim and $180,000.00 to the wrongful death claim. I make this allocation based upon the short time between her injuries and death and the negligible wage loss claim under the survival claim, in contrast to the strong showing made under the wrongful death claim on behalf of her three children, given the closeness of the family, her care of the grandchildren (services to the children), and her position as the elder of this extended family. As the elder of the family, it was Saha that the entire family, but especially her children, looked to for guidance in matters both big and small. Sadika Dervisevic Sadika Dervisevic was the most grievously injured of all the parties. She suffered a right distal fracture of her fibula and tibia, closed fracture of the sacrum of the coccyx and suffered complications of pulmonary collapse, pleural effusions and acute anemia due to internal hemorrhage while in the hospital. She also suffered a dislocation of the lumbar vertebrae and a right hip dislocation with associated comminuted fracture of the posterior acctabulum and further complications of tachycardia and vascular problems. She also suffered bruising over her face, head and body. She underwent an open reduction and internal fixation of the right tibial and fibular fracture and a closed reduction of her hip. Her hospital course was difficult and lengthy (17 days). She was discharged to her home in a wheelchair and was bedridden for the month following her discharge, receiving care at home. Despite the best efforts of her doctors, she continues to suffer disabilities and pain as a result of this accident and will, based on medical records, continue to suffer them in the future. Nina G. Milovanovich, Esquire October 29, 2007 Page Four She suffered a permanent injury through the shortening of her right leg as well as difficulties with her leg and hip as a result of the dislocation. She has been diagnosed with a peroneal nerve injury and a sciatic nerve injury with footdrop all of which cause her to walk, now and in the future, with an antalgic gate. The doctor has told her that she can expect to gain at most fifty percent of the normal function of her leg and foot and she has not been able to return to work since the date of the injury and has no realistic prospects for returning to work in the future. Her past wage loss amounts to $25,000.00. There is a lien for medical care in the amount of $58,000.00 and she is looking at a future loss of income earning capacity conservatively evaluated between $183,000.00 and $230,000.00. Based upon all of these facts, I have evaluated her claim at $300,000.00. Adelisa Dervisevic Adelisa was six at the time of this accident and suffered grade two compound fractures to the right distal fibula and tibia, as well as a Salter Harris Type H fracture of the tibia. She was seen by an orthopedist and underwent a debridement and closed reduction and percutaneous pinning of the right distal tibia and fibula, with the placement of a drain. She continued to receive care through January of 2007 by her treating physician, Dr. Olivera of Carlisle, when he discharged her from further care. She has not had any need to return to Dr. Olivera or to seek other medical care since that time. She continues to have a scar on her leg from her injuries which will, presumably, continue to fade with time, but is unlikely to fade entirely. I value Adelisa's claim at $95,000.00, including a value for the scarring on her leg. Seifudin Dervisevic Sejfudin Dervisevic sustained a blow to his head, contusion to the left chest, with fractures to the seventh and eighth rib, left shoulder injury, cervical sprain with radiculopathy and multiple contusions. The injuries to his neck and his shoulder especially caused pain and limited use of his left hand for a lengthy period of time. An MRI taken the month after the accident showed results consistent with tendonopathy as well as a anterior labral tear. The MRI of the cervical spine showed a bulge at C6-7 and Mr. Dervisevic experienced pain in both his neck and his shoulder, for which he began physical therapy on November 19, 2006. As of December, he was limited to lifting 5 pounds. In January he was able to lift 10 to 15 pounds with discomfort, and was for the first time released to return to work, with lifting restrictions, for 4 to 5 hours per day. In February, he had progressed somewhat and was released by his doctor to return to work for 5 hours a day 5 days a week. He still had restrictions in March of 2007, six months after the accident and he returned to his full time job duties only in July of 2007. However, he continues to have pain while doing his job and as of August of 2007, his doctor reported that he continues to have left shoulder Nina G. Milovanovich, Esquire October 29, 2007 Page Five weakness and possible nerve irritation in the neck. He was advised by his doctor to continue doing his home exercises and to return in 4 to 6 months. He continues to experience pain to this day and has arm and hand weakness, especially with repetitive use. He suffered a wage loss of approximately $17,000.00 throughout his recovery. In my opinion, the value of his case is $55,000.00 If I have left any questions unanswered, please don't hesitate to give me a call and I will answer them with a supplemental report promptly. T ly yours, C. VLowL Rlow@,herrlow.com RCL/gdr F MILOVANOVICH & ESPINOSA, LLC Attorneys at Law 129 East Orange Street, Suite 2 Lancaster, PA 17602 Telephone: (717) 293-1400 Toll Free: (800) 290-8222 Nina Milovanovich Fax: (208) 275-2556 Osvaldo Espinosa ninamilovanovich@peoplepc.com CLIENT/ATTORNEY AGREEMENT Estate of Th' Agreement is ente ed into by }d b tween Milovanovich & Espinosa, LLC (Attorney) and J ?? ??'RQ client). C 1. Attorney wieprovide the following services for the Client: Legal representation in legal proceedings: Assist in the administration of the Estate o 4 c- 2. Disbursement costs (filing fees, etc.) will be paid by Client. Attorney estimates that disbursement costs will be as follows: Unknown at this time. 3. Attorney agrees to explain the laws pertinent to client's problem, the available courses of action and the attendant risks. 4. Attorney agrees to notify Client promptly of any significant developments and consult with Client in advance on any significant decisions. 5. Attorney agrees to send Client copies of all pertinent written materials sent or received by Attorney pertaining to Client's case. 6. Attorney agrees to make all reasonable efforts to answer client's inquiries promptly. 7. Client agrees to pay Attorney as follows: See attached. 8. Client may terminate this Agreement, with or without cause, upon written notice to Attorney. Attorney shall return client's file immediately upon Client's terminating this Agreement. Termination shall not affect client's responsibility to pay for legal services rendered up to the date of termination. 9. Attorney may terminate this Agreement for reasons permitted under the Pennsylvania Code of Professional Responsibility. l Date /to// 9/015 Date 00.01. S loom to . LOD ?+?r? 8 COI Ste. M to S , S =At ;O;L V* S 5 , Real • -xi*ASA, ' Broker . Y $ k ` to S 10 and Trun glum% 4 ?a Per raw 4% .4006-00 SADO-W 2 0MOO .t fg"XW ?t.#t SAM iz;ip i ' ROW iativ ?sac Devis(!! DOM 060M 6% z a MOM Asmti. ' r ! wit r4 Y } C-5- Milovanovich & Espinosa, LLC 129 E. Orange Street Suite 2 Lancaster, PA 17602 Invoice submitted to: Saha Dervisevic c/o Sejfudin Dervisevic 530 2nd Street Carlisle PA 17013 November 15, 2007 Invoice #177 Additional Charges : Qty/Price Amount 10/10/2006 NM Copying cost 2 0.30 Copying cost 0.15 NM Postage 1 0.39 Postage 0.39 10/11/2006 NM Copying cost 4 0.60 Copying cost 0.15 NM Postage 1 0.39 Postage 0.39 10/12/2006 NM Fax 1 1.00 Fax 1.00 10/18/2006 NM Copying cost 9 1.35 Copying cost 0.15 10/19/2006 NM Court costs 1 110.00 Filing fees - Registrar of Wills -- Opening the estate 110.00 NM Milleage 120 55.80 Milleage to/from Cumberland Court of Common Pleas re: opening the 0.47 estate NM Toll charges 1 2.50 Toll charges (1-76) -- trip to Cumberland Court of Common Pleas re: 2.50 opening the estate Saha Dervisevic Page 2 Q /Price Amount 10/23/2006 NM Copying cost 14 2.10 Copying cost 0.15 NM Copying cost 5 0.75 Copying cost 0.15 NM Fax 7 7.00 Fax 1.00 NM Postage 4 1.56 Postage 0.39 NM Postage 1 4.64 Postage 4.64 NM Postage 1 4.88 Postage 4.88 10/24/2006 NM Copying cost 4 0.60 Copying cost 0.15 NM Postage 1 0.63 Postage 0.63 10/25/2006 NM Copying cost 2 0.30 Copying cost 0.15 NM Fax 6 6.00 Fax 1.00 10/30/2006 NM Copying cost 9 1.35 Copying cost 0.15 NM Fax 1 1.00 Fax 1.00 NM Postage 1 5.12 Postage 5.12 10/31/2006 NM Fax 2 2.00 Fax 1.00 11/1/2006 NM Postage 2 0.78 Postage 0.39 NM Copying cost 6 0.90 Copying cost 0.15 11/2/2006 NM Court costs 1 2.00 Register of Wills 2.00 Saha Dervisevic Page 3 Q /Price Amount 11/2/2006 NM Postage 1 0.39 Postage 0.39 NM Copying cost 1 0.15 Copying cost 0.15 NM Postage 1 4.64 Postage 4.64 NM Postage 2 1.26 Postage 0.63 NM Copying cost 4 0.60 Copying cost 0.15 11/13/2006 NM Fax 6 6.00 Fax 1.00 11/14/2006 NM Copying cost 1 0.15 Copying cost 0.15 NM Fax 5 5.00 Fax 1.00 11/16/2006 NM Police Accident Report 1 2.25 2.25 11/21/2006 NM Copying cost 2 0.30 Copying cost 0.15 NM Postage 1 0.39 Postage 0.39 11/27/2006 NM Fax 6 6.00 Fax 1.00 12/7/2006 NM Fax 6 6.00 Fax 1.00 12/8/2006 NM Copying cost 2 0.30 Copying cost 0.15 NM Copying cost 7 1.05 Copying cost 0.15 NM Postage 1 0.39 Postage 0.39 NM Postage 1 0.63 Postage 0.63 Saha Dervisevic Page 4 Q /Price Amount 12/8/2006 NM Payment for medical records 1 148.46 SDS for United Health Services 148.46 1/30/2007 NM Fax 5 5.00 Fax 1.00 2/13/2007 NM Postage 1 8.45 Postage 8.45 , NM Copying cost 178 26.70 Copying cost 0.15 NM Fax 2 2.00 Fax 1.00 2/27/2007 NM Fax 3 3.00 Fax 1.00 3/1/2007 NM Fax 3 3.00 Fax 1.00 4/11/2007 NM Copying cost 21 3.15 Copying cost 0.15 6/25/2007 NM Copying cost 2 0.30 Copying cost 0.15 NM Fax 3 3.00 Fax 1.00 NM Postage 1 5.21 Postage 5.21 7/3/2007 NM Fax 3 3.00 Fax 1.00 NM Copying cost 127 19.05 Copying cost 0.15 NM Postage 1 5.21 Postage 5.21 7/5/2007 NM Postage 2 12.22 Postage 6.11 NM Postage 1 6.28 Postage 6.28 7/12/2007 NM Postage 1 2.32 Postage 2.32 Saha Dervisevic 7/12/2007 NM Postage Postage NM Postage Postage NM Copying cost Copying cost 7/17/2007 NM Fax Fax 7/19/2007 NM Fax Fax 7/23/2007 NM Postage Postage 8/1/2007 NM Postage Postage NM Fax Fax NM Fax Fax 8/14/2007 NM Fax Fax 8/15/2007 NM Fax Fax 9/4/2007 NM Copying cost Copying cost NM Copying cost Copying cost NM Fax Fax NM Copying cost Copying cost 11/1/2007 NM Fax Fax 11/2/2007 NM Fax Fax Page 5 Q /Price Amount 2 3.48 1.74 1 1.38 1.38 18 2.70 0.15 2 2.00 1.00 1 1.00 1.00 1 0.41 0.41 1 0.21 0.21 7 7.00 1.00 3 3.00 1.00 1 1.00 1.00 1 1.00 1.00 5 0.75 0.15 4 0.60 0.15 3 3.00 1.00 1 0.41 0.41 5 5.00 1.00 2 2.00 1.00 Saha Dervisevic Page 6 Q /Price Amount 11/5/2007 NM Lexis 1 20.00 Lexis - legal database research 20.00 11/7/2007 NM Scanning 4 0.40 0.10 11/8/2007 NM Postage 1 0.41 Postage 0.41 NM Arbitration fee 1 457.50 Fee from the arbitrator (Richard Low, esquire) regarding suggested 457.50 settlement value and apportionment of claims NM Copying cost 2 0.30 Copying cost 0.15 NM Postage 1 0.41 Postage 0.41 11/12/2007 NM Copying cost 72 10.80 Copying cost 0.15 11/13/2007 NM Fax 4 4.00 Fax 1.00 Total costs $1,034.55 Balance due $1,034.55 pg - PAYMENT HISTORY ALC Z6 CLAIM# Z6021038 DESK# ZM YNS/DBA DERVISEVIC, LVTVO ZEKIR.A. O/C O IN ISSDAT PAYEE AMOUNT TR CVCD TE/ SFX/ CK/DRFT# PS FROM/TliRU IRS/WIT.-i AMT/NYH GROSS AMT REASON PC DT R/C 041 10074497S 1 01 071607 PARK oVENUE ASSOCIATES IN 546-40 23 PIPM MC 092406 0 2606 02 062207 UNITED MEDICAL ASSOCIATES 092606 092606 03 062207 UNITED MEDICAL ASSOCIATES 092606 092606 14.80 04 022807 UNITED MEDICAL ASSOCIATES 092406 092606 50.22 19.84 23 PIPM IF 041 100722008 C SA:-IA. DERVISEVIC #632400356MOS0 165.36 23 ?IPM RO 041 100722009 C 180:16 SAJA DERVISEVIC #632400356MOSO 561.14 23 PIPM AI 041 100600932 C 611.36 SARA DERVISEVIC #4848158 OS 113006 UNITED MEDICAL ASSOCIATES 092606 092606 28.10 SELECT CLMT LINE NUMBER MORE DATA TO FOLLOW 314.00 21 PIPM El 041 100507033 C 342.10 SARA DERVISEVIC #632400356MOS0 ID OZ6LLEO QE X3,043 a 7.911 'r,n VJW : l / ()07. 'nnd PSI - PAYMENT HISTORY ALC Z6 CLAIM# Z6021038 DESK# ZM INS/DSA DEP.V'ISEVIC, LTJTVO ZEKIRA O/C 0 LN ISSDAT PAYEE AMOUNT TR CVCD TE/ SFX/ CK/DR:T# PS FROM/THRU IRS/WITH AMT/NYX GROSS AMT REASON PC DT R/C 01 110606 BROOME VOLUNTEER EMIRG SQ 645.00 21 PIPM MC 041 100480326 C DOS: 09/x4/2006, PT# 3VO609-29 02 110606 CARDIOLOGY ASSOCIATES 122.92 21 PIPM MC 041 100480327 C DOS: 09/26/2006, PT# 75931 03 110606 UNITED HEALTH SERVICES HO 18575.90 21 PIPM HI 041 100480328 C 092406 092606 1662.54 20238.44 SAIaA DERVISEVIC #005006246036 04 ?10606 THE ESTATE OP SARA DERVIS 2000.00 21 PIPM MC 041 100480329 C PIP DEATH BENEFIT CLAIM 5 110 2zf-txI TED HEALTB -zR CE S Ho 3. 12 21 P;.RD ? 06 09240 SELECT CLMT LINE NUMBER MORE DATA TO FOLLOW 00624 ID OZ6LLEO PHA1043 I. .?l .7.90 'CA VJA?7: 1 h)(17 'I 'O.IW COBLE REBER FUNERAL HOME, LTD. 208 NORTH UNION STREET MIDDLETOWN, PA 17057 Brendan J. McGlone, Supervisor (717) 944-7413 STATEMENT OF FUNERAL GOODS AND SERVICES SELECTED File #: 41878 Information On Deceased Name: Saba Dervisevic Date of Death: September 26, 2006 Street Address: 530 2nd Street City: Carlisle State: PA Zip: 17013 This Agreement furnished in compliance with Section 13.20A of the Rules and Regulations of the Pennylvania State Board of Funeral Directors. Charges are only for those items that you selected or that are required. If we are required by law or by a cemetery or crematory to use any items we will explain the reasons in writing below. I PROFESSIONAL SERVICES Basic Services of Funeral Director and Staff.... ............................ Special Services of Funeral Director and Staff (Specify) IV Merchandise Casket/Container. Vault: Eagle, Concrete Box, Concrete Burial Vault Urn: Memorial Group .................................................... Register Book ........................................................ Acknowledgement Cards ...................................... Memorial Folders/Prayer Cards ............................ Clothing ................................................................. Miscellaneous Items of Merchandise and Service 1. Flowers 2. 3. SUBTOTAL: Merchandise and Other Services $850.00 TOTAL FUNERAL CHARGES (I thru IV) Embalming If you selected a funeral that may require embalming, such as a funeral with viewing, you may have to pay for embalming. You do not have to pay for embalming you did not approve if you selected arrangements such as a direct cremation or immediate burial. If we charged for embalming, we will explain why below. Other Preparation of the Body Dressing/Casketing & Cosmetology. ...................................... . Hairdressing ............................................................................ Sanitary Care (Topical Disinfection) ...................................... $95.00 Other (Specify) SUBTOTAL: Professional Services $945.00 II OTHER STAFF AND RELATED FACILITIES Use of Facilities, Staff, and Equipment for. Visitation (viewing) .............................................................. Funeral .................................................................................. Final Committal (Graveside or other) .................................. Memorial Service... .............................................................. Sheltering of Remains ................................................................ Other (Specify) SUBTOTAL: Other Staff and Related Facilities $0.00 III TRANSPORTATION Transfer of remains to funeral home ......................................... $310.00 Use of Casket Coach (Hearse) ......................................................... $110.00 Family Limousine/Seven (7) Passenger ............................... Family Vehicle/Four (4)Passenger ....................................... ProfessionaVClergy/Flower/Utility Transportation .............. Other (Specify) Mileage $350.00 SUBTOTAL: Transportation $770.00 SUBTOTAL FUNERAL CHARGES (I thru III) $1,715.00 OPTIONAL PACKAGED SERVICES (If an optional packaged service is selected, categories I - III are not applicable) 1. Direct Cremation .................................................................. 2. Immediate Burial .................................................................. 3. Other: SUBTOTAL: Optional Packaged Services $0,00 REASON FOR EMBALMING: ( ) Family authorized ( ) Other: Page I of 2 V CASH DISBURSEMENT Cemetery ..................................................................... Crematory .................................................................... Clergy and/or Church .................................................. Organist/Soloist/Sexton .............................................. Professional Pallbearers .............................................. Certified Copies of Death Certificates & Permit Fees Newspaper Notices (Estimates) 1. 2. 3. Gratuities ............................................................................................ Other (Specify) Other (Specify) 1. Commercial Transportation .................................................... 2. Out of Town Funeral Director ................ -............................. 3. Tent 4. 5. SUBTOTAL: Cash Disbursements me M $725.00 $2,440.00 $535.00 -eimstvs tF15 M TOTAL ESTIMATE (I - V & Packaged Service) $3,075.00 IF ANY LAW, cemetery or crematory requirements have required the purchase of any of the items listed above, the law or requirement is described below. ( ) Crematory requires container to surround the remains. (X ) Your cemetery requires an outer burial container. ( ) Other: ve prepared e above Statement o unera s and Services Selected: Brendan J. McGlone (PA) FD 014714L Name of Practitioner and License # Sign of Practitioner I have read received a copy of the Statement of Funeral Goods and Services Selected: Signature o Person making Arrangements a Case Worker Relationship to Deceased c/o Sabit Sisic 5010 Lenker St. Birch Bldg. Mechanicsburg PA 17055 439-1010 Number EXPLANATION OF PAYMENT ARRANGEMENTS All of the staff members at the COBLE-REBER FUNERAL HOME, LTD. are ready to assist your family in any way that you desire. We take this opportunity to thank you for the trust and confidence that you have placed in us. There are two types of expenses incurred in connection with a funeral. First, are cash disbursements. These are sums paid to third parties such as the cemetery, clergy, newspapers. These are listed in Section V of the Statement of Funeral Goods and Services Selected. COBLE-REBER FUNERAL. HOME, LTD. will forward the payment of cash disburesements to third parties on your behalf at no additional cost to you. However, you must make payment of these cash disbursements, by cash or check only, prior to the funeral service. These charges are NOT GUARANTEED, and are subject to price changes that may occur between date of this Funeral Purchase Agreement and the date of service. A written statement of actual charges will be provided for such items before the final bill is presented. Second, are our professional charges for the services performed or goods provided by us. In an effort to make things as easy as possible for you, we offer the following options for the payment of our professional charges. A. Payment by cash, check, Visa or MasterCard before or on the day of the funeral service. B. Payment through the assignment of insurance policy(ies) that are in good standing. In the event that the face amount of the insurance policy(ies) does not equal the total funeral charges, the balance must be paid through option A or D. C. Payment in full through a pre-need funeral trust fund established with our funeral home. In the event that the amount in the trust fund does not equal the total funeral charges, the balance can be paid through options A, B or D. D. Credit financing available through "Family Assistance." No matter which payment option you select, you are responsible for the payment of the funeral expenses. If you anticipate that the funds for the funeral will be received from the deceased's estate, you are required to pay for the funeral and then seek reimbursement from the estate. If you expect that the other family members will contribute to the payment of the funeral expenses, you are required to pay for the funeral and then collect from the other family members. The Funeral Purchase Agreement set forth below will be signed by two (2) family members (the "Purchaser's") Both family members will each be responsible for the entire amount of the funeral obligation incurred in connection with the funeral. FUNERAL PURCHASE AGREEMENT Purchasers agree to purchase from COBLE-REBER FUNERAL HOME, LTD. ("Funeral Home"), which agreees to provide same, the services and goods set forth on the Statement of Funeral Goods and Services Selected for Saha Dervisevic , Deceased, in the amount of $3,075.00 (the "Purchaser Price"), which includes cash disbursements of $635.00 The Purchase Price shall be paid on the day of the service. In the event that the Purchase Price is not paid on the day of the funeral service, interest shall accrue on the unpaid balance at the rate of 1.25% per month (15% per annum). The Purchasers acknowledge and agree by signing this Funeral Purchase Agreement, the Funeral Home has not waived its rights to file a claim against the estate of the Deceased from the funeral expenses. The Purchasers agree that in the event that the Funeral Home is required to retain an attorney to collect the Purchase Price, or any part thereof, the Purchasers shall be responsible to pay all reasonable attorneys' fees, including court costs, incurred by Funeral Home to collect the Purchase Price. The Funeral Home is not the manufacturer of any goods being purchased hereunder. Accordingly, the Funeral Home disclaims ail warranties, express or implied, of merchantability or fitness for a particular purpose. Both Purchasers agree to bejointly and severally liable for the payment of the Purchase Price. This Funeral Purchase Agreement contains the entire agreement between the Purchasers and the Funeral Home and cannot be modified or amended except in a written instrument signed by both parties. This Funeral Purchase Agreement shall be binding upon each party's successors, assigns and personal representatives. We have read and received a copy of the statement of Funeral Goods and Services. We have read and received a copy of the Explanation of Payment Arrangements and have chosen payment option A . We have read and received a copy of the statement of the Funeral Purchase Agreement and agree to the terms and conditions. TOTAL FUNERAL CHARGES (1 thru IV) ................... ................ $2,440.00 Less Pre-Paid Funds .................................................... ............... $0.00 Less Discounts ............................................................. ............... $0.00 BALANCE ...................................................................... ................ $2,440.00 Plus Cash Disbursements ............................................ .......... .. $635.00 Less Deposit ................................................................ ................ $3,075.00 ESTIMATE OF BALANCE DUE .................................. ................ $0.00 Page 2 of 2 COBLE-REBER FUNERAL HOME, LTD. By: Purchasers PNH Islamic Center 000-00-0000 Sabit Sisic 717 728 7465 p.1 B&H Islamic Center o A 5010 Ler-ker s#rr Meeanicsbur .PA.17055 Ph # . 717-761--2272 Invoice Date.Nov.29.2006 Mr.Sejfudin Dervisevic paid to B&H IC of PA. $ 3075.00 USdollars, for funeral charges. President of B&H IC of PA. Sabit Sisic i i 7 l ?V, L? ? ?J BUREAU OF INDIVIDUAL TAXES INHERITANCE TAX DIVISION Po Box 280601 HARRISBURG, PA 17128-0601 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF REVENUE WEB ADDRESS www.state.pa.us December 4, 2007 Nina Milovanovich, Esq. Milovanovich & Espinosa, LLC 129 E. Orange St., Ste. 2 Lancaster, PA 17602 Re: Estate of Saha Dervisevic File Number: 2106-0919 Court Number: CCP Cumberland Co. No. Dear Ms. Milovanovich: The Department of Revenue has received the Petition for Approval of Settlement Claim to be filed on behalf of the above-referenced Estate in regard to a wrongful death and survival action. It has been forwarded to this Bureau for the Commonwealth's approval of the allocation of the proceeds paid to settle the actions. Pursuant to the Petition, the 60-year-old-decedent died as a result of a motor vehicle accident. Decedent is survived by her adult children. Please be advised that, based upon these facts and for inheritance tax purposes only, this Department has no objection to the proposed allocation of the net proceeds of 75% to the wrongful death action and 25% to the survival action. Please be aware that the payment of Inheritance Tax is not an allowable deduction for inheritance tax purposes, therefore we would agree to the breakdown of the net allocation for this action, $119,267.51 to the wrongful death claim and $39,755.84 to the survival claim. Proceeds of a survival action are an asset included in the decedent's estate and are subject to the imposition of Pennsylvania inheritance tax. 42 Pa. C.S.A. §8302; 72 P.S. §§9106, 9107. Costs and fees must be deducted in the same percentages as the proceeds are allocated. In re Estate of Merryman, 669 A.2d 1059 (Pa. Cmwlth. 1995). I trust that this letter is a sufficient representation of the Department's position on this matter. As the Department has no objections to the Petition, an attorney from the Department of Revenue will not be attending any hearing regarding it. Please contact me if you or the Court has any questions or requires anything additional from this Bureau. Finally, the approval of this allocation is limited to this estate and does not reflect the position that the Department may take in any other proposed distribution of proceeds of a wrongful death/survival action. Sincerely, olly A. McClintock Trust Valuation Specialist Inheritance Tax Division Bureau of Individual Taxes PHONE: 717-787-1794 • FAX: 717-783-3467 • EMAIL: hmcdJntoc@state.pa.us COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY LIABILITY CASUALTY UNIT P.O.BOX 8486 HARRISBURG, PA 17105-8486 July 11, 2007 MILOVANOVICH & ESPINOSA LLC NINA MILOVANOVICH ESQUIRE 129 EAST ORANGE ST SECOND FLOOR LANCASTER PA 17602 Re: SAHA DERVISEVIC CIS #: 120151237 Incident Date: 09/24/2006 Dear Attorney Milovanovich: Pursuant to your request for a statement of claim, the Department of Public Welfare, Third Party Liability, Casualty Unit, has reviewed the information you provided regarding the above-referenced incident. It has been determined that DPW has no medical and/or cash assistance claim for this incident. If you have any questions, please feel free to contact me. Sincerely, L 6j- Ab4j4__ Barbara I. Aschenbrenner TPL Program Investigator 717-772-6617 717-772-6553 FAX L Lien Print All Lien Search ResultS as of Monday December 03,2007 The information provided by this Internet site does not constitute an official certification by the Department of Public Welfare of the amount of support arrears. Certifications of arrears amounts must be obtained from the local Domestic Relations Sections under 23 Pa.C.S. § 4352(d.1)(3) and (7). The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. The information provided by this Internet site does meet the requirements for insurance intercept purposes defined under 23 Pa.C.S. 4308.1(a) and (b). The arrears balance returned under the search criteria may be utilized to process the insurance intercept action. The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. An Insurance Intercept may be disputed in accordance with 23 Pa.C.S. 4308.1(h) and must be based on a mistake in the amount of overdue support, or a mistake in the identity of the obligor. Your Search Criteria Last Name : Dervisevic First Name : Lutvo Social Security Number : Date of Birth : 09/15/1966 09 Print No Results has been found for your Search Criteria The data is as of Monday December 03,2007. Please try again with different criteria. http:/jwww.childsuppoort.state.pa.us https://www.humanservices. state.pa.us/CSWSIdocketLien/lien_print.aspx?Current=Y Page 1 of 1 12/10/2007 Lien Print All ",lo' c-hil(i SUpport Program Lien Search ReSultS as of Monday December 03,2007 The information provided by this Internet site does not constitute an official certification by the Department of Public Welfare of the amount of support arrears. Certifications of arrears amounts must be obtained from the local Domestic Relations Sections under 23 Pa.C.S. § 4352(d.1)(3) and (7). The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. The information provided by this Internet site does meet the requirements for insurance intercept purposes defined under 23 Pa.C.S. 4308.1(a) and (b). The arrears balance returned under the search criteria may be utilized to process the insurance intercept action. The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. An Insurance Intercept may be disputed in accordance with 23 Pa.C.S. 4308.1(h) and must be based on a mistake in the amount of overdue support, or a mistake in the identity of the obligor. Your Search Criteria Last Name : Dervisevic First Name : Seifudin Social Security Number : Date of Birth : 01/15/1971 Print No Results has been found for your Search Criteria The data is as of Monday December 03,2007. Please try again with different criteria. http / _Www.childsu support. stabe?.a. us https://www.humanservices. state.pa.us/C S W SIdocketLienllien_print.aspx?Current=Y Page 1 of 1 12/10/2007 Lien Print All ,IoChlld SLApport Program Lien Search Results as of Monday December 03,2007 The information provided by this Internet site does not constitute an official certification by the Department of Public Welfare of the amount of support arrears. Certifications of arrears amounts must be obtained from the local Domestic Relations Sections under 23 Pa.C.S. § 4352(d.1)(3) and (7). The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. The information provided by this Internet site does meet the requirements for insurance intercept purposes defined under 23 Pa.C.S. 4308.1(a) and (b). The arrears balance returned under the search criteria may be utilized to process the insurance intercept action. The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. An Insurance Intercept may be disputed in accordance with 23 Pa.C.S. 4308.1(h) and must be based on a mistake in the amount of overdue support, or a mistake in the identity of the obligor. Your Search Criteria Last Name : Cehajic First Name : Lutvija Social Security Number : Date of Birth : 12/02/1964 a Print No Results has been found for your Search Criteria The data is as of Monday December 03,2007. Please try again with different criteria. hup :jLww.childsup op rt.state.pa.us https://www.humanservices. state.pa.us/C S W SIdocketLienllien_print.aspx?Current=Y Page 1 of 1 12/10/2007 Lien Print All Lien Search Results as of Monday December 03,2007 The information provided by this Internet site does not constitute an official certification by the Department of Public Welfare of the amount of support arrears. Certifications of arrears amounts must be obtained from the local Domestic Relations Sections under 23 Pa.C.S. § 4352(d.1)(3) and (7). The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. The information provided by this Internet site does meet the requirements for insurance intercept purposes defined under 23 Pa.C.S. 4308.1(a) and (b). The arrears balance returned under the search criteria may be utilized to process the insurance intercept action. The Department of Public Welfare is not liable if the information provided by this Internet site is incorrect or out of date. An Insurance Intercept may be disputed in accordance with 23 Pa.C.S. 4308.1(h) and must be based on a mistake in the amount of overdue support, or a mistake in the identity of the obligor. Your Search Criteria Last Name : Dervisevic First Name : Saha Social Security Number : Date of Birth : 10/11/1945 Print No Results has been found for your Search Criteria The data is as of Monday December 03,2007. Please try again with different criteria. http.Hwww,childsupport.state.p_a.us https://www.humanservices. state.pa.us/CS WSIdocketLienllien_print.aspx?Current=Y Page 1 of 1 12/10/2007 d ^ 3 n .4 ?. 1 J i "7 j ?ti oec 1 3 zuor, SEJFUDIN DERVISEVIC, as :IN THE COURT OF COMMON PLEAS OF Administrator of the Estate of : CUMBERLAND COUNTY, PENNSYLVANIA SAHA DERVISEVIC 530 2„ d Street Carlisle, PA 17013 Plaintiff : CIVIL ACTION - LAW/? V. :NO. 0- 7450 Civit'rierCA David A. Schriml 2713 Owego Road Vestal, NY 13850 Defendant ORDER 7,00 AND NOW, on this , day of -1212 v v -, , ?rA69, upon consideration of the foregoing Petition to Approve Settlement of Wrongful Death and Survival Actions, it is hereby ORDERED that the Petition be, and the same is, GRANTED. The settlement of the above-captioned matter in the amount of two hundred fifty thousand ($250,000.00) dollars is hereby APPROVED. It is further ORDERED and DECREED that the counsel for the Petitioner is to distribute the settlement proceeds as follows: 1. Attorneys fees and costs: a. To: Milovanovich & Espinosa, LLC, (attorneys fees - personal injury action) $ 83,333.33 b. To: Milovanovich & Espinosa, LLC, (attorneys fees - estate administration) $ 6,508.78 c. To: Milovanovich & Espinosa, LLC 1,134.55 (reimbursement of costs) 2. Inheritance taxes on survival action proceeds: a. To: Pennsylvania Department of Revenue $(2,812.50) (to be escrowed pending preparation of inheritance tax return) 3. Wrongful death and survival action proceeds ($156,210.84) to be distributed to: a. Lutvo Dervisevic $52,070.28 -o 7 ? i ? 31- r r n \i b. To: Sejfudin Dervisevic $52,070.28 c. To: Lutvija Cehajic $52,070.28 TOTAL: $ DISTRIBUTION LIST: - L,"Nina Milovanovich, Esquire, (Milovanovich & Espinosa, LLC, 129 E. Orange Street, Lancaster, PA, 17602) - c./ Mary Altman (Encompass Ins. Co., 333 Glen Street, P.O. Box 5000, Glen Falls, NY 12801) - ?,- Lisa Staff (Allstate Ins.. Co., P.O. Box 1064, Buffalo, NY 14240) / ail a`as Suite 2, 2 BY THE COURT: