HomeMy WebLinkAbout01-6497HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
SUZANNE VALLERY, a minor,
11 Starboard Drive
Taneytown, MD 21787
Plaintiffs
ROBERT PUCKETT and
NEIL MANUFACTURING CO., INC.,
Carrolton Villa Highway
Villa Rica, Georgia 30180,
Defendants
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO.: Ol - t. qq7 Civil Term
CIVIL ACTION LAW
PRAECIPE FOR WRIT OF SUMMONS
TO THE PROTHONOTARY:
Please issue a Writ of Summons to Defendants, Robert Pucker and Neil Manufacturing
Co., Inc. in the above-captioned matter.
Dated:
BY:
T~[AS~, THOM, tA~/~AFER, LLP
Mich~le J. tho~uire t
305 N. Front S~eet, PO Box 999
H~isb~g, PA 17108
IDNo. 71117
(717) 237-7153
WRIT OF SUMMONS
To: Robert Puckett and Neil Manufacturing Co., Inc, Defendants
You are notified that the above-named Plaintiffs have commenced ~on against you.
Prothonotary
- ' Deputy
HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
SUZANNE VALLERY, a minor,
Plaintiffs
ROBERT PUCKETT and
NEAL MANUFACTURING CO., INC.,
Defendants
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO.: 01-6497 Civil Term
CIVIL ACTION LAW
PETITION TO APPROVE MINOR'S COMPROMISE SETTLEMENT
AND NOW, comes Plaintiffs Harry Vallery and Roseaune Vallery, as parents and natural
guardians of Suzanne Vallery ("Plaintiffs"), and their counsel, Thomas, Thomas & Hafer, LLP,
and file this Petition to Approve Minor's Compromise Settlement and aver the following in
support thereof:
Plaintiffs are the parents and natural guardians of minor Suzanne Vallery
("Minor").
2.
3.
Plaintiffs and the Minor reside at 11 Starboard Drive, Taneytown, MD 21787.
Minor was bom on July 20, 1985, and was fourteen (14) years old on the date of
the accident described hereinafter.
4. Defendant Neal Manufacturing Company, Inc., is a corporation with a principal
place of business at Carrolton Villa Highway, Villa Rica, Georgia 30180.
5. Defendant Robert Puckett was an employee of Defendant Neal Manufacturing
Company, Inc. at all times relevant hereto.
6 This Petition is filed as a result of an accident which occurred on or about July 22,
1999, on Market Street in Camp Hill, Cumberland County, Pennsylvania.
7 At the time of the accident, Defendant Puckett was driving a 1999 Oldsmobile
and headed west bound on Market Street.
8. At the time of the accident, the Minor was a passenger in a vehicle traveling west
bound on Market Street in Camp Hill in front of the Defendant's vehicle.
Defendant's vehicle struck the rear of the vehicle in which the Minor was a
passenger.
10.
As a result of the accident, the Minor sustained injuries, including, but not limited
to, neck and back injury.
11. Minor has treated with a number of healthcare providers as a result of her injuries.
A copy of Minor's family physician records, Carroll Co. General Hospital records and
orthopedic consultation records are attached hereto, incorporated herein by reference and marked
as Exhibits "A", "B", and "C" respectively.
12. At the time of the accident, Defendants were insured by a business automobile
policy issued by Commercial Union Insurance Company, now known as Peerless Insurance.
Said policy was Commercial Union policy number MZAM670383807.
13. Plaintiffs have been and continue to be represented by Michael Kaplan, Esq. of
Kaplan & Kaplan, Attorneys at Law, 200 E. Lexington St., Suite 400 Court Square Building,
Baltimore, Maryland 21201.
14. A copy of Plaintiffs' fee agreement with Attorney Kaplan is attached hereto,
incorporated herein by reference and marked as Exhibit "D".
15. While represented by the aforesaid counsel, Plaintiffs engaged in settlement
discussions with Defendants' insurance carrier.
2
16. On behalf of Defendants, Peerless Insurance has offered to compromise this claim
for the sum of six thousand dollars ($6,000.00).
Plaintiffs believe that this offer is fair and in the best interest of Minor.
Therefore, Plaintiffs request that this Honorable Court approve the proposed
17.
18.
settlement.
19.
Plaintiffs understand that any settlement monies left over after attorney's fees are
taken out will be placed in a restricted federally insured account for the benefit of the Minor and
that no withdrawals will be permitted from the account until Minor reaches the age of majority,
unless authorized by Court Order.
20. Plaintiffs understand that proof of deposit of the settlement proceeds will be filed
promptly of record.
21. Additionally, Defendants request that Plaintiffs be authorized and directed to
execute a full and final general release in the form that is attached hereto, incorporated herein by
reference and marked as Exhibit "E"
22. Defendants also request Plaintiffs be authorized and directed to file a
discontinuance of record with the Prothonotary of the Court of Common Pleas of Cumberland
County upon the filing of proof of deposit of the settlement funds.
3
WHEREFORE, Plaintiffs HarD, Vallery and Rosearme Vallery as p~rents and natural guardim~s
of Suzanne Vallery, pray this Honorable Court enler an order compromising this action;
approving the proposed settlement; authorizing and directing Plaintiffs to execute a full and final
release; and authorizing and directing Plaintiffs to file a discon~re¢ord.
By: arry~V ~
H cry
4
VERIFICATION
I, Harry Vallery, Parent and Natural Guardian of Suzanne Vallepy, hereby state that
the statements made in the foregoing Petition to Approve Compromise Settlement are tme and
correct to the best of my knowledge, information and belief. The undersigned understands that the
statements therein are made subject to the penalties of 18 Pa.C.S. §4904 relating to unswom
falsification to authorities.
Date: 12-11-01
H~*~r~(~,~arent and
natural guardian of Suzarme Vallery
VERIFICATION
I, Roseanne Vallery, Parent and Natural Guardian of Roseanne Vallery, hereby
state that the statements made in the foregoing Petition to Approve Compromise Settlement are
tr~e and correct to the best of my knowledge, information and belief. The undersigned understands
that the statements therein are made subject to the penalties of 18 Pa.C.S. §4904 relating to
unswom falsification to authorities.
Date: 1.2'"11-01
Roseanne Vallety, as par
natural guardian of Suzanne Vallery
SUZANNE VALLERY 7.22.99
~4 YO gld who was in a MVA yesterday, She was itl the
back seat of a car, un~eatbelted. The qar was rear.
ended. She complains of neck and upper back soreness.
Some discomfort in her lower back, Slight headache, no
dizziness. No abdominal pain. Examination shows
· PERRLA. EOm' s full. TM's NMT: clear. NECK; no
ad~nopathy. LUNGS; clear. Tender trapezius musc es
bilaterally. NECK; no'adenopathyl Pull range of motion.
No torticolus. Has some mild tenderness around the
scalpula areas an~t in the lumbar areas ,.Able to bend.
Over.
DX: I beleive this is just muscle spasm from MVA.
Tylenol and Mob'in. Ice today, h~at tomorrow. I~tn pm
Recordex Services, Inc. has been retaine, d by the Medical Record Department of
CARROLL COUNTY GENERAL HOSPITAL
to fulfill requests for copies of medical records. We wish to emphasize that the
increasing demands for patient data pose a rising threat to the confidentiality of the
patient's medical information. Recordex Services strives to take every opportunity
to safeguard patients' right to privacy as outlined in the AHA's Patient Bill of Rights.
Specifically, all patients have the right "to expect that all communications and
records pertaining to their care will be treated as confidential by the hospital and any
other party entitled to review certain information in such records." As one such party,
we ask that all information transmitted herewith be treated with utmost respect and
the dignity such personal medical information warrants.
. Enclosed are.the reproduced medical documents specifically authorized by the
patient or his/her legal representative. Each medical record was carefully reviewed
to assure proper disclosure to you, the requestor. Any re-disclosure without the
express written consent of the person to whom the information pertains is prohibited.
Please be advised that the use of the information for other than the stated purpose
is prohibited, Based upon guidelines provided by the American Health Information
Management Association, the information should also be destroyed after the stated
need has been fulfilled.
If you have any questions, please do not hesitate to contact us at 1-800-525-2922
and one of our Customer Service Representatives will be happy to assist you.
Thank you for your cooperation in maintaining the patient's right to privacy.
17 Lee Boulevard · Suite D · Malvern, PA I !5-2922 * F~.x (610) 640-3844 · w-,~v, fyii.com
· ~,'~ !~ General Hospital
: 200 Memorial Avenue, WezOnimt~r, Maryland 21157
: EMERGENCY DEPARTMENT PATIENT CARE
9924303408~UNiT# 18~9~-78
· VALLERY,SUZANNE*UNDA
'o
1. C~N$'I'ITUT]ONAL;
BP RR T~ reviewed
. [] Mild [] Moderate [] Severe Soft non-[endsr
[] Chronically iii [] Eldedy and Frail [] Cachefic [] No Orgaflomagaly
jf--'l Ale.rt [] POorJy responsivs~Comatose Heine Nag Stool
2. EYES
PERRL · ScleraJ Ictarus
· Conjunctivae Pare
3, ENT
4~.~N Ex'ternal Inspection · Teeth: Edentutous / Poor repair
TM~ cJear · AuraJ acuity decreased (whispered
Pharynx I/1 / ~01_- '.".
ECK ~. '~,.-d2_./2J-~ '- ·
'~ Inspection · JVD
E~ Thrymid
5. RESPIRATORY
~ Breath sounds clear
· Wheezing / Rales / Rhonchi
· Tach~prma
$. CARDIOVASCULAR
~ Regutarrate, rhythm
Heart ,Sounds
Carotid Artedas
Femoral Armrias
· Tachycarola/B~dycaAfia .~
· GaAop (S3/S4}ff, lunnur Dr_/6 syst0Dc/dlast~
-[ PuJse~Bruits:
· Carotid L/R
· FarnOl-dl L / R
· Tendameas / Rebound / Guarding
· Heptctmegafy/SplenomegaJy/Mass
· Heme~ Pos Stool,~ele_na/Gmas Blood
· Abno/rnal bowel $oundar
indmase I decrease I absent
8. PELVIC
[] Ce~x .
[] Uterus
[] Adnexa
SKIN
Warm, D~J, No Rash
s
Motor FunctJo .n
Cerebellar Func'Uon
Gait
1. PSYCHIATRIC
~dme, place, person) · ,
· Depression / aJ-~Jety / agitation
Memory · Memc~ry (recent/remote)
, LYMPHA'JlC
.Neck w/el 8fg,Adenopathy · .
~/0 ~lg Acle~Opathy
.. MU$CUL~eI<~LETA~
· ,E~m' w/Full ROM w/o POln. · Co--res ! c:mplt~on
· Dlsloda~n / Subluxatton ! t,asity
No L~wer Ext. Edema,~/-'~ Pedal:Lower E~ f Plus)
[]
DATA REVIEWED:
· OLD RECORDS: DATE:__/~/ , FINDINGS:
· MONITOR · PULSE OX: %.
.ECG
· AMBULANCE RECORDS ·
T]IIE
[]CVP ~--I DEFIBRiLATE []EXTERNAL. PACER I-IN [~ABG r-] L~CER~T~ON REPAIR
a.)
44
CA~J~iiOLr COUN'r~ GENERAL HOSPITAL
EMERGENCY DEPARTMENT
PHYSICIAN,S ORDERS
DA'rE/TIME
7 I IT1ME INITIALS
TIME MEDICATIONS and SUBSEQUENT ORDERS ~rr~ · cou~,~--r~
x I~0~
/
· ' ' Wed Se~ 01, 1999 03:08' Dm
Outoatient Summary Report -:'
~-~:.~ ame: YALLER¥,SUZANNE LINDA
q~:'Rec #: 189a?B Page: 1
.oc: EMR 08/31/99
~hys-Service: PETROPOULOS,PETER - MEDICAL
~cct #: A9924303408 PCP: FERRA~PETER j ~.~.
*******************************************************************************
~n: 08/31/99 18~8 .
................................. Spec: Blood
)ut: 08/31/~9 1904 ~ COMPREHENSIVE METABOLIC P~NEL I Tech$: VER T587
;oll Time: 08/~1/99 1845-~ ................ ~
)rder Phys: PETROPOULOS.PETER
~esuLt Name
*STAT*STAT*STAT,
Result
~odiumCmEq/L): 139.
>otassium(mEq/L): 4.0
:hk°ri de(mEm/L): :~. .105.
; lucos e(mg/dL):
139. H
~UN(mq/dL): 10. L
: ~eati ni ne(mq/dL}: .6
~otal Prote~n(gm/dL): 7.1
[lbumi n(gmYdL): 3.9
:alcium(mQ/dL): 9.4
~ilfrub~n, Total(mg/dL): 1.0
~ST(UJL)': 19.
~Lk Phos(U/L): 107.
-'~?bon Oioxide(mEo/L): 20. L
[Aqq24303405/13300533
135-145
3.6~'5.0
101-111
65-110
17.0-44.0
· 0.5'1.4
6.3-8.6
3.?-5.6 -
9.2'10.6
0.2-1.3
10-30
70-230
22-31
' ' soec: ~[Ood
)ut: 08/31/99 1852 t CPC W DIFFERENTIAL'.I-
:oll T~me: 08/31/99 1845 ......................
)rder Phys: PETROPOULOS.PETER ' '"
*STAT*STAT,STAT.
!esult Name Result
iBC (10Eg/L): 10.5
IBC (10E1 2IL): 4· 16
: emo~lot~i ri(gm/al): 13.0
[erupt ocrt t(%): 37.6
~CV(fL): 90.3
ICH(DQ):
ICHC(gm/dL): 31.2 .: ~'
34.6 ' ':
DW(~): 11.1 L :
l ate Let s (IOEg/L): 2?2 ~ '
PV(fL): 6.1 L
YmDhocyte %(%): 15.3 L
ononuclear Cells(%): 4.1
ranulocytes Z(%): 77.5 H
osinoohi ls ~(~): 2.5
"Techs: VER T13g
£A9924303408/13~0053]
Reference Range
4.1-10.~
3.89-5.03
11.6-14o9
33.0-43.9
81.6-98.3
25.0-33.0
33· 1-35.5
11.9-15.5
150-440
?.4-10·9
20-47
3.3-9.0
46-74
r. PETROPOULOS,PETE~
210 CORPORATE BLVD SUITE
OCKVZLLE, MD 20~504697
(Continued on next
210
oage)
VALLERY,SUZANNE LINDA
189878/A9924303~08
EMR 08/31/99
3hys-ServJ ce:
~cct ~:
C CUNT GENERAL H.{~SP -~-
Wed 8eo 01, 1999 03.:08 pm
Outpatient Summary Report
VALLERY, SUZANNE LINDA
189878 Page: 2
EMR 08/31/99 ~ i!.~!
PETROPOULOS,PETER - MEDICAL '"'=;~'
A9924303408 PCP: FERRA/PETER J
In: 08/31/99 1848 -..= .................. **** :;~
Spec: Brood
)ut: 08/31/99 1852 I CBC W DZFFERENT/AL I Techs: VER T139
:oll Time: 08/31/99 1845 ............... ~ ......
3rder F~s: PETROPOULOS,PETER ~Agg24303A08/1330053]
*STAT*STAT*STAT*
~esu~t Name Result Reference Range
(Continued from Previous maQe)
~asoDhils %(%): :~ .0.6 *'
-¥mp~/Aasolute(lOE9/L): 1.6 1.0-4.0
~ono, Abso~ute(lOEg/L): 0.4 <1.~1
~ran,Absolute(lOE9/L): 8.1 H 1.5-7.5
~os-A~soLute(IOEg/L): 0.3 0~0.60 ..
~aso-A~solute(lO£9/L): ' 0.1 0-0.20 ....
,. ~. ' -, , . -. Spec': ~Lood
)ut: 08/31/99 1912 J NCG-QUALZTATIVE,SERUM [ Techs: VER T586
:o,I..l Time: 08/31/99 1845 ~ ....................... '
)~-. ~ Phys:
.... PETROPOULOS,PETER [A9924~03408/1330053]
*STAT*STAT*STAT,
tesult Name ResuEt Reference Range
tCG-QuaL,Se~um(mIU/ml): Negative Negative a 25 m~U/m{
End of t~eoort - 09/01/99 15:09
r. PETROPOULOS,PETER
210 CORPORATE 8LVD SUITE
OCKVILLE, MD 2085~4697
ZlO
VALLERY,SUZANNE LZNDA
189878/A9924303408
EMR 08/~1/99
(F'07/20/85)
HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
SUZANNE VALLERY, a minor,
Plaintiffs
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO.: 01-6497 Civil Term
CIVIL ACTION LAW
ROBERT PUCKETT and :
NEAL MANUFACTURING CO., INC., :
Defendants :
PETITION TO APPROVE MINOR'S COMPROMISE SETTLEMENT
AND NOW, comes Plaintiffs Harry Vallery and Roseanne Vallery, as parents and natural
guardians of Suzanne Vallery ("Plaintiffs"), and their counsel, Thomas, Thomas & Haler, LLP,
and file this Petition to Approve Minor's Compromise Settlement and aver the following in
support thereof:
1. Plaintiffs are the parents and natural guardians of minor Suzanne Vallery
("Minor").
2.
3.
Plaintiffs and the Minor reside at 11 Starboard Drive, Taneytown, MD 21787.
Minor was bom on July 20, 1985, and was fourteen (14) years old on the date of
the accident described hereinafter.
4. Defendant Neal Manufacturing Company, Inc., is a corporation with a principal
place of business at Carrolton Villa Highway, Villa Rica, Georgia 30180.
5. Defendant Robert Puckett was an employee of Defendant Neal Manufacturing
Company, Inc. at all times relevant hereto·
6 This Petition is filed as a result of an accident which occurred on or about July 22,
1999, on Market Street in Camp Hill, Cumberland County, Pennsylvania.
7 At the time of the accident, Defendant Puckett was driving a 1999 Oldsmobile
and headed west bound on Market Street.
8. At the time of the accident, the Minor was a passenger in a vehicle traveling west
bound on Market Street in Camp Hill in from of the Defendant's vehicle.
Defendant's vehicle struck the rear of the vehicle in which the Minor was a
passenger.
10.
As a result of the accident, the Minor sustained injuries, including, but not limited
to, neck and back injury.
11. Minor has treated with a number of healthcare providers as a result of her injuries.
A copy of Minor's family physician records, Carroll Co. General Hospital records and
orthopedic consultation records are attached hereto, incorporated herein by reference and marked
as Exhibits "A", "B", and "C" respectively.
12. At the time of the accident, Defendants were insured by a business automobile
policy issued by Commercial Union Insurance Company, now known as Peerless Insurance.
Said policy was Commercial Union policy number MZAM670383807.
13. Plaintiffs have been and continue to be represented by Michael Kaplan, Esq. of
Kaplan & Kaplan, Attorneys at Law, 200 E. Lexington St., Suite 400 Court Square Building,
Baltimore, Maryland 21201.
14. A copy of Plaintiffs' fee agreement with Attorney Kaplan is attached hereto,
incorporated herein by reference and marked as Exhibit "D".
15. While represented by the aforesaid counsel, Plaintiffs engaged in settlement
discussions with Defendants' insurance carrier.
16. On behalf of Defendants, Peerless Insurance has offered to compromise this claim
for the sum of six thousand dollars ($6,000.00).
Plaintiffs believe that this offer is fair and in the best interest of Minor.
Therefore, Plaintiffs request that this Honorable Court approve the proposed
17.
18.
settlement.
19.
Plaintiffs understand that any settlement monies left over after attorney's fees are
taken out will be placed in a restricted federally insured account for the benefit of the Minor and
that no withdrawals will be permitted from the account until Minor reaches the age of majority,
unless authorized by Court Order.
20. Plaintiffs understand that proof of deposit of the settlement proceeds will be filed
promptly of record.
21. Additionally, Defendants request that Plaintiffs be authorized and directed to
execute a full and final general release in the form that is attached hereto, incorporated herein by
reference and marked as Exhibit "E"
22. Defendants also request Plaintiffs be authorized and directed to file a
discontinuance of record with the Prothonotary of the Court of Common Pleas of Cumberland
County upon the filing of proof of deposit of the settlement funds.
3
WHEREFORE, Plaintiffs Hamt Vallery and Roseanne Vallery, as parents and natural guardians
of Suzanne Vallery, pray this Honorable Court enter an order compromising this action;
approving the proposed settlement; authorizing and directing Plaintiffs to execute a full and final
release; and authorizing and directing Plaintiffs to file a discontinuance of record.
Harry V~llery
R~anne Vallery
4
VERIFICATION
I, Harry Vallery, Parent and Natural Guardian of Suzarme Valle~y, hereby state that
the statements made in the foregoing Petition to Approve Compromise Settlement are tree and
correct to the best of my knowledge, information and belief. The undersigned understands that the
statements therein are made subject to the penalties of 18 Pa.C.S. {}4904 relating to unswom
falsification to authorities.
Date:
H~all/e~,~arent and
natural guardian of Suzanne Vallery
VERIFICATION
I, Roseanne Vallery, Parent and Natural Guardian of Rosearme Vallery, hereby
state that the statements made in the foregoing Petition to Approve Compromise Settlement are
trlae and correct to the best of my knowledge, information and belief. The undersigned understands
that the statements therein are made subject to the penalties of 18 Pa.C.S. {}4904 relating to
unswom falsification to authorities.
Date:
SUZANNE VALLERY 7.22.99
t4 YO girl who was in a MVA yesterday. She was in ~e
back seat of a car, un;:eatbelted. The car was rear-
ended. She complains of neck and upl~er back soreness.
Some discomfort in her lower back, Slight headache, no
dizziness. No abdominal pain. Examination shows
,PERRLA. EOm' s full. TM's NMT: clear. NECK; no
ade~nopathy. LUNGS; clear. Tender trapezius muscles
bilaterally. NECK; no'adenopathyl Full range of motion.
No torticolus. Has some mild tenderness around the
scalpula areas an,cl in the lumbar areas ,.Able to bend
DX: I beleive this is just muscle spasm from MVA.
Tylenol and Motrin. Ice today, heat tomorrow.. ,R~..,tn pm
._~._. MD · ~"..
Recordex Services, Inc. has been retain, e.d by the Medical Record Department of
CARROLL COUNTY GENERAL HOSPITAL
to fulfill requests for copies of medical records. We wish to emphasize that the
increasing demands for patient data pose a rising threat to the confidentiality of the
patient's medical information. Recordex Services strives to take every opportunity
to safeguard patients' right to privacy as outlined in the AHA's Patient Bill of Rights.
Specifically, all patients have the right '1o expect that all communications and
records pedaining to their care will be treated as confidential by the hospital and any
other party entitled to review certain information in such records." As one such party,
we ask that all information transmitted herewith be treated with utmost respect and
the dignity such personal medical information warrants.
-Enclosed are.the reproduced medical documents specifically authorized by the
patient or his/her legal representative. Each medical record was carefully reviewed
to assure proper disclosure to you, the requestor. Any re-disclosure without the
express written consent of the person to whom the information pertains is prohibited.
Please be advised that the use of the information for other than the stated purpose
is prohibited. Based upon guidelines provided by the American Health Information
Management Association, the information should also be destroyed after the stated
need has been fulfilled.
If you have any questions, please do not hesitate to contact us at 1-800-525-2922
and one of our Customer Service Representatives will be happy to assist you.
Thank you for your cooperation in maintaining the patient's right to privacy.
17 Lee Boulevard · Suite D · Malvern, PA
2 · Fax (610) 640-3844 · www. fyii.com
'o
~c~rroll ~unty
, '(, ': ~General Hospital
S~erior eor,~atma~ F.~Oonal ~
200 Memorial Avenue, We~tmimt~r, Maryland 21157
I=MERGENCY D£PARTMI=NT PATIPNT CARl::
9924303408;UN1~'//..1~8~98-78
VALLERY~SUZANNE'UNDA
GENERAL:
CARDIO-RESP:
OTHER:
-I-
EX, · SMOKES
ALCOHOI' d'"~i~::~R OCCASSIONAL · ABUSES
I.I~,ING ARRANGEMENT:. ~
· ALONE · ASSISTED ~ · HOMELESS
1. CO. Nb'i i ~ U¥1ONAL:
BP RR T~ reviewed
[] Mild [] Moderate [] Severe
Appears: [] ChronicaJly iii [] EIderty and Frail [] Cachefic
?--~Alert [] Poorly responsive~Comatose
EYES
PERRL
· ScleraJ }cterus
· ConjuncUvae Pale
3, ENT
~ Extemal inspection · Teeth: Edentulous / Poor repair
TM's cJasy · AumJ acuity decreased (whispered ~/oi~:a)
~--. Pharynx I/) / ~L-'
4. NeCK ~.-/~y_,U,._ ':
Inspection · JVD
Thryroid
5. RESPIRATORY
~ Breath sounds clear
· Wheezing / Rajas / Rhonchl
-~c~pn~
Soft non-lender
No Organomegaly
Hems Nog Stool
Bowel $~unds
· Tenderness / Rebound / Guarding
· Heptdmega~y/SplenomegaJy/Mase
· Hemff Pos Stool/Mele. na/Gr0s~ Blood
· Abnor~rnal bowel sounds:
/nd/ease / decrease / absent
8. PELVIC
[] Cervix
[] Adnsxa
9. SKiN
NoRash
Motor Functlo .n
Cerebellar Functfon
Ga~t
1 · PSYCHIATRIC
pace, person) -
· Depression / anxiety l agitation
· MemOry (recent/remote)
Memory
, LYMPHATIC
.Neck w/a SIg :Adsnopathy
enopa ,
,. MuSCUL~sKa. ErAr.
, ,~' W~ ROM w/o ~. · ~ / ~on
NO ~ ~ ~= ~': ~:~ ~ ( p~)
DATA REVIEWED:
OLD RECORDS: DATE
MONITOR
ECG
! __, FINDINGS:
· PULSE OX: %
AMBULANCE RECORDS -
· TIME
[] CVP [] DEFIBRILATE [] EXTERNAL PACER [] ]V [] ABG [] I.~.CEI~'Ii0N REPAI~
3.)
4.)
CA~JF~OLL COUNTY GENERAL HOSPITAL
EMERGENCY DEPARTMENT
PHYSICIAN'S ORDERS
CBC PCXR
BSC MTB PROF
COMP M'T'B PROF
~RD PROF
ABD PAIN PRO
B~A HCG
[] PT/P'r'r
[] ETOH
[] URINE TOX SCREEN
CULTURE
CULTURE
U.A.
DATE/TIME
INITIAL ORD~S I~iTERED
TIME
TIldE MEDICATIONS and SUBSEQUENT ORDERS E~,=~,:D ' COMPLg,r.u
.
~ .
Ini~ S~na~ I~ Si~s~r~ Initial
CAC~t' COUNTY GENER'AL ~osPzT~
Wed Sep 01, 1999
gutmatient Summary Report
~ ~5:?a me: VALLERY, SUZANNE LINDA Page: 1
~:'Rec #: 189878
.pc: EMR 08/31/99
~hys-Service: PETROPOULOS,PETER - MEDICAL ~!'
~cct #: A9924303408 PCP: FERRAxPETER J · · ' .'
In: 08/31/99 18~8 .... ~ ............................ Spec: ~tood
)ut: 08/31/99 1904 J COMPREHENSIVE METABOLIC P~NEL J Techs: VER T587
:oll Time: 08Y31/99 1845-~ ................ ~'~---~
)rder Phys: PETROPOULO$,PETER [Ag9~4303408/13300532
*STAT*STAT*STAT*
~esult Name Result
~ odium(mEq/L): 139.
>otassium(mEQ/L): 4.0
:hlori de(mEg/L): :~. :105.
;lucose(mg/dL): 139· H
~UN (mq/dL): 10. L
rear i ni ne(m~/dL): .6
~otal Protein(gm/dL): 7.1
bumi n(gm/dL): 3.9
:a lci u'm(mg/dL): 9.4
~i l~rubin, Total(rog/all): 1.0
~ST(U/L)': 19.
klk Phos (U/L): 107.
:a?bon Oioxide(mEo/L): 20. L
135-145
3.6~5.0
101-111
65-110
17.0-44.0
O. 5"1.4
6.3-8.6
3.7-5.& -
'9.2-10.6
0.2-1.3
10-30
70-230
22-31
.n: 0873i/99 1848 .... ~ ................. Spec: Brood
iut: 08/31/99 1852 t 'cBC W D~FFERENTIALLI-
:o~l Time: 08/31/99 1845 ......................
)rUer Phys: PETROPOULOS,PETER
*STAT*STAT*STAT*
!esult Name Result
' Tech$: VER T139
CA99~4303408/13300533
Reference ~an~e
tBC(IOEg/L): 10.5 4.1-10.9
:BC (1 OR1 2/L): 4.16 3.89-5.03
emoq Lob i n(gm/OL): 13.0 11.6-14.9
lemat ocr i t(Z): 37.6 33.0-43.9
~CV(fL): . 90.3 81.6-98.3
H (o~): 31 · 2 ':" 25 · 0-33.0
ICHC(gm/dL): 34. b ~.';: 33.1-35.5
DW(%): 11.1 L : 11· 9-15.5
ate Lets(lOEg/L): 272 ~ ' 150-440
PV(fL): 6.1 L 7.4-10.9
ymphocyte Z(Z): 15.3 L 20-47
,ononuclear Cells(Z): 4.1 3.3-9.0
ranulocytes ~(%): 77.5 H 46-74
osinoohi ls %(%): 2.5
r. PETROPOULOS,PETER
210 CORPORATE BLVD SUITE
OCKVILLE, MD 208504697
(Continued on next page)
210
VALLERY,SUZANNE LINDA
189878/A9924303408
EMR 08/31/99
(~-~7/?~1~
>hys- Service:
~cct #=
CA~I' cOuNTY GENERAL R(~SPI
Wed Sep 01, lg99 03:~08 Dm
Outpatient Summary Report
VALLERY, SUZANNE LINDA
189878
EMR 08131199
PETROPOULOS,P.ETER = MEDICAL
PaQe: 2 ~
A9924303408 PCP: FERRA,PETER J
In: 08/31/99 1848 ...................... Spec: Blood
)ut: 08/31/99 1852 J CBC W DIFFERENTIAL
:ol[ Time: 08/31/99 1845 .............. ~ ......
)rder Phis: PETROPOULOS,PETER
*STAT*STAT*STAT*
~esutt Name Result
Techs: VER T139
[A9924303408/13]O053]
Reference Ranpe
(Continuea from previous paQe)
)aso~hils X(%): ~ .0.6
.Ym=h,Amsolute(lOEg/L): 1.6
~ono, Absolute(lOE9/L): 0.4
iran,Absolute(lOE9/L): 8.!
~os,Absolute(lO£9/L): 0.~
~aso, Absolute(lOEg/L): ~ 0.1
1.0-4.0
<1.61
1.5-7.5
0~0.60
0-0 . .~0 ....
)ut: 08/31/99 1912 J 'HCG-QUALI~ATIvE, S~RUM I Techs: YER 1586
:~.l..l Time: 08/31/99 1845 ~ .......... ~ ............ · '
)~.:.~j:r Phys: PETROPOULOS/PETER "
*STAT*STAT*STAT*
~esuLt Name Result
[A9924303408/1330053]
Reference Range
Negative a 25 mIU/mt
ICG-QuaL,Se~um(mIU/ml): Negative
End of Report - 09/01/99 15:09
r. PETROPOULOS,PETER
210 CORPORATE 8LVD SUITE
OCKVILLE, MD 208~OA697
VALLERY,SUZANNE LINDA
189878/Agg24303408
EMR 08/)1/99
(F'07/20/85)
.arrollCounty
General:Hospital
200 Memorial Avenue
(7i':';!" -~: Westminster, ,Matyia~el 2 ~ 18 7-5 7 5 5
,...':' . ' (410)878.-3000 {4101871-8888
DEPARTMENT OF DIAGNOSTIC IMAGING REPORT
08/31/99 2015 189878 ' ,' '
' . ,":
PCP: FERRA, P~ER J
Chk-in # Order Exam
324893 0002 9236
ER CERVICJ[L SPINE
HISTORY: MVC, headache.
COMMENT: The odontoid process appears intact. There is
straightening of the normal cervical lordosis. White this may
merely be posiJaion~l ig.nature, it could reflect muscle spasm.
No vertebral swelling is seen. No fracture or.dislocation is
identified. The vertebral bodies and disc spaces are normal
height. The neural foramina are all capacious. The facet joints
all a~pear to be id proper alignment. Incidental note is made of
a rudimentary cervical rib at C7 on the left.
IMPREsSIoN: Possible muscle' spasm. No fracture or dislocation
seen.
MBB
Thank you for your referral,
Read By: Harry C Knipp MD
,..- ',,.,.,...,,...- \'~- · ,,'
[ES]
PETROPOULOS,PETER
9210 CORPOR3[TE BLVD
SUITE 210
ROCKVILLE, MD 20850-4697
Page :1
Final Report
ASSESSMEN..T.,-FORM .~. ~' " '
Q o'mE~ -- . i
[~1 MONFFOR FOR PATIENT ~AFETY
INITIATE PAS:i'ORAL. SUPPORI'
r'l Carroll County
General Hospital
SuF~"ior commJtmo~ F.~cq~tionaJ car~.
200 Memorial Avenue, W~tmin~ter, Maryland 21157
EMERGENCY DEPARTMENT PATIENT CARE RECORD
GENERAL / EXTREMITIES
L,~,~, Saven~, '~mlng, Afix~Yying ~,~,~, Ot.~di~, Duration, Context, Asaac~d $~gns/Symp~oms
9920803237 UN/T//18-98-78 ·
VALLERY, suZANNE UNDA
MED ER.PHYSICIANS ·
07/20/I 985 F
~HRSmtm9NA~ ' L~,~, ~ ¢::~p.,z~/~
--~ ~onj~~ ~nlun~ ~le
~ ~ ~ear ~(S) ~nje~ ~/Right/~)
~ Pha~
4. NECK
~cu~R
~ Cam~d ~efi~ - ~Ud L / R ~ '
~ ~mo~ ~es ; Femoral L/R
7. ABDOMEN
Heine N~ Stool · Heine Pos Stool~ele~Gro~ Blood
~ B~I Soun~ ' ~no~ ~1 sound:
CO.NSTT~JTIONAL: SKIN
.D HR,B,~P( -...? rev__iewed [] Intact other
Distress: t-JNA..~: I_J Mild [] Moderata [] Severe
GAIT Umlted by pain
Appears: [] WDWN [] Chrenicel~y III [] Bdedy and Frail [] Cachefic [] wnl · antalglc gait
Other:' gait not tested due to pain
other
EXTREMITY (SPECIFY) EXTREMITY ($PECIFY~ BACK/NECK
PRESENT ABSENT PRESENT ABS~N Tandemess [] []
· Tenderness [] [] · Tenderness [] [] Muscle Spa.sm [] []
· Soft l~ssue Swelling [] [] · Soft'~ssue Swelling []
· Deformity [] [] · Defermity [] []., NO"MAt. AtlNORIP. AL
· Effusion [] [] · Effusion r'~ ~ [] · ROM [] []
.0"MAL =N0~m~L No"MAJ. Am.om~ · n'PR'S [] []
RO~4 [] [] .ROM [] [] -.earoC [] []
Stabimy [] [] · smbnHy [] [] · s~ [] []
Distal NVT [] [] · DIstaJ NV'I' [] []
[] ea.~eWmp [] euucwrap
[] lmmobitiz8 . :.. [] Immobilize
[] CanelCrutchea~NaJker [] Cane/Crutches/Walker
C,~HROLL COUNTY GENERAL HOSPITAL.,
· EMERGENCY 'DEPARTMENT
PHYSICIAN'S ORDERS
992
LABS
~ CRC
[] BSCMTB PROF
[] COMP MT~ PROF
[] CARD PROF
[] ABD PAIN PROF
[] BETA HCG
[] ABG
COMPLE"Jl~D
RADIOLOGY'
PCXR
CXR (PA/LA"~
~JB
ABD -~
CT
[] ;-qll.q I SONO
[] ETOH
[] URINE TOX SCREEN . IVP
[] CULTURE
[] CULTURE
~1 UA.
~_. ~,~_.._ INIllAL ORDERS EN'~..REO
~..~ ~ ~ ~ t //~ //'~ · I'nME · INrTu~.s
MEDICATIONS and SUBSEQUENT ORDERS ~EO ~MP~
In~ S~r~ In~l S~ ~ In~ S~r~
· ~TCarrolli~unty .. :.
~'".-- General Hospital
Westminster. Maryland 21157
RESPIRATORY CARE DEPARTMENT
RECORD OF THERAPY
[] SPIJTUM INOUOTION
9920803237 UNIT//18-98-78 '~
VALLERY,SUZANNE LINDA ~
MED ER,PHYSICIANS ~
0712011985 F ~
FREQ.
MiN.
MIN.
COMMENTS
DA'T;
'PEFR
LOC
VC -
COMMENT~
RR .., HR. [
. COUGH
VC
· --- 3arro'"ouns uc ~-
~"General Hospitai · - ~
200 Memor~a! ,4 venue
West~n~nster, Mary/and 21
I DEPARTMENT OF DIAGNOSTIC IMAGING REPORT
^c='r=tsouscE A9920803237 DIS EMR~
PCP: FERRA,PETER J
osom~.~uYmcl~ LAUGHLIN,JACQUIE CLAIRE
cb_k-in # Order Exam
319767 0001 9236
319767 0001 9331
319768 0001 9257
ER CERVIC3~L SPINE
ER LUMBAR SPINE WITHOUT OBLIQUES
ER TOE 5TH*R
HISTORY: MVA. Possible fracture.
LUMBAR SPINE
COMMENT: There is a mild to moderate thoracolumbar scoliosis,
convex righT in the lumbar area, centered about L4. .No fracture
or dislocation is seen, and the lumbar vertebral bodies and disc
spaces are normal height. The pedicles and spinous processes all
.appearintact. ' ~. .....
IMPRESSION: Mild to moderate thoracolumbar scoliosis.
CERVICAL SPINE (5 VIEWS)
COMMENT: The vertebral are unremarkable without evidence of
~ract~re. or disl?cat~on. No significant degenerative changes or
oram~na£ narrowing zs identified. Incidental note is made of
rudimentary cervical ribs at C7, bilaterally.
IMPRESSION: Normal ce~icalsp!ne.
RIGHT 5TH TOE
JUl.
LAUGHLIN, JACQUIE CLAIRE
9210 CORPORATE BLVD.
SUITE 210
ROCKVILLE, MD 20850-4697
Page :1
Final Report
Continued
Carroll County
~ General' Hospital
VALLER ZANNE LINDA"
07~27~99 1728 189878
200 MemoWa/ A venue
Westminster, Maryland 2 ~ ~ 5 7-5759
(410)875-3G00 (410)871-E888
DEPARTMENT OF DIAGNOSTIC IMAGING REPORT
^CCT~SOU~C= A9920803237 DIS
PCP: FERRA.PETER'.~
o.~=.,~.~ws.c~^. LAUGHLIN,JACQUIE CLAIRE '
Checkin-Exam Code Summary
319767-9236,319767-9331,319768-9257..
HISTORY: Possible fracture, MVC.
COMMENT: There is no fracture, dislocation or radiopaque foreign
body. Mineralization is normal.
SUMMARY: Normal study.
MBB
Thank you for your referral,
Read By: Harry C Knipp MD
[ES]
LAUGHLIN, JACQUIE CLAIRE
9210 CORPOR3%TE BLVD.
SUITE 210
ROCKVILLE, MD 20850-4697
Page :2
Final Report
C}ISO"E
Q.IILOHOOO NMUNIZt,110~ ~
'~-~-~r- --
PUPILS ' "I1ME:
Oyes
NONE
O'tt~ -QNo ....... QY-=S-.-FI NO
PUPILS '11ME:
REAC'rlON
COMA ~CALE
o~i-~
TOTALS
' !
f-I*y~ -QN~ ~I-YES- OYES QNO IFYE~USr,
CartollCounW ITEMIZED BILL
General Hospital OF ALL CHARGES D -EMR[
200 Memorial Avenue
Westminster, Maryland 2~57 - 5799
PD8302195~001
~881 1.45368985 ~
~0001 LIBERTY MUTLIAL AUTO I
!0001 GREAT WEST LIFE
[-- -1
UARANTOR HARRY J VALLERY n']MASTERCARD CARDNO.
NAME '11 STARBOARD DRIVE
AND TANEYTOWN MD 21787 E] VISA EXPIRATION DAT~
ADDRESS SIGNA~JRE:
L ~ P~E D~ACH ~D R~RN ~ PO~ON W~ YOUR R~ANC:
1/81/99 159 IBUPROFEN 600MG TAB 0.09 0.09
1/31/99 987 DIPHENHYDRAHINE 50MG INJ 0.48
~/31/97 937 DIPHENHYDRAMINE 50MG INd 0 0.48
TOTAL PHARMACY 1.05
~/3i/99 7031 UM CHLORIDE 0.9~ tMJ lO00OC 8.Be 8.80
]/81/99 704& SODIUM OHL. 0.9% INJ 500CC 8.8C 8.80
TOTAL IV THERAPY
1/31/99 4038
COMPREHENSIVE METABOLIC PANEL
TOTAL LAB/CHEM
18.0C 18.00
13.00
8025 HCG,SEMI-QUANT,SERUM
TOTAL IMMUNOLOGY
33.0C 33.00
38.00
~/31199 &021
~/31/99 9238
~/81/99 6
CBC W DIFFERENTIAL
TOTAL HEMATOLOGY
ER CERVICAL SPINE
TOTAL DX X~AY
EMERGENC9 MEDICAC sCREENING
TOTAL EMERGENCY MEOICA~
20.08 20.00
20.00
74.60 74.00
74.00
55.00 55.00
55.00
4 EXTENDED ER BEYOND SCREENING
TOTAL ER/BEYOND SCREENING
110.00 110.00
II0.00
TOTAL CHARGES
TOTAL PAYMENrS/ADJUSTNEN]'S
' ~':'ll PA"llENT NUMBER
' ~ 480340 ~ I' ON ALL INQUIRIES &
-" ' '" '~- 'i ~ CORRESPONDENCE
ADDmONAL PATIENT EILUNG MAY BE NEr~;:~'~nRY FOR ANY
CHARGES NOT POSTED WHEN II-IlS SILL IS PREPARED,OR IF ANY
INSURANCE CARRIERS DO NOT PAY ANY AMOUNT OF THE
AMOUNTS SHOWN.
PLEASE
REMIT TO:
328.&~
~CarrollCounty
General Hospital
. ,CarrollCounty ITEMIZED BILL
· General Hospital
A en.e OF ALL CHARGES
Westminster; Maryland 21157 - 5799
JT-ANNE LINDA VALL/RY ]9920803237 I .T
BO00I LIBERTY MUTUAL AUTO I PD8302195~00[
[ D1-EMR/ 08/01/99[ I
PLEASE ~(~ ~CarrollCounty
.......................... REMIT TO: '~ General Hospital
7/27/99 355 REESE SHOE 270 5 1 10.80 10.8(
TOTAL HER-BUR SUPPLIES !0.8(
7/27/99 928~ ER CERVICAL SPINE 32( i I ~6.00J 66.0(
7/27199 9257 ER TOE 5TH 820 1 1 80.ooJ 30.0(
7/27/99 933I ER LUMBAR SPINE WITHOUT OBLIOUES 820 1 I 42.001 42.0(
TOTAL DX XRAYI 188.0(
7/27/99 4134 AEROSOL SYSTEM SET UP 410 & 1 I2.00/ 12.0(
TOTAL RESPIRATORY SVC/ 12.0(
7/27/99 ~ EMERGENCY MEDICAL SCREENING 451 ~ 1 54.00/ 54.0(
TOTAL EMERGENCY MEDICAL SCREENINE/ 54.0(
7/27/99 I INTERMEDIATE ER BEYOND SCREENING 452 4 1 27.00l 27.0C
TOTAL ER/BEYOND SCREENING/ 27.0C
7/27/99 3527 BEDSIDE PULMONARY SCREENING 460 2 I 11.00[ li.OC
7/27/99 8581 AERosOL THERAPY 46C 2 1 11.0 11.0C
TOTAL Pulmonapy Functions 22.0C
TOTAL CHARGES . 263.BC
TOTAL PAYMENTS/ADdUSTMENTS 0.00
~ ~ =~ ~'~"-~*.'~ PLEBE R~PE~ TO ADDITIONAL PA~E~ BILLING MAY BE ~;e;~ARY FOR ANY I
~2080~237 .................... { o~ A~ INGUmlES &~A~ENT NUMBER INSUBANcECHAROm NOTcARmERs~OS~D WUENDo miS roLL ~S ~REPARED,OB ~F ANYl~~,~ 2~3.,8'0'~ · ': 8
NOT PAY ANY AMOU~ OF ~E ~
CORRESPONDENCE AMOUNTSSHOWN.
F'
~UARANTOR HARRY d VALLERY r~MASTERCARD CARDNO.
NAME' ~.~. STARBOARD DRIVE
AND TARRYTOWN HD 21787 ~-~ VmA ~XmR~T~ON ~m
ADDRESS 81GNATtJRE;
Carroll Count) ,
General Hospital
200 Memoria! A venue
Westminster, Mary/and 21157-5755
(4101875-3000 [410]871-8888
DEPARTMENT OF I~AG. NOSTIC IMAGING REPORT
VALLL ,SUZANNE LINDA 07/20/85
07/27/99 1728 189878
~,cc~',~sou.c~ A9920803237 DIS EMR
PCP: FERRA,PETER J
..','sr¢l^. LAUGHLI~,JACQUIE CLAIRE
Chk-in #. Order Exam
319767 0001 9236
319767 0001 9331
319768 0001 9257
ER CERVIC~'SPINE
ER LUMBAR SPINE WITHOUT OBLIQUES
ER TOE 5TH*R
HISTORY: MVA. Possible fracture.
LUMBAR SPINE
COMMENT: There is a mild to moderate thoracolumbar scoliosis,
convex right in the lumbar area, centered about L4. No fracture
or dislocation is seen, and the lumbar vertebral bodies and disc
spaces are normal height. The pedicles and spinous processes all
appear intact.
IMPRESSION: Mild to moderate thoracolumbar scoliosis.
CERVICAL SPINE (5 VIEWS)
COMMENT: The vertebral are unremarkable 'without evidence of
fracture or disl?cation. No significant degenerative chan~es or
foraminal narrow~n~ is identified. Incidental note is made of
rudimentary cervical ribs at C7, bilaterally.
IMPRESSION: Normal cervical spine.
RIGHT 5T~ TOE
LAUGELIN, JACQUIE CLAIRE
9210 CORPORATE BLVD.
SUITE 210
ROCKVILLE, MD 20850-4697
Pa~e :1
Final Report Duplicate
Continued
(.,~'~ Carroll Coum, ,
~l~ General Hospital
200 Memorial A venue
Westminster, Mar'fiend 21157-5799
[410)876-3000 (410}871-6888
DEPARTMENT OFIDIA. GNOSTIC IMAGING REPORT
NAME/DOB VAL. ,Y,SUZANNE LINDA
r~,.,tEm,, 07/27/99 1728 189878
^cc'r,~sOU,C~ A9920803237 DIS
PCP: FERRA.PETER J
LAUGHLIN.JACQUIE CLAIRE
07/20/85
EMR
Checkin-'Exam Code Summary
319767_9236,319767-9331,319768-9257
HISTORY: Possible fracture, MVC.
COMMENT: There is no fracture, dislocation or-radiopaque foreign
body. Mlnerallzatlon is normal.
SUMMARY: Normal study.
MBB
Thank you for your referral,
Read By: Harry C Knipp MD
[ES]
LAUGHLIN,JACQUIE CLAIRE
9210 CORPORATE BLVD.
SUITE 210
ROCKVILLE, MD 20850-4697
Page :2
Final Report Duplicate
~1' ADVANCED CENTERS FOR
ORTH O PAEED I C
Arthur Baitch, M.D., Donald L S~, M'.D., Myle~ D. Brager, M.D.,
Samuel- O. Matz, M.D., David A. $ilber, M.D .. M.D.
Stacey It. Bern~.NM.D., Vincent J. Rotlo, ~,L~Z~..~bert M.
PHYSICAL THERAPY/BRACES/ORTHOTIC,q
PROVIDER:
PRECAUTIONS:
FREQUENCY: ~ Xp~rw~:k Dally Other
DURATION: Until nc~: Dr. vhi~#ofw~eks 3 /Unfilprogmmcomplet~__
_ Moist He. at __ Cold
Evaluate and treat
Electr/cal $~n
Massage
luntophoresis
ROM Exercise
I~sistlve Exercise
Ultrasound __ Parafm
TEN~ $obst
Whirlpool Z Crutch Tralnh~$
A~ve Exercise ~ P~asiv¢ Ex~rci.~
__ Back/Neck Rehab Routine __ Cervical Traction
.,-- C~dcal T.rlaction ~ Lumbar Tra~ion ~ Joint M0b.ili~6on
__ hokinectics Eval & Rehab ~ isokinect/cs Rehab __ Isokinectics Test
~ Spinal SmbiN~on Ping __ Back School ... C~wical Program
-- Shoulder Program __ Hip Program __ Elbow Program
__ Work Hardening Program -- Work Conditioning Pro~- __ Hand Program
~ Fun~onal Capacity Evaluation __Crutch
_ Foot h~=t wi~ cork ~ost -- Foo~ I~, singie d~n~ity __ Foo~ ~ aaa] d~']sity
-- Foot ~ UCBL __ Foot I~sert, tri layer __ Rooker bottom, betw~ sol~
I WtllageSquare W~nnin~tar, Maryland 21157 (410) ~76-8877 Fwc (410) 876-~154
13gO Progr~ Way Eldtrsbur~, Md. 21794 (410) $49-5780 Fax (410} $49-$913
ORTHOPAEDIC
V,AI i,I~.Ry, SUZANNE L.
SEPTEMBER. 24, 1999
ORTItOPAEDIC CONSULTATION
HISTORY PRESR:NT II .I.NESS; Sn,~me is a 14-year-old young hdy who was in a motor vdgcle
accident on 07/21/99. The specifics of the accidem are well documented in her file. Basicah'y she
cootiaues to have neck and'back discomforL She inki,lly saw Dr. Medin~ She then came trader the
cere~of a ehkopractor, Dr. Greg Lewis, who treated her. She also had physical therapy. She thea saw
Dr. Robert Saitzman md requested yet mother opinio~
· She cv~tl~oes to compIsln of pain. Her mother wishes to know why she is not ~ny better. She has been
out ofphysioal education since the accldem occurred.
PAST MEDICAL HISTORY: The patient has no known allergie~ She currently is on Advil and
Mo;~:~:~ She has a history of asthma and stomach ulcers.
~'! 0ut'o~proportion to light palpstion. She has full cervical motion. She has normal neurovascuhr
: Reflexes are normal She also has some ~mhsr discoffLfOIt and a negative strslght leg r~i~inl~ test.
., ,~.:!~'. ~-.:
I reviewed her file.
RADIOCdtAPHIC STUDIES: X-rays were taken of the ]~,mhar spine and the ce~ical spine at
Carroll Cotmty C-~eral Hospital on 07/27/99. The repoxts are negative.
IMPRESSION: Persistent complaints of neck and back discomfort.
DIS~ I have discussed the nature of the problem at length. Treatment options were
disotlssed. I advised her mother that subjective complaints seem to o~gh objective fil~dixlS,s on
physical ~r~,.k:.,ation, but due to her persistent complaints we ~ get an MRI scan to further evaluate
her' conditio~ I w/Il see her back a/~er the study.
SAMUEL O. MATZ, I~LD.
' D~vio A. $~.a~, H.O.
ORTHOF'AEDIC
S~MUEL O, MAT'Z, M.D.
ROBERT H, SAI..'rZMAH. M.D. G~OI~O..E H. G~EffiNST~IN, M.D.,
S~N~ SURO~, ~E ~o H~ R~C~E~, H~o SURO~.
~: Smuel M~ M.D.
: OR~OP~DIC SP~ S~GEON'S CONSULTA~ON
· ~;":~ ~. ,~F CO~ ~ upp~ ~d low~ b~k p~.
.:~ :~: ~ ~STORY OF P~S~ U.L~SS
~ ~si~ent compl~ts about
mine p~ ~d'~ba~s ~ b~
~obl~a ~ ~e p~t.
PAST Idl~.DICAL HISTORY:
Illnesses:
Allergies:
Surgeries:
Medications:
None known.
PHYSICAL EXAMINATION: '-' This is a well-developed, obese you~ ledy in no
obvious distress. NormA! reciprocal, gait. The patient complained ofassocinted
.tenderness throughout the neck, upper, middle and lower back. She was also tender over
her sacroiliac joints and greater trochnnters. She complained about motion throughout the
ap/ne. Cervical and inmbar ranges of motion were full with discomfort at the extremes.
Neuromuscular examination revealed 2/5 d~'p tendon reflexes bilaterally and symmetric
at the biceps, brachioradlnlis, triceps, knees and ank]e~. Long tract signs were absent.
$i~nS root tests were only significant for production of lower back pain.
RADIOGRAPHIC STUDIE~; . I reviewed an MRI scan of the cervical spine that
was done at '.York Imagin8 Canter on 10/07/99. There is no evidence of any significant
herO,on or stenosis or other structural abnormality.
~ Resolving cervical, thoracic and lumbar strain injuries.
No midonce ofm~y radlculopathy.
P~OE: 2
PATIENT: VALLEB. Y, SUZANNE L.
DATE: 11/16/99
TREATMENTi Continue anti-inflammatory medications, cold therapy and a
swimming exercise program. I expect that over time these injuries will heal uneventfully.
MYLE$ D. BRAGER, M.D.
Dictated but not read unless signed
MDB/ama/WM
Peter Ferra, M.D.
P~i~ted: I1!t9199 1:14 PH
~atient . Guarantor
Insurance Company Policy ~ Group # Other Info Holder Effective
I:PlP ~RRIER I.A83~--81~68L~.t ATllq SLLT~NA JONES LIBERTY ~UTUAL 87/21199 -
8:GREAT WEST LiFE PDS 14536896~ ~52399 S18.88 UPJ_LERY, H. qRRY
PO ~X 988 FPRI]ERIQ<, ~ 217~5--89~8
~ervice Oate(s) Patient Name Code Oescription oty/Src Charged Open Provider Place Cas~#
)8/1Bf9~ UAIJ_E~¥, ~Zi~INE L99~43 DFFI~CONS~TATtoN I.~ 1~.80 185.88 SALTZ~qNR ~7 i
DiagP: 7~.~ PAIN IN LImB
OiagS: 7S4.§ BAC)~ PAIN
VALL.CRY, aJZ~NE L ~9B12 (]FFI~ ~RVICE-EST PT 1.~ 80.~ 88.88 S~TZI~qN R ~ 1
OiagP: ~T.i STI~qlN I'HORACIC SPINE
Dia~: 847.8 BT~IN [~RUICAL SPI~
DiagS: 8~7.2 STRAIN LUMB~R SPITE
UP-.LLE~, ~UZAW~E L 99~74 ~ OR 3RD OPINION 1.~ 195.88 1~.88 ~TZ ~R
Cia§P: 8~?,1 ST~IN THORACIC ~INE
Die§S; 847.~ ST~IN CERVICAL SPI~
Dia~3: S47.~ STP,,qIN LU~BARSP!~
I~/15/9~ VALi.ERY, SU7.PA~NE L )1112 CANCPlI~tRESCnqEIXLEI) APPT 1.~ 8.~8 ~,~ ~TZ ~ 1
DiaBP: ~7,1 ST~IN THORACIC SPINE
Dia§~: ~i7.# ST~IN ~RVIONL ~PI~
DiagS: ~7,~ STRAIN LUPiBAR ~INE
Case ): 1 NECIVRROVSiLI)R Acer)
Oct'urrence: 07t81/99 Admission: Total Disability :
Consulted: Discharged: Partial Disability: Thru
Injury/Pregnancy:
Eepley. Related:
HETAI NER A~tEEHENT
In consideration of legal services to be rendered by Michael
Lee Kaplan, Attorney at Law, the undersigned client retains said
Attorney to prosecute all claims, including claims under uninsured
motorist and no-fault coverage, including medical payments,
property damages, for client (s) injuries and damages sustained on
or about
The
effect a
approval,
advisable
rights.
the ~- day of ~ 199~.
Attorney accepts said employment and is authorized to
settlement or compromise, subject -to the client's
or to institute such legal action or actions, as may be
in the Attorney's judgment in order to enforce client's
The Attorney's fee shall be a sum equal to thirty-three and
one-third percent (33 1/3%) of any amount recovered, or forty
percent (40%) of any amount recovered after suit and/or arbitration
proceedings have been-filed. In addition to the fees so stated,
there shall be a reasonable charge for actual time spent to
process, file and collect any sums due under any existing P.I.P.
coverage. If no recovery is obtained, no fee shall be payable to
Attorney.
If a settlement is made in the case and the client r~fuses to
accept said settlement, the attorneys shall hold a lien for one-
third (33 1/3%) if the offer is made prior to suit being
instituted, or forty percent (40%) of said offer if suit or
arbitration proceedings have been filed.
Costs may be advanced by Attorney, including investigation and
expert's fees, and said advances shall be deducted from any
recovery and returned to the Attorney at the time of disbursement
of the funds. Associate counsel may be employed at the discretion
and expense of the Attorney. Attorney shall have a lien on said
claim, suit or recovery for said fees and expenses.
In the event the appeal is taken, a new and separate agreement
shall be entered into by the parties as to services and fees.
Attorneys may withdraw at 'any time- by giving reasonable
written notfce and the client agrees to sign substitution bf
Attorney in the event of such withdrawal.
DATE C~IENT
FULL AND FINAL RELEASE
For and in consideration of payment to HARRY VALLERY and
ROSEANNE VALLERY, as parents and natural guardians of SUZANNE
VALLERY, of the sum of Six Thousand 00/100 Dollars ($6,000.00}, We,
HARRY VALLERY and ROSEANNE VALLERY (hereinafter sometimes referred to
as ~Releasors"), do hereby release and forever discharge ROBERT PUCKETT,
NEAL MANUFACTURING COMPANY~ INC. COMMERCIAL UNION
INSURANCE, CGU INSURANCE, ONEBEACON INSURANCE and PEERLESS
INSURANCE, (hereinafter sometimes referred to collectively as "Releasees") their
insurers, employees, agents, and any and ail other persons and firms, of and
from any and ail actions, causes of action, claims, demands, damages, costs, loss
of services, expenses, compensation, consequentiai damage, or any other thing
whatsoever including claims not only for personal injuries and damages on
account of or in any way growing out of, any and all known and unknown
personai injuries, debts, and property damage resulting or to result from an
incident involving the Minor Suzanne Vailery that occurred on or about July 22,
1999, on Market Street, Camp Hill, Cumberland County, Pennsylvania.
We hereby acknowledge and assume ail risk, chance, or hazard that the
said injuries or damages may be or become permanent, progressive, greater, or
more extensive than is now known, anticipated, or expected. No promise or
inducement which is not herein expressed has been made to us in executing this
Release. We do not rely upon any statement or representation made by any
person, firm, or corporation, hereby released or any agent, physician, doctor, or
other person representing them or any of them concerning the nature, extent, or
duration of said damages or losses, or the legal liability therefor.
We understand that this settlement is the compromise of a disputed claim
and that the payment is not to be construed as an admission of liability on the
p.art of the persons, firms, and/or corporations hereby released by whom liability
is expressly denied.
We further certify, state, acknowledge, warrant, and declare that each and
every person, attorney, carrier, entity or association which claims to have a lien
on the proceeds of this settlement arising out of this incident, lawsuit, or
litigation, is aware of this Release and its terms and We understand that said
released parties hereunder are relying expressly upon this unconditional express
warranty in making payment hereunder.
The Releasors accept responsibility for satisfying any liens that have been
asserted against this recovery by any worker's compensation insurance carrier,
healthcare provider or insurer, and hereby discharge the Releasees from any
such responsibility.
In further consideration of the above payment, We for ourselves, our heirs,
next of kin, executors, administrators, successors, or assigns, covenant and
-2-
agree to indemnify and hold harmless ROBERT PUCKETT, NEAL
MANUFACTURING COMPANY, INC., COMMERCIAL UNION INSURANCE, CGU
INSURANCE, ONEBEACON INSURANCE and PEERLESS INSURANCE, their
agents, employees, insurance carriers, and attorneys, from all claims, demands,
and suits for damages, costs, loss of services, expenses, or compensation which
may arise in the future on account of or in any way growing out of the injuries or
damages we sustained in this incident.
This Release contains the entire agreement between the parties hereto and
the temps of this Release are contractual and not a mere recital.
We certify that we are over eighteen (18) years of age and we further state
that we have carefully read the foregoing Release and we know the contents
thereof and we have signed the same as our free act and intending to be legally
bound thereby.
IN WITNESS WHEREOF, we have hereunto set our hands and seal this
day of ,2001.
WITN~S~H:
HARRYV~LERY
ROSEANNE VALLERY
-3-
COMMONWEALTH OF
COUNTY OF
On this day of , 2001, before me personally
appeared HARRY VALLERY and ROSEANNE VALLERY, known to me to be the
person whose name is subscribed to the within Release, and acknowledged that
he executed the same for the purposes therein contained.
IN WITNF.~S WHEREOF, I have hereunto set my hand and official seal.
NOTARY PUBLIC
My Commission Expires:
CERTIFICATE OF SERVICE
I do hereby certify that on this day I served a true and correct copy of the foregoing by
first class mail, postage prepaid, addressed to the following:
Michael Kaplan, Esquire
Kaplan & Kaplan
200 E. Lexington St., S 400
Baltimore, MD 21202
Neil Manufacturing Co., Inc.
Carrolton Villa Highway
Villa Rica, Georgia 30180
Robert Puckett
c/o Neil Manufacturing Co., Inc.
Carrolton Villa Highway
Villa Rica, Georgia 30180
Thomas, Thomas & Hafer, LLP
P.O. Box 999
Harrisburg, PA 17108-0999
0 z09
HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
sUZANNE VALLERY, a minor,
Plaintiffs
ROBERT PUCKETT and
NEAL MANUFACTURING CO., INC.,
Defendants
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
: NO.: 01-6497 Civil Term
: CIVIL ACTION LAW
ORDER
day of (~7~r~, 200~, after consideration of the Petition to
AND NOW, this __
Approve Minor's Compromise Settlement, it is hereby ordered and decreed that:
a. The Petition is granted;
b. Settlement between Plaintiffs and Defendant, by and through their insurance company, in
the amount of $6,000.00 is approved;
c. Attorney's fees will be paid to Michael Kaplan, Esq. in accordance with Exhibit D to
Plaintiffs' Petition;
d. The settlement funds (minus attorney's fees) shall be deposited in one or more savings
accounts in the name of the Minor in a bank, building and loan association, savings and loan association or
credit union, deposits in which are insured by a federal governmental agency;
e. No withdrawals will be made from the aforesaid account(s) until the Minor obtains
majority, except as authorized by a prior Order of the Court;
f. Proof of the deposit of settlement funds shall be promptly filed of record;
g. Plaintiffs are authorized and directed to execute a Full and Final Release; and
h.. Plaintiffs are authorized and directed to file a discontinuance of record upon the filing of
Proof of Deposit.
Date:
BY THE COURT:
HARRY VALLERY and
ROSEANNE VALLERY,
as parents and natural guardians of
SUZANNE VALLERY, a minor,
Plaintiffs
ROBERT PUCKETT and
NEAL MANUFACTURING CO., INC.,
Defendants
: IN THE COURT OF COMMON PLEAS
: CUMBERLAND COUNTY, PENNSYLVANIA
.'
.
: NO.: 01-6497 Civil Term
:
: CIVIL ACTION LAW
:
:
TO THE PROTHONOTARY:
Please mark the above-captioned case as settled, discontinued and ended.
Date:
Respectfully submitted,
by.,~~~//!~/~/~i~as' Thomas & Hafer, LLP
v i .I~iD~N~ -~.: J~ ~:7~¢~r'e '
305 N. Front Street
P.O. Box 999
Harrisburg, PA 17108-0999