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HomeMy WebLinkAbout08-1322IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION ?3aa. No.. ULf / ?.. - PETITION TO COMPROMISE A MINOR'S CLAIM (Jury Trial Demanded) Filed on Behalf of the Petitioner, KAYLA CLAYTON, a minor. Counsel of Record for This Party: Kimberly L. Gallucci, Esquire Pa. I.D. 92911 SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP Firm No. 911 707 Grant Street Suite 240o, Gulf Tower Pittsburgh, PA 15219 (412) 261-3232 15704 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.: o ?- 13 a 2 C"' -17,,,,,. PETITION TO COMPROMISE A MINOR'S CLAIM AND NOW, comes the Petitioner, Kayla Clayton, a minor, by and through her attorneys, SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP and Kimberly L. Gallucci, Esquire and sets forth the following Petition to Compromise a Minor's Claim: 1. Deborah Clayton is an adult individual currently residing at 6o6 4th Street, New Cumberland, Pennsylvania. She is the parent and natural guardian of minor, Kayla Clayton, who was born July 16, 1991. 2. On October 30, 2oo6, the minor-petitioner was injured in a motor vehicle accident that occurred on Hillside Road in New Cumberland, Cumberland County, Pennsylvania. 3. At the time of the subject accident, minor-petitioner was a guest passenger in a vehicle owned by Sammy Hockley and operated by Jason Hockley, Jr. 4. Minor-plaintiff was injured when Mr. Hockley lost control of his vehicle, causing the vehicle to strike a tree. 5. As a result of the aforementioned accident, minor-petitioner suffered cervical, thoracic and lumbar strains, radiculitis, a minor closed head injury with 15704 headaches and dental injuries. Attached hereto as Exhibit "A" is a copy of the minor- petitioner's medical records. 6. On the date of the subject accident, Jason Hockley, Jr., was an excluded driver on the insurance policy covering Sammy Hockley's vehicle. Jason Hockley, Jr., was also unlicensed on the date of loss. Accordingly, no liability coverage has been denied by Sammy Hockley's insurance company. 7. On the date of the subject accident, Deborah Clayton was the named insured on a policy issued by State Farm Mutual Automobile Insurance Company. This policy provided for uninsured motorist coverage. The minor-petitioner was an insured under her mother's State Farm policy. 8. Kayla Clayton, a minor, by and through her parent and natural guardian, Deborah Clayton, has entered into a settlement agreement with State Farm Mutual Automobile Insurance Company, under the underinsured motorist provision of Ms. Clayton's State Farm policy. 9. Kayla Clayton, a minor, by and through her parent and natural guardian, Deborah Clayton, has agreed to accept State Farm Mutual Automobile Insurance Company's offer of $29,000 on behalf of the minor-Petitioner as set forth more fully in the Release attached hereto and marked as Exhibit "B." 10. The minor-petitioner's parent and natural guardian, Deborah Clayton, has investigated this matter and agrees that compensation in the amount of $29,000 is a fair and equitable settlement in light of the injuries sustained by the minor-petitioner. In addition, it is hereby averred that the settlement is in the best interest of the minor- petitioner. See attached Affidavit, Exhibit "C". 15704 11. Subject to the approval of the Court, the parties have agreed to settle the minor-petitioner's claim for $29,000 with the proceeds to be distributed as follows: The sum of $29,000 shall be deposited in the name of "Kayla Clayton", by Kimberly L. Gallucci, Esquire, in a savings account or certificate of deposit in a federally insured bank or savings and loan association. The savings account or certificate of deposit shall be marked `NOT TO BE REDEEMED EXCEPT FOR RENEWAL IN ITS ENTIRETY, IN ORDER TO BE WITHDRAWN, SIGNED, NEGOTIATED OR OTHERWISE ALEINATED BEFORE MINOR, KAYLA CLAYTON, REACHES THE AGE OF MAJORITY' on July 16, 20o9, except by Order of Court of competent jurisdiction. WHEREFORE, the Petitioners request that this Honorable Court enter an Order approving the Petition to Compromise Kayla Clayton's claim in the amount of $29,000. Respectfully submitted, SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP By; Y L. lucci, Esquire for titioner 15704 Fields Family Dentistry 2101 Aspen Drive ,Mechanicsburg, °A 17055 ??I3o`c? - ® 4 ® 717-W7-91W Fax: 717-697-9428 Aid mimbutU PA 17x55 For Your Active Lifel mnw dmdunn.cotn December 14, 2006 RECEIVED State Farm Insurance Claims Deparment P.O. Box 40 Concordville, PA 19339 Re: Kayla Clayton Clain #381,102937 DEC Z 1 2006 CONCORDMuz C1t)S The above-captioned patient came into this office on November 1, 2006 for evaluation and care of her personal injuries sustained as a result of a vehicle accident on 10/30/06. PATIENT COMPLAINTS: Neck pain, headache, pain in left leg paid in jaw. The patient's face is puffy, she has lost her two fruit teeth, and she was treated in the hospital for concussion. The severity of her pain is moderate: 6 out of 10, with 10 being worse. The duration of the pain is fiupent, 50 - 75% of the time. The character of the pain is a dull ache. She also has some muscle wealmess, munbaess and tingling. Aggravating factors are coughing, beading, walking, chug body positions, and fatigue. CHIROPRACTIC HISTORY: Kayla was a patient in this office in 2004 and 2005, and retcuned for care in August of this year. She was on mainte lance care until this accident CHIROPRACTIC EXAMINATION/FINDINGS: The following chiropractic examictaboas were conducted: ROM: Peroerrtaae of utspairme t found: Cervical flexion 30% impairment; Cavical extension 40%; Thoracic tkxion 8016 and Lazmbosacral extrusion 10% Pa 'o , Tender to palpation around the neck. Short left leg. Qdhooedic Test: Mwdm m? foraminal compression . Negative for local pain; however, patient's kont of face was too Sore to perform other tests. Cervical distraction did not relieve pain. Lumbar Kempt's Test; Negative B SurfaceEMG: Sigdf cant asymmetry at C 1, C5, TI, T2, T4, L3, LS, and S1. Motion Patpation: Motion restriction at L5, T6, T4, TI, C5, and C2. CHIROPRACTIC X-RAYS: The following radiology exams were taken at Harrisburg Diagnostic Department on October 31, 2006 with study mtapreertion provided by Quantum Imaging & Therapeutic Associates. A CT brain scan without contrast showed no evidence of acute intraaarial abnormality. Cervical Spine, 2- 3 views : Negative limited cervical spine series demonstrated no abnormality of CI through C4. CHIROPRACTTC DIAGNOSIS: 847.0 Cervical Strah5praur due to MVA of 10130/06; 723A Cervical Radicutitis; 8472 Lumbar Straim/Sprain due to MVA of 10/30/06; 723A Lrmrbar Radicutitis; 839.08 Cervical VSC Multiple; 784.0 His; 83921 Thoracic VSC hxVMuld; 83920 Lumbar VSC Ind/MuhL PROGNOSIS AND CARE: Patient a slowly recovering. Care plan of 2x/vveek with re-evaluation planned end of December. Patient has been unable to come in for all appoirdments scheduled due to transportation problems. S' ty, Pamela Dunn, D.C. 38-Lre2-937 ? ? For Your Active Life! Pamela Dunn, Chiropractor 33 -A" East Simpson Suet, Mechanicsburg, PA 17455 Q Initial Report Report Interim l] Final Report Patients - Please complete the shaded areas only. Check which most closely applies. t) Chief Complaint: - - . 0'N Paia ? Mid Back Pain ? Low Back Pain ? Arm Pain it/ Right-. EI,6g Pain Le$ Right. the ? Other ... : ' . C?EN_ED 2) Mode of Onset: ? Ovemmition /Strenuous Position.. Auto. Accident .0 Fall, trip or slip ? Other..:. - DEC Z 6 3) Date• of Onset- I cn. lap l_Kg ... CONCORDVILLE CIOS 4) Location of Pain: Please circle areas on body showing where your pain is occurring: 5) Severity of Pain: ? Mild Annoyance - no impairment ? Slight - some mild impairment -..Please circle.the number that best represents D-Moderate -marked impairment your current level of pain: ? Severe - incapacitated /'bed ridden :(I.= 1009A.well, 10 = bed ridden) •1:2 3 4.5 6G7 8 9 10 6) Duration of Pain: - 7) Character of pain. ? Intermittent (25% of the time) v? shill Ache'. ? casional (25 - M of the time) F ? Burning.---. requent (50 - 75% of the time) ? Sharp !Stabbing ? Constant (75 -100% of the time). >.. : ,: - ?: Throbbing ? Other. ? Other. 8) Relation to Other Body Systems: 9) R ing Factors: ? Bowel / Bladder Exercise [a Numbness / Tingling ? Bracing /Taping R'Muscle Weakness QS sting / Standing / Lying ? No apparent Relationship 04497 Cold Paclm ? Other ? Other 7' 77ating Factors: Satige / Bowel Movement Pushing / Pulling / Ridin / S ,.>.- .. ,ra U 0 unning / Standing m Body Positions r Other ' . . 11) Medications: rin Q-15uprofen ? Acctominophcn ? Naproxen Sodium ? Other 12) Objective findings: See opposite side 13) X-ray findings: See Radiographic report dated: 14} Diagnosis (iCD9 Codes): 1} l? 7, p 2) 7 4P 4 3) 7• Z 4) 1 15) Plan for Care: Shortterm goals: Long term goals: Care frequency: - A times per week for ' 'j4_ weeks - Re-evaluation date: /_ I /6 Ji2_ HISTORY OF PRD,_ RY COMPLAINT Patient Name: Date: j 1. 1?1/ 4 ? ..? m w='i=:.SMYtSi:",,c'.fi'a'.:ri,s":ai%d."`i-f,.:,;r'+y,:.r r -34Y 1,<-.,-':'•F;? :-: t;: --<j...c i n.(na. e'otatreet)• - ? '-?;_::: •a=,;,. ::,-?a:i'.:r:_ •L. -::r:5:aWh •: ire' ...... :...:.... ?..:•;. _„ :::....:. .t . :?,?,;:c - at:d ction was...other vehicle headed...... (::;) North':'::: '.• :':)East::; ;, South . West :U /t - 7 !1 _ ( rest) , t•. Y• , _ '•H' r • • G'- . V. ?We you` ?k?a _ sttii? .tro`? c rim: 'age nii?? '1=r Le -i ?Y. ft's ') t side: ..,.;:7....A ..: _... ?..:... PP_ eIM , h:.O.iher.car'.:.•:..?./.:. . .'i w? K i:• ??8: ere.- k •- :? ' 'ou n'- k •????.. oc ed: n " u cori 7 ?_? sc o ? - Ye 10 .n .t r.r 4 G Li f? "C > I - ?'• - :..., o?j1?:?i?gvi=`.?:': _,;5 _ ,?.., v;:?,r?,?af'? ? .C? . /?:?•:?:??;? 9c>?;Were ce notif ied? ,r O..In o w u o n'w t ? - ord le a ?s ase"d' SK -: - ?Jl :t Ai;b r ? w. 7. :4 . fi?:•.:.. /:? ?'`: iii': et v: 11 `:Did.you.haye_any physics complaints:BEFORETHERCCIDENT?':`:( lease.desa?Ibbin-detail::: :.. - r -. t '• Z. 3 be•ho d Cfi w,y6u felt ou "fe!t? Y w U NGtheaccident. _'• ..-. •:.k--- ?.'-' MEDI ATELY, A RFfhe cold ' ent? ?... 'I:AE:R.T. c''` L - f•I%1T DAY' i' •y. •TE.NEXT A Y - Q : N a ?ti c ?Ca O N A{ W M W v C aa? m Ev Z Q IL a. O z Y c? C ? N !? co V N e- m O O e- O ? v m ? ? O m m z z G C C ?" aaa 20 MCC ? O ? O / ? CO#! O O C v O v , E N ,0 CO) 0 0 m $ z ? o G V2 I* I* _ U.. m J J m L 4) L 35 .9 F-' m ° K m m ? o cr o m m Co m L U 8 ? ? o Patient Name: Clayton,Kayla Practice Name: Dr. Pamela Dunn Patient Number: Practice Address: 33 " A" East Simpson Patient identifier: 28872426 Mechanicsburg, PA 1705: STATIC EMG INTERPRETATION N?TIVE On. l ll01I2006•at 11:36 AM a' final su . ... .?.; . , ? ' . • . ; • + :. • '. .' ? -..•,. ? t. parasp rface electromyggraphic scan (sEMG) study. was performed on . ..-Kayla Clayton to measure differences in:muscle tension along the spine: Paired electrode sets were used-to- - compare muscle tension at 15 lc# right pairs. of anatomical points: Standardized•,protocols,and normative-data- were utilized. The purpose of the test was to assess paraspinal muscle activity. •? ' . ... : . Paraspinal sEMG scans, taken in concert with offer examination findings, may be helpful in determining the following: ; . 1.,Asymmetrical contraction..2. Areasof muscle splinting , 3: rSeverity of the condition . 4. -Aberrant recruitment pattern 5. Responses to dysafferentation _ b. Responses to chiropractic adjustment 7. Dysponesis.- Dysponesis refers -to a reveml* physiopathologic state. consisting of errors in energy_ expenditrrre,.which can produce functional disorders: Dysponesis consists mainly-of eovert'exrors in action.. potential output from the motor and.prernotor areas of the. cortex, and the consequences 'of that output. In the sEMG scan; sEMG signals were.measu*ed- in-microvolts (millionths•of,a volt), by an.instlument with a• r frequency band of 25-500 Hz: The computer analyzes the measurements and compared them.to,a normatrve database. sEMG scans. are interpreted in several.ways j . 1: Amplitude.: This refers to the: signal level-in• microvolts. The higher the .signal level, the greater the parasomal mode activity. By comparing these readings to a nonnative database, elevated or.decxeased.signers can be. identified. . , .. . 2. Symmetry. This refers to a comparison of the left-to-right amplitudes at each spinal level. The sEMG amplitude signals of the patient-were compared to published rderence values(1)with.mild• moderate and severe elevations ofmuscie tension identified.by,color. DUmmees,between one and two standard deviations indicate- mild tension, two to three-standard deviations indicate moderate•tension,,while three or more indicate severe tension. In addition to the comparison with reference values, the amount of asymmetrical muscle activity was calculated, with mild, moderate, and severe asymmetries identified by color. Differences between one and two standard deviations indicate mild asymmetry, two to three standard deviations represent moderate asymmetry, while three or more indicate severe asymmetry. STATIC SEMG RESULTS Readings one or more standard deviations below normal means were observed at: CI(L), C5(L), T4(L), T4(R), T6(L), T6(R), T8(L), T8(R), TiO(L), T10(R), T12(L), T12(R), Ll(L), L3(L) This is indicative of reduced muscle tension. Readings up to one standard deviation above normal means were observed at: ' T2(L), LI(R), L3 (R), L5 (L) This is indicative of normal muscle tension. Readings one to two standard deviations above normal means were observed at: C1(R), T1(L), S1(L) This is indicative of a mild elevation of muscle tension. Readings two to three standard deviations above normal means were observed at: C7(L), L5(R) This is indicative of a moderate elevation of muscle tension. Readings more than three standard deviations above normal means were observed at: C3(L), C3(R), C5(R), C7(R), TI(R), T2(R), Sl(R) This is indicative of a severe elevation of muscle tension. Areas of significant asymmetry were noted at the following sites: CI(R), C5(R), T1(R), T2(R), T4(R), L3 (R), L5 (R), SI(R) PEDAL FOUNDATION EXAM As described in the Asymmetries Results above, eaon of the back of Kayla Clayton has indicated a m usculoskeletal imbalance. Because such conditions are often the result of an imbalance in the pedal foundation, an examination of this patient's feet is recommended. During the examination of the feet, the patient is asked to stand barefoot. The left and right foot are each examined for pronation, supination and normal arch shape. FOLLOW-UP PLAN The results of this acumination, taken in concert with the patient history and other clinical findings, were used in determining recommendations for the type, frequency, and duration of chi opnw is care. Follow-up moons will be performed, as needed, to evaluate Kayla. Clayton's response to the clinical services provided. • I LY DENTISTRY, LLC FAM May 22, 2007 State Farm Mutual Automobile Insurance Company ATTN: Elaine M. Haughin, Claim Representative Southpointe Operations Center 555 Southpointe Boulevard, Suite 400 Canonsburg, PA 15317 Re: Claim #38-L102-937 Patient: Kayla Clayton Dear Elaine: I am submitting the enclosed narrative report pursuant to your request of March 27, 2007. Kayla presented to my office on October 30, 2006 as an after hours emergency. She stated she was involved in a car accident and had followed instructions to have a dental review of her front teeth. I am enclosing radiographs and intraoral photographs for your records. At that time, it was observed that tooth #8 was fractured into the pulpal tissue and tooth #9 was also fractured with a "blushing" pulp. Both teeth had mobility. Options were presented to Kayla's Guardian involving keeping tooth #8 (treating with root canal therapy) versus extracting this tooth (treating with an implant, fixed partial denture, or removable partial denture). The advantages and disadvantages were reviewed involving each option. Her Guardian chose root canal treatment, crown build-up, and an eventual crown. Kayla's intraoral, extraoral, TMJ, and periodontal exam were within normal limits. It was recorded that teeth #s 6, 7, 9, and 10 had chipped incisal edges and would need bonding completed to protect the teeth from another fracture. Kayla's Guardian stated she wanted root canal therapy initiated to salvage the root and tooth preventing invasive surgery. The tooth was accessed, debrided, irrigated, and sealed. Tooth #s 8 and 9 were then built up with composites involving all surfaces of each tooth. I finally suggested there may be a future need for consultations with an Orthodontist (extrusion) and Periodontist (osseous crown lengthening). On November 27, 2006, Kayla was seen for re-evaluation. Pulp tests were performed on her anterior teeth which included percussion, electronic pulpal, and cold tests. Tooth #9 was extremely sensitive to cold, percussion, and had a high EPT value. The gingival 2101 Aspen Drive • Mechanicsburg, PA 17055 Phone 717-697-3400 • Fax 717-697-7857 www.fieldsfamilydentistry.com -'k oR 0 tissues appeared healthy in both texture and color. Incisal edge restorations were placed on teeth #s 6, 7, 24, 25, and 26. On December 18, 2006, Kayla was seen again for a re-evaluation. It was found that teeth #s 7, 9, and 10 were sensitive to cold and percussion. EPT numbers were high on these teeth as well. It was suggested there may be a need to perform endodontic treatment on teeth #s 7 and 9. Additionally, incisal edge restorations were placed on teeth #s 22 and 23. On January 29, 2007, Kayla was seen again for re-evaluation. Pulp tests revealed cold sensitivity again for teeth #s 7 and 9. Percussion was positive for tooth #9 but EPT and mobility were within normal limits for both teeth. On April 30, 2007, pulp tests elicited percussion and cold sensitivity for tooth #9. Tooth 47 elicited no percussion sensitivity but did reveal cold sensitivity and a high EPT value. Based on these findings, I have recommended to Kayla and her Guardian that endodontic treatment will eventually be needed for teeth #s 7 and 9. I have started a monitoring period for every 3 to 4 months to verify the diagnosis of irreversible pulpitis. I will continue to follow Kayla under these guidelines, along with her general oral health care, until a time that the family asks for discontinuance. I hope this narrative sheds some light on Kayla's mishap and can foster the proper format for reimbursement. If I can be of further assistance, please do not hesitate to contact me. Sincerely, Charles R. Fields, DDS, MAGI) CRF/tlg Enclosures a n, 11 . 10 01 3 :0 9P M FI EL DS FA MI LY DE NT IS TR Y, LL C = N No. 22 2 ? ?` I ^ t, ti / s Y J ' n n cl, v? 1 rC y 5 rn I • _ r 1 I I ,b P. 2 K m v a r b m ju m an. I1 . ZU UI 3 :I UN M FI EL DS FA MI LY DENTISTRY, LLC No. 222' ~I N n r l s„ I i tea ? ` c w v ti 7 h + ? 1 r + r IkA jr.b 44S b co U' I : 4{7 P. 3 A O n b r b r m E9 CLAYTON, KAYLA J-Enc #270108 ACCT#=00270108451 r }ZED FEB 0 2 2007 CONCO.RDVttLE clos PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 EMERGENCY DEPARTMENT MPT-HER-10/30/2006 ED Report - lk W 06 - 1 pg _RANSCRIBED DATE=11/02/2006 1U:20 UDN= 1996891 CLAYTON, KAYLA J RM#: MRN: 574-08-4198 CASE: 00270108451 DOB: 07/16/1991 ADM: 10/30/2006 CHIEF COMPLAINT: Status post MVA. HISTORY OF PRESENT ILLNESS: This 15-year-old female presents to the emergency department after being involved in an MVA. She apparently was a passenger in the right rear passenger seat, states she was wearing her seatbelt when the car struck a tree. There was airbag deployment. Patient is complaining of pain in her neck area, also complaining of some injury to her teeth and also nausea. The patient does have a slight headache. No visual changes. No numbness or tingling in arms or legs. No back pain. No abdominal pain. No chest pain. No shortness of breath. REVIEW OF SYSTEMS: Complete review of systems negative except as above. PAST HISTORY: Past medical history is denied. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Patient is a nonsmoker. PHYSICAL EXAMINATION: Vital signs: Temperature is 36.7. Blood pressure 121/61. Pulse 65. Respirations 16. Constitutional: Patient is alert, well developed, appears to be in mild distress. Mental status: Patient is alert, oriented to time, place and person. No recent memory loss. States that when the accident occurred, she might have "lost consciousness for a couple minutes." Patient's affect is appropriate. Eyes: Pupils are equal and reactive. Funduscopic benign. Extraocular muscles intact. ENT: No midfacial trauma other than fractures of her central incisors, #8 and #9. Neck: Paracervical muscle tenderness. No midline cervical tenderness. Respiratory: Clear to auscultation and percussion. Cardiovascular: No murmurs or gallops. Heart sounds normal. GI: No masses or tenderness. No hepatosplenomegaly. Skin: No new rashes or lesions noted. Neuro: DTR's equal and symmetric both upper and lower extremities. Strength good and equal in both upper and lower extremities. Extremities/Musculoskeletal: Joint: Capable of free range of motion without pain or crepitation. No effusion or erythema. Bone: No misalignment, asymmetry, defect, tenderness or effusion. Capable of full range of motion of joint above and below bone. Muscle: No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength. Lymphatic: No cervical adenopathy. EMERGENCY DEPARTMENT PHYSICIAN TEST INTERPRETATION: X-ray of the cervical spine revealed no acute fracture. CT scan of the head was negative. EMERGENCY DEPARTMENT COURSE: No procedures or consults required. DISPOSITION: Patient is discharged on Phenergan 25 mg p.o. q.6-8 H p.r.n. Page 1 of 2 CLAYTON, KAYLA J-Enc #2701Q 1 -OPT-HER-10/30/2006 ED Report - 212008 .{nausea. Head injury ins ructions geven. Parents pg patient should follow up with the family doctor thishweek.aHaveea followup MRI since the CT scan did show possible pineal cyst and recommended that. The patient also referred to the dentist for dental x-rays and follow up on dental fractures. Disposition: Follow with FMD and dentist- DIAGNOSTIC IMPRESSION: #9. PATIENT: Kayla Clayton c: GLEN WHEELER, MD 1. Minor closed head injury. 2. Acute cervical strain. 3. Fracture of central incisor, #8 and 4. Pineal cyst. REVIEWED AND ELECTRONICALLY SIGNED BY: GARY BAGGETT, DO 11/1412006 02:07 GARY BAGGETT, DO ----------- DD: 10/30/2006 1996891 DT: 11/02/2006 /das D#. ER REPORT ER REPORT END OF REPORT REPORT NAME=ER ER REPORT HOSP-POREGION=MB Page 2 of 2 (9 QUANTUM PINNACLE loc: DIA CLAYTON, KAYLA 1991-07-16 SSN: 574084198 MRN: 574084198 Patient Class/Status: E Ordered By: BAGGE1 f, GARY Attending: EMERGENCY ROOM, ASSOCIATES Referred By: Dictated By: BRONITSKY, BARBARA G. Accession: 5499568 DOS: 10-30-200616:36:00 ADM DX: CodeRyte Note Handle: APS-8888140 -_- _ REASON: SP MVA -_ PROCEDURE: DIA -2040-CERVICAL SPINE 2-3 VIEWS EXAM: Cervical spine, 3 views limited. HISTORY: 50-year-old complains of neck pain following MVA Results: Despite attempted swimmer's view, only C1 through proximal aspect of C5 are demonstrated in the lateral projection. There is no malalignment or fracture of the visualized vertebrae. The prevedebral soft tissues, odontoid process, and C1-C2 relationship are within normal limits. IMPRESSION: Negative limited cervical spine series demonstrates no abnormality of C1 through C4. If symptoms persist, consider followup with routine cervical spine series. To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-she coverage, a Radiologist can be contacted at 782-5881 (NH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Ahematively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful interpretations. Accordingly, If the clinical team is in search of answers to specific questions, Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission Is privileged and confidential. If the reader of this message is not the Intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. please include your questions(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission Is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1.717-782-3240. Codes: Accession CPT ICD 72040 723.1 F 9 09 0j0 ? 9,; s 38-Lf02-937 MR Approved by: Michell Ohlson Dictation Date: QUANTUM PINNACLE loc: CTS CLAYTON, KAYLA 1991-07-16 ISSN: 574084198 MRN: 574084198 Patient Class/Status: E Ordered By: BAGGETT, GARY Attending: EMERGENCY ROOM, ASSOCIATES Referred By. Dictated By. AUSTIN, CHARLES B Accession: 5499567 DOS: 10-30-200610:08:00 ADM DX: CodeRyte Note Handle: APS-8885765 REASON: SP MVA PROCEDURE: CTS - 0450 - CT BRAIN W/O CONTRAST EXAM: CT brain without contrast HISTORY, Head trauma/motor vehicle accident Results: Imaging was performed from base to vertex without intravenous contrast. There is no evidence of hydrocephalus, or intracranial hemorrhage. There is no evidence of a major arterial distribution infarction At the expected location of the pineal gland, there is a 1.2 cm in diameter low-density focus. This most likely represents a pineal cyst Eventual nonemergent MRI of the brain without and with contrast is however needed for further evaluation. IMPRESSION: There is no evidence of acute intracranial abnormality There is a cystic lesion in the region of the pineal gland warranting eventual MRI for further evaluation. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful interpretations. Accordingly, if the clinical team is in search of answers to specific questions, please include your questions(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission Is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Codes: Accession CPT ICD 70450 959.01 Pennsylvania EMS Report Service Name Unit No KR No. Date New Cmnberiond Fire Dcmffbmm AIO - 2101210 0600336 1050a0w Mat Name Date orBbrth Soelan Seee tf Number PSAP Kayla Lipton 07/16/1991 574-06-4198 060160191 Gastrointestinal Abdomen eNo Complaint Pain GU ? Nsresea ? Vomiting 0 Soft 0 Firm ? Constant 0 uaermiacm 0 No Complaint ? Dweau [] constipated 0 a-fiv ? Bmniog ? Sharp ? DrB°mY ? Fro4 uency Area(s) Effected ? Bowd Swmdr Absent @ bull ? Pain ? B=g ? LUQ ? RUQ Distended -No O Yes O Radiating- No O Yes O o tamnnaaa ? Retention ? u,Q ? RLQ Ter dcr - No O Yes O O Foley JI Totallaelput _ L Extremities Reproductive 0 No Complaints 0 No Complaints Remak Mate LA RA LL RL LA RA LL RL (3Vngimd Bk ab g 01).-J -V ? Penile Disc urp mini- 00 ? ? Pain ? ? ? ? Pregnant -No O Yes O ? Testicular Pain Para U=M ? ? O ? pallor 0 0 ? ? &avida _ Para _ Week _ Pulse O ? ? ? F-dema ? ? ? ? ?PcW Mavemmts Fetal Heart Tom _ tT O w C? o? Narrative N Amb 10 dispatched Class for an Auto Accident victim at the request of the Police Dept in the Boro r?•+ of New Cumberland in the area of the 500 Block of Hillside Rd. Amb 10 with immediate response is C advised by CCC that we are at the request of the Police Dept. for an accident victim. 10 Amb 10 AOS to find a single car accident with a 15 ywf still in the rear of the vehicle. The vehicle is a Chevy Cavalier that was fleeing the Police that has substantial damage to it all around. The vehicle has moderate damage to the rear passenger, passenger side quarter panel damage to it with rear window smashed on the vehicle, the rear bumper is ripped off, the rear of the vehicle is pushed in towards the trunk of the car, minimal space between the front seat and the back seat of the vehicle, front bumper damage, and dual airbag deployment. Police Officer Weaver explains that he had been chasing this vehicle over several blocks of New Cumberland when it made this Right turn onto Hillside Road and the driver lost control of the vehicle went off the roadway, struck a tree which made the car's passenger side rear passenger side swing into the tree and swerved and then it stopped and the driver got out and took off. The passenger stated that her neck hurts a little and that her mouth hurts. The pt then crawls over the driver seat which is leaning backwards and crawls out of the 2 door vehicle. The pt tells BLS that she had an argument with her mom last night around 9 pm andtook off and started walking through New Cumberland. The pt then said that this kid she knew stopped and she got in his vehicle and then went with him. She said she awoke this morning and got in his vehicle and was driving through the Boro when all of a sudden the Police wanted them to stop and the driver wouldn't. The pt said she kept on telling him to pull over but he just kept going faster and faster. Pt says she's not sure why she crawled In the back seat but is sure she was seatbelted at the time of the crash. Pt said she's not even sure when the driver took off or why. Due to the pt's age and injuries and potential injuries, pt is told she has to go to the hospital. TX: AOS and received report and care from Officer Weaver who Is trying to gather evidence from the scene. The pt is encountered and then the pt crawls out of the vehicle. A quick detail Printed On: 11/052006 1114 provider EMSIat Rcporting(c)1998-2006, Mcd-Medi& Inc. All Righb Rese led Pei: 22 of 4 Pennsylvania EMS Report Service Name Unit No PCR Na ?] D7&te New C wmbedand Fbe DeDgmieng Ald - 2101210 0600336 o 06 Patient Name Date ofIlirth Social Stxarfty Number PSAP Kn* CIVAM 07/16/1991 574-MMI8 060140191 assessment is performed and a e- collar is placed on the pt, Pt is then seated on the fitter which already has a LBB on it, as A#1 still holds head stabilization, Head is secured with CIDs and then is secured to the LBB, pt is then fully secured to the LBB using kwik clips and then secured to the p litter, pt is placed in the back of the ambulance, vitals are taken, en route to Hbg Hospital, which is C the closest facilty, a detail assessment is performed and vitals are retaken and a cold pack is p applied to the forehead swelling, upon arrival at Hbg Hospital, pt states she's starting to get aW headache and is a little drowsy. Pt is transported into the ER and to Examing Rm. # 12 where pt is transferred to the gumey and care and report is given and transferred to ER staff. PE: CA&O x 415 ywf, dressed in pajamas, stating that her mouth and neck hurts, head is normal and cephalic but with a small swelling to the right side of her head above the temporal region, - headache initially on scene but upon arrival at the hospital pt states she was getting one, - blurred or double vision, PERRL, skin is warm pink and dry, - fluids from the eyes ears or mouth, front top teeth are busted in half and broken off, - bleeding noted, - jvd, trachea is midline, - shortness of breath, - chest pain, chest is symmetrical and = in rise and fall, abd is soft and non tender, - nausea and/ or vomitting, pelvis is stable, upper and lower extremities are atraumatic and = in grips, strengths and movements, - tingling nor numbing sensation anywhere stated by the pt, back is atraumatic and pt states she does have neck pain which she states Isn't really pain, it just hurts, + drowsiness stated by the pt also upon arrival at the hospital which pt wasn't initially. Time P R BP.•. % ET- Rhythm. 7leehoent ResponsbGoiamaud > !A , 01:i f; I6 104/72 98 4/5/6 J:taw VS 09. 102161 T/ li'? Pfimed ott:) iiasnoob 11:24 _ •aeY EMStat Rcpurdng(c)1998-2006, Med-Media, Inc. AD Righn Rextved Page 3 of 4 N J O 1p Pennsylvania EMS Report Service Neese Unit No J PCR No. Date New CumberSand Fin AIO - 2101210 0600336 1Of WO06 P&dent Name Date of Birth Soelal Security Number PSAP >?a Claywa 07!16/1991 1 574-084198 060140191 Anterior Printed On: 11/05/2006 11:24 EMStat RepmtWc)1995-2006, Med-Meda, Inc. All Rights Reserved Pain Posterior Provider Page: 4 of 4 0 O W W 01 t!? N r+ 0 Pennsylvania EMS Report Service Name Ncsr Cumberland Fire Station Uait Name B Na Al0 - 2101210 PCR No. 0600336 Date 10/30/2006 lumeat London ? Municipality & Incident Up PSAP Ineld. Na 500 Block of Hillside Rd, New Cumberland Bow. 17070 060140191 Reftift Agency Harrisbn Hospital Patient Name G Kayla Clayton Cress C #1 Filhucc Karen E 08757 Street Address % 0 C lit Th R A 606 4th Street omas, yan E l 18423 Slate Ne C N3 4., N ew Cumberland Z 070 C 04 "' Sex Female Age 15 Years DOB 07/16/1991 Phone No. (717) 774.7264 Testa a Patient Number _ 1 Pt. Weight 911 574.0 841 Dispatch 08:09 Privatt Phyaiciso Driver's Lleeox Lnronte 08:14 Dr. Wheeler _ Arrive Seem 08:16 C Transporting Assist Units Assist OS o?,Se+eae Dent. In ontact 08:17 Depart Depart Scene 08:36 25277 25277 25281 25284 Arrive 08:44 Response tcome Trammed Medical Command Physician MC Time Available in QuIarters 09:15 Me r A ier Complaint: " my neck gad mouth hurts " Current Meds: none stated Allergies (=Ws): NKDA PMRI None Stated Level of Coosciousoetis 0 Conscious 0 Ori m d 4 Speech Neurological Skis, Temperature sit Color a o x ?J Cobaeat ? No Complain) 0 pry 0 eiotk ? Mottka Akr1 ? Unooopaative ? Inoohaeat ? Headache ? Numbness ? Moird ? Psle ? cyanmie ? Lethargic ? Combative ? sum ? StiffNecc ? Wealknns ? Diapb,Uk ? H dW ? Yenow ? ConBssed ? Mined ? erft 0 Neck Pahl ? Dmyy ? Ashen ? Other ? U-sci- ? Hysterical ? slrured ? Dy*hgia ? Gait - Unsteady ? lafant ? Aphasia Facial Droop - L O R O Hot O warm (D Cod O Cold O Respiratory ? No Com l i t Breath soma Cardiovascular Pupils HEENT p a n s 0 Airway Patent L R Pkesan 00 Chest Palo 0 PERL L R Eyes 0 No Complaint 0 Symmetrical Absent ? ? 0 No C.Vl• size - - Blurred Vision - L ?R? ? Labored Clear 0 ? &,-mw _ pinmint ?O Double Vision - L ?R? ? Retraciiom Diminishoa p ? Constant ? briamitteot Dilated ? L?A? N ? ? ? sharp ? a... ? Dan ? Pleuritic i ? Ears 0 No ? ? ? Heavy ? Rediatirrg n t,10 L?RO Coagb Rhonchi ?? Noo-Rpcti ve ?? Dbcha®e- L?RO 0 No CompWM Ptaductivc-N O As m cuic ? ? ? ?vn?y ResB _ Known Annum Blood . L ?R? o Yes O Now 0 No Complaint ? N-al Cwgeston Throat 0 No Compiaird ? NaaDainage ? sae Throat ? Dphag Deiat&m • L O R O L? R[] FPbWdt- ? Drooling ? Swelling4maris ? !VD ? Deformity Printed On: 11/05/2006 11:24 EMStat Repor&Wc)1999-2006. Mod-Media, Inc. All Rights Removal Provider Page: 1 of 4 O w 01 ON ItAl N 1m+ 1N" J O RELEASE For the Sole Consideration of 7TVEN7y-ATINE THOUSAND DOLLARS and o%oo ($29,ooo.00), the receipt and sufficiency whereof is hereby acknowledged, the undersigned hereby releases and forever discharges State Farm Mutual Automobile Insurance Company, its heirs, executors, administrators, agents and assigns and all other persons, firms or corporations liable or, who might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the future develop from an accident which occurred on or about the 3oth day of October, 2oo6. This release expressly reserves all rights of the parties released to pursue their legal remedies, if any, against the undersigned, their heirs, executors, agents and assigns. Undersigned hereby declares that the terms of this settlement have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of precluding forever any further or additional claims arising out of the aforesaid accident. Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. //'. ,, In Witness Whereof, ? i ?/y have hereunto set A ? hand(s) and seal(s) this Lday of 4/-, , 200,v In p esepce of: eav ?? ddwtq- Witness Date: ? Z//u "'Deborah Clayton Parent and Natural Guardian of Kayla Clayton IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.. AFFIDAVIT I, Kimberly L. Gallucci, Esquire, am a licensed attorney in the Commonwealth of Pennsylvania. I am, for purposes of the above-captioned Petition, acting solely on behalf of Minor-Petitioner, Kayla Clayton. I have thoroughly reviewed the medical records available in this matter, along with the Settlement and Release documents executed by State Farm Mutual Automobile Insurance Company and the Minor-Petitioner's parent and the Verifications executed by the parent of the minor. Relying on my review of these records and documents, along with my experience as an attorney, and given the nature of the injuries sustained by the Minor-Petitioner, it is my opinion that the sum of $29,000 is a fair and equitable settlement and is in the best interest of the minor, Kayla Clayton. rr?\ -"\ - Datr ? n8 15704 VERIFICATION I, Deborah Clayton, do hereby certify that I am the parent and natural guardian of the minor-Petitioner, Kayla Clayton, who is presently 16 years old. I have reviewed and discussed the proposed Settlement and Distribution set forth in the foregoing Petition and proposed Order. The averments of the Petition are true and correct to the best of my knowledge, information and belief. I believe that the proposed Settlement is in the best interest of my minor daughter, Kayla Clayton. I recommend that the Court approve the Settlement and Order of Distribution. I understand this Verification is made pursuant to provisions of 18 Pa. C.S.A. Section 4904 relating to unsworn falsification to authorities. Dated: 9 4. Deborah Clayton, Parent and Natural Guardian of Kayla Clayton 15704 CERTIFICATE OF SERVICE I hereby certify that the within Petition to Compromise a Minor's Claim was served upon counsel of record by mailing the same via first class mail, postage pre- paid, this _E?lay of, 200 Deborah Clayton P.O. Box 593 New Cumberland, PA 17070 SUMMERS, WDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP By: Ki erly L. G , Esquire Counsel for Petitioner 15704 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.: o8-1322 Civil Term AMENDED PETITION TO COMPROMISE A MINOR'S CLAIM (Jury Trial Demanded) Filed on Behalf of the Petitioner, State Farm Mutual Automobile Insurance Company Counsel of Record for This Parry: Kimberly L. Gallucci, Esquire Pa. I.D. 92911 SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP Firm No. 911 707 Grant Street Suite 240o, Gulf Tower Pittsburgh, PA 15219 (412) 261-3232 15704 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.. PETITION TO COMPROMISE A MINOR'S CLAIM AND NOW, comes the Petitioner, State Farm Mutual Automobile Insurance Company, by and through its attorneys, SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP and Kimberly L. Gallucci, Esquire and sets forth the following Petition to Compromise a Minor's Claim: 1. Deborah Clayton is an adult individual currently residing at 606 4th Street, New Cumberland, Pennsylvania. She is the parent and natural guardian of minor, Kayla Clayton, who was born July 16, 1991. 2. On October 30, 2oo6, Minor Kayla Clayton was injured in a motor vehicle accident that occurred on Hillside Road in New Cumberland, Cumberland County, Pennsylvania. 3. At the time of the subject accident, Minor Kayla Clayton was a guest passenger in a vehicle owned by Sammy Hockley and operated by Jason Hockley, Jr. 4. Minor Kayla Clayton was injured when Mr. Hockley lost control of his vehicle, causing the vehicle to strike a tree. 157°4 5. As a result of the aforementioned accident, Minor Kayla Clayton suffered cervical, thoracic and lumbar strains, radiculitis, a minor closed head injury with headaches and dental injuries. Attached hereto as Exhibit "A" is a copy of Minor Kayla Clayton's medical records. 6. On the date of the subject accident, Jason Hockley, Jr., was an excluded driver on the insurance policy covering Sammy Hockley's vehicle. Jason Hockley, Jr., was also unlicensed on the date of loss. Accordingly, no liability coverage has been denied by Sammy Hockley's insurance company. 7. On the date of the subject accident, Deborah Clayton was the named insured on a policy issued by State Farm Mutual Automobile Insurance Company. This policy provided for uninsured motorist coverage. Minor Kayla Clayton was an insured under her mother's State Farm policy. 8. Kayla Clayton, a minor, by and through her parent and natural guardian, Deborah Clayton, has entered into a settlement agreement with State Farm Mutual Automobile Insurance Company, under the underinsured motorist provision of Ms. Clayton's State Farm policy. 9. Kayla Clayton, a minor, by and through her parent and natural guardian, Deborah Clayton, has agreed to accept State Farm Mutual Automobile Insurance Company's offer of $29,000 on behalf of Minor Kayla Clayton as set forth more fully in the Release attached hereto and marked as Exhibit "B." 10. Minor Kayla Clayton's parent and natural guardian, Deborah Clayton, has investigated this matter and agrees that compensation in the amount of $29,000 is a fair and equitable settlement in light of the injuries sustained by the minor-petitioner. In 15704 addition, it is hereby averred that the settlement is in the best interest of the minor- petitioner. See attached Affidavit, Exhibit "C". ii. Subject to the approval of the Court, the parties have agreed to settle the minor-petitioner's claim for $29,000 with the proceeds to be distributed as follows: The sum of $29,000 shall be deposited in the name of "Kayla Clayton", by Kimberly L. Gallucci, Esquire, in a savings account or certificate of deposit in a federally insured bank or savings and loan association. The savings account or certificate of deposit shall be marked `NOT TO BE REDEEMED EXCEPT FOR RENEWAL IN ITS ENTIRETY, IN ORDER TO BE WITHDRAWN, SIGNED, NEGOTIATED OR OTHERWISE ALEINATED BEFORE MINOR, KAYLA CLAYTON, REACHES THE AGE OF MAJORITY' on July 16, 2oo9, except by Order of Court of competent jurisdiction. WHEREFORE, the Petitioner requests that this Honorable Court enter an Order approving the Petition to Compromise Kayla Clayton's claim in the amount of $29,000. Respectfully submitted, SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP By: berly L. (Mucci, Esquire /Iouns e for Petitioner 15704 Fields Family Dentistry 2101 Aspen Drive Mechanicsburg, ?A 17055 t? ® ? ® 7f Pamb -0fW Fsac ,Ahfaahe?rs PA 17 For Your Active L.&I www d' December 14, 2006 CE State Farm Inwranae Claims Department P.O. Box 40 - Concordville, PA 19339 Re: Kayla Clayton Claim #38LI02937 DEC Z 1 2006 CONCORDVILLE COS 71ha above-captioned patient came into this office on November 1, 2006 for evaluation and care of her personal injuries sustained as a result of a vehicle accident on 10/30/06. PATIENT COMPLAINTS: Neck pain, headache, pain in left leg, pain in jaw. The patx's face is puffy, she bas last her two front tedh, and she was treated in the hospital for concussion. The severity of bar pain is moderate: 6 out of 10, with 10 being worse. The duration of the pain is fivquent, 50 - 750/9 of the time. The character of the pain is a dull ache. She also has some muscle wealmess, numbness and titmgling. Aggravating factors are wughing, bwrfing, waft changing body positions, and fifigue. CHIROPRACTIC HISTORY: Kayla was a patient in this office in 2004 and 2005, and returned for cane in August of this year. She was on maintenam care until this accident. CHIROPRACTIC EXANGMATION/FINDINGS: The following chhoprectic examinations wem conducted: ROM: Peroerr90 of i &MM found Cervical flexion 30% impitirtnent; Cervical extension 4% Thoracic flexion 80% and Iumbosacral extension 10% PftWM-- Tender to palpation around the neck Short left leg. Orth Test Mmftur t foraminal compression . Negative for local pain; bowever, patient's Aunt of face was too sore to perform other tests. Cervical distraction did not relieve pain. Lumbar Kempt's Test: Negative B Surface EMG: Significant asymmetry at Cl, C5, TI, T2, T4, L3, L5, and S1. Motionfa Motion restriction at L5, T6, T4, TI, C5, and C2. CHIIOPRACTIC X-RAYS: Time following radiology exams were taken at Harrisburg Diagnostic Department on October 31, 2006 with study interpretation provided by Quant rn bonging & Therapeutic Assocuft A CT bram scan without con" t showed no evidence of acute intracramial abnormality. Cervical Spine, 2- 3 views : Negative limited cervical spine series domed no abnotmality of CI through C4. CHIROPRACTIC DIAGNOSIS: 847.0 Cpvical ShainNprain due to MVA of I0/3W; 723A Cervical RadkWitis; 8472 Luber StraintSprain dale to MVA of 100106; 723.4 Lumber Radicxilids; 839.08 Cervical VSC Multiple; 784.0 Headaches; 83921 Thoracic VSC Md/Muilti; 83920 Lumbar VSC WWJuK : -. jot HISTORY OF PRIA,_?RY COMPLAINT P= . For- Your Active Life! Patient Name: a Date.- ! . /__(._/ 0 Pamela Dunn, Chiropractor 33 "A" East Sitapson Sttt;et, Mecladubtu& PA 17055 p Initial Report Patients - Please complde the shaded areas only. l7 hKaim Report Check which most closely applies. .p Fmd Repoli 1). Chief Complaint. p-14C& Pain ? Mid Back Pain ? Low Back Pain ? Arm Pain- Left/ Right.. Ejil:&Pain Right.... F;J'Ilcadache ? Other CE ED 2) Mode of Onset: DEC 212006 .0 OveMettion / Strenuous Position.. Auto. Accident. -? Fall, trip or slip ? Other. . COWMINILLE . 3) DateofOnset.'J.d l30 l `^ o ... clos 4) Location of Pa/n Please circle areas on body showing where your pain is occurring 5) Severity of Pain: ? Mild Annoyance - no impairment ? Slight- some mild impairment ¦,Vodetate -marked impaiint - ? Severe - incapacitated f bed ridden 6) Duration of Pain: ? Intermittent (25% of the time) ? Occasional (25 - 50% of the time) ff-Frequent (50 - 75% of the time) ? Constant (75 -10W6 of the time). ? Other. 8) Relation to Other Body Systems: i . . ? Bowel / Bladder numbness / Tingling Muscle Weakness ? No apparrnt Relationship ? Other • ,Please circle the number that best represents your current-lgvel of pain: :(1= 100%.weil, 10 =bed ridden) -1..-'2 3. 4. 5 7 8 9 10 . :.. - .7). Character of parr: ? Bummg ? Sharp /Stabbing - ?: Throbbing ? Other. 13) X-ray findings: See Radi hie rt dated / if 14) Diagnosis (icD9 Codes): 1) 2) 7 3-W4 7. Z,- 4) 1 a 3 t q 15) Plan for Care: Short term goals: Long term goals: Care frvquency: times per week for weeks Ro-evaiuation date:-[ /_ _/ /3 -12 . n owel M ovement 12) Objective findings: See opposite side 0),AgWvf sting Factors: 9) RP 'eving Factors: ise Bracing / Taping g OSaing / Standing / Lying ti]-M / Cold Packs Other. . . Pushing /Pulling .. ? .. .. .. . [] Driving / Riding / Sitting ?V?unning /Standing Body Positions • - ... 11} Medications: prig (?-lrofea ? %Acctominophen ? Naproxen Sodium ? Other .. .. .. _ . , .....:. : .::-s :,; A y l .ll.=J 4 j : }: ,- °. i; .": .., , - r .. . ... ... _ J: St' _•A _ .'. __ _ _ ,:t.' . I: _ . -. :.. t 1 1;:. 7,. _ :'-Y L .;.:4 A {RE -.:r: 1 •AL UEST4NN =tNJI! ?? RS4 RE Y. : ,. - - _ ;N -, - ,r ..f `: '"?• `r :r: -':: i ' -:' * ,Xd? . 'Pho e?" al?18. .:: N -:amp: »;5>.,y.. '. .: r-': :i -.r•:. ,_ •k'.i:r ' A:. ..•h.I. i• - i i,•r__ r.x •= o?o - 'state° °L:•. -:. Y i . 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' le?in ur etijc e - Y 8.. ..,.. _ North - _ - :E a3ta uth;' , >) W eSt r, ; ?r " '?? ,...r.... r , . : ou.:headed {: :So 4..,,Wfiat;direction.were y ...., a. • • ''' _ . y..R: .'f; 3Mt a? < -nv n, a ., 1t S 57; 62. fir,..... :,. • ;3r ~'.' F:.''7"u :.: on name'ofatreet = °? (. :.• is v'rju - i West ?:?'ri`:' _ • --t': r:5 ;4WFiat "f : :? fieaiied (- ' :;(?- ) Sl7uth ) . (?' ??)'Ea's siiirectforwas"othervehicle . • :,'z1oit ;. - , :r ::{ -,k y f .. 'i,= - :try°. '-r Y..J a of ;: •'st?eet t arsie. (n .: _ r:.:. y ?.3. n_' !?J F:. SS ti,. . f'' Jv - a irid _ ` " tic s'-jde:-) /. !E `R s ?:? 9 re'- ?ou'sfrick . •(w' F ori Left i rY. c.. . S . . - :. i.dSz ::.:.?. .. y y :1..;=..i . ; :y. Y s :.F:a,i:'- - . J`:: '. n '7^- F.: :lcPr , Ya 'ucac 1....P. . /z. ;7 Ay rozimates eedof' ._ . . P - fF_ > 't lr. R-+t S 51? 's " a.. - t:'Ji. , C. r how a ? - 1 „ Y.. _.,`,, . fo 0 t ou kiiocked;bncorisclous?P - s` .:'.. ;(-a ) 8: 'Were. .:::..: , :. ' ,x•..- _ ?, :?:,? f . .. rGi'tr?- en. • -O i :Yeas,::,. Y . . tics notified. , :. Were- (=;). _ _ I-:;'. r: " r. : - . - ..:...•.. 7i:. ..Ft is :.:?:''.:,: ' .,:. :,tea;!.:.± .. .: ... ;a ' •: :: - - ,r tn?.:..:'::': .nit.. .,.:.. ..•... .. '. •.....,' ' ,.ou ,.... ,_:.. ?o/.'?L - t.?i?io! r: lir?,G' : . our own:words ptease;describe accid 10::nin Y y :?-. : , _?..,, 5, , ;,: :j { `' . ?n. -' a k, . ': qi._ . ?' 7•?=?-'?ssf?-:-;-?:Ca:? `fro%:;`'.'-:'' . :..' t ,_ }. , ,:;,wi - - l . i?t ;,:? y` ! .:x: :: rt V' y, s= ??:::::. '. i - r !?! .. ?-.J.: +'.W I'?- - ' - :: iK! -_ _ :?.' _. i C R .' t . t 3•{ ^ . i' s,: ? _ ?f/? _/,.:•.' [: k :. •-v: ...r.... ... t. •: ?• µ.:-. %? •;'iNF. ?ra y'?:/ '' - :il•t Yp' an : h ' ical com latntit eFORE_THE ACCIDENT?,:::{ ; r);Yes. ; :: ) Nc'' : ' If yes;:Please.de§c?itie±(n detaij 11?.:DId'you+have _ Y,P,.Ys , P. -; ., :K ,4: i'i-['. :: ::,:.. - - --.. :;{; y: ._ ? . ..a: ,.:::i. :L- . c:ir.' ':i: ''i= iii ,, . :.._ ' :. .. .. _..:..:. .. :i:« _, . .- . . , -.:-...: - . i ii . - ' flow' You felti e' be sad sc 12:Pleas ;-. : .. .:;5:. ::.:. y :. _ ; - - _ .. _? .. Gtfie a _?f ccident 4 - y : :. . . R? - -. j ..:. :., . ......... . .i EL•Y.AFTER;theaccident. L1'` , {_ _ - - t .. ?. %r .{ ?'^ :'DAY: - - - . t . i'E 1 Th..l . :c .f . -:w-.. y FL - T J r. ;.; - 114E NEXT DAY: ^ n Gl ' `' .. 'd? ., - -°._: - . • :::; . 7 J... . ?? Ul) a CL G ? a m in ? 'fl a as Coe p, E4 O ? S ? A °w 1 % c r o c r U C V m ?Zb Oitient Name: 'Clayton,Kayla Practice Name: Dr. Pamela Dunn Patient Number. Practice Address: 33 " A" East Simpson Patient Identifier. 28872426 Mechanicsburg, PA 1705: STATIC EMG INTERPRETATION NARRATIVE On.11/01/2006•at 11:36 AM a paraspinal surface electromyograptric scan (sEMG) study. was performed on . = Kayla Clayton to measure dices in•muscde-tension along the spine. Paired electrode sets were used-to. compare muscle tension at 151e@:right Pairs. of an cal points. Standardized,prowcols,and normative-data: were utilized. The purpose of the test -was to assess paraspinal muscle activity. •j Paraspinal-EMG scans, taken in concert with other exanimation findings, may be helpful in determining the following 1. Asymmetncal contraction; 2. Areas of-muscle splinting , I rSevds ity of the condition....'- 4. .. ; Aberrant recruitment pattern : .. ; 5. Responses to dysaffereatation _ 6. Responses to chiropractic adjustment 7. Dysponesis.- Dysponesis refers to .& revers<'bie physiopathologic state-consisting of errors in energy.:: expenditure, which can produce firncoonal disorders: Dysponesis consists mainly-of covert•errors in action.. potential output from the motor and .pnemotor areas of the, cortex, and the consequences *of that output. In the sEMG scan, aEMG signals were measured. in-mimovolts (millionths-of a volt), by an.instrumeat with a• frequency band of 25-500 Hz: The computes' program analyzes the measiuemesrts and compared them to •a normative database. sEMG scans. are interpreted. in several-ways: 1: Amplitude.: This refers to the.-signal level-in-6c ravoks.,The bighea• the -signal level, the greater the paraspinal muscle activity. By comparing these readings,to a normative database, elevated or.decreased-signals can be. idenrtified. . , • . - . 2. Symmetry. This refers to a comparison of the left-to-riglit amplitudes at each spinal level. The sEMG amplitude signals of the patient-were compared to published- relbrence vWuk1)with.mi1d; moderate `and severe elevations of muscle tension identified.by:color . Differences between one and two standard deviations indicate•mild tension, two to three standard deviations indicate moderate tension,.while three or more indicate severe tension. In addition to the comparison with reference values, the amount of asymmetrical muscle activity was calearlated, with mild, moderate, and severe asymmetries identified by color. Differences between one and two standard deviations indicate mild asymmetry, two to thme standard deviations represent moderate asymmetry, while three or more indicate severe asymmetry. ¦ STATIC SEMG RESULTS Readings one or more standard deviations below normal means were observed at: CI(L), C5(Lj T4(L), T4(R), T6(L), T6(R), T&(L), Tg(R), T10(L), T10(R), T12(L), T12(R), LI(L),1-3(L) This is indicative of reduced muscle tension. Readings up to one standard deviation above normal means were observed at: T2(L), M(R), M(R), L5(L) This is indicative of normal muscle tension. Readings one to two standard deviations above normal means were observed at: C1(R), T1(LI S1(L) This is indicative of a mild elevation of muscle tension. Readings two to three standard deviations above normal means were observed at: C7(L), L5(R) This is indicative of a moderate elevation of muscle tension. Readings more than three standard deviations above normal means were observed at: C3(L), O(R), C504 C7(R), TI(R), 12(R), SI(R) This is indicative of a severe elevation of muscle tension. Area of significant asymmetry were noted at the following sites: CI(R), C5(R), T1(K), T2(R), T4(R), 13(R), L5(R), SI(R) PEDAL FOUNDATION EXAM As described in the Asymmetries Results above, exmmrttntion of the back of Kayla CIW= has indicated a mrusc uloskeletal imbalance. Because such conditions are often the mull of an imbalance in the pedal foundation, an examination of this patient's feet is recommended. During the won of the feet, the patient is asked to stand barefoot. The left and right foot are each examined for pronation, supmation and normal arch shape. FOLLOW-UP PLAN The results of this cmm ination, taken in concert with the patient history and other clinical findings, were used in determining recommendations for the type, fivquency, and duration of chiropractic ewe. Follow-up examinations will be performed, as needed, to evaluate Kayla. Clayton's response to the clinical se vices provided Fields "'i . r /FFA M I LY DENTISTRY, LLC May 22, 2007 State Farm Mutual Automobile Insurance Company ATTN: Elaine M. Haughin, Claim Representative Southpointe Operations Center 555 Southpointe Boulevard, Suite 400 Canonsburg, PA 15317 Re: Claim #38-L102-937 Patient: Kayla Clayton Dear Elaine: I am submitting the enclosed narrative report pursuant to your request of March 27, 2007. Kayla presented to my office on October 30, 2006 as an after hours emergency. She stated she was involved in a car accident and had followed instructions to have a dental review of her front teeth. I am enclosing radiographs and intraoral photographs for your records. At that time, it was observed that tooth #8 was fractured into the pulpal tissue and tooth #9 was also fractured with a "blushing" pulp. Both teeth had mobility. Options were presented to Kayla's Guardian involving keeping tooth #8 (treating with root canal therapy) versus extracting this tooth (treating with an implant, fixed partial denture, or removable partial denture). The advantages and disadvantages were reviewed involving each option. Her Guardian chose root canal treatment, crown build-up, and an eventual crown. Kayla's intraoral, extraoral, TMJ, and periodontal exam were within normal limits. It was recorded that teeth #s 6, 7, 9, and 10 had chipped incisal edges and would need bonding completed to protect the teeth from another fracture. Kayla's Guardian stated she wanted root canal therapy initiated to salvage the root and tooth preventing invasive surgery. The tooth was accessed, debrided, irrigated, and sealed. Tooth #s 8 and 9 were then built up with composites involving all surfaces of each tooth. I finally suggested there may be a future need for consultations with an Orthodontist (extrusion) and Periodontist (osseous crown lengthening). On November 27, 2006, Kayla was seen for re-evaluation. Pulp tests were performed on her anterior teeth which included percussion, electronic pulpal, and cold tests. Tooth #9 was extremely sensitive to cold, percussion, and had a high EPT value. The gingival 2101 Aspen Drive - Mechanicsburg, PA 17055 Phone 717-697-3400 - Fax 717-697-7857 www.fieldsfamilydentistry.com -R-voR tissues appeared healthy in both texture and color. Incisal edge restorations were placed on teeth #s 6, 7, 24, 25, and 26. On December 18, 2006, Kayla was seen again for a re-evaluation. It was found that teeth #s 7, 9, and 10 were sensitive to cold and percussion. EPT numbers were high on these teeth as well. It was suggested there may be a need to perform endodontic treatment on teeth #s 7 and 9. Additionally, incisal edge restorations were placed on teeth #s 22 and 23. On January 29, 2007, Kayla was seen again for re-evaluation. Pulp tests revealed cold sensitivity again for teeth #s 7 and 9. Percussion was positive for tooth #9 but EPT and mobility were within normal limits for both teeth. On April 30, 2007, pulp tests elicited percussion and cold sensitivity for tooth #9. Tooth #7 elicited no percussion sensitivity but did reveal cold sensitivity and a high EPT value. Based on these findings, I have recommended to Kayla and her Guardian that endodontic treatment will eventually be needed for teeth #s 7 and 9. I have started a monitoring period for every 3 to 4 months to verify the diagnosis of irreversible pulpitis. I will continue to follow Kayla under these guidelines, along with her general oral health care, until a time that the family asks for discontinuance. I hope this narrative sheds some light on Kayla's mishap and can foster the proper format for reimbursement. If I can be of further assistance, please do not hesitate to contact me. Sincerely, fJ?? Charles R. Fields, DDS, MAGI) CRF/tlg Enclosures an. 11 . 20 07 3 :0 9P M FI EL DS FA MI LY D ENT IS TR Y, LL C - w No . 2 22 I a ll A O p • 1 w 1 ? ? 'r + Jf? Z \ n ' rr ( S` i Z k C3 s t lit , . i ' !! 1 1 I ' k r f ? ? j I ! I I T F 1 ? DI lu P. 2 x m 4 a r r m ki_ nnnl D 9 2007 3: I O n 11 PM F IE LDS FAMILY DEN I IS I KY, LL; %? N "U• ccc t . . C ~ b t A n + ? b 1 ? r r v m ti 14 a T H - 1?- [ T I I Pl- s CLAYTON, KAYLA J-Enc #2701084--- 3PT-HER-10/30/2006 ED Report - 1k1 .006 - 1 pg 1)ACCT#=00270108451 {_,_RANSCRIBED DATE=11/02/2006 iu:20 UDN= 1996891 CLAYTON, KAYLA J RM#: 890rl-MrY MRN: 574-08-4198 FEB 02 2??7 CASE: DOB: 00270108451 07/16/1991 CONCU.,DYtCLS ADM: 10/30/2006 clos PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 EMERGENCY DEPARTMENT CHIEF COMPLAINT: Status post MVA. HISTORY OF PRESENT ILLNESS: This 15-year-old female presents to the emergency department after being involved in an MVA. She apparently was a passenger in the right rear passenger seat, states she was wearing her seatbelt when the car struck a tree. There was airbag deployment. Patient is complaining of pain in her neck area, also complaining of some injury to her teeth and also nausea. The patient does have a slight headache. No visual changes. No numbness or tingling in arms or legs. No back pain. No abdominal pain. No chest pain. No shortness of breath. 1- REVIEW OF SYSTEMS: Complete review of systems negative except as above. PAST HISTORY: Past medical history is denied. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Patient is a nonsmoker. PHYSICAL EXAMINATION: Vital signs: Temperature is 36.7. Blood pressure 121/61. Pulse 65. Respirations 16. Constitutional: Patient is alert, well developed, appears to be in mild distress. Mental status: Patient is alert, oriented to time, place and person. No recent memory loss. States that when the accident occurred, she might have "lost consciousness for a couple minutes." Patient's affect is appropriate. Eyes: Pupils are equal and reactive. Funduscopic benign. Extraocular muscles intact. ENT: No midfacial trauma other than fractures of her central incisors, #8 and #9. Neck: Paracervical muscle tenderness. No midline cervical tenderness. Respiratory: Clear to auscultation and percussion. Cardiovascular: No murmurs or gallops. Heart sounds normal. GI: No masses or tenderness. No hepatosplenomegaly. Skin: No new rashes or lesions noted. Neuro: DTR's equal and symmetric both upper and lower extremities. Strength good and equal in both upper and lower extremities. Extremities/Musculoskeletal: Joint: Capable of free range of motion without pain or crepitation. No effusion or erythema. Bone: No misalignment, asymmetry, defect, tenderness or effusion. Capable of full range of motion of joint above and below bone. Muscle: No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength. Lymphatic: No cervical adenopathy. EMERGENCY DEPARTMENT PHYSICIAN TEST INTERPRETATION: X-ray of the cervical spine revealed no acute fracture. CT scan of the head was negative. EMERGENCY DEPARTMENT COURSE: No procedures or consults required. DISPOSITION: Patient is discharged on Phenergan 25 mg p.o. q.6-8 H p.r.n. Page 1 of 2 T CLAYTON, KAYLA J-Enc #270101 ?I-OPT-HER-10/30/2006 ED Report - 212006 - 1 pg Jnausea. Head injury ins ructions given. Parents are here, advised that the patient should follow up with the family doctor this week. Have a followup MRI since the CT scan did show possible pineal cyst and recommended that. The patient also referred to the dentist for dental x-rays and follow up on dental fractures. Disposition: Follow with FMD and dentist. DIAGNOSTIC IMPRESSION: #9. PATIENT: Kayla Clayton c: GLEN WHEELER, MD 1. Minor closed head injury. 2. Acute cervical strain. 3. Fracture of central incisor, #8 and 4. Pineal cyst. REVIEWED AND ELECTRONICALLY SIGNED BY: GARY BAGGETT, DO 11/14/2006 02:07 ----- -----,-DO------------ GARY BAGGETT DD: 10/30/2006 1996891 DT: 11/02/2006 /das D#: ER REPORT ER REPORT END OF REPORT ----- REPORT NAME=ER ER REPORT HOSP=POREGION=MB Page 2 of 2 QUANTUM PINNACLE foc: DiA C'-4YTON, KAYLA 1991-07-16 SSN: 574084196 MRN: 574084198 Patient Class/Status: E Ordered By. BAGGETT, GARY Attending: EMERGENCY ROOM, ASSOCIATES Referred By. Dictated By. BRONITSKY, BARBARA G. Accession: 5499568 DOS: 10-30.200616:36:00 ADM DX: CodeRyte Note Handle: APS-8888140 REASON: SP MVA PROCEDURE: DIA - 2040 - CERVICAL SPINE 2-3 VIEWS EXAM: Cervical sphe, 3 views limited HISTORY: 50-year-old complains of neck pain following MVA. Results: Despite attempted swimmer's view, only C1 through proximal aspect of C5 are demonstrated in the lateral projection. There is no malatignment or fracture of the visualized vertebrae. The prevertebral soft tissues, odontoid process, and C1-C2 relationship are within normal limits. IMPRESSION: Negative (united cervical spine series demonstrates no abnormality of C1 through C4. If symptoms persist, consider followup with routine cervical spine series. To provide the best and safest patient care: During routine daytim weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredrickson Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful Interpretations. Accordingly, If the clinical team is in search of answers to specific questions, Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have reoeive i this communication in error, please notify us immediately at: 1-717-782-3240. please include your question(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report Furthermore, tf clinical urgency necessitates an Immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any disser ination, distribution, or copy of this communication is strictly prohibited. If you have received this communication In error, please notify us immediately at: 1-717-782-3240. Codes: Accession CPT ICD 72040 723.1 FFe 09 0/0 ? 9? is 38-LI02-937 HR Approved by: Michell Ohlson Dictation Date: QUANTUM PINNACLE loc: CTS CLAYTON, KAYLA 1991-07-16 SSN: 574084198 MRN: 574084198 Patient Class/Status: E Ordered By: BAGGETT, GARY Attending: EMERGENCY ROOM, ASSOCIATES Referred By. Dictated By. AUSTIN, CHARLES B Accession: 5499567 DOS: 10-30-200610:08.00 ADM DX: CodeRyte Note Handle: APS-8885785 REASON: SP MVA PROCEDURE CTS - 0450 - CT BRAIN W/O CONTRAST EXAM: CT brain without contrast HISTORY: Head traumalmotor vehicle accident Results: Imaging was performed from base to vertex without intravenous contrast. There is no evidence of hydrocephalus, or intracranial hemorrhage. There is no evidence of a major arterial distribution infarction At the expected location of the pineal gland, there is a 1.2 cm in diameter low-density focus. This most likely represents a pineal cyst. Eventual nonemergent MRI of the brain without and with contrast is however needed for further evaluation. IMPRESSION: There is no evidence of acute intracranial abnormality. There is a cystic lesion in the region of the pineal gland warranting eventual MRI for further evaluation. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at 1-717-782-3240. To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to proving meaningful interpretations. Accordingly, if the clinical team is in search of answers to specific questions, please include your question(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal. report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at 1-717-782-3240. Codes: i Accession CPT ICD 70450 959.01 Pennsylvania EMS Report Service Name k No F ' PCR No. 1 New Cumbedmid Far - 2101210 A 10 0600336 IOJ302006 Pafieat Name Date of Bb* 1 Sochi Seevky Number MP Bapla C*" 07/10"1 574-094198 060140191 Csstrointaft al Abdomen Pain GU ONO Coe VWA ? Nausea ? v 0 sale ? F. ? ClUtan (? 1taQ,alueau ' 0 No complain ? ? o P ? Diarfm ? Constipated ? O sum ? ? Pain ? Bonft Area(s) EQedted Bawd Soon& A 0 DWI ? lowntiMA ? ltae?loa ? Ll1Q ? RUQ Distended -N No o O Y Ycs et O Radiating - No Q Yes O D Foley ? LLQ ? RLQ Tench- No O Yes O Total Output _ Erb itk s Reptroduetin e No CMp4man 0 No Comp1mift Femak Male LA RA LL RL LA RA LL RL OV,&d Bleadiua ?D=dwp ? Peck Dbcbwp Psralysis ? 0 ? ? Pam 0000 Prcpaur<-No O Yes O ? Testioular Pain Pamd mis ? ? ? ? Pallor ? ? ? ? ftvl a - Para - wort - Pulse ? ? ? © Edema ? ? ? ? ?FeW Mowemems Feld Haan Too- 40 0 w 01 Narrative tA Amb 10 dispatched Class for an Auto Accident victim at the request of the Police Dept in the Boro i-A of New Cumberland in the area of the 500 Block of Hillside Rd. Amb 10 with immediate response is 0 advised by CCC that we are at the request of the Police Dept for an accident victim. Amb 10 AOS to find a single car accident with a 15 ywf still In the rear of the vehicle. The vehicle is a Chevy Cavalier that was fleeing the Police that has substantial damage to it all around. The vehicle has moderate damage to the rear passenger, passenger side quarter panel damage to it with rear window smashed on the vehicle, the rear bumper is ripped off, the near of the vehicle is pushed in towards the trunk of the car, minimal space between the front seat and the back seat of the vehicle, front bumper damage, and dual airbag deployment. Police Officer Weaver explains that he had been chasing this vehicle over several blocks of New Cumberland when it made this Right turn onto Hillside Road and the driver lost control of the vehicle went off the roadway, struck a tree which made the car's passenger side rear passenger side swing into the tree and swerved and then It stopped and the driver got out and took off. The passenger stated that her neck hurts a little and that her mouth hurts. The pt then crawls over the driver seat which is leaning backwards and crawls out of the 2 door vehicle. The pt tells BLS that she had an argument with her mom last night around 9 pm andtook off and started walking through New Cumberland. The pt then said that this kid she knew stoppers and she got in his vehicle and then went with him. She said she awoke this morning and got in his vehicle and was driving through the Boro when all of a sudden the Police wanted them to stop and the driver wouldn't. The pt said she kept on telling him to pull over but he just kept going faster and faster. Pt says she's not sure why she crawled in the back seat but is sure she was seatbelted at the time of the crash. Pt said she's not even sure when the driver took off or why. Due to the pt's age and injuries and potential injuries, pt is told she has to go to the hospital. TX: AOS and received report and care from Officer Weaver who Is trying to gather evidence from the scene. The pt is encountered and then the pt crawls out of the vehicle. A quick dotal Primed On 11/0512006 1114 Provider EMStat Repard*c)199E-2006, Med-Medk Inc. All Rlgbn Reserved P o: 2 of 4 Pennsylvania EMS Report Service, Nome New C wnbarhmd File UnkNo A10 - 2101210 PCRNa 0600336 Dote 10/30/1006 Meet Nome Dote of Birth orleY Number ? PSAP Rryis Caayt= 07/16J1991 V4192 060140191 assessment is performed and a c- collar is placed on the pt, Pt is then seated on the titter which already has a LBB on it, as A#1 still holds head stabilization, Head is secured with CIDs and then is secured to the LBB, pt is then fully secured to the LBB using kwik clips and then secured to the p fitter, pt is placed in the back of the ambulance, vitals are taken, en route to Hbg Hospital, which Is 0 the closest facilty, a detail assessment is performed and vitals are retaken and a cold pack is p applied to the forehead swelling, upon arrival at Hbg Hospital, pt states she's starting to get a W headache and is a little drowsy. Pt is transported into the ER and to Examing Rm. # 12 where pt is transferred to the gurney and cane and report is given and transferred to ER staff. PE: CA&O x 415 ywf, dressed in pajamas, stating that her mouth and neck hurts, head is normal and osphalic but with a small swelling to the right side of her head above the temporal region, - headache initially on scene but upon arrival at the hospital pt states she was getting one, - blurred or double vision, PERRL, skin is warm pink and dry, - fluids from the eyes ears or mouth, front top teeth are busted in half and broken off, - bleeding noted, - jvd, trachea is midline, - shortness of breath, - chest pain, chest is symmetrical and = in rise and fall, abd is soft and non tender, - nausea and/ or vomitting, pelvis is stable, upper and lower extremities are atraumatlc and = in grips, strengths and movements, - tingling nor numbing sensation anywhere stated by the pt, back is atraumatic and pt states she does have neck pain which she states Isn't really pain, it just hurts, + drowsiness stated by the pt also upon arrival at the hospital which pt wasn't initially. Tone P R BP,.-. Sri EMC02 . IMASSOW .,. RhOmii- 7tembl" i ;,y`a i .:..•• ?? ?,a, :tit J . 'F s • 08:33 80 [ 104M 95 4/5/6 Imtni 02.42 72 16 102(64 // cps CA O %a Printed On: 1 1/05/2006 11:24 Dam Rcpm*ig(c)199E-2006, Mad-Molt Inc. AU Rigbn Reserved 3 of 4 Pennsylvania EMS Report t i t Summ Nose Uab No pm No. Date New Cswbcft d 9ve Depmumm A10.2101210 06OM36 19x30/1006 htleat Nape Date ar Urb Sodal Seeadq Noubw PW KryL Cloytoa 07110991 574-08419E 060140191 Anterior Penned On: 1 1105r2M 11:24 EMSts Repwfi*c)199E-2006, Me&Moft Isr- All Ri&b Rc=vW pain Posterior - Provider Page: 4 of 4 0 0 O w w O? Ot N J O ?D Pennsylvania EMS Report service Now Station Unit Name & Na "m No. Dsti New CaM=W d Fire AI O - 2101214 0600336 14r30/2006 Incident Loeadou Muskipatity k laddest Tip PSAP ludd, No. SW Bacot of H:7lside Rd, ? ? New Cumbettaul Soto, 17070 060140191 IPA RftdvkgAVAcy 1± HnrdsbnHospiW Patient Nape Crew Kayla CIs)Un C #1 FiihsoM Karen E 087570 W kreetA"was 6 4th Street 60 C 112 llamas, Ryas E 118425 a C N3 t city state Zip New Cumberiand PA 17070 C#4 Q sex Age DOB Pbsse No. 1 Fe mIe 15 Years 07/16/1991 (717)774-7264 Timrs 41 tiest Number Sold See. Na Pt, eight 911 Ql 574-08.4198 Dlspek b 080 08 14 E Pr#rale Physician Driver's Liasse : armle Arrive Scene 08:16 Dr. Wheder _ - caste 08:17 Tmwip lag Mdst Units As" OS out U.7!Nm Dent. b Depvf Seess 08:36 25277 25277 25281 25284 Arrive 08:41 A il bl 09 11 Resposse Outcome Medicol mss Cmd Physician M TIM va a : e In Qartoo 09:15 Tramporced MC 1- Complaint: "my track and mouth hints " Current Mob; nose stated Ageri0es(meft, NKDA PMHs Nine Stated L.evd of conacionsums Spemb Neurological Sarin, Temperature 8 Color 0 Caagcioas 0 Oriottod s 4 0 Coherent ? No Co uptsim 0 Dry 0 Pink O Mottled 0 Alen ? Usooopastive ? lttcobewd ? Hade to ? Ntmtban ? mwd ? Pie ? C)-? ? Lethargic ? combative ? suan ? SWNo* ? wedmcus ? Di phoretie ? Fhnhod ? Yellow O Contused O Altemd O coot 0 Near Pais ? Diay ? Ashes ? Odw ?u--.d- ? "Wiw 0 ? oQ* -Unskady ? lafim ? Aphasia Faeid Droop - L O R O Hoc O Worm ® Cad O Cold O Itapimtory Brsatb Sounds Cardiovascular p"m HUNT ? No cauphtm L R Cheat Pain 0 PERL Eyes Nocempkint 0 Airwq Pmm pram 0 0 .0 N. Cop W. Sae L R _ Barred Vision - L ?R? 0 sr-N Lruai "Pasta` ? ? ? seven _ pb Do" vision - L ?R? ? Lebomd clew ? ? ? Cssor? htmi 9cint 00 P M*bobia - L?? d. Dilated 00 Retra 0 Strider Dttaialshed wnemer 0 0 o Da o 00 cosapb>itt Eats 0 N. ? Nasal Flaring Craddes ? ? ? Hwy ? Rrtdisurtg Pain - L?R? Cottgb Rho-W ?? NOOK DF dwp- LORD 0 No Comphim Asymmetric ? ? ? Capfty RdM Krows Anamaly Band - L ?R? Ptod wdw -No O Yes O Nose 0 NDCMOWN ? N d c i an ourst m Threat 0 No Complaint ? Nasal Drainage ? Sae Tbwu ? Dyspiagla Deviation - L O R O Epbbxb - L[] R[:] lli ? D ti S E tao we nV dems ag ? ? JVD ? Deformity Printed On: 11/0520061124 EMSW ReporthWe) 1999-2006, Mal-Media, inc. All Rights Reserved Provider Page: 1 of 4 0 o? O 0 W 01 O, fit N M.? f?+ J O RELEASE For the Sole Consideration of TWENTY-NINE THOUSAND DOLLARS and oo/loo ($29,ooo.oo), the receipt and sufficiency whereof is hereby acknowledged, the undersigned hereby releases and forever discharges State Farm Mutual Automobile Insurance Company, its heirs, executors, administrators, agents and assigns and all other persons, firms or corporations liable or, who might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the future develop from an accident wllch occurred on or about the 30thday of October, 2oo6. This release expressly reserves all rights of the parties released to pursue their legal remedies, if any, against the undersigned, their heirs, executors, agents and assigns. Undersigned hereby declares that the terms of this settlement have been completely read and are fully understood and voluntarily accepted for the purpose of making a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of precluding forever any further or additional claims arising out of the aforesaid accident. Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above. Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Witness Whereof, GUS have hereunto set A-? hand(s) and seal(s) this /1 day of , 2001V In p esepce of: W Witness eborah Clayton Parent and Natural Guardian of Kayla Clayton Date: ?? ?? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.. AFFIDAVIT I, Kimberly L. Gallucci, Esquire, am a licensed attorney in the Commonwealth of Pennsylvania. I am, for purposes of the above-captioned Petition, acting solely on behalf of Minor-Petitioner, Kayla Clayton. I have thoroughly reviewed the medical records available in this matter, along with the Settlement and Release documents executed by State Farm Mutual Automobile Insurance Company and the Minor-Petitioner's parent and the Verifications executed by the parent of the minor. Relying on my review of these records and documents, along with my experience as an attorney, and given the nature of the injuries sustained by the Minor-Petitioner, it is my opinion that the sum of $29,000 is a fair and equitable settlement and is in the best interest of the minor, Kayla Clayton. Date: UC), 15704 VERIFICATION I, Deborah Clayton, do hereby certify that I am the parent and natural guardian of the minor-Petitioner, Kayla Clayton, who is presently 16 years old. I have reviewed and discussed the proposed Settlement and Distribution set forth in the foregoing Petition and proposed Order. The averments of the Petition are true and correct to the best of my knowledge, information and belief. I believe that the proposed Settlement is in the best interest of my minor daughter, Kayla Clayton. I recommend that the Court approve the Settlement and Order of Distribution. I understand this Verification is made pursuant to provisions of 18 Pa. C.S.A. Section 4904 relating to unsworn falsification to authorities. Dated: 9 I, 11 V Deborah Clayton, Parent and Natural Guardian of Kayla Clayton 15704 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor, CIVIL COURT DIVISION No.. ORDER OF COURT AND NOW, to wit, this day of , 2008, it is hereby ORDERED, ADJUDGED and DECREED that the Petition to Compromise a Minor's Claim of Kayla Clayton, in the amount of $29,000, is approved. It is further ordered that the proceeds shall be distributed as follows: The sum of $29,000 shall be deposited in the name of "Kayla Clayton", by Kimberly L. Gallucci, Esquire, in a savings account or certificate of deposit in a federally insured bank or savings and loan association. The savings account or certificate of deposit shall be marked `NOT TO BE REDEEMED EXCEPT FOR RENEWAL IN ITS ENTIRETY, IN ORDER TO BE WITHDRAWN, SIGNED, NEGOTIATED OR OTHERWISE ALEINATED BEFORE MINOR, KAYLA CLAYTON, REACHES THE AGE OF MAJORITY' on July 16, 2009, except by Order of Court of competent jurisdiction. Proof of deposit to be filed with the Orphan's Court by Attorney Kimberly L. Gallucci, Esquire, within thirty (3o) days. BY THE COURT: J. 157°4 CERTIFICATE OF SERVICE I hereby certify that the within Amended Petition to Compromise a Minor's Claim was served upon counsel of record by mailing the same via first class mail, postage pre-paid, this 51" day of , 20o8: Deborah Clayton P.O. Box 593 New Cumberland, PA 17070 SUMMERS, WDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP By: 'mberly L. allucci, Esquire Counsel for ttitioner 15704 r ? ? N? { 9-0 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor, CIVIL COURT DIVISION No.. 08- ORDER OF COURT 1301a C Zvi IerNA AND NOW, to wit this l ?? a of u c 2008 it is hereby ORDERED ADJUDGED and DECREED that the Petition to Compromise a Minor's Claim of Kayla Clayton, in the amount of $29,000, is approved. It is further ordered that the proceeds shall be distributed as follows: The sum of $29,000 shall be deposited in the name of "Kayla Clayton", by Kimberly L. Gallucci, Esquire, in a savings account or certificate of deposit in a federally insured bank or savings and loan association. The savings account or certificate of deposit shall be marked `NOT TO BE REDEEMED EXCEPT FOR RENEWAL IN ITS ENTIRETY, IN ORDER TO BE WITHDRAWN, SIGNED, NEGOTIATED OR OTHERWISE ALEINATED BEFORE MINOR, KAYLA CLAYTON, REACHES THE AGE OF MAJORITY' on July 16, 2009, except by Order of Court of competent jurisdiction. Proof of deposit to be filed with the Orphan's Court by Attorney Kimberly L. Gallucci, Esquire, within thirty (30) days. J. 157°4 vv ; 4do solvift AUVIONui-4';;C'-,4'd .30 301--J0 -u3113 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.: o8-1322 Civil Term AMENDED PETITION TO COMPROMISE A MINOR'S CLAIM (Jury Trial Demanded) Filed on Behalf of the Petitioner, State Farm Mutual Automobile Insurance Company Counsel of Record for This Party: Kimberly L. Gallucci, Esquire Pa. I.D. 92911 SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP Firm No. 911 707 Grant Street Suite 2400, Gulf Tower Pittsburgh, PA 15219 (412) 261-3232 15704 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.. PETITION TO COMPROMISE A MINOR'S CLAIM AND NOW, comes the Petitioner, State Farm Mutual Automobile Insurance Company, by and through its attorneys, SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP and Kimberly L. Gallucci, Esquire and sets forth the following Petition to Compromise a Minor's Claim: 1. Deborah Clayton is an adult individual currently residing at 6o6 4th Street, New Cumberland, Pennsylvania. She is the parent and natural guardian of minor, Kayla Clayton, who was born July 16, 1991. 2. On October 30, 2006, Minor Kayla Clayton was injured in a motor vehicle accident that occurred on Hillside Road in New Cumberland, Cumberland County, Pennsylvania. 3. At the time of the subject accident, Minor Kayla Clayton was a guest passenger in a vehicle owned by Sammy Hockley and operated by Jason Hockley, Jr. 4. Minor Kayla Clayton was injured when Mr. Hockley lost control of his vehicle, causing the vehicle to strike a tree. 15704 5. As a result of the aforementioned accident, Minor Kayla Clayton suffered cervical, thoracic and lumbar strains, radiculitis, a minor closed head injury with headaches and dental injuries. Attached hereto as Exhibit "A" is a copy of Minor Kayla Clayton's medical records. 6. On the date of the subject accident, Jason Hockley, Jr., was an excluded driver on the insurance policy covering Sammy Hockley's vehicle. Jason Hockley, Jr., was also unlicensed on the date of loss. Accordingly, no liability coverage has been denied by Sammy Hockley's insurance company. 7. On the date of the subject accident, Deborah Clayton was the named insured on a policy issued by State Farm Mutual Automobile Insurance Company. This policy provided for uninsured motorist coverage. Minor Kayla Clayton was an insured under her mother's State Farm policy. 8. Kayla Clayton, a minor, by and through her parent and natural guardian, Deborah Clayton, has entered into a settlement agreement with State Farm Mutual Automobile Insurance Company, under the underinsured motorist provision of Ms. Clayton's State Farm policy. 9. Kayla Clayton, a minor, by and through her parent and natural guardian, Deborah Clayton, has agreed to accept State Farm Mutual Automobile Insurance Company's offer of $29,000 on behalf of Minor Kayla Clayton as set forth more fully in the Release attached hereto and marked as Exhibit "B." 10. Minor Kayla Clayton's parent and natural guardian, Deborah Clayton, has investigated this matter and agrees that compensation in the amount of $29,000 is a fair and equitable settlement in light of the injuries sustained by the minor-petitioner. In 15704 addition, it is hereby averred that the settlement is in the best interest of the minor- petitioner. See attached Affidavit, Exhibit "C". ii. Subject to the approval of the Court, the parties have agreed to settle the minor-petitioner's claim for $29,000 with the proceeds to be distributed as follows: The sum of $29,000 shall be deposited in the name of "Kayla Clayton", by Kimberly L. Gallucci, Esquire, in a savings account or certificate of deposit in a federally insured bank or savings and loan association. The savings account or certificate of deposit shall be marked `NOT TO BE REDEEMED EXCEPT FOR RENEWAL IN ITS ENTIRETY, IN ORDER TO BE WITHDRAWN, SIGNED, NEGOTIATED OR OTHERWISE ALEINATED BEFORE MINOR, KAYLA CLAYTON, REACHES THE AGE OF MAJORITY' on July 16, 20o9, except by Order of Court of competent jurisdiction. WHEREFORE, the Petitioner requests that this Honorable Court enter an Order approving the Petition to Compromise Kayla Clayton's claim in the amount of $29,000. Respectfully submitted, SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP By: +ounseblfor rly L. ucci, Esquire Petitioner 15704 Fields Family Dentistry 2101 Aspen Drive Mechanicsburg, ?A 17055 ? ?i ?olcc? =®4$*_ For Your Active Life! December 14, 2006 State Farm Insurance Claims Depwtment P.O. Box 40 Concordville, PA 19339 Re: Kayla Clayton Claim #381,102937 Pa.mb Dunn, O*gxm*x- 33 A'East Skr pson A 717-97-8100 Fax: 717.6 -OM MWhmrcabraU PA 17M www drsdunn.eom CE D DEC Z 1 2006 CONCORDVILLE cm The above-captioned patient came into this office on November 1, 2006 for evaluation and care of her personal injuries sustainer) as a result of a vehicle accident on 10/30106. PATIENT COMPLAINTS: Neck pain, headache, pain in left leg pain in jaw. The patient's face is puffy, she has lost her two front teeth, and she was treated in the hospital for concussion. The severity of her pain is moderate: 6 out of 10, with 10 being worse. The duration of the pain is frequent, 50 - 75% of the time. The character of the pain is a dull ache She also has some muscle weakness, numbness and tingling. Aggravating factors are coughing bending, walking, cog body positions, and CHIROPRACTIC HISTORY: Kayla was a patient in this office in 2004 and 2005, and rehaned for care in August of this year. She was on maintenance care until this accident. CBIROPRAMC EXAhMATIONIFIPIDINGS: The following diiropractic examinations were conducted: ROM: Percent m of irnnairrnent found: Cervical flexion 30% impairment; Cervical extension 40%; Thoracic flexion 80% and Lumbosacral extension 10% Palpatr'on: Tender to palpation around the neck. Short left leg. Orthopedic Test: Maximum foraminal compression. Negative for local pain; however, patient's front of face was too Sore m perform other tests. Cervical distraction did not relieve pain. Lumbar Kempt's Test: Negative B Surface EMG: Significant asymmetry at Cl, C5, TI, T2, T4, L3, L5, and Sl. Motion Palpation: Motion restriction at L5, T6, T4, TI, C5, and C2. CHIROPRACTIC X-RAYS: The following radiology exams were taken at Harrisburg Diagnostic Department on October 31, 2006 with study imetpretation provided by Quantum imaging dt Therapeutic Associates. A CT brain scan without contrast showed no evidence of acute intac anial abnormality. Cervical Spine, 2- 3 views : Negative limited cervical spine series demonstrated no abnormality of CI through C4. CHIROPRACTIC DIAGNOSIS: 847.0 Cervical Strain/Spain due to MVA of 10130106; 723.4 Cervical Radiculitis; 8472 Lumbar Strain/Sprain due m MVA of 10/3006; 723.4 Lumbar Radiculitis; 839.08 Cervical VSC Multiple; 784.0 Headaches; 83921 Thoracic VSC hhd/Muffi; 83920 Lumbar VSC Ind/Muhi. PROGNOSIS AND CARE: Patient is slowly recovering. Cate plan of 2x/week with re-evaluation planned end of December. Patient has been unable to come in for all teems sdrodrrled due to tranxhorlation problems. S' lyJ?ak__ U-n . Pamela Duren, D.C. r1liltiiiii(111,11t For. Your Active Life! Pamela Dunn, Chiropractor 33 -A" East Simpson Street, Mechanicsburg, PA 17055 ? Initial Report ? Interim Report .? F'W Report ' Patients - Please complete the shaded areas only. Check which most closely applies. 1) - Chief Complaint R. N Pain ? Mid Back Pain ? Low Back Pain ? Arm Pain - Left / Right-. bl[:?g Pain Le$ Right eadache ? Other CFtEI 2) Mode of Onset. : ? Ovet elcettion / Strenuous Position.. Auto. Accident. .[I F4 trip or slip ? Other- . 3) Date. ofOnsetlle l30 / CKQ 4) Location of Pain: Please circle areas on body showing where your pain is occurring: ti 5) Severity of Pain: ? Mild Annoyance - no impairment ? Slight- some mild impairment Please circle the number that best represents [- f1odelate -•marked impairment your current level of pain: ? Severe - utcapacitated f bed ridden .(1 = 1000/a.welL 10 =bed ridden) 1=2 14.5 5 ©7 8 9 10 6) Duration of Pain: im the 7) . Character of pain: : ?'?ull Ac>se' e) t ? Intermittent (25% of ? Qpcaslonal (25 - 500A of the time) . :, ? Burning: Frequent (50 - 75% of the time) ? Sharp/ Stabbing ? Constant (75 -100% of the time) . .: ; :. ': ?: Throbbing ? Other. ? Other. 8) Relation to Other Body Systems: 9) R ing Factors: ? Bowel /Bladder [DUO Exercise 1 bness / Tingling 94 ? Bracing / Taping - Nfuscle Weakness 19-S Ming; / Standing / Lying ? No apparent Relationship a Other ating Factors: /Riding /Sitting coning /Standing aces; Body Positions 11) Medications: 04497 Cold Packs ? Other DEC 2 t 2W6 CONCORDVILLE cloy (?-l profen ? Acctominophen ? Naproxen Sodium ? Other 12) Objective findings: See opposite side 13) X-ray findings: See Radio hic report dated: 14) Diagnosis (1CD9 Codes): 1) 2) 15) Plan for Care: Short term goals: Long term goals: Care frequency: A times per week for ? Re-evaluation dater/_?J?? 3) 7. 2 4) 1 3 t q Movement Sn /Bowel g Pushing /Foiling E HISTORY OF PRD,_?RY COMPLAINT P= Patient Name: a Date: L l. /J 0 6 ;, r':'- r7's'..?.:,::,.. . :i-. :.• . . 1 ._, ": . .. ? _ - . . - - - " '. . ... .'.'--.'.'.'1.?.':?.m':: -?::::-:?A' " . . ':' ? :?. I . _' - -. m . . : ?, , • - :..:.. . . .. •?:: ::.ti: v \ "'; ::-P: .. , {': _ ... .- . , :. , ,. .. ;.. Y .. ;.. a .. ....,.... ....: _. '!: •i :?:'.'?}i ;: i:: :'??: ._ •i:.' .. ... •': :... i .. - ::"..'. .::. . .•1 ' :.' ...: .. PERSONAL;:INJU1 . . .. IQNNAtRE _:' -> ..-_::: ':' ==-:r ' =:.•;. ;:: ':::: :.....,::_.:, .-...:....., . . . f:' - - I )'Y; / . ` `.`7 .. :-•: 'F?tto a /!Y , . /?? ...- I 4?,; Name' _ - -.;. :::::;: : ::: ' :-r ?q : 'I a' ?o Z3"F. ":lei ?:#,(?i-' r- ': State Address: Y. .<; - - - _- - # 9?' ,' :' .. `f .: D `ez- ° ?? `.= A9es: s 'Birtt;date ? ....... :•::..:? =; 4 //... Em lover s. d A dress="" <? ' _.P.... . / ,.Y,. :::: ErriP.!o er's Name - xr.. . -' - :;;oo , !:' ' - p ::a' -:B c"' - pG A' t. `% D n sN u =Your. - P' - .- + g g /? fns Co : ;: cy - X: > ... 1•• ,.. ... -.. -e . .:-.-.,k .,, r .r...y ..1.... .s ,..s... - . - -. . -. :, ..... r. . .p - :.... Narrie ornPolic if ottie?thati sel . ... ., _Y:( :._......-:......:.. :.?.- - _ - F'. 6 .:: ': : ,. ' li D: :- ?' .- : `P.rt`'s Narne ., Res Posiale At ?. . _ _.. Y ---? k . - _. p ''. _ '`til.:.:?','--." ':'.' : =i; .Z _ •State 5fi'jr, ' :'ff Gt Address, -.... _ - ?;- ;?' €t.- : :. % . :. y;e ..:..93 - :Polk ` .. ..:: _ :. `=e` Y.- Pblic :Hold : er.s:Nam s x.. ., _ -........-, .:.. ' . .... ,.: -'A••::t,.:.:. .. : :...:....:::. • ' ? :. - TTOR ' . ,v 1_ ^' - }w. : ?'- : i....: I?. `.:i..-_' =J: - Rli rie Nam :r - ;. :t: A i - ?Z - •ta =S te? ddress'> r• x_ - o''? N (We ? Ye§- nesses 't ` sari :wit re:the e Y, ;. - -_ .: ;r: r_ CID . f..,..:e:'::: , , .. . ... uu ; ' ?4 °r _ Z :.> A. ........:.. .... . "".."40 " ; j ' : ?0.: ;?:,. ,.... of. Accident 1..Qate _, ........ Y.. . ?: - ., yip, - r t ar.. n er. - ou . . Front.Seat< :Back:Seat:r:= Driver... - : Passe I> 4, - n.. .-.... .. .. .t._. _ ..: .,...... [.Vii o-v - .: / .,& ., Q !.i ... x n_:'"eat tielts1 S :IY ar s t>eof: eo le'in ourvehicie?• V?1ere"you a 3."' Nurn w?' , _, ..P : . P. . - g . , :. _,. 4> ..What:direction ,were ou .:headed?? North: astt ; ( ;)South;' ".(-;>:jiWest. x =r:.. ? :.? W_ ,,v,. . :: Y (f ), u (-$ H. h:,.l. ,'->`#n. is ' :.., .r•. 9.:";'T::'. ?: r-Fr.!:': itY >• AM. :: "':'S„+.'"-•:. i":. T n ..?„ •,:,31, '•i. .: .3] '.G ;3R',, •, 1.` ° ".:- °S,•Y, ..u - ir? .. ?.^F:....-, .. .?{.y. :. i =' >: x. ?.Z''. ..[ a:f... .. . .'?:':. £iP`.. ); E .'?ri:..,. .1.... . r[L,: :1 Ir.. tr -ti.. •rr: M. - ,. _.z1.. - ?¢. ` on name of:street .. ^ !: 1 ''•^ %_:' _i i' ?.. .. y. .- :...ham ::'South: - West - ::. ;:What direction was other velilcle:heade ort :)'.Fast:, ;:(- - (..?.-), :. ,...e....::, F . _ -:= = ':?- ; : t . r t...: ::: ; eat :U= S': :::,. :,... ':.. :::.::.,r }:= ± h -- -': ?.: on: name.of street ' _:.:: L y_:;,,.,;_._.._..: .,.Y ..4 s.:....-,;. ..._K. ?•-:...:4,P•i. :1:. rT i•F' lk' :. :?V. ..>'l. .. .4'.: &. Were> ou;struck:from... • .:, :Behind. ,:• . (.: )Front:.;;:' ` (:::;);Left side _: {;) Right-side:' : `:.''' ,. :......:... ) .- : :.._..:....:. :,. s ocar ?? •? m ' h ? .-!...... r >T:A roximate°.s eed_0f ur > mPh-:<Othe r: P.. • r::..::. :.?_ - ..a l ... ' .:..._ , K ! . I? `for ho w -I , •ri ..C :t3: °Vlfere. '6u knocketl;unconscfous? i= Yes` ' Y ; g. Y „?.. ?'. - >:, P - ?:' e' 1T? n. C. Wer - - u `No' Ice•notif#ed9 ':Yes: Were i - x• . :.. °;:10::;In, our:own:words : lease describe acadent:,- :'G.ti'?..,. ... ii .-. ®o/?.. 5a?r1i?i? lvl ' 't'°.."Uri.; .... Y. P.-:: :.-X: :7':.:. , :..u a. ;: :t'. ?' - ` - .. Q ii i:g4 ! :':_.. ; :: :; t = ; ° j`:', ° - ., .. ,: -- t' .. ::=' =h f' .. +,'` r. :• :. ::: :} ,,.. µ ::C:.. +' , s.. *" i i' :.'.' - :. Ala : :, - _ .?J :.. _ _ ..:. -'.-_:.. ;17 e" , : l2: _ :, - Lv6C /: `: :t? 1 :Z. fJ? .. ,. ?, ., O%Wj .. , Y ? T? • - 3 , :11:Did ou!have anPh #cal com Taints BEFORE':THE ACG#DENT? `. s ~Yes ' °•`' No::;..- - , es, ease.desc !b--?'.-riri data . . ( ). ) Y P Y, .--Yg P. _.,. .:,_ i.` . - : ;: ::r::, .......:.:. .:.... _, .. .: - "_t: ..• .': .:. ;: ,' `' -I' .. . ?;i: ' •..,. J 'C:"^':. ' '•: 1,i =:::'.. . ::.:.. •: ' . •:. e ibe. ho w' You felt:: _ , . . . .... .....:.:..... . • '12 Pleasedsag - ;' .::... :.... _ . k -. . ac. a :'.DURING: the accident : . - .::. ; ,.w:: - ..,+: ... . .. . ., . .. b;••.IMMEDIATELY.AFTER.the accident,.. .. ..-.... ......_._... :.. _._:..... _.,::..:.... [.•-. - .. :.: '. ! :, : • - .. :?j- . . ?:,:. = . ?. . c`:'LATFR l`Hi4T QAY: .; - `et .::......- :.;: :::: [ d:•THE.NEXTQAY:.+U? i{l C1C 11 .? i :; -. 2s i.` :` i,%j` ' ?? .. . - -': . - ,., . r_:':::- . _ :; m ?m ?ti ? r Q ?Ca o rA C as O` c IA V Z :R L as W 0 Z Y N Q ti co CO T V N ?- co O O T 0 L: r T m L: m ? ? v m O m Z Z S a m aa w a cr o o .. Q o o o c E N O 'd M to co -C o 2 m c ? v a ? ° ? ? ® m m m LL ? s? m LL m 1 r o o m co m O cr. Y c ° N 0 c m w L C ? C?J N a: ?j ? E -Patient Name: Patient Number. Patient ideri ier: 'Clayton,Kayla 28872426 Practice Name: Practice Addn3ss: Dr. Pamela Dunn 33 "A" East Simpson Mechanicsburg, PA 1705: STATIC EMG INTERPRETATION NARRATIVE On. 11/01/2006-at 11:36 AM a pw.WjrW surface electromyographic scan (sEMG) study. was performed on ..Kayla Clayton to measure differences in;muscle..•tension along the spine. Paired electrode sets were used-to. compare muscle tension at 15 left-fight pairs.of anatomipal points: Standardzed•.protocols:and normative•data-. were utilized. The purpose of the test was to assess paraspinal muscle activity.., ' . Paraspinal •sEMG scans, taken m concert with other examination findings, may be helpful in determining the following: : • '' 1. Asymmetrical, contraction; `. 2. Anus of.muscle spurting 3_ rSe ." of the condition - _ 4. -Aberrant recruitment pattern : .. i 5. Responses to dysafferentation 6. Responses to chiropractic Austment 7. Dysponesis.- Dysponesis refers -to a reversible physiopathologic state consisting of errors in energy.:: expenditure,.which can produce hnctional disorders: Dysponesis consists mainly-of covert'errors in action.- . potential output from the motor and.premotor areas of the, cortex; and the consequences *of that output. In the sEMG scan, sEMG signals were measured in-microvolts (millionths-of.a volt] by an.instxumdnt with a r frequency band of 25-500 Hz. The computer program- analyzes the measurements and compared them to ,a normative database. sEMG scans. are interpreted. in several.ways: 1: Amplitude,: This refers to the:sinal level•in•microvolts.,The higher the-signal level, the greater the paraspinal muscle activity. By comparing these readings to a normative database, elevated or.decreased-signals can be . identified. f . 2. Symmetry. This refers to a comparison of the left-to-right amplitudes at each spinal level. The sEMG amplitude signals -aft patient-were compared to published reference values(I)with-mild; moderate and severe elevations of muscle tension identified.by,color. Differences.between one and two standard deviations indicate, mild tension, two to three standard deviations indicate moderate•tension,,while three or more indicate severe tension. In addition to the comparison with reference values, the amount of asymmetrical muscle activity was calculated, with mild, moderate, and severe asymmetries identified by color. Differences between one and two standard deviations indicate mild asymmetry, two to three standard deviations represent moderate asymmetry, while three or more indicate severe asymnwtry. STATIC SEMG RESULTS Readings one or more standard deviations below normal means were observed at: C1(L), C5(L), T4(L), T4(R), Tom), Tom), TS(L), T8(R), TIO(L), TIO(R), T12(L), T12(R), LI(L), I3{-) This is indicative of reduced muscle tension. Readings up to one standard deviation above normal means were observed at: T2(L), M(R), 13(R), L5(L) This is indicative of normal muscle tension. Readings one to two standard deviations above normal means were observed at: Cl(R), T1(L), Sl(L) This is indicative of a mild elevation of muscle tension. Readings two to three standard deviations above normal means were observed at: C7(L), L5(R) This is indicative of a moderate elevation of muscle tension. Readings more than three standard deviations above normal means were observed at: C3(L), C3(R), C5(R), C7(R), T1(R), T2(R), SI(R) This is indicative of a severe elevation of muscle tension. Areas of significant asymmetry were noted at the following sites: Cl(R), C5(R), Tl(K), T2(R), T4(R), L3(R), M(R), S1(R) PEDAL FOUNDATION EXAM As described in the Asymmetries Results above, ammination of the back of Kayla Clayton has indicated a musculoskeletal imbalance. Because such conditions are often the result of an imbalance in the pedal foundation, an examination of this patient's feet is recommended. During the examination of the feet, the patient is asked to stand barefoot. The left and right foot are each examined for pronation, supination and normal arch shape. FOLLOW UP PLAN The results of this examination, taken in concert with the patient history and other clinical findings, were used in determining recommendations for the type, frequency, and duration of chiropractic care. Follow-up examinations will be performed, as needed, to evaluate Kayla Clayton's response to the clinical services provided. Fields "I r /FFA M I LY DENTISTRY, LLC May 22, 2007 State Farm Mutual Automobile Insurance Company ATTN: Elaine M. Haughin, Claim Representative Southpointe Operations Center 555 Southpointe Boulevard, Suite 400 Canonsburg, PA 15317 Re: Claim #38-L102-937 Patient: Kayla Clayton Dear Elaine: S: Y; I am submitting the enclosed narrative report pursuant to your request of March 27, 2007. Kayla presented to my office on October 30, 2006 as an after hours emergency. She stated she was involved in a car accident and had followed instructions to have a dental review of her front teeth. I am enclosing radiographs and intraoral photographs for your records. At that time, it was observed that tooth #8 was fractured into the pulpal tissue and tooth #9 was also fractured with a "blushing" pulp. Both teeth had mobility. Options were presented to Kayla's Guardian involving keeping tooth #8 (treating with root canal therapy) versus extracting this tooth (treating with an implant, fixed partial denture, or removable partial denture). The advantages and disadvantages were reviewed involving each option. Her Guardian chose root canal treatment, crown build-up, and an eventual crown. Kayla's intraoral, extraoral, TMJ, and periodontal exam were within normal limits. It was recorded that teeth #s 6, 7, 9, and 10 had chipped incisal edges and would need bonding completed to protect the teeth from another fracture. Kayla's Guardian stated she wanted root canal therapy initiated to salvage the root and tooth preventing invasive surgery. The tooth was accessed, debrided, irrigated, and sealed. Tooth #s 8 and 9 were then built up with composites involving all surfaces of each tooth. I finally suggested there may be a future need for consultations with an Orthodontist (extrusion) and Periodontist (osseous crown lengthening). On November 27, 2006, Kayla was seen for re-evaluation. Pulp tests were performed on her anterior teeth which included percussion, electronic pulpal, and cold tests. Tooth #9 was extremely sensitive to cold, percussion, and had a high EPT value. The gingival _h-p OR 2101 Aspen Drive • Mechanicsburg, PA 17055 Phone 717-697-3400 • Fax 717-697-7857 www.fieldsfamilydentistry.com tissues appeared healthy in both texture and color. Incisal edge restorations were placed on teeth #s 6, 7, 24, 25, and 26. On December 18, 2006, Kayla was seen again for a re-evaluation. It was found that teeth #s 7, 9, and 10 were sensitive to cold and percussion. EPT numbers were high on these teeth as well. It was suggested there may be a need to perform endodontic treatment on teeth #s 7 and 9. Additionally, incisal edge restorations were placed on teeth #s 22 and 23. On January 29, 2007, Kayla was seen again for re-evaluation. Pulp tests revealed cold sensitivity again for teeth #s 7 and 9. Percussion was positive for tooth #9 but EPT and mobility were within normal limits for both teeth. On April 30, 2007, pulp tests elicited percussion and cold sensitivity for tooth #9. Tooth 47 elicited no percussion sensitivity but did reveal cold sensitivity and a high EPT value. Based on these findings, I have recommended to Kayla and her Guardian that endodontic treatment will eventually be needed for teeth #s 7 and 9. I have started a monitoring period for every 3 to 4 months to verify the diagnosis of irreversible pulpitis. I will continue to follow Kayla under these guidelines, along with her general oral health care, until a time that the family asks for discontinuance. I hope this narrative sheds some light on Kayla's mishap and can foster the proper format for reimbursement. If I can be of further assistance, please do not hesitate to contact me. Sincerely, Charles R. Fields, DDS, MAGI) CRF/tlg Enclosures n. 11. 2 00 1 3: 09 PM FIE LD S FA MIL Y DE NT IST RY , LL C N o. 22 21 ( ?1 I v l` ? 1 i d I t V } 1t ? ? ? ? i ` 1 . ? , H r ,y ? 1 pi "I Ja NL P. 2 m m O 9 r 7 r m m m n. 11. 2 00 7 3:1O PM F IE LD S FA MILY DE NTI ST RY, LLC { N o. 2221 r m 4 tv ? n .••• N * t r t K 1 7 1 i X . • ry n ? W ? r v , ai I T P. 3 A O n a r n r m Ei m m ?h CLAYTON, KAYLA J-Enc #2701084--- OPT-HER-10/30/2006 ED Report - 11 _006 - 1 pg 'ACCT#=00270108451 -__RANSCRIBED DATE=11/02/2006 1u:20 UDN= 1996891 CLAYTON, KAYLA J RM#: }r RE? C,?ENE? MRN: 574-08-4198 FEB ?2 2??7 CASE: 00270168451 DOB: 07/16/1991 ADM: 10/30/2006 CONCO.,DV t1.L clos PinnacleHealth System P.O. Box 8700 Harrisburg, PA 17105-8700 EMERGENCY DEPARTMENT CHIEF COMPLAINT: Status post MVA. HISTORY OF PRESENT ILLNESS: This 15-year-old female presents to the emergency department after being involved in an MVA. She apparently was a passenger in the right rear passenger seat, states she was wearing her seatbelt when the car struck a tree. There was airbag deployment. Patient is complaining of pain in her neck area, also complaining of some injury to her teeth and also nausea. The patient does have a slight headache. No visual changes. No numbness or tingling in arms or legs. No back pain. No abdominal pain. No chest pain. No shortness of breath. REVIEW OF SYSTEMS: Complete review of systems negative except as above. PAST HISTORY: Past medical history is denied. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Patient is a nonsmoker. PHYSICAL EXAMINATION: Vital signs: Temperature is 36.7. Blood pressure 121/61. Pulse 65. Respirations 16. Constitutional: Patient is alert, well developed, appears to be in mild distress. Mental status: Patient is alert, oriented to time, place and person. No recent memory loss. States that when the accident occurred, she might have "lost consciousness for a couple minutes." Patient's affect is appropriate. Eyes: Pupils are equal and reactive. Funduscopic benign. Extraocular muscles intact. ENT: No midfacial trauma other than fractures of her central incisors, #8 and #9. Neck: Paracervical muscle tenderness. No midline cervical tenderness. Respiratory: Clear to auscultation and percussion. Cardiovascular: No murmurs or gallops. Heart sounds normal. GI: No masses or tenderness. No hepatosplenomegaly. Skin: No new rashes or lesions noted. Neuro: DTR's equal and symmetric both upper and lower extremities. Strength good and equal in both upper and lower extremities. Extremities/Musculoskeletal: Joint: Capable of free range of motion without pain or crepitation. No effusion or erythema. Bone: No misalignment, asymmetry, defect, tenderness or effusion. Capable of full range of motion of joint above and below bone. Muscle: No crepitation, defect, tenderness, masses or swellings. No loss of muscle tone or strength. Lymphatic: No cervical adenopathy. EMERGENCY DEPARTMENT PHYSICIAN TEST INTERPRETATION: X-ray of the cervical spine revealed no acute fracture. CT scan of the head was negative. EMERGENCY DEPARTMENT COURSE: No procedures or consults required. DISPOSITION: Patient is discharged on Phenergan 25 mg p.o. q.6-8 H p.r.n. Page 1 of 2 f CLAYTON, KAYLA 3-Enc #27010') ?1-OPT-HER-10/30/2006 ED Report - 2/2006 - 1 pg .(nausea. Head injury ins ructions given. Parents are here, advised that the patient should follow up with the family doctor this week. Have a followup MRI since the CT scan did show possible pineal cyst and recommended that. The patient also referred to the dentist for dental x-rays and follow up on dental fractures. Disposition: Follow with FMD and dentist. DIAGNOSTIC IMPRESSION: #9. PATIENT: Kayla Clayton c: GLEN WHEELER, MD 1. Minor closed head injury. 2. Acute cervical strain. 3. Fracture of central incisor, #8 and 4. Pineal cyst. REVIEWED AND ELECTRONICALLY SIGNED BY: GARY BAGGETT, DO 11/14/2006 02:07 --------------------------- GARY BAGGETT, DO DD: 10/30/2006 1996891 DT: 11/02/2006 /das D#: ER REPORT ER REPORT END OF REPORT ----- REPORT NAME=ER ER REPORT HOSP=POREGION=MB Page 2 of 2 QUANTUM PINNACLE C!AYTON, KAYLA SSN: 574084198 Ordered By. BAGGETT Referred By: Accession: 5499568 DOS: 10-30.200616:36:00 1991-OT-16 MRN: 574084198 Patient ClasstStatus: E GARY Attending EMERGENCY ROOM, ASSOCIATES Dictated By. BRONITSKY, BARBARA G. ADM DX: CodeRyte Note Handle: APS-8888140 REASON: SP MVA PROCEDURE: DIA - 2040 - CERVICAL SPINE 2-3 VIEWS EXAM: Cervical spine, 3 views limited. HISTORY: 50-year-old complains of neck pain following MVA. Results: Despite attempted swimmer's view, only C1 through proximal aspect of C5 are demonstrated in the lateral projection. There is no malalignment or fracture of the visualized vertebrae. The prevertebral soft tissues, odontoid process, and C1-C2 relationship are within normal Emits. IMPRESSION: Negative limited cervical spine series demonstrates no abnormality of C1 through C4. If symptoms persist, consider followup with routine cervical spine series. To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Altematbvely a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful Interpretations. Accordingly, if the clinical team Is in search of answers to specific questions, Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782.3240. please include your questions(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained it this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Codes: Accession CPT ICD 72040 723.1 toc: DIA 1-44-909 ?00l c/OS 38-1-102-937 MR Approved by: Michell Ohlson Dictation Date: t QUANTUM PINNACLE CLAYTON, KAYLA SSN: 574084198 Ordered By: BAGGET[, Referred By. Accession: 5499567 loc: CTS 1991-07-16 MRN: 574084198 Patient Class/Status: E GARY Attending: EMERGENCY ROOM, ASSOCIATES Dictated By. AUSTIN, CHARLES B DOS: 10-30-200610:08:00 ADM DX: CodeRyte Note Handle: APS-8885765 REASON: SP MVA w PROCEDURE: CTS - 0450 - CT BRAIN W/O CONTRAST EXAM: CT brain without contrast HISTORY: Head trauma/motor vehicle accident Results: Imaging was performed from base to vertex without intravenous contrast. There is no evidence of hydrocephalus, or intracranial hemorrhage. There is no evidence of a major arterial distribution infarction At the expected location of the pineal gland, there is a 1.2 cm in diameter low-density focus. This most likely represents a pineal cyst. Eventual nonemergent MRI of the brain without and with contrast is however needed for further evaluation. IMPRESSION: There is no evidence of acute intracranial abnormality. There is a cystic lesion in the region of the pineal gland warranting eventual MR[ for further evaluation. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. To provide the best and safest patient care: During routine daytime weekday, weekend, and holiday on-site coverage, a Radiologist can be contacted at 782-5881 (HH), 657-7199 (CGOH), or 791-2467 (Fredricksen Center). Alternatively a Quantum Radiologist can be reached by phone 24 x 7 x 365 at 932-8030. As Clinicians' consultants, the Quantum Radiologists are genuinely committed to providing meaningful interpretations. Accordingly, if the clinical team is in search of answers to specific questions, please include your questions(s) on the xray request form, and the question(s) will be specifically addressed in the Radiologist's report. Furthermore, if clinical urgency necessitates an immediate verbal report, please insure that the xray request includes a reliable phone number where you can be reached immediately. Study interpretation provided by Quantum Imaging & Therapeutic Associates. If you have received this document by facsimile, the information contained in this transmission Is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution, or copy of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately at: 1-717-782-3240. Codes: Accession CPT ICD 70450 959.01 Pennsylvania EMS Report Date Service Name Unit No PCR No. New Cumbatend Fire Mportatcot A10-21017M 0600336 i0J70?006 radcatName DateorBbrth SNnmber rSAP Kayla ganon 07/1611991 060140191 Gastrointestlnal Abdomen Pain GU ONo Complaint 0 Soft ? F. 0 No Camphtitrt ? Consuot ? lnscmittan Nausea 0 c ? p ? Guwding 13 ? '?1 O Sim a arthea p D S p Bo d sounds Absent 0 0 Doll 0 p Area(s) Effected Drsoetded -No O Yes O Radraictg- No O Yes ? ooontimn ? Rebmlioo O ? LUCp RUQ ? Fob ? 1LQ ? RLQ Teder - No O Yes O Total Output Extremities Reproductive ® No C WWms No Complaints Female Male LA RA U. RL LA RA L]. RL (3VsgWd Sicedin ?DWhwp p Peaft Discuale paralysis ? ? ? ? pain 0000 NvVwa -No O Yes O ? TesticularPala past-;a ? O ? ? Mor ? ? ? ? clew" _ pia - weer - Pulse ? ? ? ? Edema ? ? ? ? ?FeW Movements Feld Hart Tooa _ Narrative Amb 10 dispatched Class for an Auto Accident victim at the request of the Police Dept in the Boro of New Cumberland in the area of the 500 Block of Hillside Rd. Amb 10 with immediate response is advised by CCC that we are at the request of the Police Dept. for an accident victim. Amb 10 AOS to find a single car accident with a 15 ywf stiff in the rear of the vehicle. The vehicle is a Chevy Cavalier that was fleeing the Police that has substantial damage to it all around. The vehicle has moderate damage to the rear passenger, passenger side quarter panel damage to it with rear window smashed on the vehicle, the rear bumper Is ripped off, the rear of the vehicle is pushed in towards the trunk of the car, minimal space between the front seat and the back seat of the vehicle, front bumper damage, and dual airbag deployment. Police Officer Weaver explains that he had been chasing this vehicle over several blocks of New Cumberland when it made this Right turn onto Hillside Road and the driver lost control of the vehicle went off the roadway, struck a tree which made the car's passenger side rear passenger side swing into the tree and swerved and then It stopped and the driver got out and took off. The passenger stated that her neck hurts a little and that her mouth hurts. The pt then crawls over the driver seat which is leaning backwards and crawls out of the 2 door vehicle. The pt tells BLS that she had an argument with her mom last night around 9 pm andtook off and started walking through New Cumberland. The pt then said that this kid she knew stopped and she got in his vehicle and then went with him. She said she awoke this morning and got in his vehicle and was driving through the Boro when all of a sudden the Police wanted them to stop and the driver wouldn't. The pt said she kept on telling him to pull over but he just kept going faster and faster. Pt says she's not sure why she crawled In the back seat but is sun: she was seatbelted at the time of the crash. Pt said she's not even sure when the driver took off or why. Due to the pt's age and injuries and potential injuries, pt is told she has to go to the hospital. w° C? O\ N r•+ r•+ J 0 ?o TX: AOS and received report and care from Officer Weaver who is trying to gather evidence from the scene. The pt is encountered and then the pt crawls out of the vehicle. A quick detail Provider Printed On: 11/05/2006 11:24 EMStet Rcpmd*c)1991-2006, Mod-MWia, Inc. All R1gf its Reserved P e: 22 of 4 Pennsylvania EMS Report Service Name Unit No PCR No. Date New Gumbaland Fin PqMMqI At0 - 2101219 0600336 1IN301M oy Number PSAP Patient Name Date .[Birth Social Sec rtl KM*CIWM 07/16/1991 S74 08 198 060140191 assessment is performed and a c- collar is placed on the pt, Pt is then seated on the litter which already has a LBB on it, as A#1 still holds head stabilization, Head is secured with CIDs and then is secured to the LBB, pt is then fully secured to the LBB using kwik clips and then secured to the p fitter, pt is placed in the back of the ambulance, vitals are taken, en route to Hbg Hospital, which is C the closest facilty, a detail assessment is performed and vitals are retaken and a cold pack is p applied to the forehead swelling, upon arrival at Hbg Hospital, pt states she's starting to get a W headache and is a little drowsy. Pt is transported into the ER and to Examing Rm. # 12 where pt is , CPS transferred to the gumey and care and report is given and transferred to ER staff. PE: CA&O x 415 ywf, dressed in pajamas, stating that her mouth and neck hurts, head is normal and oephalic but with a small swelling to the right side of her head above the temporal region, - headache initially on scene but upon arrival at the hospital pt states she was getting one, - blurred or double vision, PERRL, skin is warm pink and dry, - fluids from the eyes ears or mouth, front top teeth are busted in half and broken off, - bleeding noted, - Jvd, trachea is midline, - shortness of breath, - chest pain, chest is symmetrical and = in rise and fall, abd is soft and non tender, - nausea and/ or vomitting, pelvis is stable, upper and lower extremities are atraumatic and = in grips, strengths and movements, - tingling nor numbing sensation anywhere stated by the pt, back is atraumatic and pt states she does have neck pain which she states Isn't really pain, it just hurts, + drowsiness stated by the pt also upon arrival at the hospital which pt wasn't initially. Time P R B3,•.. SG ET -CO2 Rhythm- T.eabord -I JUXPONI .0 0833 80 I 1002 98 4/516 Initial VS 08:42 72 16 102164 J // ON Vt N J 0 A?4,04? Printed On: 11/05/200611:24 'der f 4 EMStat Rcpating(c)1998-2006, Med-Me?a, Inc. All Rights Reserved Page 3 01' Pennsylvania EMS Report I I semce Naae UWI No Date New Cumbalu d gin AIO - 2101210 0600336 10002006 Padeat Name Date a<Dlrtb Sodal Seca ft Number PSAP Kayla Clayton 0711611991 574-08-0193 060140191 Anterior Printed On: 11/05/2006 11:24 EMStat Repmd*c)1998-2006. Med-MccHa, Iw- AU Ruts Reawnd Pain Posterior Provider Page: 4 of 4 O O? O O W W O? Qt N r.r J O ?O Pennsylvania EMS Report Service Name Neer Cumberland Fire Station Unit Name & No. AIO - 2101210 PCR No. 0600336 Date 10/30!2006 Incident Location Munieipauty & Incidwt Tip New Cumberland Bar% 17070 MAP held. No. 060140191 500 Block of Hillside PA IPA ItteehingAgency HarisbnugHnalp Patient Name Crew We Clayton C #1 Fifhnae, Karen E 087570 w Street Address 606 4th Street N2 Thomas Ryon E 118425 C ' C w Chy state Zip New Cumbairad PA 17070 C #4 C' See Ate D08 Phone No. Ti Female 15 Years 0766/1991 (717) 774.7264 coes 19 a Patient Nunber social See, Na 574-084198 Pt. Weight 911 Dispatch 08:09 r 08:14 Private Physician Driver's Liaemc Ar Arrivve e Scene 08:16 Dr. Whoeler contact 08:17 Transporting Assist Volts Assbt OS out OoSeene Dcst In 25277 25277 25281 25284 Depart Seen 08:36 Arrive 08:44 09:11 Av ilabl Response Outcome Medici Command P6ysiciao MC 71me a e In Quarters 09:15 Transported Me r A Chief Complaint: "my neck and mouth hurts " Current Mods: now stated Allergies (coeds): NKDA PMHx Nape Stated Level of Consciousness Speech Neurological Shia, Temperature & Color 0 Conscious 0 Oriented x 4 0 Coherent ? No Complaint 0 Dry 0 Pink o Mottled 0 Alert ? Uncooperative ? Incoherent O Headache ? Numbness o Moist ? Pale ? Cyanotic ? Led-gin [] Combative ? S'deat O SntfNedr O Weakness O Diapbastic 0 RwW ? Yellow O Confined ? Altered D crying 0 Nedr Pala ? Dray O Ashen ? Other ? Uacosse - ? Hy=iw O Sh..d ? Dyspha& D Gait - U-1r.4 ? infant ? Aphasia Facial Droop- L O R O Hot O Warm O Cool O Cold O Respiratory Breath Sounds Cardiovascular Pupils HEENT ? No Complaint. L R Chest Palo 0 PERL Eyes 0 No CaapLmt 0 Airway Patent Present ®0 .0 No Comply L R Size Burred Vision - L ?R? 0 srsimoui-W Absent ?? o sevaft pispoint Double Vision -LORD ? Labored Clear ? ? ? Constant ? Intermittent ilated o0 D PhotophobEa - L ORo ? Retractions ? Stridor Dmnmished 00 Whocz s O ? O Sharp ? Ba o erg Food pp Ear! ®Naeor nlsirr ? Nasal Flaring Crackles ? ? Pictnitic ? Han O t ? Heavy ? R Sluggish 00 Paton, LORD Cough Rhonchi ? ? Nw-Rosetive ?? L R » scharge - 0 0 e No Complaint Asymmetric 00 O Capillary, Refill - Knowo Aoomsly Blood - LORD Productive-No O Yes O _ Now 0 NoComplalm Nand Cm stion ? p "throat 0 No Con rosird 0 Nwal Drainage ? Sore '!brook ? Dyspineglee Deviation - L O R O Epistaxis - Lo R o 0 Drooling 0 SwetlisgUc= ? JVD O Deformity Printed On: 11/0520061124 EMStat Reporting(c)1999-2006. Mod-Media, Inc. All Rigbu Reserved O w ON to N IN A J O ??^'LKet?s6 Provider Page: 1 of 4 RELEASE For the Sole Consideration of TWENTY-NINE THOUSAND DOLLARS and oo/loo ($29,000.00), the receipt and sufficiency whereof is hereby acknowledged, the undersigned hereby releases and forever discharges State Farm Mutual Automobile Insurance Company, its heirs, executors, administrators, agents and assigns and all other persons, firms or corporations liable or, who might be claimed to be liable, none of whom admit any liability to the undersigned but all expressly deny any liability, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, and particularly on account of all injuries, known and unknown, both to person and property, which have resulted or may in the future develop from an accident id-ach occurred or. or about the 30th day of October, 2oo6. This release expressly reserves all rights of the parties released to pursue their legal remedies, if any, against the undersigned, their heirs, executors, agents and assigns. Undersigned hereby declares that the terms of this settlement have been completely read and are fully understood and voluntarily accepted for the purpose of malting a full and final compromise adjustment and settlement of any and all claims, disputed or otherwise, on account of the injuries and damages above mentioned, and for the express purpose of precluding forever any further or additional claims arising out of the aforesaid accident. Undersigned hereby accepts draft or drafts as final payment of the consideration set forth above. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or a statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. In Witness Whereof, n i have hereunto set A? hand(s) and seal(s) this L day of 4?-' , 200,v Zoe, In presence of: Acs . Witness eborah Clayton Parent and Natural Guardian of Kayla Clayton Date: 15?? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.. AFFIDAVIT I, Kimberly L. Gallucci, Esquire, am a licensed attorney in the Commonwealth of Pennsylvania. I am, for purposes of the above-captioned Petition, acting solely on behalf of Minor-Petitioner, Kayla Clayton. I have thoroughly reviewed the medical records available in this matter, along with the Settlement and Release documents executed by State Farm Mutual Automobile Insurance Company and the Minor-Petitioner's parent and the Verifications executed by the parent of the minor. Relying on my review of these records and documents, along with my experience as an attorney, and given the nature of the injuries sustained by the Minor-Petitioner, it is my opinion that the sum of $29,000 is a fair and equitable settlement and is in the best interest of the minor, Kayla Clayton. oate W -09- 15704 VERIFICATION I, Deborah Clayton, do hereby certify that I am the parent and natural guardian of the minor-Petitioner, Kayla Clayton, who is presently 16 years old. I have reviewed and discussed the proposed Settlement and Distribution set forth in the foregoing Petition and proposed Order. The averments of the Petition are true and correct to the best of my knowledge, information and belief. I believe that the proposed Settlement is in the best interest of my minor daughter, Kayla Clayton. I recommend that the Court approve the Settlement and Order of Distribution. I understand this Verification is made pursuant to provisions of 18 Pa. C.S.A. Section 4904 relating to unsworn falsification to authorities. Dated: Deborah Clayton, Parent and Natural Guardian of Kayla Clayton 15704 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.: o8-1322 Civil Term PROOF OF DEPOSIT OF PROCEEDS OF MINOR'S SETTLEMENT (Jury Trial Demanded) Filed on Behalf of the Petitioner, State Farm Mutual Automobile Insurance Company Counsel of Record for This Parry: Kimberly L. Gallucci, Esquire Pa. I.D. 92911 SUMMERS, MCDONNELL, HUDOCK, GUTHRIE & SKEEL, LLP Firm No. 911 707 Grant Street Suite 2400, Gulf Tower Pittsburgh, PA 15219 (412) 261-3232 15704 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KAYLA CLAYTON, a minor. CIVIL COURT DIVISION No.: o8-1322 Civil Term PROOF OF DEPOSIT I, Kimberly Gallucci, Esquire, counsel for State Farm Mutual Automobile Insurance Company, the Petitioner in the above-captioned matter, hereby certify that the settlement proceeds were deposited at Wachovia Bank, Harrisburg Capitol Finance Center, Harrisburg, Pennsylvania 17101, on April 28, 20o8. The proceeds were deposited in an certificate of deposit, which is federally insured. The account was opened in the name of Kayla Clayton, "not to be redeemed except for renewal in its entirety, nor to be withdrawn, signed, negotiated or otherwise alienated before minor, Kayla Clayton, reaches the age of eighteen." Attached hereto and labeled as Exhibit "A" is a true and correct copy of the account verification documentation. 15704 Respectfully submitted, SUMMERS, MCDONNELL, HUDOCK GUTHRIE & SKEEL, LLP May-08-08 10:30am From-WACHOVIA +7172342731 TDAHD A340226 BPZF0076 Time Deposit Hold Org: 075 Serv: CDA Acct: 247402113372184 State: PA Account Information T-754 P 03/03 F-157 BC741075 04/28/08 10:12 Short Name: CLAYTON KAYLA J Product Description: CUSTOM CD Product Type: 211 Available Balance: 29000.00 ----------------------------- Hold Information -------------------------------- Origin : PA Sequence Number: 01 Source : A340226 Hold Amount 99999.00 Effective Date 04282008 Expiration Date: 01012049 Description : NO W/D PER COURT ORDER UNTIL CHILD IS 18 Hold Type: Consumer Loan Commercial Loan Other Loan X Miscellaneous RTC Hold N HOLD COMPLETED Command: F1=14elp F2=Erase F3=Exit F'5=Refresh F10=Term May-08-08 10:30am From-WACHOVIA +7172342731 T-754 P 02/03 F-157 AMS3 A340226 BPZF0076 Acct Maint - Comments CZ663001 04/28/0 Customer: Cust Tax Id: 10:1 Org: 075 Serv; CDA Acct: 247402113372184 State: PA Merger: Name: Address: Bank: 024 Status: OPEN KAYLA J CLAYTON 606 4TH ST NO W/D PER COURT ORDER UNTIL CHILDIS 18 NEW CUMBERLAND PA 17070 Sel Comments: Comm Typ: IN Br: 85396 Eff: 04252008 NOT TO BE REDEEMED EXCEPT FOR RENEWAL II Src: A260718 Exp: 10252008 ITS ENTIRETY IN ORDER TO BE WITHDRAWN Comm Typ: IN Br: 85396 Eff: 04252008 SIGNED NEGOTIATED OR OTHERWISE ALEINATEI Src: A260718 Exp: 10252008 BEFORE MINOR KAYLA CLAYTON REACHES THE Comm Typ; IN Br: 85396 Eff: 04252008 AGE OF MAJORITY Src: A260718 Exp: 10252008 Comm Typ: Br: Eff: Src: Exp: Comm Typ: Br: Eff: Src: Exp: CHANGE COMPLETED - NAME/ADR/TAXID CHG MAY APPLY TO CDC Command: AMS4 PF1=Hlp 3=Exit 4=Next 5=Refresh 7=Bkwd 8=Fwd CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing has been served via first-class U.S. mail, postage prepaid, this 9th day of May, 20o8, upon the following: Deborah Clayton P.O. Box 593 New Cumberland, PA 17070 (Mother of Minor-Petitioner) SUMMERS, MCDONNELL, HUDOCK GurHRIE & SKEEL, LLP mberly Gall - Esquire ounsel for Petitioner 15704 (7 ~q .Z -XI N r, j