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Home My WebLink About09-2496SCHMIDT KRAMER PC By: Gerard C. Kramer, Esquire ' Attorney No. 44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Fax. (717) 232-6467 gkramerA,,schmidtkramer. com IN RE: ZACHARY TAYLOR, an IN THE COURT OF COMMON PLEAS Incapacitated person by DANA : CUMBERLAND COUNTY, ARMSTRONG, guardian, PENNSYLVANIA Plaintiff QRPI !A 4'S NO.: 0y. ,t ?{ 9tr ?urol Imo,.. INCAPACITATED PERSON IN ACCORDENCE WITH PA. RULES OF CIVIL PROCEDURE 206.4 1. The petitioner Dana Armstrong, formally Dana Taylor, is an adult individual, the natural mother, and the appointed guardian of Zachary Taylor. Her current address is 2100 Cedar Run Drive, No. 204, Camp Hill, Cumberland County, Pennsylvania 17011. 2. Plaintiff, Zachary Taylor, is an adult individual who suffers from mental disabilities. He resides with his mother at 2100 Cedar Run Drive, No. 204, Camp Hill, Cumberland County, Pennsylvania 17011. 3. Zachary Taylor's father is John Taylor. His address is 44 Village Drive, Stroudsburg, Monroe County, Pennsylvania 18360. 4. Zachary Taylor has been adjudged as partially incapacitated and a guardianship of his estate has been awarded by Order of court in Centre County dated November 8, 1994. A copy of which is attached as Exhibit "A". 4. Zachary Taylor has been adjudged as partially incapacitated and a guardianship of his estate has been awarded by Order of court in Centre County dated November 8, 1994. A copy of which is attached as Exhibit "A". 5. John Taylor and Dana Armstrong had been appointed joint guardians of the estate of Zachary Taylor by Order of September 8, 1994, Court of Common Pleas Centre County. 6. Zachary Taylor was injured in an automobile accident that took place on September 13, 2003 at 1:10 pm on Interstate 495 West, known as the Capital Beltway in Maryland. At the time of the accident, Zachary Taylor was a passenger in a motor vehicle. 7. The Defendant that caused the accident was a Joleen Howard. Joleen was insured with Progressive Insurance. 8. As a result of the accident, Zachary Taylor suffered from injuries which consisted of L1 vertebrae fracture, contusions of the shoulder, and a dental injury. 9. As a result of the accident, Zachary Taylor underwent medical care with Emergency Room physicians. A copy of the Emergency Room report is attached as Exhibit "B". 10. He followed up with the Hershey Medical Center. See Hershey Medical Center records attached as Exhibit "C". 11. Zachary Taylor also treated with his family physician at the Hershey Medical Center with Dr. Bollard. See report concerning his condition from Dr. Bollard attached as Exhibit "D". 12. Dana Armstrong on behalf of Zachary Taylor filed suit against Joleen Howard. 13. In an attempt to amicably resolve this matter, the Defendant's have offered the amount of $22,500.00 in full settlement of the claim. 14. Dana Armstrong believes that it is in Zachary Taylor's best interest to accept the settlement. 15. Dana Armstrong has entered into a contingency fee agreement with Schmidt Kramer. 16. By the terms of the agreement, Zachary Taylor, with Dana Armstrong as the guardian for Zachary Taylor, has committed to pay Thirty-three and One- third Percent (33 1/3%) of any settlement received after the initiation. of suit. 17. The law firm has agreed to reduce this fee to Twenty-five Percent (25%). 18. The Petitioner requests that the Court distribute the present payment of Twenty-two Thousand Five Hundred Dollars ($22,500.00) as follows: Total Settlement $22,500.00 Attorneys Fees - 25 % Schmidt Kramer PC $5,625.00 Attorneys Costs Schmidt Kramer PC $1,850.09 Monies Withheld for Any Further Outstanding Costs which Balance $0.00 to be Returned in 30 days Balance to Client $15,024.91 19. The additional guardian, John Taylor, has been notified of the settlement and agrees to the settlement. A copy of his joinder is attached as Exhibit "E". 20. Plaintiff requests that the court issue and Order approving the settlement and allowing the guardian Dana Armstrong to sign a general release on behalf of Zachary Taylor and receive the settlement funds to be handled in accordance with the initial guardianship agreement. 21. Dana Armstrong will consent with John Taylor on purchases made with funds and provide an accounting of the settlement to the Court of Common Pleas Centre County. WHEREFORE, Petitioner, Dana Armstrong, requests that this Honorable Court enter an Order approving the foregoing compromised settlement, permitting the Petitioner to execute the Release, and directing the distribution of proceeds as set forth herein. Respectfully Submitted, SCHMIDT KRAMER PC Dated: AX 1ile7 By: erard C. Kramer Attorney at Law Attorney I.D. #44715 209 State Street Harrisburg, PA 17101 (717) 232-6300 Attorney for Plaintiffs VERIFICATION I, Petitioner, DANA ARMSTRONG, guardian of Zachary Taylor, an incapacitated person, have reviewed the contents of the Petition for Settlement of a Person Injury Case for an Incapacitated Person and hereby verify that the statements set forth herein are true and correct to the best of my knowledge, information, and belief. I am satisfied that the offer of settlement, referred to in this Petition, for my son's, Zachary Taylor injuries, is just and reasonable and I am willing to accept that offer. I understand that any intentional false statements herein are made subject to the penalties of 18 Pa.C.S. § 4904 relating to unsworn falsifications made to authorities. Date: L ) 4 Dana Armstrong, Parent and Natural Guardian of Zachary Taylor, An Incapacitated person IN THE COURT OF COMMON PLEAS OF CENTRE COUNTY, PENNSYLVANIA IN RE: Zachary Taylor No. 14-94-0153 ORDER AND NOW, this 8th day of November, 1994, after conference with all counsel in the above matter, it is ORDERED that i Paragraph 7 of the Court's previous Order of September 8, 3994, is Amended to read as follows. This Decree assumes that both natural parents, Dana Taylor and John Taylor, will provide custodial care for Zachary Taylor with his father having up to six (6) months per year based upon the best interest of Zachary. During that period of time that Zachary is with his mother, Dana Taylor, she shall be Zachary's limited guardian. During that period of time that Zachary is with his father, John Taylor, the father shall be Zachary's limited guardian. If there is any conflict in terms of the amount of time that Zachary will spend with his mother or with his father the Court will review this matter upon petition of any party. b O U w a a 0 u_ 0 LL1 LL, N C I O ? 0 co "i U- - n Q: U- r? Q l:! cy CU i cr- I g1,?// Certified from the records this ......... A............. j Divis on of Common Plec 1 Court of Centre Coun:,/, Po IN THE COURT OF COMMON PLEAS OF CENTRE COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: ZACHARY TAYLOR No. 14-94-0153 FINAL DECREE AND NOW, this GZ-h day of September, 1994, upon consideration of the annexed petition and after hearing held following due notice, it is hereby ORDERED and DECREED that, based upon a finding that Zachary Taylor suffers from mental retardation as well as kidney disease and, as a result, is so severely mentally impaired that he is unable to make, communicate, or participate in certain-decisions relating to his estate and person, Zachary Taylor is adjudged partially incapacitated in the following areas: Zachary Taylor needs a limited guardian to help with his general care, maintenance, and therefore.it is hereby ORDERED that Zachary Taylor reside with his natural mother and proposed guardian,. Dana Taylor, at the natural mother's residence, subject to periods of time with his natural father, John Taylor, co-guardian of Zachary. It is found that Dana Taylor and John Taylor must ensure that Zachary Taylor receive the proper training, education, medical care, psychological, social or any other vocational services that Zachary may need in order to function in the manner that he is now functioning. Therefore, Dana Taylor and John Taylor are appointed limited guardians of the person of Zachary Taylor with authority to handle the following specific areas relating to the person of the incapacitated person: to ensure Zachary's general care maintenance, residence and habitation, educational, medical, and psychological and vocational areas. Further, it is found that Zachary Taylor is in'need of a limited guardian of his estate and therefore Dana Taylor and John Taylor are appointed limited guardians of the estate of Zachary Taylor with the authority to handle the following specific areas relating to the estate of the incapacitated person, Zachary Taylor: Aside from the above general care ordered, the limited guardians are responsible to manage Zachary Taylor's finances to include disposition of social security funds, any earnings from employment, payment of all necessary bills, accounting to this Court on a yearly basis.for all of the partially incapacitated person's income and expenses. Within twelve months from the date of this decree and at least annually thereafter, the respective guardians shall file with this Court a report as required by the Register's office. Zachary Taylor's social security income will be pro-rated between the parents and guardians based upon the time spent with each parent. This Decree assumes that both natural parents, Dana Taylor and John Taylor, will provide custodial care for Zachary with each parent having him for a period of as close to six (6) months each year as possible. During those six (6) months that Zachary is with his mother, Dana Taylor, she shall be Zachary's limited guardian. During those six (6) months that Zachary is with his father, John Taylor, he shall be Zachary's limited guardian. Either parent may petition this Court to appoint him/herself as sole limited guardian in the event that- the other parent does not maintain custodial care for an approximately six month period during the calendar year. Zachary Taylor has ten (10) days from the date of this Decree to file exceptions. Failure to file exceptions within that time will result in this Decree becoming final. Zachary Taylor has been advised of his right to appeal and to petition to modify or terminate the guardianship by copy of this Decree and by the Statement of Rights attached thereto. cn ? CJ) r ? - rTI M p R1 >- ""D p . O O CO ? O -n r-t 3 M O C-) P- ?13 O O C) G Ln --I Certified from the records this .........::/..,' day of ......, .......... Diivisi of'Common Pleas Court of Centre County, PQ. STATEMENT OF RIGHTS AN ORDER HAS BEEN ENTERED WHEREBY YOU HAVE BEEN ADJUDICATED A PARTIALLY INCAPACITATED PERSON AND UNABLE TO CARE FOR YOURSELF AND/OR MANAGE YOUR PERSONAL AFFAIRS. YOU HAVE THE RIGHT TO FILE EXCEPTIONS TO THE COURT'S DECISION WITHIN TEN (10) DAYS OF THE DATE OF THE COURT'S ORDER. IF YOU FAIL TO FILE EXCEPTIONS, THE ORDER WILL BECOME FINAL. IN THE EVENT THAT YOU FILE EXCEPTIONS AND THEY ARE DENIED, YOU HAVE A RIGHT TO FILE AN APPEAL TO THE SUPERIOR COURT WITHIN THIRTY (30) DAYS OF THE DATE OF THE DENIAL OF THE EXCEPTIONS. IN ADDITION, YOU MAY' PETITION THE COURT AT ANY FUTURE TIME TO MODIFY OR TO TERMINATE THE LIMITED GUARDIANSHIP IF THERE IS A SIGNIFICANT CHANGE IN YOUR CAPACITY OR IF YOUR LIMITED GUARDIAN FAILS TO PERFORM HISMER DUTIES IN ACCORDANCE WITH THE COURT'S ORDER. IF YOU WISH TO APPEAL THE ORDER OR TO PETITION THE COURT TO MODIFY OR TERMINATE THE LIMITED GUARDIANSHIP, YOU MAY BE REPRESENTED BY AN ATTORNEY. IF YOU DO NOT HAVE AN ATTORNEY, YOU MAY REQUEST THAT THE COURT APPOINT ONE TO REPRESENT YOU. IF YOU CANNOT AFFORD AN ATTORNEY, THE SERVICES OF AN ATTORNEY WHOM THE COURT MAY APPOINT WILL BE PROVIDED AT NO COST TO YOU. 3 LAW. 209 State Stree YSScchh'mbiddt Ro nca & Krartler I'C Harrisburg, Pennsylvania 17101 VW 14% ? 04 Suburban Hospital Attn: Medical Records Department 8600 Old Georgetown Road Bethesda, MD 20814 Re: Patient: Zachary Taylor DOB: 10/11/71 Treatment dates: 09/13/03 to present Dear Sir or Madam: C""? t 717.232.6300 Fax 717.232.6467 www.srklaw.com Please be advised this firm represents the above-referenced patient for injuries received as a result of an automobile accident. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. Please note that this request was previously made on March 2, 2004. If there is some difficulty in processing this request please contact this office. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. Gerard C. Kramer Attorney at Law GCK/ det Enclosure HIPPA AUTHORIZATION TO DISCLOSE HEALTH INFORMATION To: Suburban Hospital From: Dana Armstrong, as pareniDate of Birth: 10/11/1971 and guardian of Zachary Taylor Social Security Number: 185-68-9025 1. I authorize the use or disclosure of the above-named individual's health information as described below: 2. The above individual or organization is authorized to make the disclosure. 3. The type and amount of information to be used or disclosed is as follows: the entire chart concerning the above-named individual. 4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. 5. This information maybe disclosed to and used by the following individual or organization: Schmidt, Ronca, & Kramer P.C. 209 State Street, Harrisburg, PA 17101 for the purpose of: potential legal proceeding. 6. I understand that I have the right to revoke this authorization at any time. I understand if I rep clue this authorization I must do so in writing and present my written revocation to the health informati»i management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my po Ecy Unless otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this authorization will expire in six months. 7. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Schmidt, Ronca, & Kramer, P.C., 209 State Street, Harrisburg, PA 17101 (717) 232-6300. 8. I also authorize my attorneys or their delegate to photograph my person while I am present in any hospital, 9. I agree that a photostatic copy of this authorization shall be considered as effective and valid as the original. Date: l 6/11/2004 ,., Signature of Patient or Legal Repre ntative Parent and guardian. If signed by Legal Representative, Relationship to Patient 209 State Street '1 1 kS.Y?(a 10j rjqloor Harrisburg, Pennsylvania 1710 Ip i P 1 101 `(1 \` 717.232.6300 Cz v ` T 'M FAX 717.232.6467 215.546.0942 FAX L www.srklaw.com SchmidtAonca & Kramer PC Please respond to Harrisburg office. o INJURY LAWYERS March 2, 2004 `-- I3„7\nFS .; 10 zoo mAR Suburban Hospital Attn: Medical Records Department ..`.." 8600 Old Georgetown Roa?:d?r-oan sir-al Recc Bethesda, MD 20814 Re: Patient: Zachary Taylor ' DOB: 10/11/71 Treatment dates: 09/13/03 to present fir. Dear Sir or Madam: /9,o?s Hoahh Intermati_onn Se?ces, ?nc Dat Init Pen Comp Please be advised this firm represents the above-referenced patient for injuries received as a result of an automobile accident. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. If you have any questions, please feel free to call me at any time. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. Gerard C. Kramer Attorney at Law GCK/det Enclosure cc: Billing Department . HIPPA AUTHORIZATION TO DISCLOSE HEALTH INFORMATION To: A49,s From: 2j9.C.h/41-y' / lam Date of Birth: /0)/1/7/ Social Security Number: ZCC3S-'--6 O-<9 1. I authorize the use or disclosure of the above-named individual's health information as described below: 2. The above individual or organization is authorized to make the disclosure. 3. The type and amount of information to be used or disclosed is as follows: the entire chart concerning the above-named individual. 4. I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human - immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and drug abuse. 5•. This information may be disclosed to and used by the following individual or organization: Schmidt, Ronca, & Kramer, P. C. 209 State Street, Harrisburg, PA 17101 for the purpose of. potential legal2roceeding. 6. I understand that I have the right to revoke this authorization at any time. I understand if I revoke this authorization I must do so in writing and present my written revocation to the health inforinatiali management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy Unless otherwise revoked, this authorization will expire on the following date, event or condition: If I fail to specify an expiration date, event or condition, this authorization will expire in six months. 7. 1 understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact Schmidt, Ronca, & Kramer, P.C., 209 State Street, Harrisburg, PA 17101 (717) 232-6300. 8. I also authorize my attorneys or their delegate to photograph my person while I am present in any hospital. 9. I agree that a photostatic copy of this authorization shall be considered as effective and valid as the original. Date: jQaT_Zi 2)g t , Signature of Patient or Legal Repre ntative If signed by Legal Representative, Relationship to Patient PATIENT INFORMATION 111N1111111111111 RECORD 1 Acct: 029243961 PATIENT NAMEIADDRESS ACCOUNT NO. ROOMIBED TYPE LOCATION/SERVICE MEDICAL RECORD NO. TAYLOR,ZACHARY 029243961 ER ER 1664365 DATE OF BIRTH AGE SEX M. S. RELIGION RACE PRIORI' 10/11/71 31 M PHONE PERSON TO NOTIFYIADDRESS RELATIONSHIP SOCIAL SECURITY NUMBER EMPLOYER HOME PHONE OTHER PHONE PHONE RELATIONSHIP GUAR. EMPLOY. HOME PHONE OTHER PHONE FINANCIAL CLASS S P ACCIDENT INFORMATION REASON FOR VISIT . MVC BACK AND ABD PAIN ACCIDENT OATErnME PRIMARY CARE PHYSICIAN TELEPHONE NUMBER PRIMARY CARE/OTHER PHYSICIAN ADMIT DATE/TIME ADMIYTING PHYSICIAN ATTENDING PHYSICIAN USER 09/13/03 1406 ER,PHYSICIAN N S 7 POL# SUB : CO: COV# REL: CO## N S 2 N S t 3 N S a IF Infection Control Hx: FMPITAL PROPERTY DO NOT REMOVE Date/Time Printed: 09/13/03-1406 SUBURBAN HOSPITAL Healthcare System 8600 Old Georgetown Road ? Bethesda, Maryland 20814 (301) 896-3100 l?l 111111 PATIENT INFORMATION RECORD FORM No. 4 - 1020 R(12!01) ovl SUBURBAN HOSPITAL TAYLOR, ZACHARY Acct# 029243961 Unlt# 1664365 Acct: 029243961 10/11/71 31 M ER,PHYSICIAN CONSENT TO TREAT, ASSIGNMENT OF INSURANCE BENEFITS, ASSIGNMENT OF MEDICARE BENEFITS, RELEASE OF RESPONSIBILITY FOR PROPERTY, FINANCIAL RESPONSIBILITY AGREEMENT, AND SEPARATE PHYSICIAN BILLING. 1. CONSENT: The undersigned consents to x-ray examinations, Laboratory procedures, Anesthesia, Medical or Surgical treatment, or other Hospital services rendered the patient under general and special instructions of the attending physician or consulting physician. The patient is under control of his/her attending physicians, their assistants, or designees, who are in charge of the care and treatment of the patient. The hospital is not responsible for acts of care and treatment ordered by the physician which are properly performed pursuant to his/her instructions. The undersigned understands that each physician will bill and collect for his/her professional services, separate and apart from the hospitals billing and collections. The undersigned understands that all doctors furnishing services to the patient, including the Radiologist, Pathologist, Anesthesiologist, intensive care and the like, are independent contractors and are not employees or agents of the hospital. The undersigned further acknowledges that the patient's admission and discharge are arranged by the attending physician and that the patient Is obligated to leave the hospital upon release by his/her physician. 2. GENERAL DUTY NURSING: The hospital provides general and duty nursing care. Under this system, nurses are called to the bedside of an awake patient by a signal system. If the patient is in such condition as to need continuous or special duty nursing care, it is agreed that such must be arranged by the patient, his/her legal representative, or his/her physicians, and hospital shall in no way be responsible to provide such care. 3. HOSPITAL SERVICES: The undersigned recognizes that the practice of medicine and surgery is not an exact science, and acknowledges that no guarantees have been made as to the results which may be obtained from hospital care and treatment and the rendition of medical services by the attending physician. 4. PERSONAL VALUABLES: It is understood and agreed that the hospital maintains a safety deposit box for the safekeeping of money and valuables. Valuables must not be kept in your room. Such articles include, but are not limited to: Money, Jewelry, Rings, or other articles of value. The hospital shall not be liable for loss or damage to any of your personal property and cannot guarantee you against the loss of such valuables. If you place them in this safety deposit box we can provide you some protection in accordance with an agreement and receipt for the storage of personal property which will be signed by you. The hospital, also, does not take responsibility for personal property or dentures. 5. RELEASE OF INFORMATION: It is agreed upon that all records concerning the patient's hospitalization remain the property of the hospital. The undersigned agrees that to the extent necessary to determine liability for payment and to obtain reimbursement, the hospital may disclose all or part of the patient's record to any person or entity which is or may be liable for all or any portion of the hospitals charges, Including but not limited to insurance companies, workers compensation carriers, health-care service plans, welfare funds, or the patient's employer. The hospital will obtain written authorization to otherwise release information concerning the patient, except in those circumstances when the hospital Is permitted or required by law to release information upon inquiry, the hospital may make available to the public, certain basic information, including the patient's name, address, age, sex, general description of reason for treatment, and general condition. If the patient or the patient's legal representative does not want such information to be released, the undersigned must make a written request for such information to be withheld. 6. ASSIGNMENT OF INSURANCE BENEFITS: In the event that the patient or the undersigned is entitled to benefits arising out of any policy of insurance insuring the patient, those benefits are hereby assigned to the hospital for application to the patient's bill. Said insurance company is directed to make insurance payments to the hospital. 7. AGREEMENT TO PAY FOR SERVICES: I (we) accept responsibility for payment of hospital and physician services covering hospitalization or treatment of the below named patient. If payment is not made and additional collections efforts are required, I hereby agree to pay all bills rendered for said patient together with all collection costs, interest fees, and reasonable attorney's fees of 35% of the balance due. I understand that all bills are payable and become due upon presentation. 8. MEDICARE OR MEDICAID BENEFITS. See Attached 9. FAILURE TO NOTIFY HOSPITAL OF INSURANCE COVERAGEISERVICE OUTSIDE OF INSURANCE PLAN: "If at the time of the patient's admission the Hospital is not advised that the patient is or may be covered by insurance, the patient agrees to make payment In full for all services rendered, regardless of whether the patient was actually covered by insurance at the time of admission. In addition, If the patient receives services that are outside of the patient's insurance plan, the patient agrees to make payment in full for all such services rendered." The undersigned certifies that he has read and understands the foregoing, and is the patient or is duly authorized by the patient as the patient's general agent to execute the above and accept its terms. WITNESS MY HAND AND SEAL THIS _DAY OF Year , AT BETHESDA, MD 20814 0 AM ? PM Signed (Patient)/Date ZACHARY TAYLOR Print/Type Name of Patient Witness to Patient Signature PrinVType Name of Witness Signed (Other Responsible Party) /Date Print/Type Name and Address of Other Responsible Party Witness to Other Responsible Party Signature Print/Type Name of Witness Social Security Number of Other Responsible Party 11111A?IMI? Date/Time Printed: 09/13/03-1406 SUBURBAN HOSPITAL TAYLOR, ZACHARY ItlI?I??tfll Acct# 029243961 ( t `I Unit4 1664365 ACCt: 029243961 00 10/11/71 31 M ER,PHYSICIAN CONSENT TO TREAT, ASSIGNMENT OF INSURANCE BENEFITS, ASSIGNMENT OF MEDICARE BENEFITS, RELEASE OF RESPONSIBILITY FOR PROPERTY, FINANCIAL RESPONSIBILITY AGREEMENT, AND SEPARATE PHYSICIAN BILLING. I . CONSENT: The undersigned consents to x-ray examinations, Laboratory procedures, Anesthesia, Medical or Surgical treatment, or other Hospital services rendered the patient under general and special instructions of the attending physician or consulting physician. The patient is under control of his/her attending physicians, their assistants, or designees, who are In charge of the care and treatment of the patient. The hospital is not responsible for acts of care and treatment ordered by the physician which are properly performed pursuant to his/her instructions. The undersigned understands that each physician will bill and collect for his/her professional services, separate and apart from the hospitals billing and collections. The undersigned understands that all doctors furnishing services to the patient, including the Radiologist, Pathologist, Anesthesiologist, Intensive care and the like, are independent contractors and are not employees or agents of the hospital. The undersigned further acknowledges that the patient's admission and discharge are arranged by the attending physician and that the patient is obligated to leave the hospital upon release by his/her physician. 2. GENERAL DUTY NURSING: The hospital provides general and duty nursing care. Under this system, nurses are called to the bedside of an awake patient by a signal system. If the patient is in such condition as to need continuous or special duty nursing care, it is agreed that such must be arranged by the patient, his/her legal representative, or his/her physicians, and hospital shall in no way be responsible to provide such care. 3. HOSPITAL SERVICES: The undersigned recognizes that the practice of medicine and surgery is not an exact science, and acknowledges that no guarantees have been made as to the results which may be obtained from hospital care and treatment and the rendition of medical services by the attending physician. 4. PERSONAL VALUABLES: It is understood and agreed that the hospital maintains a safety deposit box for the safekeeping of money and valuables. Valuables must not be kept in your room. Such articles include, but are not limited to: Money, Jewelry, Rings, or other articles of value. The hospital shall not be liable for loss or damage to any of your personal property and cannot guarantee you against the loss of such valuables. if you place them in this safety deposit box we can provide you some protection in accordance with an agreement and receipt for the storage of personal property which will be signed by you. The hospital, also, does not take responsibility for personal property or dentures. 5. RELEASE OF INFORMATION: It is agreed upon that all records concerning the patient's hospitalization remain the property of the hospital. The undersigned agrees that to the extent necessary to determine liability for payment and to obtain reimbursement, the hospital may disclose all or part of the patient's record to any person or entity which is or may be liable for all or any portion of the hospitals charges, including but not limited to insurance companies, workers compensation carriers, health-care service plans, welfare funds, or the patient's employer. The hospital will obtain written authorization to otherwise release information concerning the patient, except In those circumstances when the hospital is permitted or required by law to release information upon inquiry, the hospital may make available to the public, certain basic information, including the patient's name, address, age, sex, general description of reason for treatment, and general condition. If the patient or the patient's legal representative does not want such information to be released, the undersigned must make a written request for such information to be withheld. 6. ASSIGNMENT OF INSURANCE BENEFITS: In the event that the patient or the undersigned is entitled to benefits arising out of any policy of insurance insuring the patient, those benefits are hereby assigned to the hospital for application to the patient's bill. Said insurance company is directed to make insurance payments to the hospital. 7. AGREEMENT TO PAY FOR SERVICES: I (we) accept responsibility for payment of hospital and physician services covering hospitalization or treatment of the below named patient. If payment is not made and additional collections efforts are required, I hereby agree to pay all bills rendered for said patient together with all collection costs, interest fees, and reasonable attorneys fees of 35% of the balance due. 1 understand that all bills are payable and become due upon presentation. 8. MEDICARE OR MEDICAID BENEFITS: See Attached 9. FAILURE TO NOTIFY HOSPITAL OF INSURANCE COVERAGE/SERVICE OUTSIDE OF INSURANCE PLAN: "If at the time of the patient's admission the Hospital is not advised that the patient is or may be covered by insurance, the patient agrees to make payment in full for all services rendered, regardless of whether the patient was actually covered by insurance at the time of admission. In addition, if the patient receives services that are outside of the patient's insurance plan, the patient agrees to make payment in full for all such services rendered.' The undersigned certifies that he has read and understands the foregoing, and Is th lent or is duly authorized by the patient as the patient's general agent to execute the above and accept its terms. WITNESS MY HAND AND SEAL THIS _DAY OF Year AT ET/ EySBi?,814 ? AM ? PM Signed (PatientyDate ZACHARY TAYLOR Print/Type Name of Patient Signed (Other Responsible Party) /Date ZACHARY TAYLOR / CHAMP HILL, PA Print/Type Name and Address of Other Responsible Party -185-68-9025 al Security Number of Other Responsible Party Witness to Other Responsible Party Signature PrinVType Name of Witness 11111111IM11111111111 Date/Time Printed: 09/13/03-1422 e. V , ` cCONI SUBURBAN HOSPITAL PATIENT DATABASE ajor ? Mend ? Trauma ED Triage RN't 0 1I, ` ?J}f j ? `C1 I TV Nmne 2_,1/ DOB/Age Date \ 3 U Time J ( - Admitted from: 4 Via: Accompanied by: __e , 1 Medication Allergies ? NKDA Reaction Other Allergies ? Norte Reaction ? Latex/Adhesive, If yes refer to latex policy ? Dyes/Contrast/Metals ? Food ((_ist) r Or ympanic/R R d P 1 r 02 Sat/02 HT. 1 WT. Lb/Kg ? Measured ? Stated Fingerstick Glucose: Tetanus: ? < 5 years ?>P years ? su k5&A ? Denies P e nanc Chief Complaint or History of Present Illness PMD: Referred by: ED Triage Level: ? Emergent (1) Urgent (1I) ? Non-urgent (171) Triage Protocols: 0 Yes ? No Past Medlcal isto : Surgical History: Date: Medications Dose Frequency Last Dose Meds/Vitamins /OTC/Herbals Dose Frequency Last Dose c> a( Pain Assessment of dmi?siop score on ? Numeric 0-10 Scale Rl ;aes Scale ? Behavioral Scale Location Ift Duration Quality O Dull Ache ? Sharp ? Tight ? Intermittent ? Constant Radia ng ? Other 'tBet(er with Worse with Z ON: -Problem ? Glasses/ Lenses ? Cataracts ? Glaucoma HEARING: ? No Problem ? Hearing Impaired ? Hearing d SPEECH: o Problem ? Limitations ? Language DVNTITION: RO?Vo Problem ? Upper Full-Partial ? Lower Full-Partial ? Bridges/Crowns DISCHARGE PLANNING: Do you live in a ? NH* ? Assisted Livings ? Group Home* ? Shelter* ? Detcntion Center ? Homeless` 014VA Do you anticipate changes to your prior living arrangements? ? Yes' i1Q'No Are you currently receiving home care services? Q Yes* Q ?No ? Impaired ? R !L ? Interpreter ? Ca ed/Loose Teeth If Yes or asterisk, Social Services Consulted ? PSYCHO-SOCIAL / FUNCTIONAL RISK ASSESSMENT: Does the patient appear malnourished /underweight? El Yes rh% ? If yes, consult PMD or El Dietary Consult In the past year, has anyone threatened or physically harmed you in any way? ? Yes ffNo ? if yes, refer to Crisis (CIS) or ? Info given Has the patient (if over 65) received the pneumococcal vaccine? W. Yes ? No ? If no, refer to PMD Patient describes recent changes in mobility IADLs/communication /swallowing ability? ? Yes IN& ? If yes. ret'er to PMD or ? PM & R Referral A. Do you smoke? 0 Yes V o Pk per day x years. Date Quit B. Do you drink alcohol? ? Yes 0 No Amount Frequency Last Drink C. Do you use other substances? ? Yes Er No Amount Frequency Last Use ED Has the patient had an unexpiained rsistent productive cough lasting longer than 3 weeks? ? Yes ?041w ? If yes, refer to ID SI itul any cha s) T LE DAT IT/ ) TIME RIN ( TIME PRINTED SIGNATURE (initial any changes) DATE SIGNATURE (initial any changes) TITLE DATE TIME PRINTED SUBLWAN HOSPITAL Healthcare System 8600 Old Georgetown Road I Bethesda, Maryland 20814 PATIENT DATABASE FORM 1-1097 (01103) 0L 9243961 0:./13/0" s_,1 TAYLOR t ZAON:,iv~ 1 10/11/71 0.;. 1, EMERGENCY DEPARTMENT ? ORDER SHEET 09243961 09/13!03 ?iR "frR ZACHAR1 0rR.c.R.PHY'.:JC1 16i'i3S5 IJ 0 1 ALLERGIES > DATE TIME ` pA MD. ERS REA N ENTERED COMPLETED TIME INITIAL DIAGNOSTIC ORD SO TIME INITIAL TIME INITIAL ? CCU ? SERIAL CE ? CODE PURPLE ? CBC ? ELR ? COMPMET O TRAUMA ? AMYLASE O LIPASE ? ETOH ? I-STAT ? ACCUCHECK ? PT/PTT ? D-DIMER ? SEDRATE ? ABG O BLOOD C&S ? LIVER PANEL ? URINE DIP O UA O C&S O PREG O TOX ? RAPID STREP O MONO ? TYPE & SCREEN ? CROSS _ UNITS O WET PREP O GC PROBE ? CHLAMYDIA O RESTRAINTS ? OCCULT BLOOD Q/C ? CSF STUDIES -11 L- / S S l' CXR O PA&PAT O PO WT ? ABD SERIES O KUB ? UPRIGHT O C-SPINE LEVEL _ ? T-SPINE ? LS SPINE 1 0 EXTREMITY ? CT HEAD W W/O CONTRAST (please circle) ? Cr CHEST W WIO CONTRAST (please circle) ? SPIRAL CT (check below for cvntrast) ? CT ABD/PELVIS (check below for contrast) ? PO&IV ? PO ONLY ? IV ONLY ? NONE ? U/S ? VQ SCAN O 1 )C / O Zu f\?? ? MON6GIV ? EKG ? PULSE OX ? OXYGEN ROUTE M.D. ROUTE SITE RATE COM PLETED TIME 'INITIAL ? Td 0.5 ml IM MEDICATIONS /IVs TIME INITIAL 1 ??- ?- lA1V. VWW FU ? 1 M.D. CALL PLACED CALL TIME IN1TlAL CONSUL NT TIME INITIAL RETURNED COMMENTS 2 DISPOSITION- ? TRANSFERRED TO (time) ? DISCHARGED (Time) ? STABLE ? IMPROVED AMA O ADMITTED (Time) IXPI INITIAL SIGNATURE & TITLE INITIAL GNATU & YAW SUBURBAN HOSPITAL Healthcare System 8600 Old Georgetown Road Bethesda, Maryland 20814 EMERGENCY DEPARTMENT ORDER SHEET OR 5 v F M -1065 (3/07) ;.?}_.- ? - - ..My '- "•S"?`*.'^r ??ir„'•?-.f .`? ,...?.._,?_, ?.- ......v. rv-?.: t- 1e^-,.,,:+n_.n.i?,.?:, ,,.Y'-w...-?'t r^= -. <<.,-?•?.,.?. :..?,...-".'?•?-1 '": 'nor ?-* ??.... ;.r-?r^r?- - BETHESDA-CHEVY CHASE RESCUE SQUAD, INC. EMS Incident Report Unit: Incident : Date: BCCRS Call # Location: 71 . Patient Assessment Priority .3 Wei ht: F Nature and History of current complaint: Allergies: 1 / A LOC ,/} ? DOB_ 110 I I Patient's Medical Histo : _ d fin: (color/temp/moisture) Age: r G?(?L? b Coma Scale 1?, 7 l59' N i' Lun / Ey Pupils: , ' v Move nt Ve Time: Pulse: Time: Pulse: 107- Medications B/P Res p. f J> B/P Res : I U 1 Ou ECG:, 02 Sat: ECG:: 02 Sat: Time: Pulse: T ..._MAW Pulse: B/P _B B/P es : ECG: 02 Sat: ECG: ALS IV: Site Ga: Rate: IV: Ga: Rate: Time: Rx: Response: / Time: Rx: Response: Time: Rx: Response: Time: Rx: Response: Time: Rx: Response: Time: Rx_: Response. NARRATIVE / TREATMENT: SE)Lo?. ,E)CD: you, CREW MEMBERS Driver Patient Name: Co-pilot j r-- /Cf f 3rd Address: Qr ( o ` Orr' 4th ' 5th ,.,, i'1?' Tir 1 Attendant Signature Date `, Rece- in h sician Si nature i `1 • RELEASE FROM RESPONSIBILITY WHEN PATIENT REFUSES SERVICES This is to certify that I, am refusing [circle appropriate] (emergency care) / (transport) offered by the emergency medical services provider(s). I acknowledge that I have been informed of the risks of refusing services and I hereby release the emergency medical services providers from any claims for damages or injury arising from my refusal of emergency medical services. Witness Signed patient 'stguardian's signature Relationship Witness relationship 0 EMERGENCY DEPARTMENT Nursing Assessment Page 1 of 2 :)^S !a 4396I OS/13/05 -,? ALLERGIES )I. ?CUNVI_Q_ TAYLOR • ZACtIAi,'. Z071 0.1 . s i? . P ?t Y I C l p y l DATE: D TIME: ??nl ^ „ ? ?? ) Z y . glrl?fr PLATE N o/Psyche: A,O x3 C f d Cardiac: ? N/A Pulse Respiratory: ? N/A a Skin: ? N/A Elastic turgur ? Poor turgor S?Celetallj tC1.wA qual ROM o deformities GI: /A ? Bowel so ads Present/Absent EENT: lgtA Visual acui y: R on use b gular e ry ? Deformity El Hyperactive BS I ? Com ative El Lethargic ? Unresponsive ? (+) LOC ? Irregular pulse: ? A e C C = Clear W = Wheezing D = Diminished Diaphoretic War ? Cool Pink ? Pale ? Rash ? Open fracture a illary refill ? Hypoactive BS ? Non-tender ? Tender ? Guarding Pupils: R L ? Brisk ? Sluggish ? Dizziness ? Weakness ? Headache L ? •" Prescnt A = Absent R = Roles ? Jaundice ? Mottled < 3 sec > 3 sec ( ? Rigidity C1 Rebound ? No response ? Paralysis ? Suicidal ? Homicidal ? Delusional. ? a ucina[ions GU; N/A ? T Freq ency ? Burning C3 Hematuria RC = Rhonchi CR = Crackles ? SOB ? Cough P NP ? Accessory muscles ? Laceration ? Petechiae ? Ecchymosis ? Bum ? Edema C3 Decubiti ,Equal strength ? Weakened strength ? R ? L ? Unsteady Gait tenderness ? N/ V/D ? Constipation ? Bloody stool ? Nasal drainage ? Bleeding nose ? Sore throat ? Dysphagia ? Earache L R GLASGOW CO MA SCALE Initial assessment completed by: Signature Tt Eye Opening A. Spontaneous ? 3. To Speech 2. To Pain ? 1. No Response VITAL S IGNS Best 6. Obeying ? 5. Localizes Motor 4. Withdraws ? 3. Abnormal Flexion Time T P R BE 02 Sat 02 Rhythm Input Output Response ? 2. Extension ? I. No response ?j Best S. Orientated O 4. Co d Verbal 3. Inappropriate ? inc sible y t v Response ? 1. None TOTAL 1 IV STARTS _ .? ?? 1 0 t (/ Location Gauge g tries Time Initial IV FLUIDS Addi i R it I Time Type t ves ate n MEDICATIO NS Time Medication Dose ute6ite Ro Initials Time Patient Response to Medication/NA Initial `` ` ? IV) Initia i ture Initials Signature W) ) Q A, W &gL SI:JBURBAN HOSPITAL Healthcare System 8600 Old Georgetown Road Bethesda, Maryland 20814 , (301) 896.3100 EMERGENCY DEPARTMENT NURSING ASSESSMENT lt? 'r A 1 ? FORM 5.1070 (03)03) EMERGENCY DEPARTMENT NURSING ASSESSMENT Page 2 of 2 nA•rt:. NURSING PROGRESS NOTES INIT. An C' 5 vc., f t y 4. r lW k (A ' N ? I Y1 Initials Si nature Initials Signature R.N. DISCHARGE NOTE DISCHARGE TIME: _?- DISCH GE VITAL SIGNS: ISPOSITION ADMIT ROOM # EDUCATIONAL ASSESSMENT Ability to read: es O No Special needs met: /A 0 Yes How: T: Z P: ? Rears ssm nt S initial complaint: R: O L_ Referral: ?N pr v Teachin di li d t b U an ng a zes n ers er Signature: Title Signature: 7ttle ) vw - Emergency P/hysicci?ian ?ttii"m""??e: Age; Weight: -Sex: M / F BP: j RR,. Temp; .wet f.7: 1.3 01"Onts; rN t.: I. ?undetemuned l days PTA data Patient: • I bike i pedestrian versus car i mot cle / bike l pedestrian t objeeTTttSst control Pt. Location: passenger f /bask` Rt(L) ) 11-ocation of injury: ( In u descr{ tlon (qua itt ): deformity I dislocation / sprain / strain 1 contusion / laceration i puncture / . abrasion / FB / burn Pala.- ? none / at real / C weight bearing I E use pain duality: sharp / dull! aching / throbbing bike I pWestria ," Associated SX; ? none S eed of im act estima4e : 1r3unknon'n no complaints /'Just stiff and sore' mph: ds i bony deformity i swelling Paint 'ad / face / neck l chest / abd I Im act site vehicle : be I tvis i RUE I LUE / RLE I LLE (? f? C : unknown/ dazed/ * LOC otxation: sec i minutes l hours Remembers: incident t coming to hospital Modf in cio? ? Glasgow Coma Score: / 15 Restraints: one I / lap belt --afbvit ; l Airbag deployed: ?no Prior Rx: ?. o Vehicle damage: mild I modera extensive EMS: EMS: windshield broken / steering wheel bent / Other. Location of damage: ambulatory at scene / extrication spinal immobilization Contributing factors: ETOH / drags / seizure syncope t suicide attempt Other All systems reviewed: ? negative Cl negative except as marked ? constitutional: lover i chins I 0 Musculoskeletal: otherpainful areas. dfaphoresls i weak I faint ? Skin; akin problems ? Eyes: FS sensation I vision problems ? NEUR: numbness I tingling 1 d ENMT: ear, nose or throat complaints i focal deficits I paralysis I dizzy I hearing problems / hoarseness change in behavior I incontinence I 0 CV: chest discomfort / palpitations selzures ? Resp: Soa i breathing problems 1 0 P5Y: psych problems i anxiely I cough / wheezing OGI: N I V depression ? Hematological / Lymphatic: ?GU: urinary problems I kidney problems bruising I blooding LMP: fit I ASN 0 Endocrine: polyuria / polydipsia ? Immunology i Allergies: HIV I AIDS I splenectomy Copyrl& 0 21100. ttvO.Med. 910 OL9243961 OS/13/03 ER TAYLOR, ZACH A'IY 31h 10/.11/71 DR.EAsPHY5ICIA D R a Patent Plate 1 1664 3 G pt) Releried lyfl self / efinic i PAID i fsmdy / EMS 101 Arrived by: EMS / walk-in i wheelchair Historian: patient i tamify I Mend / EMS Past, Family, Social History: ktrx r-j: f arse Level 1: 2 of 7 arras PMH; ? none ?unknown Sur ical Hx: ? note C1 unknown peptic ulcer / GI deed Prior trauma' "r '-?"""' ?" • Other / arthritis / CAD / IDO mellitus . NIOD moliitus -Lf Famil Hx. ? none ?unknown bhromboph labitia / clotting problems OM / CAD Mods: (3 none a RN note dotting problems ASA / NSAIDs t coumadin $ocia{ HX: ?unknnown insulin / steroids Tobacco; _packs per day _ years antihistamines 1 n . I sedatives Current ? no / yes Allergies: ee RN none ETOH: drinks i week Tetanus current: 0 yes / no Recent? Drugs: occupatiom _ Home situation: lives alone Physical Exam: LerN;.2: IJ orpMlanat; Ceve/ f: S7oryanfanaa; Level s: 1• oryen/uNs Q Exam limited by ncy or Gen. Anxiou no / i pl. uncooperative e avers Dis no / dd / modem every nl O O-- NUVIGpnal status. obese Hydration: ? M/ dehydrated t,ongboard I cervical i ED / EMS) I IV / intu lon/ splint Hell eck (Musculoskeletal 'ttwut trauma, skin rut ll ROM f i d t ): NEU le ented x 3 sensory ni u thou ten , eck w Eye ' , ? reflexes intact, symmetrical ? d gait, cerebellar function r s full )?ERRLA. EOM ? cranial nerves intact lids, conjunctiva nl ? comes, chambers, discs ni p5Y: ENMT: affect, mood nt ? nose ni ? judgment, memory rJ extern ears, canals, TM's N (R) / (L) upper extremity teeth, orophsrynx nl (mark A as R, L or B); CV. e-ro-peardnce n1, nontender. ? rate. rhythm fftAOM full without pain: C3 ; art samds nl • le - ? -- - :: 6 pvlses'= hecn b alf 4 exiremibes U-1111-111gth and tone fit b Resp, Chest: (R) / (L) lower extremity rrcp dislrrsz .: _.. Gear, equal U-b/Ea'lh sounds rv - - (mar' ni as 9, i. or D'•: /K , 0 chest inspection, palpation nt , , Vey nce nl, nontander. ? 00 NOM fun without pain: ? Spine 1 / ribs (MS): astable: ? acic, lumbar inspection, 8-St angth and tone n{:.0 uNn nl setts stable, inspection, - p n nl Glasgow Coma Scon -t and ous 3 inspectioh, palpation nl Eyes open: 4-spontane Stable , 2 -to pain 1-none Gil Amid 1 Flank: Ver I: Snl 4-confused 3•Inappr0priate H? earance RS nt 2-inherent sounds 1-none , nontender soR gLQr 6 nl Saocelizea pain M , ? tank nl appearance, nontender MN"thdraws 3-decorticate (flexion) 2-decerebrate (extension) 1-none [] rectal nl, home neg. Musculoskeletal: Skin: ? gait N l] fir appearance without cyanosis ? toes. nails rd ? hydrated, warm b dry, nl capillary refill (physical exam continued, page 2 S N 8600 Old Georgetown Road ryiand 20814 Bet esda h HOSPITAL -,3 gp 896 01 Xeatthcare,Syatem Emergency Department MVA Form 5-2051 hae cart MVA #51 MVA #51 Repast exam at: Findings: allam&ni rlanlcinn M-nItinn-` ,? •_ w - tjj: arralahderward. LU. lowlcWwlax: L!: moderate: U: high Slash box if ordered 0, check np"ia ? and note abnormal* Lab: /r ow . (3 CBC: [3rd Oil exxcedl: aABG: on -Room air 1 02:' T% I liter Hct Hb p0 Pe02 wsc pC02 Bkarbonate Seg Band Monocytss pM / hypoxk IACidDas (metabokc l rasp) L ymphs Eat Alkalosis (metaWic 1 rasp. ) 13 Chem: ? rd Dot exceW: 0 P. Oximeby - %- on - Room Air 102, Sodium_ Potassium _ Glu _,. _ % / liter (3 it / hypoxic Chkxide _ C02 _ Anion gap ? EKG: ? NSP ? nl intervals BUN _! Creahnine ? nl ORS ? of ST-T waves ?ETOH ?Orug screen ? PT, PTT, INR ? TCM x _ units RSC Compared to: ? uA: ?rd ?trl exceoF ? unchanged / changed , WBCs T Bacteria RSCs DIP Read by. []Emergency Physician (3 Pregnancy test: 0 Cardiac monitor. (3 NSR 1) Cm Dermatwnd / staples .=up(:aicia: / su'xc:: risers : inw cmucr.:f::: ii c: ?, U #of_-0 2) -cm Dom abortd I staples . superficial / subcutaneous ! intramuscular # of , -0 # of O Comments: []sensabonintact []vascular intact Level of contamination: [] dean / minimal I moderate / severe Anesthesia: local cc of b: spinsphrins 1 Bicarbonate [] Preparation Suture removal instruction: `days [] Explored: [] no FB / FS iderodfJed []irrigate [] debrided ?undennined []revised [] FS removed (for above: minimal s 1, moderate * 2, extensive • 3) 0,29243961 0D/13/03 EA TAYLOR poi. "ARY Diagnostic o s de tons: sn ofe X[_,?-raY-raY: (Read: ncy Physcian sdid ) 1-p 2-p O M ; 3-- ? ? M 41-13 ? nl 5-- ? crv 0.- ? / ? nt Medications I Orders ? 02 (] IV ? Tetanus: diphtheria Toxoid.5cc/bf / 17G ? Pain meds: ? Immobilization Applied by. ? Emergency Physician ? other 10 compression dressing ? uvoches ? NPO other procedures / meds: Rosooose Procedure: see addendum: Critical Care: minutes Course: same / better l worse Consultation ! Cher data revile Consulted Dr. (lime) Suggests: admit l discharge igsee: Case discussed with: patient / family f other. Reviewed / discussed with Radiologist: Reviewed: NH / EMS / RN t Old Records / Pt. Ouestionnalre tl? ? admit: ICU t morktor I OR / media of 1 surgical /. orthopedics Transfer to: Admit physician: Coon: better! worse Voz; l kaI Instructions given: ?wrfde of Follow up. ?PMD / other. in _ days I prn / as scheduled Restrictions: ((oH work E mmadiete duty agym ?schoo!) -days Discharge Rx: I y C" Cpc_:. _ dal '/MO / DO PA-0 / NP Signature v date MO f 001 PA-C I NP Signature SUBURBAN 8600 Old Georgetown Road 0 HOSPITAL 301-896-3880ry1and 20814 Healthcare System Emergency Department MVA Form 5-2051 cepy4 to zone, t?v a d*ed. BAG _ Hoe 2 nr2 SUBURBAN HOSPI'TAI, - Healthcare System DEPARTMENT OF RADIOLOGY Me TAYLOR, ZACHARY NMr 2100 CEDAR RUN DR n a STATE CTLW HILL PA 17 1l is 1664365 AM TYPE PAD DA Q ;anNENT HIS AY R/O FX TENOM MD ER, PHYSICIAN LERGY CODE=, AD )WENT 11 CAM FOL - FOOT W am (AM 1664365 NAME TAYLOR, ZACH DATE 09/13/2003 EXkY FOL MR! 16643 KWE TAYLOR, ZA DATE 09/13/20 puw FOL EXAM MR* 1664 K49 TAYLOR, Z DATE 09/13/2 EXAM FOL EXAM Dos ACCT A 09/13/200. PHONE Y INITIALS MAN HOSPITAL GTNC!- ERMAN, E)u1r ocAtis RBAN HOSPITAL GINCHERMAN, %XAM EXm RBAN HOSPITAL GINCTIERMAN, YEt EXAM EXAM F?R' 10/ 1/197JAge 31 M M= 3880 3961 VARSV.ouw 091 /2003 1657 &WERED SW PRIOnWtY S t BY owept GINUERMAN, IY MID ma X-RAY REI M ,- Rad. Sipn4iut4 SUBURBAN HOSPITAL MFI$ 1664365 r- AE TAYLOR, ZAC100"CLAN E 09/13/2003 GINCHEFAM, M FOL EXAM EXAM MR# 1664365 SUBURBAN HOSPITAL . IE TAYLOR, ZA.GHAJkTCIAN E 09/13/2003 GINQII IN, M FOL EXAM M Eww SUBURBAN HOSOFTAL MR# 1664365 1E TAYIAR, ZA1SIMAN E 09/13/2003 GINCHMM, M FOL EXAM rV EXAY ' • I TS: SUBURBAN HOSMAI Healthcare System --- EPARTMENT OF RADIOLOGY I, TAYLOR, ZACHARY EET 2100 CEDAR RUN DR ra srATrCHAMP HILL PA 1703 # 1664365 WENT DOB M TYrf RAD 04 MNEW HISTORY RO 'X Mlu&NG MD ER, PHYSICIAN ORGY CODEYNE, AM 0/11/1977Aes 31 sex M wC ER ( 3883 W SHR - SHOULDER 1 AM AM 7M1 ACCT f 09/13/200'. PHONE * 1664365 BURBAN HOSPRAL NAME TAYLOR, ZA IAN DATI 09/13/2003 ER, PHYSICIAN EX u SHR EXAM EXAM EUM BURBAN HOSPITAL hIRO 1664365 NAME TAYLOR, Y DATE 09/13/2003 ER,PHYSICIAN DGUd SHR EXAM EXAM EXAM BURBAN HOSPITAL MRO 166436 NAME TAYLOR, DATE 09/13/ I CTAN IXAM SHR 7 17 EXAM 9243961 PAEV.IMM '09/1 e 1702 EM m VRW ?pRrr S BY ORDERING ER, PHYSICIM MD X-RA`s ® .rrru Rad. Signature -4 t i MR$ 1664365 SUBURBAN HOSWAL N ETAYLOR, ZACHAAYYSI M 09/13/2003 ER,PHY'SICTAN SHR EXAM aw MAO 1664365 SUBURBAN H001TAL WE TAYLOR, ZACHARYYS1KVA WE 09/13/2003 ER, PHYSIC- SFIIR ExaM ' EXAM MR X 1664365 SUBURBAN HOSMAL TAYLOR, ZAC'H Rk"ICM 09/13/2003 ER,PHYSZC SHR EXAM EXAM 003 1011111111 iE TAYLOR, ZACHARY EEr2100 CEDAR RUN DR ra 8TATj;CHAMP HILL PA 170 1 „ 1664365 M TYPE RAD DATA MNiNTHSTORV R/O 1^X1 S/P V A 'ENDING MD ER, PHYSICIAN ARW CODEINE, ADVI W"NT EED 11 W SPLC - SPINE L AM AM AM we ACCT Y 09/13/2003 PHONE a INITIALS 1iUR9AN HOSPITAL Mai 1664365 WME TAYLOR, ZA DATE 09/13/2003 GINCEIERMAN, YEt7 am SPLC om EUAN EXAM UBURBAN HOSPffAL MAP 1664365 MAME TAYLOR, ZA Y DATE 09/13/200 GINCHM MAN, 'xw SPLC EXAM EXAM exA?a _ SUBURBAN HOSPTTAL Healthcare System,-, PARTMENT OF RADIOLOGY 0/ 1/1973ACC 31 sex M Loc ER 0 9243961 PR6b. EXAM ,L E 14300MAGD MWP PmollR S eY opnmmo GINCHERMM , Yjw do X-RA`" RES !lam' e"-?? ??--?; ?•? Rad. Signature -?. km # 1664365 SUBURBAN NOSOITAL i TAYLOR, ZACC-VA 09/13/2003 GZNC i, SPLC ExArrl EXA?+ MR ° 1664365 SUBURBAN HOSPITAL TAYLOR, ZACHAMYSICM 09/13/2003 GnXl- ;RMAN, SPLC 9YAM gum M" 1664365 SUBURBAN HOSPITAL TAYLOR,ZACHAMYWM 09/13/2003 GINCHERIki, SPLC EKAM ... exAA+ . 1 3880 r'440'r-o,- r. rM? "SUBURBAN HOSPITAL, INC 8600 Old Georgetown Road--Bethesda, MD•20814--(301)896-3880 INSTRUCTIONS FOR << TAYLOR >> Our doctors and staff appreciate your choosing us for your emergency medical care needs. Read these aftercare instructions carefully. Please call us if __..y4u_ haye?'anv.__ri ?esa?'ons about; Your medical .problem: We are here to serve you. -=---_-__-----==?f==:x=-------------------------------------------------------- MOTOR VEHICLE ACCIDENTS: You have suffered injuries in a car crash. Although you have been injured, hospital care does not appear to be needed right now. You can expect increasing pain and stiffness from your bumps and bruises for the first day after an accident. These minor injuries are usually much better after 3 days. Neck muscle strains are very common with car crashes and can cause moderate pain and spasm Treatment for these strains and bruises includes rest, ice :C.;r_,pack's'ti f'th;H`:s ,.2' days, :and medicines.:,to'. reduce pain and inflammation. Signs of more serious injuries that require medical attention right away include: r, ?.? . ? Severe• neck, chest, or abdominal pain. : f,pi :'4'*;'''Trouble breathing or repeated vomiting. Weakness, fainting, or numbness. . r- y 4 ., Nr' * Pain that shoots into your arms or legs. Please see your doctor or return here for follow-up care as advised. Wear your safety belt properly every time you get into a car; this is your best protection against serious injury. ------------------------------------------------------------------------------- FRACTURED VERTEBRA: Your exam shows you have a fracture of one or more vertebra, the bony parts that form the spine. If these injuries are severe, they can damage the spinal 'cord and cause paralysis and numbness of parts of the body. Most of the time vertebral fr"actures happen in older people when they fall. There is usually ?:rk. s»'•: ,kr no;_damag'e to the spinal cord when this happens. Hospital care may not be i.,r Ilnlecessary for minor compression fractures, or other stable spine injuries. Normally there is pain and stiffness in the back after a vertebral fracture. Bed rest, pain medicine, and a slow return to activity is often the only treatment that is needed. Neck and back braces may be helpful in reducing pain and increasing mobility. Exercises to improve motion and strengthen the back muscles may also be useful after the initial pain goes away. During the`e"Ifi'rst few days after a spine fracture you may feel nauseated or evomt;:"If this is severe, hospital care with IV fluids will be needed. Please rrange? ;for, follow-up care as recommended to assure proper long-term care and 'rev"e'nt1 dh of further spine injury. Call your doctor or the emergency room right away if you have: * Increasing pain, vomiting, or are unable to move around at all. * Numbness, tingling, weakness, or paralysis of any part of your body. * Difficulty breathing, cough, fever, chest or abdominal pain. ------------------------------------------------------------------------------- CONTUSIONS: You have'"a deep bruise (contusion). Contusions are areas of tenderness and swelling 'in°th`e^so'ft tissues. They are the result of trauma and bleeding in xth`e;inju'red?'area.' Minor trauma will give you a painless bruise; more severe 4Y, << TAYLOR >> p 2 contusions may stay painful and swollen for a few weeks. Treatment includes: * Rest the injured area until the pain and swelling are better. * Apply ice packs every few hours for 2-3 days, then moist heat. ;r. ;-Elevatethe injury to reduce swelling. •? * ssion bandages also help reduce swelling and motion. A hematoma may form in large contusions; this is a collection of blood in the deep tissues. Hematomas are usually reabsorbed by the body naturally, but sometimes they need to be drained. Please see your doctor or go to the emergency room right away if your contusion shows signs of infection (increased redness, swelling, pain), of if the area becomes numb, cold, blue, or much more painful. ------------------------------------------------------------------------------- SHOULDER PAIN: Your?examshgw txou?x.shoulder pain is due to either tendinitis, bursitis, or €eenions' that:;-s:urr'ourid:ahe::joint (the rotator cuff) . All ?t7ese+conditons cause pain and inability to move the shoulder; they can also ?? rlad;to a -"frozen" immobile shoulder if they are not treated properly. The atment of these related problems is similar: Rest the shoulder and avoid any painful movements for the next week. Use a sling for comfort if needed for up to one week. * Apply ice packs every few hours to the shoulder for 2-3 days; then begin heat treatments to improve motion when the pain is better. * Oral medicine to reduce inflammation and pain is very helpful. * Cortisone-like medicine injected into the bursa or around the 11.nfl'ammecd tendon can also bring prompt relief. Shoulder.""reh'a'bilitation exercises are important in preventing a frozen joint. _ti r,.,...i•. 4 , . k 1;-%When.;your"pain improves you should bend forward and gently swing your arm a pendulum 3-4 times daily to help restore motion. Please see your ? f 'a A 'W for further care as advised. Rarely shoulder pain is caused by heart problems; call your doctor, 911, or the emergency room right away if you have severe chest pain, weakness, sweating, breathing difficulty, or nausea. ------------------------------------------------------------------------------- PRESCRIPTIONS: Fill all the prescriptions ordered by your doctor and take them as directed. Generic medicines are as good as brand names, and often less expensive. * If you' •ha-ve"beeh 'given an antibiotic, be sure to take all of it. * .,Keep,::you-r;"drugs out of the reach of children, in a cool, dry, dark place. .;--?*`Ddn't {give your medicine to other people or use it for other illnesses. ?1P '*iS.top-your medicine and call us right away if you have drug allergy symptom „or:bacl side-effects. Call also if you vomit or cannot swallow the medicine 4. t .;,.."*` 9iing your medicines with you any time you go to emergency for treatment. Ask your doctor or pharmacist about drug or food interactions that may be important to know about when taking your prescription or herbal medicines. ------------------------------------------------------------------------------- NARCOTIC PAIN MEDICINE: You have been prescribed a narcotic for pain relief. These drugs are usually combynedy,with?.ace,taminophen (Tylenol#3, Percocet, Darvocet, Anexsia, Vicodin) or aspir infr1 mpirin'#3, Percodan, Synalgos-DC) for increased effect. Narcotics act''on=,thecent'ral nervous system to reduce pain; they also impair mental Wabilities. We advise you not to drink alcohol, drive a ;d or +operate dangerous equipment when you are taking one of these drugs. rig term use of narcotic pain medications may be habit-forming. << TAYLOR >> P. 3 „You`''c'atn""I`es'se'n'`stomach irritation from your medicine by taking it with meals „?...+or' a,,,;full gl•ass of water. Common side effects of narcotics are: nausea and mi':tng, heartburn, constipation, dizziness, sleepiness, and mood changes. y. vs .1? w,have::bothersome side effects or symptoms of an allergic reaction "chives, rash), stop taking your medicine and call your doctor or the emergency room right away. Please keep your narcotic medicine well out of the reach of children. ------------------------------------------------------------------------------- FOLLOW-UP CARE: Your physician today has been DR. GENE GINCHERMAN, MD For follow-up care you have been referred to the following doctor or clinic: r.TI,OP,EDIST IN PA P?I$a's'e "make an appointment for further treatment as needed or in 2-3 days. Tell your referral doctor or clinic that we have sent you, and bring you medicines and instructions to the office. If you had x-rays, an EKG, or lab tests today, they have been reviewed by your doctor. We will contact you at once if other important findings are noted after further review by our staff. If you do not continue to improve or if your condition worsens, please call your doctor" the emergency department right away so you can be examined. I. a1 wl'' ecelpt of these instructions. I understand that my condition y.e .. d,. •4 •yf{i+.,^? ]! ? . t?mya s:eq e. mo, e care and will arrange for further treatment as recommended. / v V VfS g nature Patient or Representative S nature Saturday, September 13, 2003 - 06:08 PM ?., ;;. , W?Mn't NAME: TAYLOR,ZACHARY ACCT # 029243961 MR # 1664365 AGE: 31 EXAM DATE: 09/13/2003 LOCATION: ER STATUS: REG ER DOCTOR: GINCHERMAN, YEVGENIY SUBURBAN HOSPITAL DEPT OF RADIOLOGY RE: 000631574 SPINE LUMBAR COMPLETE HISTORY: MVA. FINDINGS: There is a small fracture of the upper anterior endplate of L1. This does not extend deeper into the vertebral body. There is no narrowing of the spinal canal. The remainder of the vertebral bodies are unremarkable. No significant disk space narrowing is identified. CONCLUSION: FRACTURE OF THE UPPER ANTERIOR ENDPLATE OF L1. D:9/13/03 ** REPORT SIGNITURE ON FILE 09/14/2003 ** REPORTED BY: JANET M. STORELLA, M.D. (ES) SIGNED BY: STORELLA,JANET M 09/13/2003 MDI/MAH BATCH NO: 4577 SUBURBAN HOSPITAL, INC 8600 Old Georgetown Road--Bethesda, MD 20814--(301)896-3880 INSTRUCTIONS FOR. << TAYLOR >> Our doctors and staff appreciate your choosing us for your emergency medical care needs. Read these aftercare instructions carefully. Please call us if you have any questions about your medical problem. We are here to serve you. ------------------------------------------------------------------------------- MOTOR VEHICLE ACCIDENTS: You have suffered injuries in a car crash. Although you have been injured, hospital care does not appear to be needed right now. You can expect increasing pain and stiffness from your bumps and bruises for the first day after an accident. These minor injuries are usually much better after 3 days. Neck muscle strains are very common with car crashes and can cause moderate 4 pa,.in.and spasm. Treatment for these strains and bruises includes rest, ice ?`t packs for'' t}ie first 2 days, and medicines to reduce pain and inflammation. Signs of more serious injuries that require medical attention right away include: * Severe neck, chest, or abdominal pain. * Trouble breathing or repeated vomiting. * Weakness, fainting, or numbness. * Pain that shoots into your arms or legs. Please see your doctor or return here for follow-up care as advised. Wear_ ye ur safety belt properly every time you get into a car; this is your best_ protection against serious injury. I ------------------------------------------------------------------------------- ,0'.FRACTURED VERTEBRA: f'".,'yYour exam shows you have a fracture of one or more vertebra, the bony parts that form the spine. If these injuries are severe, they can damage the spinal cord and cause paralysis and numbness of parts of the body. Most of the time vertebral fractures happen in older people when they fall. There is usually no damage to the spinal cord when this happens. Hospital care may not be necessary for minor compression fractures, or other stable spine injuries. Normally there is pain and stiffness in the back after a vertebral fracture. Bed rest, pain medicine, and a slow return to activity is often the only treatment that is needed. Neck and back braces may be helpful in reducing pain and increasing mobility. Exercises to improve motion and strengthen the r;..',"back muscles may also be useful after_ the initial pain goes away. During the first few days after a spine fracture you may feel nauseated or vomit=. If this is severe, hospital care with IV fluids will be needed. Please arrange for follow-up care as recommended to assure proper long-term care and prevention of further spine injury. Call your doctor or the emergency room right away if you have: * Increasing pain, vomiting, or are unable to move around at all. * Numbness, tingling, weakness, or paralysis of any part of your body. * Difficulty breathing, cough, fever, chest or abdominal pain. .-------`--- -------------------------------------------------------------------- 'O? have a deep bruise (contusion). Contusions are areas of tenderness and `Pli;,swelling g in the soft tissues. They are the result of trauma and bleeding in the injured area. Minor trauma will give you a painless bruise; more severe << TAYLOR >> 6,,Icontusions may stay painful Rest the injured area .s.' * Apply ice packs every * Elevate the injury to * Compression bandages P. 2. and swollen for a few weeks. Treatment includes: until the pain and swelling are better. few hours for 2-3 days, then moist heat. reduce swelling. also help reduce swelling and motion. A hematoma may form in large contusions; this is a collection of blood in the deep tissues. Hematomas are usually reabsorbed by the body naturally, but sometimes they need to be drained. Please see your doctor or go to the emergency room right away if your contusion shows signs of infection (increased redness, swelling, pain), of if the area becomes numb, cold, blue, or much more painful. ------------------------------------------------------------------------------- SHOULDER PAIN: Your.exam shows your shoulder pain is due to either tendinitis, bursitis, or an"i'Jury to the tendons that surround the joint (the rotator cuff). All } these conditions cause pain and inability to move the shoulder; they can also lead to a "frozen" immobile shoulder if they are not treated properly. The treatment of these related problems is similar: * Rest the shoulder and avoid any painful movements for the next week. Use a sling for comfort if needed for up to one week. * Apply ice packs every few hours to the shoulder for 2-3 days; then begin heat treatments to improve motion when the pain is better. *"Oral medicine to reduce inflammation and pain is very helpful. Cortisone-like medicine injected into the bursa or around the inflammed tendon can also bring prompt relief. Shoulder rehabilitation exercises are important in preventing a frozen joint. When your pain improves you should bend forward and gently swing your arm like a pendulum 3-4 times daily to help restore motion. Please see your doctor for further care as advised. Rarely shoulder pain is caused by heart problems; call your doctor, 911, or the emergency room right away if you have severe chest pain, weakness, sweating, breathing difficulty, or nausea. ------------------------------------------------------------------------------- PRESCRIPTIONS: F'l1 all the prescriptions ordered by your doctor and take them as directed. eleric medicines are as good as brand names, and often less expensive. 1f-you have been given an antibiotic, be sure to take all of it. Keep your drugs out of the reacts of children, in a cool, dry, dark place. Don't give your medicine to other people or use it for other illnesses. * Stop your medicine and call us right away if you have drug allerqy symptom or bad side-effects. Call also if you vomit or cannot swallow the medicine * Bring your medicines with you any time you go to emergency for treatment. Ask your doctor or pharmacist about drug or food interactions that may be , important to know about when taking your prescription or herbal medicines. ------------------------------------------------------------------------------- NARCOTIC PAIN MEDICINE: "r..,`lob-have been prescribed a narcotic for pain relief. These drugs are usually coriibined with acetaminophen (Tylenol#3, Per_cocet, Darvocet, Anexsia, Vicodin) or aspirin (Empirin#3, Percodan, Synalgos-DC) for increased effect. Narcotics act on the central nervous system to reduce pain; they also impair mental alertness and physical abilities. We advise you riot to drink alcohol, drive a car, or operate dangerous equipment when you are taking one of these drugs. Long term use of narcotic pain medications may be habit-forming. P. 3 ?41,q ?a 6i. i You can lessen stomach irritation from your medicine by taking it with meals or a full glass of water. Common side effects of narcotics are: nausea and vomiting, heartburn, constipation, dizziness, sleepiness, and mood changes. _ If you have bothersome side effects or symptoms of an allergic reaction (itching, hives, rash), stop taking your medicine and call your doctor or the emergency room right away. Please keep your narcotic medicine well out of the reach of children. ------------------------------------------------------------------------------- FOLLOW-UP CARE: Your physician today has been DR. GENE GINCHERMAN, MD For follow-up care you have been referred to the following doctor or clinic: ORTHOPEDIST IN PA Please make an appointment for further treatment as needed or in 2-3 days. Tell your referral doctor or clinic that we have sent you, and bring you medicines and instructions to the office. If you had x-rays, an EKG, or lab tests today, they have been reviewed by your doctor. We will contact you at once if other important findings are noted after further review by our staff. ?,?f}?Yyou do not continue to improve or if your condition worsens, please call oUr'doctor or the emergency department right away so you can be examined. 'f acknowledge receipt of these instructions. I understand that my condition may require more care and will arrange for further treatment as recommended. statt signature Patient or Representative Signature Saturday, September 13, 2003 - 06:08 PM sl?iy'y: r• ?? ' yn ltfP ?:,?•:r' O 0 l V (// / 209 State Street Harrisburg, Pennsylvania 17101 717.232.6300 FAX 717.232.6467 www.srklaw.com Ronca & Kramer Pc Please FiNYERS 29, 2004 Hershey Medical Center 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Attention: Medical Records Department 1528 Walnut Street, 3rd Floor Philadelphia, PA 19102 215.790.7303 VOICE 215.546.0942 FAX ?? 3 a Y-oy to Harrisburg office. Re: Patient: Zachary Taylor DOB: 10/11/71 Treatment dates: 09/13/03 to present. These records should include the records of Dr. Jonas Sheehan. Dear Sir or Madam: Please be advised this firm represents the above-referenced patient for injuries received as a result of an automobile accident. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. 1 have enclosed an executed medical authorization permitting the release of this information. If you have any questions, please feel free to call me at any time. Very truly yours, SCHMIDT, RONCA 8a kMER, P.C. Gerard C. Kramer SOURCECORPIIEAL HSERVE T Attorney at Law Req #: ? 3niti ax Date• Pages: FEche: - Images: G,CK/det Q FS 13 I711171(l a NURSES NOTES r DS 0 kf RAlY8 Hp a LABS CI MININIUM NECESSARY ?fvT{RE Enclosure 0 0 ER n PRCIGRESS MOTES 0 LITHE ? G cores n ORDERS 'fib S cc: Billing Department 0 EKG o n ERr 3 1.11a4Eis D vA.s^a Reco(dex Acqutsiljon Corp d. cb SOURCECORP ORP HEAL THSERVE Swle D SOW(ECOW 17 Lee Boulevard P 0 Box 3017 Malvern, PA 19355 PH, 610-640-W 1-800526-2971 W-ALT3f,SUNf FAX: 610-6"44/1907 Recordex Acquisition Corp., dba SOURCECORP HEAL THSERVE has been retained by the Medical Record Department of Milton $. Hershey Medical Center to fulfill requests for copies of medical records. Enclosed are the reproduced medical documents specifically authorized by the patient or his/her legal representative. We wish to emphasize that the increasing demands for patient data pose a rising threat to the confidentiality of the patient's medical information. SOURCECORP HEALTHSERVE strives to take every opportunity to safeguard the 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 pre 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. Please be advised of the following state and federal disclosure statements governing medical records in Pennsylvania: Is: nf+grmai ir, 1i? teen disclosed to you from reoartis 00; W see ; W n7a'bts ycw. ..?kin9? futhe? tills disClos +e lS ?Y pe . by tfie wtitberi coosertt of.rt pem. - v horn 't s;. a is. at Ord ed # r the corn denbia(ity of .the, HIV -Relabel In6666ti66 Act k Wera i autli riz tion foc if> i elease of riiedi'cal or other:infomaatiori i5 not t for this pilrnoee._ Based upon guidelines provided by the American Health Information Management Association, the records should be destroyed after the stated need has been fulfilled. We thank you for your cooperation in maintaining the patient's right to privacy. Each medical record has been carefully reviewed to assure that proper disclosure goes only to the authorized Requestor. If you have any questions, please do not hesitate to contact us at 1-500-525-2922 and one of our Customer Service Representatives will be happy to assist you. FEB-26-2003 WED 12'.17 PH INT HED ASSOC _?--_---- Center College of medal PHYSICAL THERAPY REFERRAL Patient's •: tff& C Doctor: Service: Diagnosis: 7 \\ ?C+ r<L EVAL ATION AND TESTING PROCEDURES _.lCConsutt T' ACV k_ I T-gep - ____ Activities of Daily Uving Evaluation Cardiac Rehabilitation Cybex Goniomo"/ROM JOSST Measurement Manual Muscle Test Splint Fabrication _.., Static Dynamic _ Other MODALITIES Cold Pacs Contrast Baths Diathermy Electrical Stimulation '(TENS, HVGS, Low Vott, EI•ctrostim tae) Hot Pats Ice Massage JOBST Compression Massage _ Moistaire Paraffin -Traction Cervical Pelvic Ultrasound Ultraviolet/Cold Quartz Whirlpool Other *TENS: Transoutaneouc Eleotrical Nerve Stimulation: HVGS: High Volt Galvanic Stimulation PT 1 (6166) FAX NO. 717'z312034 P,.. 01 NAME: TAYLOR ZAGURY MD: WLLARD (EDWARD R M": wit M., 10111//tell INS: motOARg LOC: IV? **#1 8174965 MDN: 36WO SEX: M VISIT DATES O21go/goo: Date: 3/710? 16,'0 Age: -2, ) (0_ ugwt1oK-.) I Inpatient: i ph": 4 "jq -1(j `'1- . THERAPEUTIC EXERCISE Coordination/Wance Gait Training Full Weight fearing Partial Weight Bearing Toe Touch Weight Searing Non Weigha Bearing Home Exercise Program - ,,, lsokinetio Exercise" ..P, Muscle Re-education Neuromuscular Facilitation Posture Training Pre-prosthetic Training and Stump Conditioning Progressive Resistive Exercise Prosthetic Training ROM Active ___. Active Assistivo Passirre Tilt Table - Wheelchair Skips Other COMMENTS: - - i t LA A,112 VV17 ny svioU4 PHYSICAL THERAPY REFERRAL. PENNSTATE Milton S. Hershey Meal Center IP College of Medicine ADULT OUTPATIENT PROGRESS NOTE _, PT _,COT _ Speech - Rehab Technology NAME: I -_-R' ZACHARY MD: BOLA EDWARD R MR#: 95411 DOB: 10/11/1971 INS: MEDICARE LOC: OT OOSN: 3227137 MDR: 33020 SEX: M VISIT DATE: 03/07/2003 DX: 6/4 .-.e,*_ dj A REFERRING PHYSICIAN: DATE OF ONSET: DATE OF INITIAL EVALUATION: ?-7 FREQUENCY/DURATION: GOALS: 1. 3. 0 2. ho 4. DATE TREATMENT INITIAL GOALS COMMTI,NTS d11, 3. aN Wis. ya l -4 a?c 7? c.? .?.rE2 S?+t 1 c+c t . /%;C•ti, ? , yo • or 94 ?. a3, ay I-y a, ?- d.?•? a trc e?t ?m014 . 40 C? 1. Re assessment 10. Lumbai Stabilization 19. Splinting/Lasting 28. Fluidotherapy 37. Speech/Articulation Treatment 2. Consultation 11. Neuromuscular Retraining 20. Cryotherapy 29. Wound care 38. Language Therapy 3. Pt. no show 12. Biodex Rehabilitation 21. Moist heat 30. Visual perceptual 39. Videostrobe 4. Pt. cancel/reschedule 13. Traction Pelvic/Cervical 21 Massage 31. System design 40. Voice therapy 5. Ultrasound/phonophoresis 14. Electrical Stimulation 23. Therapeutic Exercise 32. Equipment Setup/Program 41. Patient/Family Education 6. [ontophoresis 15. Wheelchair mobility 24. ROM/Stretching 33. Equipment Modification 42. Home program 7. Gait training 16. Edema management 25. Functional Activities 34. Oral Motor Exercise/Stimulation 43. Discontinue Service 8. Vestibular Exercise 17. Desensitization 26. Functional Mobility 35. Dysphagia Therapy 44, 9. Manual Techniques 18. Sensory Re-education 27. Balance/Coordination 36. Cognitive Retraining 45. SIGNATUR? ? - INITIAL SIGNATURE INITIAL ______ SIGNATURE INITIAL-_., SIGNATURE INITIAL MR 740 12/96 Page 1 of 2 ADULT OUTPATIENT PROGRESS NOTE THE MILTON S HERSHEY MEDICAL CENTER MEDICAL RECORD COPY PO BOX 853 MR328 (REV 9/00) HERSHEY, PA 17033 +----------++-----------++----------++-------++--------++----++---++---++-+ MR# 0095411 11307045207 (109/14/03 11TI12ME44 AIIROOM/BEDllWHTEIIECUlI7RCIIAj 10 +----------++-----------++----------++-------++--------++----++---++---++-+ +-------------------------++----+-+----------++---++--++----++---++---++----+ IPATIENT T AYLORZANAME CHARY limEX11B10/11/1971IIA311ISSIIMRSAIIEIIOVIINON +-------------------------++---++----------++---++--++----++---++---++----+ +--------------------------------++--------------------++---++------------+ (PATIENT ADDRESS 11CAMP CITY HILL (IPA 1 170110DE I 2100 CEDAR RUN DR #204 +--------------------------------++--------------------++---++------------+ +------------++---------------------------++---------------++-------------+ I PT 717 P612E0309IIPT EMPLOYER ((EMPLOYER PHONE 11185-68-9025 +------------++---------------------------++---------------++-------------+ +--------------------------++-------------++-------------++---------------+ (ACONTACT RMSTRONG DANA 11717PHONE612-1655 11WORK PHONE 1120UNTY 1 +--------------------------++-------------++-------------++---------------+ +-------------------------------------------------------------------------- INSURANCE INFORMATION NAME POLICY # GROUP NUMBER MEDICARE 185689025A GATEWAY HEAL 22219158 00000 SELF PAY 0 + ------------------------------------------------------------------------- + +-------------------------------------------------------------------------+ REGISTRAR BAF +-------------------------------------------------------------------------+ +-------------------------------------------------------------------------+ (COMMENTS I + ------------------------------------------------------------------------- + + ------------------------------------++-----------------------------------+ (ATTENDING PHYS 1 ((ATTENDING PHYS 2 46317 VALENTINE ELIZABETH G Q +------------------------------------++-----------------------------------+ +------------------------------------++-----------------------------------+ FAMILY PHYSICIAN REFERRING PHYSICIAN BOLLARD EDWARD R PO BOX 850 UNIVERSITY HOSPITAL HERSHEY PA 17033 717 531-8161 FAX: FAX: +------------------------------------++-----------------------------------+ ED Summary TAYLOR, ZACHARY J - 95411 * Final Report * EMERGENCY DEPARTMENT NOTE PATIENT NAME: TAYLOR, ZACHARY PATIENT NUMBER: 0095411 SEX: M DATE OF SERVICE: 09/14/2003 DATE OF BIRTH: 10/11/1971 HISTORY: The patient is a 31-year-old male here with a chief complaint of back pain. HISTORY: Most of the history is obtained from the patient's mother, who was also in the MVA. The patient is mentally retarded and cannot give accurate details. The patient supposedly was lying down in the rear seat of the vehicle, unrestrained, when they were involved in a T-bone collision on the passenger side. This occurred earlier in the evening in Virginia and they were seen in a suburban Washington, D.C. hospital. The patient had x-rays there that showed anterior body fracture of L1. He was given Tylenol with codeine and told to follow up with a neurosurgeon or orthopedic doctor as an outpatient closer to home. When they arrived here in their home area, mom felt that she wanted a second opinion immediately and brought him here for further evaluation. There has been no pain radiating down in the legs. No numbness, tingling, or weakness. He had no loss of consciousness. He has had no complaints, other than the back pain. PAST MEDICAL HISTORY: Positive for mental retardation, myoclonic jerks, kidney stones, and surgeries for hernia and knee problems. MEDS: Valproic acid, Furadantin, and he has had some Tylenol with codeine tonight for pain. ALLERGIES: Questionable allergy to Advil. SOCIAL HISTORY/FAMILY HISTORY: Noncontributory. REVIEW OF SYSTEMS: As per the HPI. All others negative. He denies any headache, neck pain, abdominal pain, chest pain, or shortness of breath. PHYSICAL EXAM: Temp is 35.8, pulse 94, respirations 20, blood pressure 98/57, 02 sat 94% on room air. Skin is pink, warm, and dry. HEENT exam: Head is atraumatic, normocephalic. No raccoon's eyes or battle signs. Pupils are equal, round, and reactive to light. TMs are clear with no hemotympanum. No rhinorrhea. Neck is nontender, full range of motion without pain. Back: Tender in the mid lumbar area. Chest wall is nontender. Breath sounds equal bilaterally. Heart: Regular rate and rhythm, without murmur. Abdomen is soft and nontender; no guarding or rebound. Extremities: No tenderness, swelling, or deformity. Pulses are 21. Neurologic exam: Motor strength is 5/5 and equal in both legs. Sensation is intact to light touch. DTRs are symmetric. ED COURSE: We reviewed the x-rays from the outlying hospital, since they had them with them. The patient was noted to have an anterior body fracture of Ll with good alignment and no other abnormalities noted. We called Printed by: Shiner, Crystal L Page 1 of 2 Printed on: 4112/2004 9:09 AM (Continued) ED Summary TAYLOR, ZACHARY J - 95411 Neurosurgery to find out their wishes regarding follow up on this patient. They came to see the patient and also wished us to get a CT scan with reconstruction. At 7 a.m. shift change, the patient was still be evaluated by Neurosurgery. Please see the written ED record for the final plan. DIAGNOSIS: L1 fracture. #643370 DICTATING MD: ATTENDING MD: Elizabeth G. Valentine, MD EGV/vsc D: 09/23/2003 c: Edward R. Bollard, MD H039 Printed by: Shiner, Crystal L Printed on: 4/12/2004 9:09 AM T: 09/23/2003 10:49 Page 2 of 2 (End of Report) The Milton S Hershey Medical Center - Emergency Department 500 University Drive Hershey, PA 17033 (717)531-8333 Patient: ZACHARY TAYLOR Medical Record Number: 95411 Date: 0911412003 Time: 10:00 Discharge Instructions IMPORTANT: We examined and treated you today on an emergency basis only. This was not a substitute for, or an effort to provide, complete medical care. In most cases, you must let your doctor check you again. Tell your doctor about any new or lasting problems. We cannot recognize and treatall injuries or illnesses in one Emergency Department visit. If you had special tests, such as EKG's or X-rays, we will reviewthem again within 24 hours. We will call you if there are any new suggestions. After you leave, you should follow the Instructions below. Follow these instructions: • Talk to your doctor before taking other medicines (including over-the-counter medicines). • Sit or stand slowly to avoid dizziness. • Take this medicine with food or milk to avoid an upset stomach. • Store this medicine away from heat, moisture or direct light. • Watch for signs of dependence. They include: • feeling that you "cannot live without this medicine". • you need more of this medicine than before to get the same relief. • Do not drink alcohol, drive or operate machinery while taking this medicine. You were treated today by KENNETH VANDER HAVE, MD WEAR THE JEWITT BRACE AS DORECTED THIS INFORMATION IS ABOUT YOUR FOLLOW UP CARE Call as soon as possible to make an appointment in 6 WEEKS at the NEUROSURGERY CLINIC. You can reach the NEUROSURGERY CLINIC at (717)531-6955, UNIVERSITY HOSPITAL P.O. 850, HERSHEY, PA, 17033. This is a central appointment desk, called Careline, and they will help you set up your appointment at this clinic. If you have any problems or concerns before the appointment, call the Emergency Department. THIS INFORMATION IS ABOUT YOUR DIAGNOSIS COMPRESSION FRACTURE OF THE SPINE L2 A compression fracture of the spine is a break in one or more of the bones that make up the spine. These bones are called vertebrae. A compression fracture is a type of break in which the bone collapses, or becomes smaller. Compression fractures are usually caused by osteoporosis, a disease in which bones become weak. When you go home, follow these instructions: • Avoid lifting or bending. • Rest often. • Return to your normal activities when your doctor tells you your back is healed well enough to do so. • Wear your back brace or support as instructed by your doctor. • Take your medications exactly as prescribed. • Keep follow up appointments with your doctor. • Ask your doctor if you need treatment for osteoporosis. Call your doctor if: • You have increased pain. • Your pain medications are not helping your pain. • You have weakness, numbness, or tingling in your arms or legs. • You have trouble controlling your bowels or bladder. • You have any questions or concerns. THIS INFORMATION IS ABOUT YOUR MEDICINE HYDROCODONE & ACETAMINOPHEN (Vicodin, Lortab). Take this medicine by mouth in the following dose: 1-2 TEASPOONS every 4-6 hours if needed for pain. This is a mixture of medicines used to relieve pain. Side effects may include: sleepiness, upset stomach or constipation (hard stools). Allergy would show up as: rash or itching, wheezing or shortness of breath. This medicine can be habit forming if used for a long period of time. Call your doctor if you have: • any sign of dependence. • any sign of allergy. • increased pain not helped by the pain medicine. • any new or severe symptoms. CIGARETTE SMOKING. This is surely America's greatest health problem! The facts are clear that cigarette smoking will shorten your life. Smoking can cause many illnesses along the way. If you need help to quit smoking, talk to your regular doctor. SEATBELTS. There is no doubt that seatbelts save lives. Every day people without seatbeits are more severely hurt. Buckle up to reduce your chances of injury. YOU ARE THE MOST IMPORTANT FACTOR IN YOUR RECOVERY. Follow the above instructions carefully. Take your medicines as prescribed. Most important, see a doctor again as discussed. If you have problems that we have not discussed, call or visit your doctor right away. If you cannot reach your doctor, return to the Emergency Department. SATISFACTION SURVEY. It's been a privilege for us to care for you. You may receive a survey in the mail. We hope you will be able to take a few moments to complete the survey. It helps us to improve service and reward staff. We like to post the surveys for all the staff to see. CHECK OUT. PLEASE FOLLOW THE BLUE ARROWS OUT TO THE REGISTRATION/CHECK OUT AREA. THE MEDICAL OFFICE ASSOCIATES WILL NEED TO VERIFY INSURANCE INFORMATION WITH YOU PRIOR TO YOU LEAVING THE DEPARTMENT. "I have received this information and my questions have been answered. I have discussed any challenges I see with this plan with the nurse orjAwsician." ( ` ` CHARY TAYLOR or Responsible Person d ZACHARY TAYLOR or Responsible Person has received this information and tells me that all questions have been ansered. RN Staff Signature Portions Copyrighted 1987-2003, LOGICARE Corporation Page 1 of 1 Coronals Reconst CT * Final Report * CT TOMO CORONALS/3D RECON PATIENT NAME: TAYLOR,ZACHARY JOHN PATIENT MRN: 00095411 PATIENT DOB: 11-Oct-1971 EXAM NUMBER: 476-091403 EXAM: CT TOMO CORONALS/3D RECON ORDERING PHYSICIAN: ELIZABETH VALENTINE Exam: CT LUMBAR SPINE UNENH-ADULT Exam: CT TOMO CORONALS/313 RECON CT SCAN OF THE LUMBAR SPINE CLINICAL HISTORY: 31-year-old male with low back pain, L1 anterior vertebral body fracture. TECHNIQUE: Routine thin sliced CT scan of the lumbar spine was performed, with coronal and sagittal reformations. DISCUSSION: There are no prior studies. There is a right oblique anterior superior lip fracture of the L1 vertebral body. The fracture fragment is not significantly displaced, and there is minimal anterior wedging, with moderate loss of height. There is no evidence of significant kyphosis at this level. There is no retropulsion of bony fragments, and there is no involvement of the posterior elements. There is no evidence of bony spinal canal stenosis. There is no significant hematoma associated with this fracture. Numerous renal calculi are noted, the largest of which is on the right side measuring 6 mm. IMPRESSION: 1. Right oblique interior superior lip of L1 fracture, without significant displacement. There is mild anterior wedging. 2. The bony spinal canal is patent, and there is no retropulsion of fracture fragments. 3. Multiple bilateral renal calculi are noted. These findings were reviewed with the clinical team. Dr. Mosher reviewed the images and discussed the interpretation with Dr. Romeo. TAYLOR, ZACHARY J - 95411 DICTATED: 0 REVIEWED AND SIGNED: MICHAEL A. ROMEO, D.O./TIMOTHY J. MOSHER, M.D. 0/Hd Printed by: Shiner, Crystal L Page 1 of 1 Printed on: 4/12/2004 9:09 AM (End of Report) PENNSTATE ® Milton S. Hershey Medical Center College of Medicine CONSULTATION REPORT TO: DR. ? DEPARTMENT: t* REQUESTING PHYSICIAN'S NAME: TAYLOR ZACHARY 1!Ra 95411 10/11/197 OOS# 3145207 W H T E DATEAEAO; REQUEST: 3 O URGENT O ROUTINE MED CAL R ASO FOR THE CONSULTATION: LOP sip rrue. PROVISIONAL DIAGNOSIS: CONSULTATION REPORT BY TEACHING PHYSICIAN: (FELLOWS, RESIDENTS, STUDENTS, ANCILLARY STAFF USE REVERSE SIDE) The teaching physician must 1) Document CC, 2) either document HPI, PMFSH and ROS or indicate review of those documented on reverse side by filling in the circle ( O ) below, 3) personally perform and document key portions of the PE, 4) state the clinical impression or diagnosis(es), and indicate the Plan of Care. 00 Oro, fool? -1VT -N ? O PMFSH, ROS and HPI on reverse side have been reviewed by ea ng Physician. ?p CONSULTANT: h? E Aar dckL eT _?w / .41 (TEACHING PHYSICIAN) Name (print) U ignature Date Time MR 11 Rev. 12198 CONSULTATION REPORT TAYLOR ta;,HARY '4 5 CONSULTATION REPORT R' 4 1 I 1(} / 1 l 11 9 7 t' 00S4 374520% WHTE FELLOW OR RESIDENT: Document Chief Complaint (CC) and History of Preser Illness (HPI). Perform and document Physical Exam (PE). Document Plan of Care and relevant diagnostic test results STUDENT OR ANCILLARY STAFF: Document Patient Identification (ID), Past Medical History (PMH), Family History (FH), Social History (SH), and Review Of System (ROS). +? --rte 60m b?^VC C tM• Oawe* S44*) 6Y?,aKr d 604A 0- C- LI.S 96,,m ck L 1 vAoul 6 o AZ -?c o?La- s s u.b Lor. / V?''''' - Vo s? L eP 6& }i6 0? P cvwo 1 KlwT ?fJ ?1 d00,01- Name (print) .4- craft- Title Signatdre G wGt-o Date Time MR 11 Rev. 12/98 CONSULTATION REPORT PENNSTATE NAME: TAYLOR, ZACHARY Milton S. Hershey Medical Center MD: VALENTINE ELIZAB MD#: 46317 MR#: 95411 College of Medicine DOB: 10/11/1971 SEX: M INS:. MEDICARE LOC: WHTE TWAGE 1 OOS#: 3745207 VISIT DATE: 09/14/2003 _ T) ' TIME: J LAST/ FIRST , D{O AGE: ? NON-URGENT ? AMBULATORY ? W/C 171 URGENT 0 POLICE ? EMERGENT El AMBULANCE El CARRIED MECHANISM: ? AUTO ? RESTRAINT 14 AIRBAG ? D IV R ? PASSE R ? M/C ? HELMET ? BIKE ? FALL ? OTHER CHI F COMPLAINT ! VC f? M V , / A ? 130-0 „1 ? VITALS: O /? P R h ", v b l (y (? ? AX TEMP 1 `l _[_f ((J_ 5 t I C? 5 6 R- C?'kc cO-QX % 1 L1 PR BP 02 SAT - I ?ryry ? fRfJ? lit l/ 71 +? lJ?-C/ OL C VJT J PA P? " QU" DATLIIGIE IOCGIa ED. 07 IN SCALE TETANUS: ? < 5 YRS > 5 YRS JABUSE: NUT 1 NAL ASSESS: JALLERGIES: / IMMUNIZATIONS: ? uTD ? NOTUTD ? YES C NO >10 L T. LOSS El YES NO NKDA d I no" ? DENIES PMH/PSH NEWJMS BCP: ? YES ? NO ? SEE LIST IME ? HTN ? DIABETES LJ SEIZURES - 17 '7 f U IV ? CARDIAC I/GERD ? SMOKER L _ ? 02 17 COPD RENAL ? PSYCH °, ? C-COLLAR ? LONGBOARD r- V) ? ASTHMA ? CANCER ? CVA ? SPLINT,- IUVA / S!!R ? D-STICK _ 1 ? MEDS PH VITALS: MONITOR 02 SA7 PR BP TRl R IGNA E: A SESS T RN SIGNATURE: TIME DONE: ' O ? NO C OMPLAINTS IMIPIIS R"ACNIN TIME_ ? ALERT LE ? SI ? HEADACHE SIZE R _ L__ LI LABS ? CONSCIOUS ? COHERENT ? NECK PAIN REACTIVE R ? L ? ? MEDICATION - ? LETHARGIC ? INCOHERENT ? STIFF NECK PINPOINT RD L n ? X-RAY .__ ____ __,_i_____-_ __ ? CONFUSED ? SLURRED ? FACIAL DROOP DILATED R ? L ? ? DRESSING O UNCONSCIOUS ? APHASIA ? DYSPHAGIA FIXED RD L ? ? ICE ? ORIENTED X ? EXPRESSIVE ? NUMBNESS SLUGGISH RD L ? ? OTHER ? BABY ? RECEPTIVE 0 WEAKNESS ? OTHER - ? BABY ? DIZZY - NON-REACTIVE R ? L ? ? DELIBERATE ? OTHER _ OTHER I M*NT ? GCS ? PINK ? WARM ? FLUSHED _ GAIT: ? STEADY ? UNS TEADY ? PALE C DRY ? HOT RE1!MQDUCTIWE ? NO COMPLAINTS 11~04Y ° ? NO COMPLAINTS ? CYANOTIC ? COOL ? ASHEN ? PREGNANT GRAVIDA_ _ PARA _ A8- RESPIRATION BREATH SOUNDS ? JAUNDICED ? CLAMMY ? DIAPHORETIC EDC FHR ---- ? AIRWAY PATENT PRESENT ? R ? L ? OTHER -_ ._-_._ _- _ __------,.. FETAL MOVEMENT ? YES ? NO ? SYMMETRICAL & UNLABORED CLEAR ? R ? L ' Q NO COMPLAINTS ? VAGINAL BLEEDING ? LABORED DIMINISHED ? R 0 L Lic-i dPATION ? VAGINAL DISCHARGE ? RETRACTIONS ABSENT ? R ? L ?NAUSEA ? VOMITING COLOR ? PAD COUNT --- ? STRIDOR WHEEZES ? R ? L ?DIARRHEA X , COLOR ,- ? PENILE DISCHARGE ? NASAL FLARING RALES ? R ? L ? LAST BM NWR'IIIACERIN ] NO COMPLAINTS ? OTHER RHONCHI ? R ? L PAIN AREA ? DENIES COUGH ,rub I f7 ?T ? NO COMPLaMS _ _ SEVERITY _ (NONE SEVERE) 1-OPEN FRACTURE ? NON PRODUCTIVE ? SORE THROAT O CONSTANT 0 1 2 3 4 5 6 7 8 9 10 SHARP { 2-AMPUTATION ? PRODUCTIVE ? DYSPHAGIA ? ITTANT 0 DULL ` 3-GUNSHOT WOUND DESCRIBE ? BURNING O NON RADIATING 4-DEFORMITY - ? DROOLING G RADIATING - A - / ? S-STAB WOUND 6-BURN ? NO COMPLAINTS NOSE WHERE__-_,_ __ -- - r R L 7-PAIN 8-RASH SP IS ? NO COMPLAINTS ABDOMEN ? SOFT ? FIRM - LIMB RA LA RL LL ?DISTENDED ?GUARDING E-ECCHYMOSIS A-ABRASIONS PARALYSIS EPISTAXIS R0 L? ? TENDER ? NON TENDER GCONTUSION PARESTHESIA DRAINAGE R ? L ? BOWEL SOUNDS ? ABSENT R L L-LACERATION COLOR ? PRESENT, _ ---- SW-SWELLING PULSES V _ _ T.TENDERNESS CONGESTION R? L? -- S-SENSATION PgIN PACKING R ? L ? EYES. WOUND NCTURE WO PALLOR ? NO COMPLAINTS ? NO COMPLAINTS BURN PAIN R ? L ? PAIN RD LO [ARAHtYAS(l?AR ? NO COMPLAINTS OU TEARING ERYTHEMA RD LEI R ? L U DISCHARGE R ? L ? ? MONITOR ? CONSTANT ? SHARP D NO COMPLAINTS PHOTDPHOBIA R ? L ? FOREIGN BODY R ? LE) OTHER R ? L ? RHYTHM ? INTERMITTENT ? DULL ? URGENCY FOREIGN BODY OTHER R ? L ? R ? L ? - ? PACEMAKER ? BURNING [7] HEAVY C] PAIN ACUITY -- ? SOB ? PLEURITIC ? BLEEDING LENSJCORRECT_ED __ CHEST PAIN E DENIES ? NAUSEA ? NON RADIATING ? INCONTINENT AREA ? EDEMA ? RADIATING O FOLEY MENTALASSESSIUNT '- WHERE: ?FREOUENCV FECT F EMORY SEVERITY (NONE SEVERE) ? CAP REFILL: ? RETENTION APPROPRIATE 0 INTACT GCCOHERENT a 0 1 2 3 4 5 6 7 8 9 10 ? JVD ? BURNING ? AGGRESSIVE ? ANXIOUS L] DISORGANIZED ? IMPAIRED ? HALLUCINATING E )CONFUSED -- ? OTHER C FLAT ? SLOW TO RESPOND ? CRYING COMMENTS PAIN SCALE USED: ADULT NON COMMUNICATIVE PEDS NEO-NATAL ? DEFENSIVE MR829 06/01 EMERGENCY DEPARTMENT PATIENT FLOW RECORD PENNSTATE NAME: TAYLOR, ZACHARY MD: VALENTINE ELIZAB MD#: 46317 The Milton S. Hershey Medical Center MR#: 95411 1 The College of Medicie DOB: 10/ 1 / 1971 SEX: M INS: MEDICARE LOC: WHTE Department of Emeraencv Medicine Record MRR1R OOS#: 3745207 VISIT DATE: 09/14/2003 Date: /' 0 ulse Temp: Oral ?Rectal P61 V j D I RR Q BP 002 sat Last dT J LMP ED Pathway Room Time Physician Time C : PMH: HPI: Is CL 51C- .(,-kn 121 WAS b6aw 'tZ" rP r S4st ?,t r M d G KD S - L 1 d +p Glh?h "Tl t7 ? ?s Kos h? Cam/ t? `?\ Allergies: ? 14,6 1 Pain: Y N Location Quality Onset R di / FHx: Cardiac Y N Diabetes Y N a ation Quantit 10 T ? Factors y ROS: Unobtainable - Y N As noted, others stems ne ative Y N Other: Constitutional: Wt. Chan e N Y Fever N Y Chills N Y Weakness N Y Fatigue N Y Soc Hx: ETOH Y N Smoker Y N PPD Eyes: Blurry vision N Y Diplopia N Y Eye Pain N Y Photophobia N Y ENT, mouth: Sore throat N Y Epistaxis N Y Ear Pain N Y Rhinorrhea N Y Other: Cardiovascular: Chest pain N Y Pleuritic N Y Exertion N Y Palpitations Y r _ -.. _F- ¢ ?, y Respiratory: Cough N Y Sputum N Y Dypnea N Y Orthopnea Wheezing N Y GI: Abd. Pain N Y Nausea N Y Vomiting N Y Constipation Diarrhea N Neutrophil GU: Hematuria N Y D suria N Y Frequency N Y Vaginal D/C N Y Incontinenece N Y At icals Musculoskeletal: Ann pain N Y Le pain N Y Back pain N Y Leg swelling N Y yp Skin: Rash N Y Lesion N Y N Y Ca Neurological Numbness N Y Tingling N Y Seizure N Y Syncope Dysphasia N Y Psychiatric: Suicidal N Y Anxiety N Y ingestion N Y Depression N Y Hallucinations N Y Iq 9 Other: Troponin I: Myoglobin: Physical Exam: Rectal: Hemocult ( +) (_) PT: PTT: e Q INR: T. Bill: Alk Phos: I ? ?' r ALT: Amylase: Lipase: C _ C ,L J U/A U-HCG (+) ( ) - d) AAA PIA4 T Drug Screen: 1 a , Cultures: Blood 1 2 Urine Study #1: ? See attached PROGRESS NOTE for additional information ` n c ?1 !.v ? Result: ftv MDM I Differential Diagnosis: 3) 6) 1) 4) 7) L 1 U V t I Y/- Study #2: /? l' 1 L l C?S ?-? ??tiil? 2) 5) 8) ? Result: Procedure Note: Study #3: EKG: ? Result: ED course: Treatment: Y ?? ? sdtt l tt f}, Re onset 0700 m - ' "fir oiool' A. Fib ? 23hr ? 4 day ? Chest Pain ? Dehydration Discharge I str c s: Please go directly to check out ecretary at waiting room desk DVT ? 23hr ? 5 day ? Com Acq. Penumonia ? 23hr trauma ? Cellulitis Follow up with within / - days. 1641 0 ¢n1ra. r ' - 111 Return to emergency department if ^ he 1)-- --- - 2) 3) 't^ Pl debt i'"q tUra AtiendiFlCt5lcRtature _y _ __ D n u' ' T t i I sloe T n ? Resolved ? Improved ? No change Service: Time: Where: ? Cobra form V0, "z PENNSTATE Milton S. Hershey Medical Center NAME: TAYLOR, ZACHARY MD: VALENTINE ELIZAB IV College of Medicine MRq: 95411 DOB: 10/ 11 / 1971 INS: MEDICARE EMERGENCY DEPARTMENT PATIENT FLOW RECORD LOS: W374 OOSk: 3745207 MDN: 46317 SEX: M VISIT DATE: 09/14/2003 Date:-, NURSE'S NOTES Og lS` < r? - AS o a I ? ern.- niArn 4\ to IN TAKE nt lTa{ TIME ORAL IV N/A = Not applicable FR = French Td = Telanus diphtheria VIS = Vaccination information sheet EXP = Expiration INIT = Initial = At ItMOB. = Immobilizer M/C = Motorcycle BCP = Birth Control Pills INIT = Initials EXT = EXTENDED O.R. = Operating Room w/ = with TIME URINE NGT EMESIS UTD = Up to date NRM = Non•rebreather mask LOC = Loss of consciousness CPR = Cardio-pulmonary resuscitation BVM = Bag-valve-mask ALS = Advanced life support ETT = Endo-tracheal tube O' SAT = Oxygen saturation LA = Left arm LL = Left leg RA = Right arm RL = Right Leg IV = Intravenous F = Fiberglass _ TOTAL I I TOTAL P = Plaster sol = Solution QG OK - Quality Control OK LIS Low Intermittant Suction Di.°or SI I IVIV .+!I-DISCHARGED @ ACCOMPANIED BY 1 , `OJT ?JL ' BULATORY ? CARRIED HEELCHAIR ? AMBULANCE OW-iOGICARE INSTRUCTIONS GIVEN TO: ? PATIENT,-e-T?A_MILY ? PARENT ? OTHER ? VERBALIZED UNDERSTANDING ? IV DISCONTINUED ? HEMOSTASIS ACHIEVED ? DRESSING APPLIED ? CRUTCH/SPLINT TEACHING COMPLETED WITH RETURN DEMONSTRATION ? PRESCRIPTIONS GIVEN ? REPORT CALLED TO EXT. CARE FACILITY @ ? ADMITTED TO ? REPORT GIVEN TO @ ? REPORT GIVEN TO @ ? TO O.R. @ ? TRANSFERRED TO @ ? AIR ? AMBULANCE ? BELONGINGS ? W/PATIENT ? SAFE ? NONE ? W/FAMILY ? BELONGINGS FORM COMPLETED NURSE SIGNATURE INIT. NURSE SIGNATU _ T NURSE SIGNATURE INIT. NUBS SIGN/IATyU?RoE? ?, S f "' ? T,-,U r? INIT. ER PT. Flow Sheet EMERGENCY DEPARTMENT PA NT FLOW RECORD White to MR Yellow to FMn NAME: TAYLOR, ZACHARY PENNSTATE MD: VALENTINE ELIZAB MR#: 95411 Milton S. Hershey Medical Center Y College of Medicine DOB : 1011 1 / 1971 INS; MEDICARE LOC: sia52o7 EMERGENCY DEPARTMENT PATIENT FLOW RECORD MEDICATION PAIN SCALE USED: ADULT NONCOM PED. NEONATAL TIME ORD. MD INIT. MEDICATION / DOSAGE ROUTE . TIME GIVEN SITE PAIN SCALE RN INIT. rim dT 0.5cc ? ADULT ? PEDS LOTA EXP. PHYSICIAN ORDERS TIME MD TIME RN ORD. INIT. LAB STUDIES DONE INIT. ? HCT ? D DIMER ? CBC ? PLT. CT. ? DIFF ? PT ? PTT ? ABG ? ACETONE ? Na ? K ? CI ? CO ? BUN ? Creat ? GLUCOSE ? CA ? MG ? PHOS ? LFT'S ? AMYLASE ? LIPASE ? TROPONIN ? MYOGLOBIN ? UHCG ? UADIP ? U/A c MICRO ? Ur. C&S ? URINE DRUG SCREEN ? GC CULTURE ? CHLAMYDIA ? BLOOD CULTURE ? #1 ? #2 ? ETOH ? T&C UNITS ? T & S ? GLUCOMETER ? I STAT MUSCULOSKELETAL- MD INIT. TIME ORD. LOCATION: ? R: ? L: ? FRACTURE ? SPRAIN ? STRAIN ? CONTUSION ? DISLOCATION ? SPLINT F P ? CAST F P ? ACE ? ANKLE IMMOB ? KNEE IMMOB ? WRIST SUPPORT ? SLING ? SHOULDER IMMOB. ? C-COLLAR ? CAST SHOE ? CRUTCHES ? HAS OWN MD#: 46317 SEX: M VISIT DATE: 09/14/2003 VITAL SIGNS TIME TEMP PULSE R BP 02 SAT INIT. 0 C) G _?2 I ETIME ORPERED___,._ORTHOSTAtICVITALS MD INIT. TIME L riNG BP PULSE SITTING BP PULSE STANDING BP PULSE INVASIVE LINES El SALINE LOCK MD INIT. TIME ORDERED TIME ORD. MD INIT. SOL. RATE GAUGE SITE TIME DONE RN INIT. MISC. ? MONITOR TIME DONE FK,W ? 02SAT ? 02 ? EKG ? PEAK FLOW ? RESTRAINTS ? SECLUSION ? FOLEY SIZE AMT. COLOR CLARITY ? NGT/OGT SIZE EE LIS CONTENTS I ? GASTROCULT ? QC OK 1 ? HEMETEST ? QC OK X-RAY ORt*RS TIME{ (RiE RN 1W ? CXR ? KUB ? AAS F1 PELVIS ? CERVICAL SPINE ? CT SCAN ? SESTAMIBI ? ULTRASOUND ? DOPPLER ? MRI ? EXTREMITY: ? ECHO DR SIGNATURE fINIT. N R E SISIyA ?T?U,,n RE C C? I? DR SIGNATURE IjIT. AA, SIGNATURE INIT. MR 692 6/01 . PENNSTATE The Mg aa S. Husbay MsdiW Cana AUTHORIZATION FOR EMERGENCY TREATMENT AND RELEASE OF INFORMATION The undersigned has been informed of the emergency treatment considered necessary for the patient whose name appears on the reverse hereof (attached sheets, and stamped below or above) and that the treatment and procedures will be performed by physicians, members of the house staff and employees of the hospital. Authorization is hereby granted for such treatment and procedures. The undersigned has read the above authorization and understands the same and certifies that no guarantee of assurance has been made as to the results that may be obtained. The Penn State Milton S. Hershey Medical Center may disclose information about me and the treatment I am receiving, including copies of my medical record for purposes of treatment, payment, and medical center operations as described in our Privacy Notice. I acknowledge that the Penn State Milton S. Hershey Medical Center Privacy Notice has been. provided to me. INSTRUCTIONS: Please read all of the above. An authorization for emergency treatment must be signed before treatment can be given. Authorization must be signed by the patient, or by an authorized person in the case of a minor or when the patient is physically ormentally incompetent. DATE: f b? SIGNED-4 A.M. TIME: P.M. or Q (authorize person) Relationship to Patient: Witness: ( y? ? Privacy Notice Given-Patient unable to sign ? Privacy Notice Given-Patient declined to sign ? Other_ on S Hershey Medical Center - Emergency Department .niversity Drive Hershey, PA 17033 (717)531-8333 Patient: ZACHARY TAYLOR Medical Record Number: 95411 Date: 09114/2003 Time: 10:00 Discharge Instructions IMPORTANT: We examined and treated you today on an emergency basis only. This was not a substitute for, or an effort to provide, complete medical care. In most cases, you must let your doctor check you again. Tell your doctor about any new or lasting problems. We cannot recognize and treat all injuries or illnesses in one Emergency Department visit. If you had special tests, such as EKG's or X-rays, we will review them again within 24 hours. We will call you if there are any new suggestions. After you leave, you should follow the instructions below. You were treated today by KENNETH VANDER HAVE, MD. WEAR THE JEWITT BRACE AS DORECTED THIS INFORMATION IS ABOUT YOUR FOLLOW UP CARE Call as soon as possible to make an appointment in 6 WEEKS at the NEUROSURGERY CLINIC. You can reach the NEUROSURGERY CLINIC at (717)531-6955, UNIVERSITY HOSPITAL P.O. 850, HERSHEY, PA, 17031 This is a central appointment desk, called Careline, and they will help you set up your appointment at this clinic. If you have any problems or concerns before the appointment, call the Emergency Department. THIS INFORMATION IS ABOUT YOUR DIAGNOSIS COMPRESSION FRACTURE OF THE SPINE L2 A compression fracture of the spine is a break in one or more of the bones that make up the spine. These bones are called vertebrae. A compression fracture is a type of break in which the bone collapses, or becomes smaller. Compression fractures are usually caused by osteoporosis, a disease in which bones become weak. When you go home, follow these instructions: • Avoid lifting or bending. • Rest often. • Return to your normal activities when your doctor tells you your back is healed well enough to do so. • Wear your back brace or support as instructed by your doctor. • Take your medications exactly as prescribed. • Keep follow up appointments with your doctor. • Ask your doctor if you need treatment for osteoporosis. Call your doctor if: • You have increased pain. • Your pain medications are not helping your pain. • You have weakness, numbness, or tingling in your arms or legs. • You have trouble controlling your bowels or bladder. • You have any questions or concerns. Portions Copyrighted 1987-2003, LOGICARE Corporation Page 1 of 3 The Milton S Hershey Medical Center - Emergency Department 500 University Drive Hershey, PA 17033 (717)531-8333 Patient: ZACHARY TAYLOR Medical Record Number: 95411 Date: 09/14/2003 Time: 10:00 THIS INFORMATION IS ABOUT YOUR MEDICINE HYDROCODONE & ACETAMINOPHEN (Vicodin, Lortab). Take this medicine by mouth in the following dose: 1-2 TEASPOONS every 4-6 hours if needed for pain. This is a mixture of medicines used to relieve pain. Side effects may include: sleepiness, upset stomach or constipation (hard stools). Allergy would show up as: rash or itching, wheezing or shortness of breath. This medicine can be habit forming if used for a long period of time. Follow these instructions: • Talk to your doctor before taking other medicines (including over-the-counter medicines). • Sit or stand slowly to avoid dizziness. • Take this medicine with food or milk to avoid an upset stomach. • Store this medicine away from heat, moisture or direct light. • Watch for signs of dependence. They include: • feeling that you "cannot live without this medicine". • you need more of this medicine than before to get the same relief. • Do not drink alcohol, drive or operate machinery while taking this medicine. Call your doctor if you have: • any sign of dependence. • any sign of allergy. • increased pain not helped by the pain medicine. • any new or severe symptoms. CIGARETTE SMOKING. This is surely America's greatest health problem! The facts are clear that cigarette smoking will shorten your life. Smoking can cause many illnesses along the way. If you need help to quit smoking, talk to your regular doctor. SEATBELTS. There is no doubt that seatbelts save lives. Every day people without seatbelts are more severely hurt. Buckle up to reduce your chances of injury. YOU ARE THE MOST IMPORTANT FACTOR IN YOUR RECOVERY. Follow the above instructions carefully. Take your medicines as prescribed. Most important, see a doctor again as discussed. If you have problems that we have not discussed, call or visit your doctor right away. If you cannot reach your doctor, return to the Emergency Department. SATISFACTION SURVEY. It's been a privilege for us to care for you. You may receive a survey in the mail. We hope you will be able to take a few moments to complete the survey. It helps us to improve service and reward staff. We like to post the surveys for all the staff to see. CHECK OUT. Portions Copyrighted 1987-2003, LOGICARE Corporation Page 2 of 3 The Milton S Hershey Medical Center - Emergency Department 500 University Drive Hershey, PA 17033 (717)531-8333 Patient: ZACHARY TAYLOR Medical Record Number: 95411 Date: 09114/2003 Time: 10:00 PLEASE FOLLOW THE BLUE ARROWS OUT TO THE REGISTRATION/CHECK OUT AREA. THE MEDICAL OFFICE ASSOCIATES WILL NEED TO VERIFY INSURANCE INFORMATION WITH YOU PRIOR TO YOU LEAVING THE DEPARTMENT. "I have received this information and my questions have been answered. I have discussed any challenges I see with this plan with the nurse or physician." ZACHARY TAYLOR or Responsible Person ZACHARY TAYLOR or Responsible Person has received this information and tells me that all questions have been answered. RN Staff Signature Portions Copyrighted 1987-2003, LOGICARE Corporation Page 3 of 3 Med Outpt Note TAYLOR, ZACHARY J - 95411 * Final Report * OUTPATIENT NOTE PATIENT NAME: TAYLOR, ZACHARY PATIENT NUMBER : 0095411 SEX: M DATE OF SERVICE: 09/16/2003 DATE OF BIRTH: 10/11/1971 SUBJECTIVE: The patient presents to Cherry Drive on September 16, 2003 for complaint of motor vehicle accident on Saturday with a diagnosed fracture of L1 on the anterior superior lip. Mom states that the patient was laying on the backseat, not belted in the rear of a rented Cadillac on their way to a wedding in Virginia. Mom states that a car hit their vehicle in the passenger rear causing their car to fish out and actually go up over an embankment. The patient's mother states that the patient did not have loss of consciousness. Pt. complained of low back pain per mom. He was taken by ambulance to the Bethesda Emergency Department. At that facility, he had x-rays that revealed a fracture of L1. The patient's mom spoke to the triage nurse here and she recommended to be seen at the Hershey Medical Center Emergency Department. They had a CT scan of Zachary's back showing the L1 fracture on the anterior superior lip. At that time, the patient was seen by a neurosurgeon and given a back brace at Hershey Medical Center and also prescribed a hydrocodone syrup. The neurosurgeon would like to have Zachary reevaluated in approximately six weeks. Mom states she has been giving Zachary the hydrocodone every four to six hours for pain. She has been giving him one to two teaspoons every 4- hours. Today, she did give him two teaspoons. The patient also complains of left toe pain and right shoulder pain. The patient denies any numbness or tingling. OBJECTIVE: On physical exam, weight is 243 pounds, blood pressure is 100/74, pulse is 80, and temperature is 97.1 degrees. Patient appears in no acute distress. Heart has a regular rate and rhythm. Lungs are clear to auscultation with good breath sounds throughout. The patent has good range of motion of the cervical spine. EOMs are intact. Pupils are round and reactive to light. Ears: TMs are without erythema. Throat is without erythema. The patient can abduct his arms to 180 degrees. The patient can flex and extend his knees, his ankles and his hips without any difficulty. The patient's back is nontender to palpate throughout the vertebrae, nontender to palpate in the paravertebral areas. The patient does have some ecchymoses at the right AC joint. The left great toe is ecchymotic and edematous. Mom states this toe was x-rayed but it was negative for fracture. Abdomen is obese. The patient is tender to palpate in the left shoulder as well, but there is no ecchymosis, erythema or edema. Legs are nontender to palpate. ASSESSMENT: 1. Fracture of 1.1_ on anterior superior lip. 2. Right shoulder contusion. 3. Left great toe contusion. PLAN: The patient can continue the hydrocodone as directed. He should rest, continue to wear the back brace as prescribed, and keep the follow-up appointment that they have with Dr. Bollard next week. The patient was also Printed by: Shiner, Crystal L Page 1 of 2 Printed on: 4/12/2004 9:09 AM (Continued) Med Outpt Note TAYLOR, ZACHARY J - 95411 given a referral to Behavioral Health. He requests therapy because of posttraumatic stress disorder. #217725 DICTATING MD: Denise L Beltowski, PA-C ATTENDING MD: Edward R. Bollard, MD Assistant Professor of Medicine DLB/dts D: 09/16/2003 T: 09/18/2003 12:40 Printed by: Shiner, Crystal L Page 2 of 2 Printed on: 4/12/2004 9:09 AM (End of Report) Med Outpt Note TAYLOR, ZACHARY J - 95411 * Final Report * OUTPATIENT NOTE PATIENT NAME: TAYLOR, ZACHARY PATIENT NUMBER: 0095411 SEX: M DATE OF SERVICE: 09/29/2003 DATE OF BIRTH: 10/11/1971 SUBJECTIVE: Patient presents today status post motor vehicle accident approximately two weeks ago. The patient was an unbelted passenger in the backseat who was lying down. Apparently, he was struck at the level of his feet on the passenger rear door. It did throw him forward into the seat. He complained of some back pain alo4g with right knee and right shoulder pain. He was subsequently found to have a small fractured L1 vertebrae. He has been placed in a splint by Orthopaedics. He states the splint is often uncomfortable to him as far as his flank is concerned. Otherwise, he does not seem to be having many difficulties. His shoulder pain and knee pain are gradually improving. He had an episode of increasing diarrhea and abdominal pain apparently around the accident and then with a visit from his father. This has gradually improved since starting on his Prednisone therapy. His pain is adequately controlled with the liquid Hydrocodone and the prednisone therapy. His current medications include valproic acid 750 mg t.i.d., Macrodantin 50 mg q day (25 mg per 5 cc), multivitamin q day, vitamin C 500 mg q day, Hydrocodone liquid 5 cc q six hours p.r.n. pain, Prednisone 20 mg q.a.m. with food. OBJECTIVE: His weight today was 240 pounds. Blood pressure 100/80. Pulse 72. Temperature 97.1. The patient is wearing his splint today. He otherwise is in no acute distress. His right shoulder had some point tenderness over the acromion but no bony deformity. He had difficulty with lateral extension secondary to the pain. He otherwise was neurovascularly intact. His right knee showed no effusion at this time. He had no point tenderness over his lumbar spine. ASSESSMENT/PLAN: 1. Orthopaedics - L1 fracture in current immobilization secondary to motor vehicle accident. He will follow up with Orthopaedics for this. His pain control is adequate. It is improved with the Prednisone and that, of course, will be tapering over the next two weeks. He will also be tapering his Hydrocodone as tolerated. 2. GI - Inflammatory bowel disease/ulcerative colitis. Patient seems to have a flare that was initiated by the stress of this situation. He seems much improved from an abdominal pain and diarrhea standpoint. There has been no bright red blood per rectum. We will continue to taper this on a clinical basis. He was not able to tolerate the 40 mg as I had previously suggested. Follow up to see the patient back in the office in two to three months. Printed by: Shiner, Crystal L Page 1 of 2 Printed on: 4/12/2004 9:09 AM (Continued) Me Outpt Note PENDING LABS AND STUDIES: None. #228218 DICTATING MD: ATTENDING MD: Edward R. Bollard, MD Associate Professor of Medicine ERB/mts D: 09/30/2003 TAYLOR, ZACHARY J - 95411 T: 09/30/2003 18:34 Printed by: Shiner, Crystal L Page 2 of 2 Printed on: 4/12/2004 9:09 AM (End of Report) PENNSTATE ` JU Milton S. Hershey Medical Center I P? College of Medicine PROGRESS REPORT-OPHTHALMOLOGY NAME: TAYLOR, ZACHARY MD: QUILLEN DAVID A MR#: 85411 DOB: 10/11/1871 INS: MEDICARE LOC: OPH1 008#: 3828775 MD#: 85650 SEX: M STANDARD VISIT DATE: 10/20/2003 DATE TIME PROGRESS NOTES ? INPATIENT OUTPATIENT NAME - TITLE Ophthal ology - It? 2? U3 I ?'. doF 1,44 -? 1Aj sv ,? Lol fr?OGf MR 6.8 (2/03) PROGRESS REPORT-OPHTHA OLOGY Med Outpt Note * Final Report * OUTPATIENT NOTE PATIENT NAME: PATIENT NUMBER: SEX: M TAYLOR, ZACHARY J - 95411 TAYLOR, ZACHARY 0095411 DATE OF SERVICE: 11/10/2003 DATE OF BIRTH: 10/11/1971 DATE OF BIRTH: 09/11/1971 HISTORY: The patient presents to Cherry Drive on November 10, 2003, for complaint of abdominal pain, right shoulder pain, and right side pain. The patient also complains of pain in the left great toe since his motor vehicle accident. Mom states that the pain in the right abdomen is due to his brace that he was wearing. He only wore the brace for approximately 2 weeks. She states that the pain has been intermittent and he does take Tylenol for the pain, but when he requests pain medication, she does give him the hydrocodone. PHYSICAL EXAMINATION: On physical exam, the patient's weight is 242.5, blood pressure is 100/60, pulse is 68, temperature is 96.7. On physical exam, the patient appears in no acute distress. He ambulates without any difficulty. He shows me his left great toe. There is no obvious edema. No ecchymosis. There is no edema. When I palpate the toe at the MCP joint, the patient complains of pain, but when he is distracted, the area is nonpainful to palpate. The patient has good flexion and extension of the left great toe. On physical exam, heart is regular rate and rhythm. Lungs are clear to auscultation. The patient's right ribs are nontender to compression. Abdomen is obese. It is nontender to palpate throughout. There is no ecchymosis. There is no erythema. No edema. The right abdominal pain is not reproducible on physical exam. ASSESSMENT: Left great toe trauma. The patient will have the left great toe x-rayed. PLAN: Monitor the patient for increased signs and symptoms. The patient has a followup appointment with Dr. Bollard in approximately 1 week. I advised the patient to keep that appointment and he can review the abdominal pain at that time. 260765 DICTATING MD: Denise L Beltowski, PA-C ATTENDING MD: Edward R. Bollard, MD Associate Professor of Medicine DLB/cbt D: 11/10/2003 T: 11/12/2003 15:54 Printed by: Shiner, Crystal L Page 1 of 1 Printed on: 4/12/2004 9:08 AM (End of Report) Toe XR * Final Report * CHERRY DRIVE X-RAY TOE 1ST DIGIT LEFT GREAT PATIENT NAME: TAYLOR, ZACHARY JOHN PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 11/10/2003 EXAM NUMBER: 85051 ORDERING PHYSICIAN: BOLLARD, EDWARD TAYLOR, ZACHARY J - 95411 AP, LATERAL, AND OBLIQUE RADIOGRAPHS LEFT GREAT TOE, 10 NOV 2003 History: Left great toe pain Discussion: There are no comparison films Findings: There is no acute fracture or dislocation. There is a rounded smooth oval ossification lateral to the interphalangeal joint, possibly from old trauma. Joint spaces are otherwise within normal limits. Impression: There is no radiographic evidence of acute bony abnormality of the left great toe. Dr. Janet Neutze reviewed the images and discussed the interpretation with Dr. Michael Feightner. DICTATED: NEUTZE, JANET REVIEWED AND SIGNED: NEUTZE, JANET / DATE DRAFTED: 11/10/2003 01:50 PM DATE OF FINAL SIGNATURE: 11/11/2003 02:58 PM Printed by: Shiner, Crystal L Page 1 of 1 Printed on: 4/1212004 9:08 AM (End of Report) Surg Outpt Note TAYLOR, ZACHARY J - 95411 * Final Report * OUTPATIENT NOTE PATIENT NAME: TAYLOR, ZACHARY PATIENT NUMBER: 0095411 SEX: M DATE OF SERVICE: 11/11/2003 DATE OF BIRTH: 10/11/1971 HISTORY: The patient returns to the Neurosurgery Clinic today. He is a 31-year-old man who was involved in a motor vehicle accident and seen in the emergency department here for an Ll anterior body fracture. A brace was given to him for alleviation of his back pain. The brace did seem to alleviate his back pain, but he thought it was too constricting on the sides and produced some flank pain. Therefore, he discontinued using the brace after its use for a few weeks. At the time of today's clinic visit, he feels that both the back and the flank pain have improved although the flank pain is still present. PHYSICAL EXAMINATION: On examination today, he has a somewhat decreased range of motion in the low back in all planes. There is no paravertebral muscle spasm or tenderness. His neurological examination in the lower extremities is unremarkable with normal strength and reflexes. IMPRESSION: The impression at the present time is that the patient is doing well status post Ll compression fracture. PLAN: I told him I did not have a good explanation for his flank pain. I do not see any neurological concerns here. I will be seeing him on a p.r.n. basis. 262052 DICTATING MD: ATTENDING MD: Robert Harbaugh, MD REH/cbt D: 11/11/2003 T: 11/13/2003 12:58 c: Edward R. Bollard, MD H039 Printed by: Shiner, Crystal L Page 1 of 1 Printed on: 4/12/2004 9:08 AM (End of Report) PENNSTATE PM Milton S. Hershey Medical Center ® College of Medicine Head and Neck Surgery Penn State Milton S. Hershey Medical Center Tel: (717) 531-8945 Division of Otolaryngology Penn State College of Medicine Fax: (717) 531-6160 Head and Neck Surgery Division of Otolaryngology, H091 500 University Drive, P.O. Box 850 Hershey, PA 17033-0850 Fred G. Fedor, MD November 11, 2003 Chief, Professor Facial Plastic and Reconstructive Surgery Brendan C. Stack, Jr., MD, FACS Edward Bollard M.D. Associate Professor Head and Neck Surgery Division of General Intemal Medicine H015 Mic•rovascular Reconstructive Surgery Penn State Hershey Medical Center 500 University Drive Jon E. Isaacson, MD Hershey, PA 17033 Assistant Professor Neurotology & Otology RE: TAYLOR, ZACHARY iele Carr, DDS MD MSHMC#: 095411 associate Professor Pediatric Otolaryngology Dear Dr. Bollard: Johnathan D. McGinn, MD Assistant Professor Otolaryngology-Head and Neck Surgery At your request, I had the opportunity to evaluate Zachary Taylor. As you recall, he is a 32-year-old gentleman who is cognitively impaired. He lives with his mother who attended today's office visit. t.:e•trge H. Conner, MD She is very helpful in the interview process. She is concerned that Zachary may have lost some t_ rentus Professor hearing recently. He has a long history of hearing loss, although in the last few years it has been j:•fe L Bentz, MF4 PA-C getting worse and he has been wearing hearing aids bilaterally for the past three years. More recently Clinic manager he was involved in a motor vehicle accident. He was the back seat passenger in a motor vehicle accident the occurred in September 2003. He did not lose consciousness and did not suffer a head Julie A. Rhoades, AuD Erica D. Colt, MS, CCC-A injury, although he did suffer a spinal fracture and had to wear a back brace. His mother reports that l) Michele Gerrish, AuD he has had significant additional hearing loss since then. He has not had any recent infections or Audiology drainage. A thorough review of systems and past medical history was performed and is documented Came Ruggiero, M$ CCC-SLP in our hospital chart. Speech Pathologist Physical examination revealed a mildly obese white male appearing older than his stated age. The cranium was normocephalic and atraumatic. Extraocular motility was intact. The tympanic membranes were clear and mobile bilaterally. The nasal and oral mucosae were without lesions. The a septum was in the midline. Dentition was good. His voice was normal. His neck was without adenopathy or thyromegaly. An audiogram revealed a severe to moderately severe sensorineural hearing loss bilaterally with symmetric speech discrimination scores. There did appear to be a slight drop in the hearing in the right ear. My impression is that Zachary does have bilateral severe hearing loss and might require a boost of his current hearing aids. I sent him over to the audiologists so that they can perform that task. Otherwise I see nothing else medically for me to offer him and have not made plans to see him again. I have released him back to your care. Please feel free to call if you have further questions. Sincerely, --? GC1 C-1 Jon E. Isaacson, M.D. Assistant Professor Neurotology & Otology JEl:pf D:11/11/03 R&T: 11/13/03 cc: Medical Records An Equal Opportunity University PENNSTATE 19 Milton S. Hershey Medical Center College of Medicine DIVISION OF OTOLARYNGOLOGY HEAD AND NECK SURGERY NAME: TAYLOR, ZACHARY MD: ISAACSON JON E MRN: 95411'- DOS: 10/11/1971 INS: MEDICARE LOG: 8200 DOSM: 3817279 MD#: 25105 SEX: M STANDARD VISIT DATE: 11/11/2003 SOCIAL HISTORY, (Please Circle) *If pt is a child answer these questions At the liar nts MaritaiStatu$- i J Married, /. Divorced /h-Widowed Patient's Ag - " tl mo"` yes - Cwaren- des, # of childRnlf r I " Who lives in the housefiold.with,you? r> Occupation (if retiud, previous occupation):' - r-- Do your smoke? No /. Yes - `- # of packs i£." es't J # of yea a` If the patient is a rnttior, are they o used to smoke?- Yes DQ you drink alcohol?&I / Yes :.How m h? I7o you (or have you ever) abused drugs? a J Yes / QujL ' Explain: 4tive you ebir been physically or emi tion abused? No Whatlan uage do you best understand? How do *46u hest le' rrt? Written g erbal : ' eo PAST SURGERIES / HOS ITAI"T7 ? NS: FAMILY MEDICAL HISTORY (Please answer "yes" or "no") Can. .cer= ' Stroke- Hypcrtension- 'Asthma- Diabetes- Seizures- , .._? .. eartAttack, Heartbisease- `Other- . °; PAS MEDI -AL HISTORY' REVIEW OF SYSTEMS Do o u have or Did you ever have? Y N Problem Comments Y- N Problerni Comments. Asthma wheezin Unusual Muscle Weakness umbness Chronic bronchitis em s ma ' Chro" " Fa " Pneumonia Mdne stones urihar disease bladder problem(s) " . :;Chro'tuc,sinus nasal problems He" atias Liver disease Chronic ear Rain, draina a hearing loss HIV AIDS :Voice or swallowing problems Unintentional *ei t loss or R-a iri Sleep apnea (stop breathing during Persistent nausea diarrhea _ Rhout iatic fever Heartbur i Watal hernia reflux Heart murmur" Blcoditigg tetideic « Ir" ar heartbeat Skin `roblems r `Che?c Pain Diabetes Heart"attack heart failure Th oid'disehae told mass H eitension (high blood pressure) Arthritis, Bone or Joint problems ' . $ co e fainti s ells CHILDREN: -=. Seizures a 'ile s Immunizadotis to date Chronic headaches Other: '. Stroke Ministroke Medications: Allergies: ?? G .,L Or-A Latex allergy: Aspirin/Blood thinner: Yes f No Are you (or the patient) experiencing any pain today? No ? Yes `^"`• Comments: 't History obtained from: atien Family Attendant Staff Signature:" v REVIEWED BY PHYS IAN: M.D. DATE: MR 853 (Rev. 8/03) Page 1 of 2 MEDI L T AND QUESTIONNAIRE /?/? C/-4-13 PHYSICAL EXAM: (check normal or abnormal) i Chief 414aint: t/ f co Vital Signs: wt ht? BP, T_ P_ R, Normal Aurlurrndr General Appearance - Well Nourished, Well Developed ? es -Pupils, Lids, Sclera conjunctivae Ii tory of Present Illness: Ears - canals, Tympanic Membranes, heating ? Nose - septum, turbinates, mucosa ? -- r ? Oral Cavity-lips, gums, teeth, tongue, palate, tongue, ? tonsils, floor of mouth Labs, Records, X-rays, Tests: C< ?? ?? ? F-] Pharynx /Larynx Voice Procedures Done with Visit: (Flexible, Rigid, Strobe, Biopsy) ? Neck - Masses, Thyroid ? ? Respiratory/Lungs ? ? Cardiovascular - Rhythm, Carotids, Murmurs ? DX: Follow-up Plan: Abdomen ? ? Skin - color, lesions ? ? Neurologic - Cranial Nerves II-XII intact, gait ? Time Discussing Plan: Return Status: ? Psychiatric -judgement, Affect, Orientation ? Drawine'._ '?S? its. ` JON E. ISAACSON, M.D. 12/01 Dictated (circle if done) Physician Signature: D. Resident Signature: , M.D. MR 853 (Rev 6102) Page 2 of I OF OTOLARYNGOLOGY-HEAD AND NECK SURGERY NAME :_._.._ _. __ ...?._. NAME: TAYLOR, ZACHARY MD: ISAACSON JON E MDM: 25105 ID: MRM: 95411 DOS: 10/11/1971 SEX: M _, __. _..... INS: MEDICARE STANDARD LOC: S200 j TESTER:_, OOS#. 3817279 VISIT DATE: 11/1112003- DATE/TIME: 11/11/2003 01:57 pm GSI TYMPSTAR MIDDLE EAR ANALYZER PROBE S/N: 20010867 TYMP SCREENING TEST 1 Ytm 226 Hz R ml 1.5, 1.0 0.51 0.0 . i -400 -200 0 +200 +- 600/200daPa/s daPa EARCANAL VOLUME: 1.4 daPa ml TYMP 1: 10 0.4 GRADIENT: 7S daPa REFLEX: I 1000 HZ NT TYMP SCREENING TEST 2 Ytm 226 Hz L ml 1.0 0.5 0.0.1 MR 109 Rev 7/01 Pg 1 of 2 -400 -200 0 +200 ?+- 600/200daPa/s daPa EARCANAL VOLUME: 1.8 d?aP?a ml TYMP 1: o-? 1S 0.3 GRADIENT: 60 daPa REFLEX: I 1000 Hz NT Med Outpt Note * Final Report * OUTPATIENT NOTE TAYLOR, ZACHARY J - 95411 PATIENT NAME: TAYLOR, ZACHARY PATIENT NUMBER: 0095411 DATE OF SERVICE: 11/17/2003 SEX: M DATE OF BIRTH: 10/11/1971 PLACE OF SERVICE: Cherry Drive Internal Medicine SUBJECTIVE: The patient presents today for evaluation of his multiple musculoskeletal complaints status post motor vehicle accident. He did suffer a spinous compression fracture. His back pain seems to be minimal. However, he continues to complain of some right flank pain. He did not seem to have a pleuritic component. It seems to be more positional in nature. Also, he complains of left great toe pain that resulted from the accident. Previous plain films of the toe had been negative. His current medications include valproic acid 250 mg/5 cc 15 cc t.i.d., Macrodantin 25 mg/5 cc 10 cc q.d., multivitamin q.d., hydrocodone 5 mg/5 cc; he is taking 5 cc q.6h. p.r.n. pain, prednisone taper that is now completed. OBJECTIVE: His weight today was 237 pounds, down 5 pounds in the last week, blood pressure was 96/68, pulse 88, temperature 98.0 degrees Fahrenheit. His right flank showed no ecchymosis. There was no abdominal tenderness. I applied AP and lateral pressure to his rib cage without any symptomatology. There was no rub. Great toe showed some mild tenderness at the DIP joint. There was no erythema or warmth. He had normal movement of the other joints. There appeared to be no bony deformity. His plain films were reviewed that were unremarkable of his great toe. ASSESSMENT AND PLAN: 1. Orthopedics - status post multiple musculoskeletal trauma from motor vehicle accident - the patient was in the rear seat at the time of the accident and obviously he had sustained multiple contusions. However, no other fractures appear to be evident except that of his spinous process (refer to previous notes). I encouraged him to just continue activity as tolerated and these should be resolved over time. 2. Neurology - myoclonic movement disorder - the patient is due to have his valproic acid level checked. I wrote for this today. FOLLOW-UP: I will see the patient back in the office in four to six months. PENDING LABS AND STUDIES: Valproic acid level. #267333 DICTATING MD: ATTENDING MD: Printed by: Shiner, Crystal L Page 1 of 2 Printed on: 4/12/2004 9:08 AM (Continued) Med Outpt Note Edward R. Bollard, MD Associate Professor of Medicine ERB/dts D: 11/18/2003 T TAYLOR, ZACHARY J - 95411 11/18/2003 20:51 Printed by: Shiner, Crystal L Page 2 of 2 Printed on: 4/12/2004 9:08 AM (End of Report) Patient: TAYLOR, ZACHARY J Flowsheet Print Request MRN: 95411 Date Range: 9/12/2003 9:07 AM - 4/13/2004 9:07 AM Results 11/1 7/2003 1 R 1?IU 102 H P+LT-,. 39 T Bili 0.4 Ak Fhos 65 of IULDL 'uHDL ?UChol/HDL LJTG , . i Head/Neck SPlne, IMu*Woske otal Outpt Ltr Printed by: Shiner, Crystal L Printed on: 4/12/2004 9:07 AM Page 1 Patient: TAYLOR, ZACHARY J Flowsheet Print Request Printed by: Shiner, Crystal L MRN: 95411 _ Date Range: 9/12/2003 9:07 AM - 4/13/2004 9:07 AM Printed on: 4/12/2004 9:07 AM Results 2/121212/2 -U AM 97 MALT' JT Bill :Ik Rhos :.:. JChol 227 H IILDL 139 H IHDL 51 lCh6VHDL 4.5 TO ..', ; 185 Heattl/Neck - Spine M Ilos"tel Outpt Note' Outpt`Ltr Page 1 Med Outpt Note OUTPATIENT NOTE PATIENT NAME : PATIENT NUMBER: SEX: M * Final Report * TAYLOR, ZACHARY J - 95411 TAYLOR, ZACHARY 0095411 DATE OF SERVICE: 12/23/2003 DATE OF BIRTH: 10/11/1971 HISTORY: The patient presents today in a Santa suit. He is here for evaluation of his recent motor vehicle accident and nephrolithiasis. He is questioning whether or not he can do some cross-country skiing. He really denies any other complaints except for some intermittent back pain. His current medications include valproic acid 250 mg/5 cc's. He is taking 15 cc's t.i.d., Macrodantin 25 mg/5 cc's, 10 cc's q.d., multivitamin q.d., hydrocodone 5 cc's q 6 hours p.r.n. and there's 5 mg of hydrocodone/5 cc's, prednisone taper per ulcerative colitis. The patient is not taking it at this time. PHYSICAL EXAMINATION: Weight today is 235 pounds, which is down 7 pounds over the last month, blood pressure 102/70, pulse 88, temperature 96.4. His lungs were clear to auscultation bilaterally. There was no point tenderness over his spinous processes. Cardiac was regular rate and rhythm. There are no pending labs today. IMPRESSION: 1. Cardiovascular - obesity - poor exercise tolerance. The patient has not had a baseline lipid panel in over five years. It was ordered today. I did encourage him to begin cross-country skiing if possible. We discussed some mechanisms to purchase his skis. I believe this would be low impact and very beneficial for his compression fractures and his weight. 2. Urology - nephrolithiasis. The patient has been stable at this time. There has been discussion about having them surgically removed. He is holding off at this time. FOLLOW-UP: I will see the patient back in the office in 3-4 months. PENDING LABS AND STUDIES: Fasting lipid panel and glucose. #298705 DICTATING MD: ATTENDING MD: Edward R. Bollard, MD Associate Professor of Medicine ERB/dts D: 12/23/2003 T: 12/23/2003 15:33 Printed by: Shiner, Crystal L Page 1 of 1 Printed on: 4112/2004 9:08 AM (End of Report) Med Outpt Note OUTPATIENT NOTE PATIENT NAME: PATIENT NUMBER: SEX: M TAYLOR, ZACHARY J - 95411 * Final Report * TAYLOR, ZACHARY 0095411 DATE OF SERVICE: 01/30/2004 DATE OF BIRTH: 10/11/1971 SUBJECTIVE: The patient presents for back pain and left shoulder pain. The patient is a 32-year-old male with mental retardation who was recently in a motor vehicle accident in September of 2003 with a compression fracture who presents with continued low back pain and left shoulder pain. His mother states that this pain has been worse over the last week after sitting on the floor for a period of time. The patient cannot give an exact quantity to the pain. He states he does have significant pain with lifting his left arm. OBJECTIVE: On physical exam, he was afebrile, his pulse was 72, and blood pressure was 100/62. Generally, he was pleasant in no apparent distress. Back exam revealed tenderness to palpation over his compression fracture area with some mild paravertebral tenderness. Shoulder exam revealed tenderness at the subacromial bursa to palpation with tenderness with active and passive range of motion of the left shoulder. There was no obvious warmth. ASSESSMENT AND PLAN: 1. Compression fracture. The patient is currently getting narcotics at night for his pain. It seems to be worsening and continued for a prolonged period of time. At this point, I will not change any management but we may consider in the future, if he does not have significant improvement, possible kyphoplasty for realignment of his vertebral height. 2. Left shoulder subacromial bursitis. The patient cannot take pills but will take Motrin liquid over-the-counter three times a day with food over the next one to two weeks to decrease inflammation. I spoke with his mother about this on the phone and she will call if he has any worsening of his pain. Otherwise, they will follow up with Dr. Bollard at their next scheduled appointment. #331642 DICTATING MD: ATTENDING MD: Jennifer P. Goldstein, MD JPG/dts D: 01/30/2004 Printed by: Shiner, Crystal L Printed on: 4/12/2004 9:08 AM T: 02/02/2004 10:23 Page 1 of 1 (End of Report) .Outpt Note * Final Report * OUTPATIENT NOTE PATIENT NAME: PATIENT NUMBER: SEX: M TAYLOR, ZACHARY J - 95411 TAYLOR, ZACHARY J 0095411 DATE OF SERVICE: 03/22/2004 DATE OF BIRTH: 10/11/1971 SUBJECTIVE: The patient presents with his mother today to discuss his ongoing back pain related to his traumatic L1 compression fracture. As previously noticed, the patient sustained this fracture in a motor vehicle accident last year. He has continued with persistent pain requiring narcotic analgesics. He denies any other new complaints today. His current medications include valproic acid 250 mg/5 mL, the patient takes 750 mg t.i.d.; Macrodantin 25 mg/5 mL, the patient takes 50 mg daily; multivitamin daily; and hydrocodone 5 mg/5 mL, the patient is taking 5-10 mg every 6 hours p.r.n. back pain. OBJECTIVE: His weight today was 248 pounds, which is up another 12 pounds over the last two months. Blood pressure 96/72, pulse 72, and temperature 97. No other exam is performed at this time. I reviewed with the patient the diagnosis from the possibility for the vertebroplasty. I gave him a brochure on this. ASSESSMENT AND PLAN: Orthopedics - traumatic compression fracture of L1 with persistent pain - he is going to follow up with Dr. Jonas Sheehan to see if he is a candidate for the vertebroplasty. He will continue on the hydrocodone 5-10 mg every 6 hours as needed. I encouraged him to attempt to lose weight given the increasing weight will not help with his symptomatology, whatsoever. FOLLOW UP: I will see the patient back in the office in 3-4 months. PENDING LABS AND STUDIES: None. 384163 DICTATING MD: ATTENDING MD: Edward R. Bollard, MD Associate Professor of Medicine ERB/cbt D: 03/22/2004 T: 03/24/2004 16:41 Printed by: Shiner, Crystal L Page 1 of 1 Printed on: 411212004 9:08 AM (End of Report) Surg Ltr * Final Report * March 24, 2004 Dr. Edward R. Bollard UPG-Internal Medicine 670 Cherry Drive Hershey, PA 17033 RE: Zachary J. Taylor MSHMC# 095411 Dear Dr. Bollard: TAYLOR, ZACHARY J - 95411 I saw Zachary Taylor in the neurosurgery clinic today in conjunction with Kristine Kuzma, APRN, BC. As you know, Mr. Taylor is a 32-year-old gentleman who was referred to us for a chief complaint of intermittent low back pain and an L1 anterior body fracture. He was in a motor vehicle accident on 9/13/03 in which his car was T-boned on the passenger's side. This occurred in Virginia in the evening while on the way to a relative's wedding. At that time, he had x-rays done which showed an anterior body fracture of L1. He was given a back brace to wear. The brace did help to decrease his pain, but he did not wear it all the time due to flank pain. He denies any leg pain. On rare occasions he has some tingling down the legs. He had one episode where he fell coming out of a movie theater, but he states his "knees gave out." The patient's past medical history, past surgical history, medications, allergies, family history, social history, and review of systems have been obtained, confirmed, and documented in the patient's medical record. On physical examination today, his gait is normal. He can tandem walk without any difficulty. Sensory examination is normal to touch and pin in the lower extremities. On motor testing, his strength is 5/5 in all muscle groups individually tested in the lower extremities. Deep tendon reflexes are 1+ and symmetrical at the knees and ankles with toes downgoing. There is no evidence of clonus. I reviewed his plain films from September. He has had no studies more recent than that. There is a small anterior superior chip fracture at L1. We're going to repeat his plain films today and make sure that his fracture has healed. A kyphoplasty is usually not a good idea in healthy dense bone with traumatic fractures. The procedure is more likely to be beneficial in osteoporotic bone with compression fractures. We're going to send him for the films today and make sure things look okay. I think some physical therapy might be helpful. Thank you very much for sending this pleasant young man to me. Please feel free to call with any questions or concerns you may have. Reviewed & Electronically Signed By: Jonas M. Sheehan, MD Assistant Professor of Neurosurgery JMS:gcc F:\taylorz032404 Printed by: Shiner, Crystal L Page 1 of 2 Printed on: 4/12/2004 9:07 AM (Continued) Surg Ltr Printed by: Shiner, Crystal L Printed on: 4/12/2004 9:07 AM TAYLOR, ZACHARY J - 95411 Page 2 of 2 (End of Report) OUTPATIENT SERVICES REGISTRATION +-----------+---------------------------+------------+-------------+---+------+ Med Red# Patient Name Soc Sec # Pat Phone ISexiMaritll 100095411 (TAYLOR ZACHARY J 1185-68-9025 1717 612-0309 M S +-----------------------------------------------------------------------------+ Patient Address 2100 CEDAR RUN DR 204 +-------+-----------------------+--+----------+-------------+-----------------+ I21tY ICAMPeHILLlty IPAI17011STZip ode I11Birth 0/11/D1971 1717 e979-1642one: I +-------------------------+------------+------------------------+-------------+ Patient Employer Emp Phone Guarantor Name Guar SSN I TAYLOR ZACHARY J 1185-68-9025 I +--------------------+--+-------------------------+---------------------------+ Employer City ISTIPatient Occupation 12100 Guarantor Address 1 +---------------------------+---------------------+---------------------------+ I Guarantor's Employer I Guar Emp Phone I Guarantor Address 2 tI +---------------------------+--+------------------+------------------------+--+ 1Guar Emp City 1STIGua17r612Phone0309 7ICAMPGuaraHILL ntor City: IPA( +--------------------------------------------------------------------------.--+ PRIMARY CARE PHYSICIAN BOLLARD EDWARD R MD 33020 PO BOX 850 UNIVERSITY HOSPITAL HERSHEY PA 17033-0850 PHONE: 717 531-8161 FAX: +--------------------------------------+--------------------------------------+ Referring Physician BOLLARD EDWARD R PO BOX 850 UNIVERSITY HOSPITAL HERSHEY Phone: 717 531-8161 Fax: MD PA 17033-0850 33020 Attending Physician SHEEHAN JONAS M MSHMC-NEUROSURGERY 500 UNIVERSITY DRIVE HERSHEY Phone: 717 531-8807 Fax: MD PA 17033-0000 89110 +-----------------------------------------------------------------------------+ Insurance Information AUTO INSURANCE PAE300165086 ADJ DAN PETTY AD09132003 MEDICARE 185689025A +---------------------------+--------------------------------------------------+ Visit Date: 03/24/04 + ------------------------------------------------- + +----------------------------------------------------------------------------- + Nearest Relative: ARMSTRONG DANA Relationship: MOTHER PO BOX 10525 Phone: 612-1655 Bus Phone: EXT: HARRISBURG, PA 17105 Notify in Emergency? Y +-----------------------------------------------------------------------------+ Form: MR86 IS THIS THE RESULT OF A SPECIFIC ACCIDENT OR INJURY ? YES NO IF YES PLEASE ANSWER THE FOLLOWING: HEALTH HISTORY FORM 4A E: TAYLOR, ZACHARY J (3 PAGES) NR#: 95411 Mpg: 10/11/1971 INS: AUTO INSURANCE _OC: SURO SOS#: 4301494 MD#: 59110 SEX: M STANDARD VISIT DATE: 03/24/2004 DATE / V/A4 HMC # NAME Zl l Il ILI ( DOB JD AGE - NAME OF PERSON COMPLETING FORM (IF OTHER THAN PATIENT) RELATIONSHIP TO PATIENT WERE YOU REFERRED BY ANOTHER PHYSICIAN? YES NO IF YES, PLEASE; COMPLETE THE INFORMATION BELOW: PHYSICIAN ! fI / ?tll i ???? ADDRESS CITY, STATE & ZIP CODE IF YOU HAVE A PRIMARY CARE PHYSICIAN OTHER THAN YOUR REFERRING PHYSICIAN, PLEASE COMPLETE THE INFORMATION BELOW: PHYSICIAN ADDRESS CITY, STATE & ZIP CODE IF YOU WOULD LIKE THE INFORMATION FROM TODAY'S VISIT SENT TO A PHYSICIAN OTHER THAN THOSE LISTED ABOVE, PLEASE COMPLETE THE INFORMATION BELOW: PHYSICIAN ADDRESS CITY, STATE & ZIP CODE dtt? b WHAT IS THE REASON FOR TODAY'S VISIT? DATE OF ACCIDENT / NJURY TYPE OF ACCIDENT ARE YOU INVOLVED IN LITIGATION REGARDING THIS CONDITION? YES ARE APPLYING FOR OR RECEIVING WORKER'S COMPENSATION FOR THIS OR ANY OTHER CONDITION? YES -/ NO ARE YOU APPLYING FOR OR RECEIVING DISABILITY FOR THIS OR ANY OTHER CONDITION? NO YES NO PAST MEDICAL HISTORY DO YOU HAVE ANY OTHER MEDICAL PROBLEMS? YES IF YES, PLEASE CHECK: ASTHMA DIABETES HEART DISEASE NO KIDNEY DISEASE LIVER DISEASE HIGH BLOOD PRESSURE OTHER ,b-zzu'v ?' Cd l Lza-j PLEASE LIST ALL PREVIOUS HOSPITALIZATIONS AND/OR OPERATIONS DATE (mo/yr) HOSPITAL PROBLEM / OPERATION DO YOU OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? CONTITUTIONAL SYMPTOMS RECENT WEIGHT GAIN PERSISTENT FEVER, CHILLS NIGHT SWEATS LOSS OF APPETITE DIFFICULTY SLEEPING FREQUENT NAUSEANOMITING CARDIOV ASCULARlRESPRATORY ASTHMA HEART PROBLEMS V HEART MURMURS HEART ATTACK NIGH BLOOD PRESSURE HIGH CHOLESTEROL LUNG PROBLEMS _ 'BRONCHITIS PNEUMONIA _ CHEST PAIN , 'CHRONIC COUGH BLOOD IN YOUR SPUTUM (SPIT) TUBERCULOSIS RHEUMATIC FEVER IRREGULAR HEART BEAT SHORTNESS OF BREATH AT NIGHT SHORTNESS OF BREATH ON STAIRS HEMOTOLOGICAL _ BLOOD TRANSFUSIOINS BLACK OR TARR Y STOOLS _ ANEMIA EXCESSIVE BLEEDING/BRUISING NEUROLOGICAL STROKE BLACKOUTS OR DIZZINESS SEIZURE OR EPILEPSY HEAD INJURY HEADACHE DOUBLE VISION TEMPORARY WEAKNESS OR NUMBNESS TEMPORARY LOSS OR BLURRING OF VISION GE ITOURINARY KIDNEY OR BLADDER PROBLEMS DIFFICULT/FREQUENT URINATION PROSTATE PROBLEMS LACK OF BLADDER CONTROL rp !i?'.C? Lf? ' f Z KIDNEY STONES GASTRONINTESTINAL GASTROINTESTINAL ULCERS LIVER DISEASE OR HEPATITIS ABDOMINAL PAIN CONSTIPATION/DIARRHEA GYNECOLOGICAL PREGNANCY BREAST DISCHARGE IRREGULAR MENSTRUAL PERIODS IF PREMENOPAUSAL, PLEASE GIVE DATE OF LAST MENSTRUAL PERIOD DERMATOLOGICAL UNUSUAL iPROLONGED RASH ANY PROLONGED LESION / LUMPS ENDOCRINE DIABETES HORMONE REPLACEMENT THYROID DISEASE MUSCULOSKELETAL J- BACK PAIN PAIN IN LEGS WITH EXERCISE DRY MOUTH OR EYES NECK PAIN JOINT OR MUSCLE PAIN RHEUMATOID ARTHRITIS OTHER MEDICATIONS PLEASE LIST ANY MEDICATIONS (PRESCRIPTION AND NON PRESCRIPTION) THAT YOU ARE CURRENTLY TAKING MEDICATION DOSAGE NUMBER TAKEN DAILY V 141-, HAVE YOU HAD ANY ALLERGIC OR UNUSUAL REACTION AFTER CONTACT WITH ADHESIVE TAPE, MEDICATIONS, FOOD OR DRUGS? YES NO ITEM REACTION PERSONAL HISTORY OCCUPATION IF NO LONGER WORKING, LAST DAY WORKED MARITAL STATUS I SINGLE MARRIED _ DIVORCED SEPARATED WHO LIVES WITH YOU? A(, el`&l HAVE YOU EVERY SMOKED? YES NO IF YES, HOW MAY PACKS PER DAY? IF YOU DISCONTINUED, HOW MANY YEARS AGO? DO YOU DRINK ALOHOLIC BEVERAGES YES HOW MANY YEARS ? IF YES, WHAT KIND? HOW OFTEN? NO HOW MUCH ? DO YOU USE ANY RECREATIONAL DRUGS (COCAINE, MARIJUANA, ETC.) _ YES -t NO IF YES, WHAT KIND? HOW OFTEN? LAST TIME USED FAMILY HISTORY DOES OR DID ANYONE IN YOUR FAMILY (PARENTS, GRANDPARENTS, SIBLINGS, CHILDREN, ETC) SUFFER FROM ANY OF THE FOLLOWING: ASTHMA CANCER __z HEART DISEASE HIGH BLOOD PRESSURE WHICH, IF ANY, OTHER DISEASES RUN IN YOUR FAMILY? IS THERE ANYTHING ELSE THAT WOULD BE HELPFUL FOR US TO KNOW? L-spine XR * Final Report * X-RAY LUMBAR SPINE 2-3 VIEWS PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 03/24/2004 EXAM NUMBER: 244891 ORDERING PHYSICIAN: SHEEHAN, JONAS X-ray of the lumbosacral spine History; Fracture TAYLOR, ZACHARY J - 95411 Discussion; AP, lateral view of the whimsical spine were performed. Correlation is made with patient's previous is seeking performed in September 14, 2003. Again noted is a wedge compression deformity of the L1 vertebra with depression of the superior endplate. There appears to have been some healing at the fracture site during the interval. No new wedge compression deformity is identified. Again identified is calcification in both renal areas likely representing calculi. Impression; Healing fracture of the L1 vertebra. Bilateral renal calculus. DICTATED: SINGH, RAJWINDER REVIEWED AND SIGNED: SINGH, RAJWINDER / DATE DRAFTED: 03/25/2004 01:02 PM DATE OF FINAL SIGNATURE: 03/26/2004 10:45 AM Printed by: Shiner, Crystal L Page 1 of 1 Printed on: 411212004 9:08 AM (End of Report) PENNYATE Milton S.1 College of Medical Center ne PROGRESS REPORT NAME: TAYLOR, ZACHARY MO: HARWGH ROBERT MRN: 96411 DOB: 10/11/1971 INS: MEDICARE ?.Oc: SURG OOSN: 3828393 MDM: 89125 SEX: M STANDARD VISIT DATE: 11/11/2003 Date/Time PROGRESS NOTES: (Include Name, Title) -, 4 ?'/ D? ?pm C' A rp ???? ,cam a YsGt? o-n R y a&. .. 1/ 7 Z-/ -1Y -6 1 •? n 6-i 44 r? MR 6 Rev. 6/01 PROGRESS REPORT !SLAW dt, Ronca & Kramer Pc AWYERS November 24, 2004 Hershey Medical Center 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Attention: Medical Records Department Re: Patient: Zachary Taylor DOB: 10111/71 Treatment dates: 03/24/04 to present. Dear Sir or Madam: Please be advised this firm represents the above-referenced patient for injuries received as a result of an automobile accident. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. If you have any questions, please feel free to call me at any time. Very truly yours, SCHMIDT, RONCA & KRAMER, P.C. Gerard C. Kramer Attorney at Law GCK/det Enclosure cc: Billing Department -(p 3n4eAnaL rh?cl Cf? j 2- 209 State Street 1528 Walnut Street, 3rd Floor Harrisburg, Pennsylvania 17101 Philadelphia, PA 19102 717.232.6300 215.790.7303 VOICE FAX 717.232.6467 215.546.0942 FAX www.srklaw.com I Please respond to Harrisburg office. 1W 1 1, r SOURCECORP,FIRAL Reg o?oZ I,?;t ls?! ` Date q 40 EDP i:, F Ys f` "ESSARY ;w CONS tn? 'NKr i Milton S. Hershey Medical Center The Milton S. Hershey College of Medicine Medical Center A! LITHIORIZATION FOR RELEASE OF HOSPITAL RECORDS Health Information Services, P.O. Box 850, Hershey, Pennsylvania 17033 Name of Patient. Date of birth /0 Medical Record Number Social Security # THIS AUTHORIZATION WILL NOT BE ACCEPTED UNLESS ALL ITEMS ARE COMPLETED. THE INFORMATION BEING DISCLOSED MAY fNCLUDE HIV/AIDS, DRUG/ALCOHOL ABUSE & MENTAL HEALTH DATA. I HE? . IZE HERSHEY MEDICAL CENTERIUNIVERSITY HOSPITAL TO RELEASE TO OR B. 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I hereby release the provider of said records from any legal responsibility or liability in connection with the release of the records indicated and herein. ///r C7 yle Signat-ji of r Re 54: )tative Date oyl? iRelationship if signed Dy other Than Patienti U(? n w _ _? ?? - ?11 `7) 2-?Z-6,3 ':^:itnesST BE SIGNED PHONE Note to recipient of information: This information has been disciosec tC OU `ror,, the records protected by Pennsylvania Law. Pennsyl'Jal to 1;3'w prohit)its ,ou fronl rnakinc any further disclosure of inis .nforniauon Unless further disclosure is expressiv permitte7 3y the,,vn ten consent of the person to vhcrn it pera ins. (Zip Code) MR 543 Rev. 3103 AUTHORIZATION FOR RELEASE OF HOSPITAL RECORDS ,rte, Ntwo? HEALTHSERVE SOURCECORP HEAL THSERVE has been retained by the Medical Record Department of Milton S. Hershey Medical Center Hecr/th Intorr N017 SerViCeS to fulfill requests for copies of medical records. 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If you have any questions, please do not hesitate to contact us at 866 420-7455 and one of our Customer Service Representatives will be happy to assist you. PENNSTATE Milton & Hershey Medical Center ® College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 Patient Sex: Male Date of Birth: 10/11/1971 Patient Location: SURG, , Visit Number: 4301494 Visit Type: Clinic O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Sheehan, Jonas M March 24, 2004 Dr. Edward R. Bollard UPG-Internal Medicine 670 Cherry Drive Hershey, PA 17033 RE: Zachary J. Taylor MSHMC# 095411 Dear Dr. Bollard: 3/26/2004 1:51:33 PM I saw Zachary Taylor in the neurosurgery clinic today in conjunction with Kristine Kuzma, APRN, BC. As you know, Mr. Taylor is a 32-year-old gentleman who was referred to us for a chief complaint of intermittent low back pain and an LI anterior body fracture. He was in a motor vehicle accident on 9/13/03 in which his car was T-boned on the passenger's side. This occurred in Virginia in the evening while on the way to a relative's wedding. At that time, he had x-rays done which showed an anterior body fracture of L1. He was given a back brace to wear. The brace did help to decrease his pain, but he did not wear it all the time due to flank pain. He denies any leg pain. On rare occasions he has some tingling down the legs. He had one episode where he fell coming out of a movie theater, but he states his "knees gave out." The patient's past medical history, past surgical history, medications, allergies, family history, social history, and review of systems have been obtained, confirmed, and documented in the patient's medical record. On physical examination today, his gait is normal. He can tandem walk without any difficulty. Sensory examination is normal to touch and pin in the lower extremities. On motor testing, his strength is 5/5 in all muscle groups individually tested in the lower extremities. Deep tendon reflexes are 1+ and symmetrical at the knees and ankles with toes downgoing. There is no evidence of clonus. I reviewed his plain films from September. He has had no studies more recent than that. There is a small anterior superior chip fracture at L1. We're going to repeat his plain films today and make sure that his fracture has healed. A kyphoplasty is usually not a good idea in healthy dense bone with traumatic fractures. The procedure is more likely to be beneficial in osteoporotic bone with compression fractures. We're going to send him for the films today and make sure things look okay. I think some physical therapy might be helpful. Date Printed: 1211612004 Time Printed: 10:54 AM Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 1 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Sheehan, Jonas M 3126/2004 1:51:33 PM Thank you very much for sending this pleasant young man to me. Please feel free to call with any questions or concerns you may have. Reviewed & Electronically Signed BY: Jonas M. Sheehan, MD Assistant Professor of Neurosurgery JMS:gcc F:\taylorz032404 Date Printed: 1211612004 Time Printed: 10:54 AM HEALTH HISTORY FORM 4AME: TAYLOR, ZACHARY J 3 PAGES MD: SHEEHAN JONAS M MR#: 95411 )OB: 10/11/1971 INS: AUTO INSURANCE _OC: SURO DOW 4301494 MDB: 89110 SEX: M STANDARD VISIT DATE: 03/2412004 DATE ?-`4/,11GI--1-t 0U HMC # 1 J NAME (LG!' ? ?(?? DOB JQ JI ! AGE, , NAME OF PERSON COMPLETING FORM (IF OTHER THAN PATIENT) RELATIONSHIP TO PATIENT ? WERE YOU REFERRED BY ANOTHER PHYSICIAN? YES NO IF YES, PLEASE COMPLETE THE INFORMATION BELOW: PHYSICIAN ADDRESS CITY, STATE & ZIP CODES o? IF YOU HAVE A PRIMARY CARE PHYSICIAN OTHER THAN YOUR REFERRING PHYSICIAN, PLEASE COMPLETE THE INFORMATION BELOW: PHYSICIAN ADDRESS CITY, STATE & ZIP CODE IF YOU WOULD LIKE THE INFORMATION FROM TODAY'S VISIT SENT TO A PHYSICIAN OTHER THAN THOSE LISTED ABOVE, PLEASE COMPLETE THE INFORMATION BELOW: PHYSICIAN ADDRESS CITY, STATE & ZIP CODE WHAT IS THE REASON FOR TODAY'S VISIT? A Aj?o AM- 'I'll IS THIS THE RESULT OF A SPECIFIC ACCIDENT OR INJURY ? IF YES, PLEASE ANSWER THE FOLLOWING: eta-" 6 pv tm YES NO DATE OF ACCIDENT / NJURY ./,5 0J TYPE OF ACCIDENT Q.A (/ ARE YOU INVOLVED IN LITIGATION REGARDING THIS CONDITION? YES NO ARE APPLYING FOR OR RECEIVING WORKER'S COMPENSATION FOR THIS OR ANY OTHER CONDITION? YES NO ARE YOU APPLYING FOR OR RECEIVING DISABILITY FOR THIS OR ANY OTHER CONDITION? YES NO PAST MEDICAL HISTORY DO YOU HAVE ANY OTHER MEDICAL PROBLEMS? YES NO IF YES, PLEASE CHECK : ASTHMA DIABETES HEART DISEASE I KIDNEY DISEASE LIVER DISEASE HIGH BLOOD PRESSURE OTHER PLEASE LIST ALL PREVIOUS HOSPITALIZATIONS AND/OR OPERATIONS DATE (mo/yr) HOSPITAL PROBLEM / OPERATION DO YOU OR HAVE YOU EVER HAD ANY OF THE FOLLOWING ? CONTITUTIONAL SYMPTOMS RECENT WEIGHT GAIN LOSS OF APPETITE _ PERSISTENT FEVER, CHILLS J NIGHT SWEATS DIFFICULTY SLEEPING FREQUENT NAUSEA/VOMITING CARDIOV ASCULAR/RESPRATORY ASTHMA HEART PROBLEMS HEART MURMURS HEART ATTACK r HIGH BLOOD PRESSURE HIGH CHOLESTEROL LUNG PROBLEMS _ 'BRONCHITIS PNEUMONIA CHEST PAIN V CHRONIC COUGH BLOOD IN YOUR SPUTUM (SPIT) TUBERCULOSIS RHEUMATIC FEVER IRREGULAR HEART BEAT SHORTNESS OF BREATH AT NIGHT SHORTNESS OF BREATH ON STAIRS HEMOTOLOGICAL BLOOD TRANSFUSIOINS BLACK OR TARRY STOOLS ANEMIA EXCESSIVE BLEEDING/BRUISING NEUROLOGICAL STROKE BLACKOUTS OR DIZZINESS SEIZURE OR EPILEPSY HEAD INJURY HEADACHE DOUBLE VISION TEMPORARY WEAKNESS OR NUMBNESS TEMPORARY LOSS OR BLURRING OF VISION GE ITOURINARY KIDNEY OR BLADDER PROBLEMS DIFFICULT/FREQUENT URINATION PROSTATE PROBLEMS :z LACK OF BLADDER CONTROL ?jW.?? GLCiC-Lf?J Z KIDNEY STONES GASTRONINTESTINAL GASTROINTESTINAL ULCERS LIVER DISEASE OR HEPATITIS ABDOMINAL PAIN CONSTIPATION/DIARRHEA GYNECOLOGICAL PREGNANCY BREAST DISCHARGE IRREGULAR MENSTRUAL PERIODS IF PREMENOPAUSAL, PLEASE GIVE DATE OF LAST MENSTRUAL PERIOD DERMATOLOGICAL UNUSUAL /PROLONGED RASH ANY PROLONGED LESION / LUMPS ENDOCRINE DIABETES HORMONE REPLACEMENT THYROID DISEASE MUSCULOSKELETAL BACK PAIN PAIN IN LEGS WITH EXERCISE DRY MOUTH OR EYES NECK PAIN JOINT OR MUSCLE PAIN RHEUMATOID ARTHRITIS OTHER MEDICATIONS PLEASE LIST ANY MEDICATIONS (PRESCRIPTION AND NON PRESCRIPTION) THAT YOU ARE CURRENTLY TAKING MEDICATION DOSAGE NUMBER TAKEN DAILY Il r,(' rte? ???! rte( - S A-L, p'.o C(?OLr?Z-l- l^ 2D HAVE YOU HAD ANY ALLERGIC OR UNUSUAL REACTI 7 AFTER CONTACT WITH ADHESIVE TAPE, MEDICATIONS, FOOD OR DRUGS? YES NO ITEM REACTION PERSONAL HISTORY OCCUPATION -"' IF NO LONGER WORKING, LAST DAY WORKED MARITAL STATUS SINGLE MARRIED DIVORCED SEPARATED WHO LIVES WITH YOU? 6!1-Z 1 ' Q& HAVE YOU EVERY SMOKED? YES -Z NO IF YES, HOW MAY PACKS PER DAY? HOW MANY YEARS? IF YOU DISCONTINUED, HOW MANY YEARS AGO? _ DO YOU DRINK ALOHOLIC BEVERAGES YES IF YES, WHAT KIND? HOW OFTEN? NO HOW MUCH ? DO YOU USE ANY RECREATIONAL DRUGS (COCAINE, MARIJUANA, ETC.) YES -/- NO IF YES, WHAT KIND? HOW OFTEN? LAST TIME USED FAMILY HISTORY DOES OR DID ANYONE IN YOUR FAMILY (PARENTS, GRANDPARENTS, SIBLINGS, CHILDREN, ETC) SUFFER FROM ANY OF THE FOLLOWING: -2 ASTHMA CANCER HEART DISEASE HIGH BLOOD PRESSURE WHICH, IF ANY, OTHER DISEASES RUN IN YOUR FAMILY? _ IS THERE ANYTHING ELSE THAT WOULD BE HELPFUL FOR US TO KNOW? PENNSTATE M Cc S. Hershey Medical Center : of Medicine PROGRESS REPORT NAME: TAYLOR, ZACHARY MD: HARBAUGH ROBERT MRM: 95411 )OB: 10/11/1971 INS: MEDICARE _OC: BURG OOSN: 3828393 MDM: 89125 SEX: M STANDARD VISIT DATE: 11/11/2003 Date/Time PROGRESS NOTES: (include Name, Title) o? Et -OR An 9// A;u O s tit - CT ?[ - c- je' t 1? j L4 MR 6 Rev. 6/01 PROGRESS REPORT NSTATE NAME: TAYLOR, ZACHARY J PEN Milton S. Hershey Medical Center MD: REESE CARL T MR#: 96411 MD#: 28100 College of Medicine INS: 1 G/ 1 / / NS: MEDICARE E SEX : M STANDARD LOC: SURG OOS#: 4727316 VISIT DATE: 09/23/2004 PROGRESS REPORT MR 6 Rev. 6101 PROGRESS REPORT FENNSTATE Milton S. Hershey Medical Center College of Medicine OPHTHALMOLOGY EXAM FORM ? New Requested by HISTORY CC/HPI: r NAME: TAYLOR, ZACHARY J MD: QUILLEN DAVID A MR#: 95411 DOB: 10/11/1971 INS: MEDICARE LOC: OPH1 DOS#: 4797156 ollow-up from /V ALLERGIES: Ocular: REVIEW OF SYSTEMS (ROS) Y N Y N Y N Y N ? ? CONSTITUTIONAL ? ? RESPIRATORY ? ? MUSCULOSKELETAL ? ? ALLERGIC/ ? ? EYES ? ? GASTROINTESTINAL ? ? NEUROLOGICAL IMMUNOLOGIC ? ? EARS, NOSE, MOUTH, THROAT ? ? GENITOURINARY ? ? PSYCHIATRIC ? ? ENDOCRINE ? ? CARDIOVVA-SSCULA ? El INTEGUMENTARY U ? HEMATOLOGIC/LYMPH ? ? ALL OTHERS If Yes, describe. )+Jl' ?It74 MEDICAL HISTORY: FAMILY HISTORY: History (ROS/PMFH) Reviewed 0 EXAMINATION General Medical Status: ? Visual Acuitv Rinht ? no change ? chafes noted above. )(Oriented to time, place, person XAffect appropriate /h I off Distance sc Distance cc Near Wearing Manifest Cycloplegic ? Rx Given Add Add Systemic: ? Pupils: R mm mm- 7+ PD ? Color ? Pachymetry: ? Keratometry: L mm mm - PD Dark Light Reaction ri} V L ?? [ v" t ? Intraocular Pressure: r C/ ? Visual Field: [] Humphrey * \X, pplanation ?? (Confrontation) ? Goldmann * nopen ? full t n t Tangent * @ t See additional form Dil ted Wi ? ri ?4 7 versions full ? other ? orthotropic in primary @ I( (.? Abbreviations: Technician APD = afferent pupillary defect cc = with correction sc = without correction White Copy -Medical Records MR 905 Rev. 1104 Page 1 of 2 OPHTHALMOLOGY EXAM FORM Yellow Copy - Department MD#: 85650 SEX: M STANDARD VISIT DATE: 10/21/2004 Page 1 of 2 Lids and Adnexa:/.(JNeg • Slit Lamp Examination: O R nl I fd?? ? r e ? NAME: TAYLOR, ZACHARY J U POs MD: QUILLEN DAVID A MR#: 95411 DOB: 10/110971 INS: MEDICARE LOC: OPH1 O OOS#: 4797156 L nl I Conjunctiva Cornea ? Tear Film ?? Ant. Chamber ?O iris - > Lens ? - MD#: 85650 SEX: M STANDARD VISIT DATE: 10/21/2004 • Gonioscopy: &(9 Cornea Lens Lens Cornea 000 000 • Fundus Examination: R L nl nl Vitreous ? u Optic Nerve ? (]/[] Post Segment ? ? i Optic Nerve Head: 00 RESIDENT PARTICIPATION ? YES TEACHING PHYSICIAN DOCUMENTATION/SUMMARY History {Exam MDM PHYSICIAN RTC: J (JJ NEXT,t4`I&: 1 0 Refraction 1-1 Gonio ~1 / / C- L Dilated Exam ? VF ? other Date this day i saw, examined and was physically present for the key portions the services provided. I agree with the resident's plan and notes. ? Extended Cphthalmoscopy see additional form MR 905 Rev. 1/04 Page 2 of 2 OPHTHALMOLOGY EXAM FORM White Copy - Medical Records Yellow Copy - Department MEDICAL DECISION MAKING ? Dictated ? Consult requested: ? Patient Instructions Given Initials PENNSTATE sm Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: IM7, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUI-IMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 4726349 1 O u It p a t i e n t N o t e D o c u m e n t Modified Document Electronically Signed by: Ballentine, Noel H OUTPATIENT NOTE DATE OF SERVICE: 8/20/04 CHIEF COMPLAINT: "I have a bump on my neck." 8/30/2004 9:57:49 AM HPI: This is a 32-year-old gentleman with mild mental retardation status post L1 fracture after an MVA in September of 2003, who also has myoclonic movements, ulcerative colitis, who presents with his mother and states for about 3 to 4 weeks, they have noticed a bump on the back of his neck on the left side. This bump has not grown in nature nor is it painful. He did have a cough and cold about 2 weeks ago for 4 or 5 days' duration, which resolved on its own without any intervention. The mother states this bump preceded this cold by about a week and has remained there. The patient denies any fever or chills, weight loss, fatigue, lethargy, night sweats, nausea, vomiting, fever, or chills. The patient has no sick contacts at home. He lives with his mother. They have been essentially homebound due to pain in the back due to L1 fracture. His current medications include valproic acid, multivitamin, p.r.n. hydrocodone. OBJECTIVE: Weight 234, temperature 97, blood pressure 128/84, and pulse 80. General: He is A&O x3 with mild mental retardation and one must read somewhat slowly for him to comprehend, but he is able to comply and answer all the questions appropriately. He is in no current pain right now. The HEENT exam reveals the extraocular muscles are intact. No nystagmus or jaundice. The posterior pharynx is clear without exudates. There is no lymphadenopathy in the anterior submandibular or submental nodes. There is no lymphadenopathy in the right posterior aspects of the neck. The left occipital region has 1.5-cm circular lymph node, which is freely mobile, nontender, and non-fluctuant. The lungs are clear. The extremities show no signs of edema. He does have pain in the left greater toe, which he also complains about, but very minimal and better controlled with Tylenol. Range of motion is intact in the left toe as is sensation, proprioception, and motor. No point tenderness in the back is elicited. ASSESSMENT AND PLAN: A 32-year-old gentleman with left occipital lymphadenopathy. This is a fairly nonspecific finding in the gentleman with multiple medical problems and a recent URI. I am not concerned for any type of active infection or abscess growing at this time. The patient's mother basically wanted reassurance as to what it was and not Date Printed: 1211612004 Time Printed: 10:53 AM PENNSTATE Milton S. Hershey Medical Center College of Med dne Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t N o t e D o c u m e n t Modified Document Electronically Signed by: Ballentine, Noel H 8/30/2004 9:57:49 AM any type of abscess. I would not change his medication regimen. For his toe pain, I told him to take Tylenol 1 tablet morning and 1 in the evening p.r.n. for foot pain and to be careful as he is on valproic acid. The patient and his mother understand and agreed to do so. They will see Dr. Bollard in the next few weeks as scheduled. If the lymph node gets bigger or does not resolve in the next few weeks, we can consider doing EBV testing and/or FNA of the lesion if the symptoms worsen. 45345 and 45399 Review/Sign: Mehul K Trivedi, MD Review/Sign: Edward R Bollard, MD Review/Sign: Noel H Ballentine, MD MKT /SAT DD: 08/24/04 DT: 08/24/04 09:06 Date Printed: 1211612004 Time Printed: 10:53 AM PENNSTATE N"m UP Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: SURG, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 4727316 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: Reese, Carl T OUTPATIENT NOTE DATE OF SERVICE: 09/2312004 9/27/2004 8:17:15 AM Zachary and his mom are here today for followup. Zachary is a former patient of Dr. Erickson. He does have a history of multiple renal calculi. Last year, he was scheduled to undergo an ESWL. He was also to take Polycitra. In the interim, they were involved in a motor vehicle accident, which caused him to have an L1 fracture. His mom states he also refused to take his Polycitra. He currently is complaining of some lower back pain. On examination, this 33-year-old male in no acute distress. There is no CVA tenderness, but there is some spinous tenderness overlying 1-1-1-2. I reviewed his CT scan, which demonstrated multiple small stones in the kidney on the right, the largest one is a 5 mm stone, which appears to be intra parenchymal. I held a long discussion with Zachary and his mother about his treatment options. He will not take his pain medicine. I do not feel that the stones currently are causing him any discomfort. I believe this pain is all musculoskeletal in origin. I had offered them possible ESWL but could not guarantee that we could get rid of stones. The mother understood this and they feel that probably just a observation protocol is warranted at this time. I will see him back in 6 months. Thirty minutes were spent with the patient, more than 50% of the time was spent in counseling. 86802 Review/Sign: Carl T Reese, MD CTR /RHE DD: 09/23/04 DT: 09/27/04 07:47 Date Printer!: 1211612004 Time Printed: 10:53 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: IM7, , Visit Type: Clinic PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 4766304 1 O u t p a t i e n t N o t e D o c u m e n t I Final Document Electronically Signed by: Bollard, Edward R OUTPATIENT NOTE DATE OF SERVICE: 9-29-04 10/3/2004 12:45:59 PM SUBJECTIVE: The patient presents today with several concerns. He states he recently started school at Harrisburg Area Community College. He noticed some toe pain, but he is unable to identify which toe it was. The pain has subsequently resolved. He continues with his back pain requiring narcotic analgesics. His mother questions whether or not physical therapy might be a possibility for him now. He states that occasionally he will take one dose of his pain medication each day and sometimes twice at night if he has had an active day. He also states his feet feel "hot" at the bottom, but he does not notice any real changes to the area. He has recently followed up with his urologist for his nephrolithiasis. He continues to have a 5 mm stone present in his left kidney that looks more parenchymal than in the collecting system as this time. His current medications include valproic acid 750 cc t.i.d., Macrodantin 50 mg q.d., multivitamins q.d., hydrocodone/APAP 5 mg q.h.s. OBJECTIVE: His weight today was 229 pounds, which is down nine pounds in the last four months. Blood pressure 112/78, pulse 100. His lungs were clear to auscultation bilaterally. Cardiac was regular rate and rhythm. He had a nonsustained and nondisplaced PMI. There are no murmurs, rubs, gallops, or clicks appreciated. Examination of his right index finger showed a verrucous papule at the margin of the nailbed. His feet showed some scaling lichenification on the right midfifth metatarsal without any skin breakdown. There were no lesions on the soles of his feet. There are no pending labs today. ASSESSMENT AND PLAN: 1. Orthopedics - L1 compression fracture with persistent pain - he has been evaluated for vertebroplasty and is not considered to be a candidate. We are going to refer him to physical therapy at this time. He will continue on his pain medicines as written. 2. Urology - recurrent nephrolithiasis. He will continue to follow up with the urologist as scheduled. 3. Dermatology - common wart of the right index finger - I referred him to Dermatology, given the location of the lesion and the potential for nailbed involvement. 4. Cardiovascular - obesity - sedentary lifestyle - I was very encouraged with the patient's weight loss and congratulated him and hope that he will continue to do so. FOLLOW UP: I will see the patient back in the office in three months. PENDING LABS AND STUDIES: None at this time. Date Printed: 1211612004 Time Printed: 10: 53 AM PENNSTATE NOR W Milton S. Hershey Medical Center College of. MeAcane Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: Bollard, Edward R 10/3/2004 12:45:59 PM 95700 Review/Sign: Edward R Bollard, MD ERB /DMD DD: 09/30/04 DT: 09/30/04 09:59 Date Printed: 1211612004 Time Printed: 10:53 AM PENNSTATE Milton S. Hershey Medical Center College of Wdicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: IM7, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 4878813 1 O u t p a t i e n t N o t e D o c u m e n t Final Document Electronically Signed by: Bollard, Edward R OUTPATIENT NOTE DATE OF SERVICE: 10/8/2004_ 10/12/2004 1:00:24 PM CHIEF COMPLAINT: He presents with a cough that is continuous and intermittent sore throat HISTORY OF PRESENT ILLNESS: Zachary came to the appointment along today. He brought a note from his mom that states that he has had a continuous cough, no fever, some swollen glands, and she questions whether or not he should be getting a flu shot. His past medical history is significant for mental retardation. He has had myoclonic movement disorder, recurrent pyelonephritis, nephrolithiasis, ulcerative colitis, hemorrhoids, and obesity. His medications are valproic acid 250 mg per 5 cc, and he takes 15 cc p.o. t.i.d., Macrodantin 25 mg per 5 cc, 10 cc daily, multivitamin daily. He takes hydrocodone suspension 2.5 mg per 5 cc. PHYSICAL EXAM: He is afebrile. His blood pressure is 110/72, his pulse is 86, his weight is 231.9 pounds. HEENT: There is some tenderness in palpating the maxillary sinuses. His TMs were gray in color with good light reflex. Nares were erythematous and severely congested. There was dried mucous rhinorrhea in the nose. His pharynx was normal. There was no palpable cervical lymphadenopathy. His chest was clear in all lung fields. Cardiovascular: Regular rate and rhythm. No murmur. ASSESSMENT AND PLAN: Viral upper respiratory infection. I recommended that they begin Dimetapp 2 teaspoons every 6 hours for 7 to 10 days, Robitussin DM 2 teaspoons every 6 hours, and he could Robitussin cough drops while at work. He will be schedule to receive a flu shot on the nursing schedule in November of 2004 since he is at some low to moderate risk. 107424-cbt Review/Sign: Anne S Weaver, PA-C Review/Sign: Edward R Bollard, MD ASW /RAW DD: 10/08/04 DT: 10/11/04 15:05 Date Printed: 1211612004 Time Printed: 10:53 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 Patient Sex: Male Date of Birth: 10/11/1971 Patient Location: PT, , Visit Number: 4895430 Visit Type: Recurring O u t p a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 10/19/2004 10:25:13 AM OUTPATIENT THERAPY NOTE DATE OF SERVICE: 10/12/04 INITIAL PHYSICAL THERAPY EVALUATION DIAGNOSIS: Low back pain. CURRENT DATE OF PRESCRIPTION CERTIFICATION: 9/29/04. ONSET DATE: 9/03. DATE TREATMENT STARTED: 10/12/04. DATE PLAN ESTABLISHED: 10/12/04. SUBJECTIVE CHIEF COMPLAINT: Zachary was involved in a motor vehicle accident in 9/03 where he was an unbelted passenger in the back seat and was lying down. He was thrown forward into the seat ahead of him and at that time complained about low back pain along with right knee and shoulder pain. On x-ray, he was found to have a small fractured L1 vertebra. He was splinted by Orthopedics and was unable to wear the splint because of problems with pain. He also has had prior shoulder pain and knee pain that he was seen in physical therapy for. Today, he describes the pain at his waistline when he is sitting down for a long time or when he is standing for a long time. He also indicates that he has difficulty when bending over to pick something up and that sleeping is okay. He sometimes has pain with walking and rolling. He is a poor reporter due to his MR status. PAST MEDICAL HISTORY: As stated before, L1 fracture, 9/03. He has brain damage from birth and is mentally retarded. He has had significant kidney issues with left kidney infections, kidney stones bilaterally, shoulder pain on the left, right knee surgery, ulcerative colitis, and a problem with myoclonic jerks. PRIOR FUNCTIONAL LEVEL: His activity level was decreased generally prior to this accident. PRESENT FUNCTIONAL LEVEL: As stated before, he has difficulty with static sitting, standing, or bending over. DIAGNOSTIC TESTS: None. MEDICATIONS: Hydrocodone and Furadantin. OBJECTIVE: Date Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE NOR 10 Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 10/19/2004 10:25:13 AM Range of motion: Range of motion is within functional limits in the extremities, and spinal range will be measured in the next session. Strength: is within functional limits; however, endurance generally is decreased. Palpation: He has pain on palpation of the PSIS areas with tender points there and tender points in the L5-S1 area. He also reveals an anterior vertical rotation of his sacrum. There is some lack of mobility of the sacrum upward on the left side. Mobility and gait: He is ambulatory independently with a slow gait pattern. ASSESSMENT: Zachary is a 33-year-old white male who is mentally retarded and has had increased back pain since his motor vehicle accident in 2003. He would benefit from physical therapy to realign his sacrum to neutral, decrease the lack of mobility in the sacrum and the PSIS areas as well as improve his capability to manage the pain through some positions that he may be able to learn. Rehab potential is fair. SHORT-TERM GOALS: 1. Zachary will report decreased pain in his low back within four sessions. 2. Zachary will reveal improved back flexion to 30 degrees of lumbar flexion in six sessions. 3. Zachary and his mother will be able to use strain/counterstrain techniques to decrease pain levels in the home setting. LONG-TERM GOAL: Zachary and his mother will be able to manage the pain levels using techniques learned in physical therapy. INITIAL TREATMENT: Muscle energy technique with mobility templates for anterior vertical rotation, muscle energy technique for bone bruise technique and clean-up of IDM, DOM across the sacrum and PSIS. PLAN: One-time-weekly physical therapy to include muscle energy strain/counterstrain, advanced strain/counterstrain, myofascial release, visceral myofascial release, neural tissue tension, and a referral to Center IMT in Washington, DC. TIME SPENT: 30 minutes evaluation, 30 minutes treatment. Date Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE sm Milton S. Hershey Medical Center College of Nkdicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S #117942 Review/Sign: Laura S Hamann LSH /SMC DD: 10/18/04 DT: 10/18/04 14:00 CC: Edward R Bollard, MD PSMSHMC Medicine 10/19/2004 10:25:13 AM Date Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE ® Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: IM7, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 4938380 1 O u t p a t i e n t N o t e D o c u m e n t Modified Document Electronically Signed by: Bollard, Edward R OUTPATIENT NOTE DATE OF SERVICE: 10/26/2004 11/5/2004 11:45:04 AM CHIEF COMPLAINT: He presents with cough and chest congestion for about 3 weeks. HISTORY OF PRESENT ILLNESS: Zach this time was accompanied to the appointment by his mom. His mom stated that she first noticed the coughing after he had aspirated some valproic acid, she feels about 3 weeks ago. He has not had any fevers or chills. He denies runny nose, stuffy nose, though he has had some watery eyes, most problematic has been a cough. It is keeping him awake at night. Generally, it has been cough. Occasionally, now it is productive, but it is not colored sputum. In the past, we felt that he may have had some occasional mild reactive airway disease for which we have treated him with p.r.n. albuterol syrup and he has responded well to that. MEDICATIONS: His current medications are valproic acid 250 mg/5 cc 15 cc p.o. t.i.d., Macrodantin 25 mg/5 cc 10 cc daily, multivitamin daily, hydrocodone 2.5 mg/5 cc q.6h. p.r.n. PHYSICAL EXAM: He is afebrile. His blood pressure was 100/70, pulse is 68, weight is 238 pounds. HEENT: There is no sinus tenderness. His TMs were gray in color with good light reflexes. Nares were pale and boggy and moderate to severely congested. The pharynx was normal without any exudate. Cervical lymph nodes were nonpalpable. Chest was clear except decreased breath sounds and prolonged expiratory phase at the bases. No wheezing was heard with forced expiration or no rates or rhonchi. Cardiovascular: Regular rate and rhythm without murmur. ASSESSMENT AND PLAN: A seasonal allergic rhinitis with some reactive airway disease. We will have him begin Claritin syrup 2 teaspoons once daily through the month of November, and albuterol syrup 1 teaspoon in the morning and before bedtime. He may take 1 teaspoon every 6 hours as needed for cough or shortness of breath through November, then discontinue. Followup appointment is scheduled with Dr. Bollard in 2 to 3 months. The patient was seen today while supervising attending, Dr. Jones, was present in the clinic. Dote Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE Milton S. Hershey Nie&cal Center College of Nk&dne Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t N o t e D o c u m e n t Modified Document Electronically Signed by: Bollard, Edward R 11/5/2004 11:45:04 AM 129589 Review/Sign: Anne S Weaver, PA-C Review/Sign: Edward R Bollard, MD Review/Sign: Edward R Bollard, MD ASW /MSZ DD: 10/28/04 DT: 10/28/04 07:10 Date Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE 10 N[ilton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 F S p i n e - S t u d y Final X-RAY LUMBAR SPINE 2-3 VIEWS PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 03/24/2004 EXAM NUMBER: 244891 ORDERING PHYSICIAN: SHEEHAN, JONAS X-ray of the lumbosacral spine History; Fracture Discussion; AP, lateral view of the whimsical spine were performed. Correlation is made with patient's previous is seeking performed in September 14, 2003. Again noted is a wedge compression deformity of the L1 vertebra with depression of the superior endplate. There appears to have been some healing at the fracture site during the interval. No new wedge compression deformity is identified. Again identified is calcification in both renal areas likely representing calculi. Impression; Healing fracture of the L 1 vertebra. Bilateral renal calculus. DICTATED: SINGH, RAJWINDER REVIEWED AND SIGNED: SINGH, RAJWINDER / DATE DRAFTED: 03/25/2004 01:02 PM DATE OF FINAL SIGNATURE: 03/26/2004 10:45 AM Date Printed: 1211612004 Time Printed: 10:54 AM PENNSTATE 060 Milton S. Ikrshey Medical Center College of licine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 C h e m 1 s t r 10/26/2004 Tue 0 10/26/2004 Tue 0 Procedure Na Units mmol/L Ref Range [135-145] 12:20:00 PM 137 Procedure Ca Units mg/dL Ref Range [8.5-10.0] 12:20:00 PM 9.1 K Cl- HCO3 BUN Cret Glu mmol/L mmoUL mmol/L mg/dL mg/dL mg/dL [3.5-5.0] [98-110] [22-32] [8-22] [0.8-1.4] [70-120] 3.4 95 33 9 0.9 66 Date Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 L i v e r / G I Procedure ALT T Bili Alk Phos AST Units unit/L mg/dL unit/L unit/L Ref Range [10-50] [0.1-1.0] [40-110] [10-40] 10/26/2004 Tue 0 12:20:00 PM 26 0.6 85 25 Date Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 D r u g M o n i t o r 10/26/2004 Tue 0 Procedure Valproate Units ug/mL Ref Range [50-100] 12:20:00 PM 59 Date Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE Nihon S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 C a r d i a c / L i p i d Procedure Chol LDL HDL Chol/HDL TG Units mg/dL mg/dL mg/dL mg/dL Ref Range [125-200] [50-130] [>35] [30-250] 10/26/2004 Tue 0 12:20:00 PM 249 170 49 5.1 148 Date Printed., 1211612004 Time Printed: 10.52 AM PENNSTATE Milton S. Hershey Medical Gaiter College of Wdicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 E n d o c r i n e Procedure TSH Units uIU/mL Ref Range [0.3-5.0] 10/26/2004 Tue 0 12:20:00 PM 2.79 Date Printed 1211612004 Time Printed: 10:52 AM PENNSTATE ONO Milton S. Hershey Medical Ceder College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 N u t r i t i o n Procedure Alb Prot Units g/dL g/dL Ref Range [3.5-5.5] [6.5-8.3] 10/26/2004 Tue 0 12:20:00 PM 4.3 7.3 Date Printed: 1211612004 Time Printed: 10:52 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine May 6, 2005 Name: TAYLOR, ZACHARY, HMC Number: 95411 DOB: 10/11/1971 Date of Service: 04/22/2005 Gerard C. Kramer, Esq. Schmidt, Ronca, and Kramer, PC 209 State Street Harrisburg, PA 17101 Dear Mr. Kramer: I am writing this correspondence in followup to our recent telephone conversation on May 4, 2005 concerning my patient, Mr. Zachary Taylor. This is in reference to a reported motor vehicle accident in which he was a passenger during September 2003. I have been providing primary care for Mr. Taylor for approximately seven years. He has several medical issues that have been stable but has not required any significant analgesic medications prior to the aforementioned accident. Immediately following the motor vehicle accident in September 2003, Mr. Taylor was complaining of severe back pain. He was evaluated initially at an outside medical facility and was documented with having a compression fracture of the L1 vertebrae. He was subsequently seen in our Emergency Department at the Penn State Milton S. Hershey Medical Center on September 14, 2003 and underwent a thin-sectioned CT scan of the lumbar vertebrae, which documented the burst compression fracture of the L1 vertebrae. The patient required narcotic analgesia at that time for his pain management. Since September 2003, we have referred Mr. Taylor for various modalities including physical therapy and rigid bracing for his lumbar compression fracture, in the hope of aiding his rehabilitation and pain management. He was also seen in consultation by a neurosurgeon. At that time, he did not feel that surgical intervention or vertebroplasty would be indicated. In spite of the conservative measures for this condition, Mr. Taylor has continued to require narcotic analgesia for his discomfort. He is able to carry on his activities of daily living with this condition but continues to complain of pain with certain bending, lifting, and twisting maneuvers. Although the nature of compression fractures is that they heal without significant residual deficits if there is no initial nerve root impingement, I am unable to provide a long-term prognosis concerning his pain associated with this condition. I hope this will help you in the evaluation of Mr. Taylor's medical situation that has evolved since September 2003. If you have any questions or concerns about this correspondence, please do not hesitate to contact me at your convenience. Internal Medicine Associates Penn State College of Medicine The Milton S. Hershey Medical Center Internal Medicine Associates, HS04 670 Cherry Drive Hershey, PA 17033 Tel: (717) 531-5160 Fax: (717) 531-2034 Sincerely, Edward R. Ballard, M.D. Associate Professor of Medicine An Equal Opportunity University Ls z PENNSTATE b Milton S. Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-6257 Penn State College of Medicine Fax: (717) 531-7048 Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 RE: TAYLOR, ZACHARY J OUTPATIENT LETTER May 6, 2005 Name: TAYLOR, ZACHARY, HMC Number: 95411 DOB: 10/11/1971 Date of Service: 04/22/2005 Gerard C. Kramer, Esq. Schmidt, Ronca, and Kramer, PC 209 State Street Harrisburg, PA 17101 Dear Mr. Kramer: I am writing this correspondence in followup to our recent telephone conversation on May 4, 2005 concerning my patient, Mr. Zachary Taylor. This is in reference to a reported motor vehicle accident in which he was a passenger during September 2003. I have been providing primary care for Mr. Taylor for approximately seven years. He has several medical issues that have been stable but has not required any significant analgesic medications prior to the aforementioned accident. Immediately following the motor vehicle accident in September 2003, Mr. Taylor was complaining of severe back pain. He was evaluated initially at an outside medical facility and was documented with having a compression fracture of the L1 vertebrae. He was subsequently seen in our Emergency Department at the Penn State Milton S. Hershey Medical Center on September 14, 2003 and underwent a thin-sectioned CT scan of the lumbar vertebrae, This document has been electronically signed. Patient Name: TAYLOR, ZACHARY J Patient Number: 0095411 Page ( of 2 For information about our physicians and services, contact the MD Network. 1-800-233-4082 www.pennstatehershey.com which documented the burst compression fracture of the L1 vertebrae. The patient required narcotic analgesia at that time for his pain management. Since September 2003, we have referred Mr. Taylor for various modalities including physical therapy and rigid bracing for his lumbar compression fracture, in the hope of aiding his rehabilitation and pain management. He was also seen in consultation by a neurosurgeon. At that time, he did not feel that surgical intervention or vertebroplasty would be indicated. In spite of the conservative measures for this condition, Mr. Taylor has continued to require narcotic analgesia for his discomfort. He is able to carry on his activities of daily living with this condition but continues to complain of pain with certain bending, lifting, and twisting maneuvers. Although the nature of compression fractures is that they heal without significant residual deficits if there is no initial nerve root impingement, I am unable to provide a long-term prognosis concerning his pain associated with this condition. I hope this will help you in the evaluation of Mr. Taylor's medical situation that has evolved since September 2003. If you have any questions or concerns about this correspondence, please do not hesitate to contact me at your convenience. Sincerely, Edward R. Bollard, M.D. Associate Professor of Medicine #107835 Sincerely, Edward R Bollard, MD ERB /SAT DD: 05/06/05 DT: 05/10/05 08:05 CC: Gerard C. Kramer, Esq. Schmidt, Ronca, and Kramer, PC 209 State Street Harrisburg, PA 17101 This document has been electronically signed. Patient Name: TAYLOR, ZACHARY J Patient Number: 0095411 Page 2 of 2 For information about our physicians and services, contact the MD Network. 1-800-233-4082 www. pennstatehershey. com REQUEST FOR SERVICE --ADULT OUTPATIENT Patient's Name & Address: ZACHARY TAYLOR 2100 CEDAR RUN DRIVE #204 CAMP HILL, PA 17011 CUMBERLAND Home Phone: 717-612-0309 Work Phone: Ext. Referral Date: 10/06/2003 DOB: 10/11/1971 Age: 32 Sex: M Social Security: 185-68-9025 Marital Status: HMC# - 95411 Name of Parent or Spouse: DOB: Age: .00 Referral Source: DR. BELTOWSKI Reason for Request: THERAPY Intake Disposition: 10/13/2003 2:00 PM PAT LEOCHA CC or Request for information: PTSD Previous Therapy: NO Previous Medication: Previous Psych. Hosp.: NO School District: Education Level: SES: 0 Employment Status: DISABLED Insurance: (1). MEDICARE (2). GATEWAY Brief Background: PT IS A 31 YO M, WHO WAS INVOLVED IN A CAR ACCIDENT ON 9/13/03. B/F ACCIDENT, PT WAS DX W/ SLIGHT MR. HE HAS SEVERE BRAIN DAMAGE THAT OCCURRED AT BIRTH. SINCE ACCIDENT, HE HAS HAD MULTIPLE MED PROBLEMS. PT WAS DESCRIBED AS "VERY VERBAL AND IN TOUCH W/ HIS FEELINGS." IT WAS STATED THAT HE WOULD LIKE TO TALK TO SOMEONE ABOUT HIS FEELINGS REGARDING THE ACCIDENT. SUSPECTED PTSD. ?9? IN P F0Fp Ao f cs(o/03 u44 PENNSTATE Milton S. Hershey Medical Center College of Medicine PROBLEM SUMMARY PATIENT NAME: NAME: TAYLOR, ZACHARY MD: LEOCHA PATRICIA MR#: 95411 DOB: 10/11/1971 INS: MEDICARE LOC: POPE OOS#: 3832608 RECORD #: MD#: 56105 SEX: M STANDARD VISIT DATE: 1011312003 Known Allergies: CHRONIC PROBLEMS DATE # DATE PROBLEM SIGN RESOLVED SIGN JJ AQ,trt (( t J ? OPERATIVE/INVASIVE DATE PROCEDURES COMMENTS SIGN nno nc 11 /nn Initial Evaluation De?ar-reat of Ps??c?,iat^- 'v(C cU FA 1-033 ?. 1 _ _.. .,._v : a:i dame: cr Gc? 2ti %a z -?? D`re: i' 3 -IC;= Rez:-ed ' PCP' -? i U Chief Complaint: & Vij i(Caii `f ?,-b a-tc-Z i-T Present Illness: /1) iq q ji3 jo /11 Q d I cci& &,eA;*, Loss of (+)interest or pleasure (?> tilocd S1i q SIe°p inc=ense DF.-. Y _ his NiNA Ev[A Enerav ` Feelings of wilt or worthlessness Wr or app change ev l ? w•-4 Impaired conc or decisiveZess Obsert.ed e restlessness or slowness T'nm of death or suicide r-r Dvs,--ml eatin Avoidane° behavior ca,i-j AnYie^? ?tJ Somatic 5:{'3 p ?`euEi-r' Flailuc's Ir:-itable r -levared mood Paranoia r? es compuis M!/?l, cev?d c??ive2? i?opeless;"heip(ess Subst abuse anic attac'.{s. palpit diapn sha Ln<T dv_ spnea choLn_? chest pain di=1 airt JereL%deners CCnln OI * 1, i-ar Ioss oL ctl or `oing Crn- fear of ' in_ naus;"-cd diSu°ss Faresth Chills/?lCr 'IUslieS Past Psychiatric History: D_^_or :re:iication. his: ? ?. _ ate: [ - - 3 L:ity 1 ? ?.iuatcn Family History: Fs-rc auc: - SUc05-L ce acuse: Suicide ti1::;cr me, icy! Social/Personal History: Chilchccd i^_ery!ti?: it 1 %ft. S'. ,,t a ^ n .ter?l+iu ,,.? .-^^,,--+?r• L.: ., =QC' R :3t10risi'p tc rears =c teache s: 'Wor I]1Si r%: Curent ilv=, slamrt on: _1. cc , l Sexual histor' Current relat?onsiues: o tilarAtal : Children: Reli??iaus Le?aI: ation: Past NledicaLSur icil History: Cestatio n: Dev'tal milestones: Allermes:CHI'seizt:res: vLP or Com:,acecdon: 1L Altemmarive appreac .-s: Tobaccc:: t-- B hail: Herbals: OT C coeds: Ca_f'eine: HF,/r sn tac:ors tZsLI112: Curve^t -oresc??ticr! _l?ecications: Per=r:State Geisinger Health System Initial Evali,--tion .L len.tal Status Examination: (ruin. of') BP Wt Appearance: Behavior: Psychomotor activity: Abnormal movements: Speech: rate art.,c Mood: Affect: range _ intensity T'rnou.ght: assoc'ns phobias/avoidance _ delusions hallucinations obsess/comp content suicidal thzts homicidal thrts Violent thvts Attn/cone: Orientation: Memory: recent remote Lanuage ccmprehsn AlawjM naming Fd of knowledge: a?r?cI ". Intelliaence_ Insicrit: Judgment: Abstraction: Calculation tifuscie strength: Muscle tone: Gait/sration: DSyt-IV Diagnosis: Axis i s n - person place time repetition Lymph nodes: A.Yis II r - Axis III Axis IV Gr?.?,---, , AYi : v t',? Cornn.ents: ?i am e: ?• C"?? 1 ?? j ?.?j. ?,?t'?:?? Date: lc1i3 /cj EPIC P & rhythm rare tone pressure lability predom ai Lect RR Ht volume spontaneity appropriateness - v Cadence HERSHEY MEDICAL CENTER Page: 1 Scheduling ADULT BH NORTHEAST Printed: 7/08/04 10:57 Patient History Report For: 95411 - Taylor,Zachary J Date Time Len Status Dept Prv/Rsc visit Notes 11/07/2003 2:00 60 C_an(PAT* ABH-NE LEOCHA, PA* RET AD* 10/13/2003 2:00 60 Comp ABH-NE LEOCHA, PA* NEW AD* r LA rM Schmidt, Ronca & Kramer Pc INJURY LAWYERS March 7, 2006 hlershey Medical Center 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Attention: Medical Records/Medical Bills Department ..?,? ;-? ?? ?? ! ?? ? ? ?? ?.:? ?r? ' /? ??'" , ?.._. t o ;, Re: Patient: Zachary Taylor DOB: 10/ 11 / 71 Requested Records: 11/5/04 to present including records of Dr. Gleason, a pulmonologist Requested Bills: 9i 13/03 to present Dear Sir or Madam: , £ f .: ? ! , , ?, ? k, _. r? Please be advised this firm represents the above-referenced patient for injuries received as a result of an automobile accident. Please forward to me copies of all medical records from 11 / 5 / 04 to present including records of Dr. Gleason, a pulmonologist and itemized billing statements from 9/ 13/03 to present relating to the care and treatment of the patient for the above- referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. If you have any questions, please feel free to call me at any time. Very tr. my yours, SGHMIDT, RONCA & KRAMER, P.C. ?_ erard C. Kramer Attorney at Law GC'K/det Enclosure ??? 1 0 2006 cc: Billing Department C?r?.?..` ? d,? m?,? ?? 3-t3-off a??s?i? 209 State Street Harrisburg, Pennsylvania 17101 717.232.6300 FAX 717.232.6467 www.srklaw.com _ ? - ? ?1--- d' Cv ?? J6J3k?6.C?x`3?.? 6? SER r ,? ?„ ?? ate ?-`?y ?v.` .' ? {j C:t F, ? "?3TEa A 7, 1` ?;? i;7 ;,.iiT?y -,> ?',?,-.r„ ,G ??6 ? ia??u?? t??o "1- ''ll.ton S. Hershey' Medical C0'I7teC The Milton S. Hershey College of Medicine Meaical Center Al.`-7HORIZATI0N FOR RELEASE OF HOSPITAL RECORDS icity) v (State", Health Information Services, P.O. Box 850, Hershey, Pennsylvania 97033 ?t? K f Na",ie of Fatient < L' tC?rt Social Security / Da of birh I l _ / !_? Medical Record Number __ .._._ Phone # ( t TH 3 AUTHORIZATION WILL NOT BE ACCEPTED UNLESS ALL ITEMS ARE COMPLETED. TH! INFORMATION BEING DISCLOSED MAY INCLUDE HIVIAIDS, DRUG/ALCOHOL ABUSE & MENTAL HEALTH DATA. I HERESY AUTHORIZE HERSHEY MEDICAL CENTERIUNIVERSITY HOSPITAL TO A,: RELEASE TOJ OR B. RECEIVE FROM tCircle One) iName of authorized person, agency, institution. or otheri (Street) Reason for Request: 7f 0/ jZip Code) Type of information to be released consists of: DISC=HARGE DATE(S) OUTPATIENT VISIT DATE(S) Discharge Summary 'ies) History r Physical Operative Report __..._.Diagnostic Test(s) ndicate Type of Test & Date Y_ Other (please specify - LL ardi 1?d This consent is subject to 4,, fat o AV time except to the extent that the person who is to'make the disclosure has already taken action in reliance on it. If you wish to revoke this authorization, you must do so in writing to the address at the top of this form, to the attention of the HI' IC Privacy Officer. If not previously revoked, this consent will terminate ninety (90) days from the date of signature. Failure to sign this `orm will not impact your right to receive care at Hershey tvtedical Center. Neither our treatment nor your payment is conditioned upon your signature on this fcrm. I here:Dy release the provider of said records from any legal responsibility or liability in connection with the release of the records indicated and herein. Signature of Pat,tmt cr R pri7er5ir Date Ile f y n212t?on;t;gi if s?yneC D', 01,Ier,;o1 n P ucnt? _ 1!? C°- fsseci - PAUST BE SIGNED PHONE Note to recipient of information: 'his 1a! cn n. ;> ;? _,:ciCse' a cn t'-.e rec: .,tec;ed y P r.r,s, ivania _vv. ?!'j ne ,vn!,a_n MR 543 Rev. 3'03 AUTHORIZATION FOR RELEASE OF HOSPITAL RECORDS /10? sorNcxoRR Nlvtan? HEAV7 WRVE SOURCECORP HEAL THSERVE has been retained by the Medical Record Department of Milton S. Hershey Medical Center Health Information Services to fulfill requests for copies of medical records. Enclosed are the reproduced medical documents specifically authorized by the patient or his/her legal representative. We wish to emphasize that the increasing demands for patient data pose a rising threat to the confidentiality of the patient's medical information. SOURCECORP HEALTHSERVE strives to take every opportunity to safeguard the 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. Please be advised of the following state and federal disclosure statements governing medical records in Pennsylvania: This lnfbrmation has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2). The rules prohibit you from maldng any further disclosure of this information unless further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise -permitted-by 42 CFR-Part-2: - This information has been disclosed-to you from state records whose confidenballty is protected by state statute. State regulations limit your right to make any further disclosure of this information without prior consent of the person to whom it pertains. This information has> been disclosed to you from records, protected by Pennsylvania law. Pennsylvania law prohibits you from makinq; any further disclosure- of, this- iftm ation unless further disclosure. is expressly permitW by the written consent of the person to *hom it.pertains or is authorized by the. Confidentiality of" the HIV-Related, Information' Act, a general authorization for the release of"medical 'or other information is not sufficient for this purpose. SOURCECORP rwHEALTHSERVE ne 1030 Ontario Road RO. Box 8408 Green Bay, W1 54308-8408 phone.920.469.5000 fax.920.469.5010 www.imcwi.com Based upon guidelines provided by the American Health Information Management Association, the records should be destroyed after the stated need has been fulfilled. We thank you for your cooperation in maintaining the patient's right to privacy. Each medical record has been carefully reviewed to assure that proper disclosure goes only W the authorized Requestor. If you have any questions, please do not hesitate to contact us at 866 420-7455 and one of our Customer Service Representatives will be happy to assist you. PENNSTATE Milton S. Hershey Medical terder ® CoRega of Medicine AUDIOLOGICAL DATA RECORD NAME: TAYLOR, ZACHARY J MD: ISAACSON JON E MR#: 95411 DOB: 10/11/1971 INS: AUTO INSURANCE LOC: 8200 OOS#: 5154069 MD#: 25105 SEX: M STANDARD VISIT DATE: 02/02/2005? Complaint/purpose `At ',- PURE TONE AUDIOGRAM 125 250 500 1000 2000 4000 8000 -10 0 10 20 M z 30 > J ? 40 O rn J 0 O ? 50 z Cr a ~ 60 zz Q 70 80 90 100 110 MASKING R L 111 L R L I R L I R L I R JL LEVEL RE: otl6 HTL Audiometer Used _? ?-/ l3f 1 TYMPANOMETRY (KEY ON REVERSE SIDE) RE LE Date c?-Q-o5 SPEECH TESTING RE PTA SRT WR LE MASK dB d8 - t 7 3 dB dB i 5 Li % N5 dB % @ d 8 dB %% @ dB % @ dI °/ @ dB RELIABILITY: gj0O FAIR P OOR I RECORDED HEADPHONES ACOUSTIC REFLEX THRESHOLDS ACOUSTIC REFLEX HZ 500 1000 2000 4000 PROBE RT. Contralateral HTL dB Ipsilateral HTL dB Reflex Decay PROBE LT. Contralateral HTL dB 0 Ipsilateral -77 HTL dB Reflex Decay u3or6 r cc" y ? b 1 c7L YOL I lX Cork , C 41 c CLINICAL AUDIOLOGIST/PHYSICIAN MR 109 Rev 7/01 Pg 1 of 2 AUDIOLOGICAL DATA RECORD NAME: .......... NAME: TAYLOR, ZACHARY D#: 25105 I D: MD: ISAACSON JON E MRN: 95411 SEX: M DOB: 1011111971 STANDARD INS: AUTO INSURANCE TESTER: LOC: $200 OOSN: 5154069 VISIT DATE: 02102/2005 DATE/TIME: 02/02/2005 10:44 am GSI TYMPSTAR MIDDLE EAR ANALYZER PROBE S/N: 20010867 TYMP SCREENING TEST 1 Ytm 226 Hz R ml 1.5 1.0 0.5 0.0 -400 -200 0 +200 4-- 600/200daPa/s EARCANAL VOLUME: 0.9 daPa TYMP 1: 10 GRADIENT: 70 REFLEX: I 1000 Hz TYMP SCREENING M-1 t). a daPa TEST 2 Ytm 226 Hz L ml 1.5 1.0 0.5 0.0 -400 -200 0 ?- 600/200daPa/s EARCANAL VOLUME: 1.2 d?r_,,-1 ml TYMP 1: - - 'LO 0.4 GRADIENT: 95 daPa REFLEX: T 1000 Hz NT +200 daPa MR 109 Rev 7/01 P9 1 of 2 AUDIOLOGICAL DATA RECORD PENNSTATE NAME: TAYLOR, ZACHARY J MD: ISAACSON JON E MR#: 95411 DOB: 10/11/1971 INS: AUTO INSURANCE LOC: S200 OOS#: 5154069 MD#: 25105 SEX: M STANDARD Milton S. Hershey Medical Center College of Medicine AUTHORIZATION FOR BENEFIT ASSIGNMENT AND INFORMATION RELEASE VISIT DATE: 02/02/2005 I hereby assign any benefits payable to Penn State Milton S. Hershey Medical Center for providing medical services. I understand that I am responsible for any balance in excess of the benefits/contract payable by this plan. Penn State Milton S. Hershey Medical Center may disclose information about me and the treatment I am receiving, including copies of my medical record for purposes of treatment, payment and medical center operations as described in our Privacy Notice. I acknowledge that I have been offered the Penn State Milton S. Hershey Medical Center Privacy Notice. Z??N nature of Patient or Patient's representative ZACH 7ZAyfoj? Print Name Privacy Notice Offered - Patient Unable to Sign Privacy Notice Offered - Patient Declined to Sign Other n Date Relationship to Patient DO NOT COPY THIS FORM. ORDER FORMS FROM HMC STORES, CAT. #83012 MR 889 (Rev. 3/04) WE The Milton S. Hershey Medical Center The College of Medicine 500 UNIVERSITY DRIVE HERSHEY, PENNSYLVANIA 17033 PULMONARY DIAGNOSTICS Date: 01/13/05 Age: 33 Gender: Male Name: Taylor, Zachary J. Height(in): 70 Weight(lb): 246 Id: 95411 Race: Caucasian Physician: Dr. Lawrence Jones Diagnosis: Cough Shortness Of Breath Technician: Margaret Weeter, RRT Medication: Any Info: Occ Exposure: Spirometry (BTPS) FVC Liters FEV1 Liters FEV1/FVC % FEF25-75% Usec FEF/FIF50 PEF Usec FIVC Liters PIF Usec Flow MW Umin 16 12 Dyspnea Rest: Yes Dyspnea Exercise: Yes Cough: Yes Persistent: Yes Productive (cc): Smoker. No Quit: No How Long: Stopped: Cigarettes: No Cigars: No Pipe: No PBar:755 Temp: 21 Ref Pre Pre Meas % Ref 5.32 2.95 55 4.37 2.62 60 82 89 4.51 4.19 93 2.92 7.01 5.32 1.74 33 1.83 8 4 0 -8 Volume 8 6 4 2 0 Post Post Post Meas % Ref % Chg -12 2 -1 0 1 2 3 Time 4 5 6 7 8 -2 0 Volume 6 8 PRED PRE POST Comments: Good patient effort. Resting Oxygen Saturation on Room Air = 91-93 %. Broncho- dilator not given; the patient did not qualify due to a FEV1/FVC ratio within 8.3 of the predicted value. ATS criteria not met for: end of spirometry. Interpretation: Norm Set: Crapo/Hsu Room 1 Version: IVS-0101-06-2C DEC-27-2004 MON 08:14 AM 1NT MED ASSOC FAX NO, 7175312034 P. 01 PENNSV NAME: TAYLOR, ZACHARY J - MD: ALAM SHOAIB MDII: 47045 " N ime NAME, TAYLOR, ZACHARY J MRN; 95411 MD: JONES LAWRENCE `BI'th(MR#: 95411 MDM: 33061 r DOB: 10/11/1971 SEX: M INS: MEDICARE STANDARD 008: 10/11/1971 INS: MEDICARE ' Al % SEX: M STAN LOC: PUDX n( I DARD OSk: 5149643 VISIT DATE: O PULMONP, 01/13/2001 ??; tS124tig4 "0.) VISIT DATE: 12/24/2004 - . PHYSICIAN ORDER, ENCOUNTER and FAX FORM ' SENDER: H114, P.O. BOX 850, HERSHEY, PA * F<X: 7?? 531- a03 y PHONE: 717-531«6962 FAX: 717-531-0049 ' PHONE. " PA .GER FOR EMERGENCY): Instructions: Complete all applicable fields labeled with an asti,risk' including all patient, Isolation and sender information. Check order, and all applicable signs and symptol its, monitoring and all disease(s). Look on the back for test descriptions and additional diagnoses. These must be ;opted to front. If a bronchodllstor FlowNolume Loop Is ordered, bronchodilatom must be hold " hours before test. ? The order must be signed by physician. TI N P 9. CIRCLE AeELICABLE: NONE RESPIRATORY CONTACT DROPLET ADULT CDM X ' TEST DESCRIPTION PEDS SIGNS AND SYNipT0111115 ICb-9 X PROF CODE PROF 4794010 512714 *vT soirorr ou want a 7394010 Chest dk= 786.59 47U375 512704 IowNolums Loop also chock all her this 739437 CWuah nwsrrwker 4794060 612734 111 or low o ume Loo or thi: CW0 smoker 491.0 4794200 5127 with a ve 7394200 RIM 600 x I 786.09 4794240 L512706 I Luria Volumes ysm P r 40 786.3 4724240 1 5129% 1 Lung Volumes by N2 washout mate m ?thod J3 7".49 1 47 512707 Carton Monoxide ion SiMity CC 73 4794360 12798 rwa Resistance Doris with Lu i Volt, 73 on 4795070 512705 no See bat k 70 = 47 51 I challenge Say i of 786.06 512709 G mono Stress ere ise k 7 7 >P 4784780 $12715 O 0noy Set check RA/F102 Sin le detern ination .1 1 612710 6 min, desaturation walk RAIR02 0yalify for he m 0 7394761 Who"ina -27 4796800 5127112- 1 ABG on oom Air RA or F102 See bat k Otter 4794112 5128 29 Nocturnal O)umetry S ter k ' 12315 entamkiine treaUrwn 512"ll Pentamidine nebuli er Drug effect monkort V5111169 12822 Nebulizer tment 794.2 . 512989 IdDl Spacer at b"Ith exam V70.5 P/MEP LACE (610 oil es in the CAC9) SP head k3naplont V42.1 512821 Bronchial Ch0low Metho SIP 47'31 512817 Rhing9M sal ins on 305.1 2 512818 La =Other 512701 L- ustion L Vo Ely-al COMMENTS/ ADDITIONAL INFORM ATION: • DISEASE ICD4 X ' DISEASE I CD-9 X ` DISEASE !CD-9 X Am otrois t.at ! §gwosis 335.20 Emphysema 492,8 u =4"40 Asthma RAD 493.0 Hypm 1 n' ' 495.1 Pneumonia u 486 Asthrna mia ALL !04.00 Pubm 1 518.3 fo h 425.4 Louk '05.00 Pulmonary Lung CH Leukemila-C&Ncify) 11135 r Nun Involvement 17.8 Chro-nic Luna Disease COPD 518.99 Lymphoma (Hadgkin's) L=phoais (Non-Hodgkin's) ' %.80 10.0 wR 517.8 . Cystic Fibrosis, luna involve Lung can rims Toxic Inhalation- - 987.0 OTHER: Fill in dx. From back or otter sours ' SIGNATURE OF ORDERING PHYSICIAN OR CLINICIAN " DATE OF REQUEST 1 A C_ IZ o L/ PRINTED NAME OF ORDERING N "bo PHYSICIAN OR CLINICIA CONFIDENTIALITY STATEMENT This fax contains information from The Milto i S. Hershey Medical C.Aer may be confidential and/or priviledged. The information is intended only for the use of the Individual or entity named on this tronmission shoot. If you are not the intended you am hereby notified that any disclosure, copying, distribution or the tak ng of any action in reliance on the contents of this information is recipient , strictly prohibited. If you have received this communication in error, please notify u: immediately by telephone (oolleot, if applicable) and return the document to us at the above address via the U.S. Postal Sorvl< o (postage will be reimbursed). Thank you MR 886 (4/03) Page: 1 of 2 PENNSTATE WM Milton S. Hershey Medical Center College of. Medicine PROGRESS REPORT DERMATOLOGY HPI: " C. I-xct SH/FH/PMH/MED/A4,L (NOTES, LABS, LETTERS, ETC. REVIEw.j Do you have non-skin related pain ? If Yes: ? refer to primary care do NAME: TAYLOR, ZACHARY J MD: ADAMS DAVID R MR#: 95411 D013: 10/11/1971 INS: MEDICARE LOG: DRM1 OOS#: 5161407 K I ROS: (QUESTIONNAIRE REVIEWED:IC :r). 8(a EXAM NI Find NI Find HEAD Rt ARM HAIR Lt ARM LIDS/CON1 Rt LEG LIPS/TEETH Lt LEG NECK NAILS CHEST GEN APPEARANCE ABDOMEN BACK ORAL MUCOSA GENT/GROIN/BUTT LYMPH NODES OTHER EXAM/LAB: ASSESSMENT: Date/Time: MD#: 75115 SEX: M STANDARD VISIT DATE: 0210412005 PLAN: Return to clinic Bx Cry D Cry est y f t Location: Skin prep: Alcohol or Chlorhexidine Anesthesia: Lido w/ Epi or wio Epi Method: Shave or mm Punch Hemostasis: AICI or Gelfoam j Closure: Open or -0 S?at4re Dress ng/Wound Care: Sterile/Gjvi A Attending present for procedpre:o??_ Referring physician contactek: o Side effects, Risks/Benefits discussed: Scar, infection: ql)( Medication side effects: Handout: 1 - saw and evaluated the patient. 1 and the plan of care as documente x, PE and Rx reviewed by: ?jf)l Ad I i v? with tTie in? n / ti C.?, / e resident's note: ttending Signature Dr. Miller Dr. Anderson Rev. 08/27/07 nnvpic(imr/(ormslprogl. yd (kfs) PENNSTATE NAME: TAYLOR, ZACHARY J MD#: 75115 Milton S. Hershey Medical Center MD: ADAMS DAVID R College of. Medicine MR#: 95411 SEX: M 1971 DOB: 10/11/ STANDARD INS: MEDICARE DERMATOLOGY QUESTIONNAIRE LOC: DRM1 VISIT DATE: 02!04/2005 OOS#: 5161407 Please fill out the following Dermatology Questionnaire so that we can serve you better. Thank You. 1. Print patient's full name - A C 14A ?Y 1'/ Y L-0 K 2. Date of Birth l O ` L1 1 3. Home Phone Number 1- (v i X- 6-13 C 9 4. Work Phone Number - - Who referred the patient here? (Name & Address) iJ 61 -,-l Who is the patient's primary care doctor? (Name & Address) f? /Z Y?lr What language does the patient best understand ? For Children: Parent #1 Name Parent 42 Name Occupation Occupation Medical History _ P1Pacn list shim mmiirntinnc vrrn take (inrlmdinv those not renuiring a nrescrintion-creams. herbal sumlements. etc.) 12. 11- 4 5. 6. 7. 8. f 10 I 'll 1 112 - Medication Allergy? Yes/No If yes, please li following Does the patient have any of DeNo Breathing problems: o C9? Liver Problems: YesA& Kidney Problems Diabetes: Yes6D Heart Murmur: Surgery: 'Yes what type: Is the patient pregnant? Menstrual Periods regular: Skin Cancer: le Other Cancer: High Blood Pressure: ? Do you take antibiotics before dental procedures? Infectious disease (HIV, Hepatitis, etc.) Do you have any other medical problems: If Yes, what type: !.Z C e>?-? ??arc_ ? kif ,?sc, Yes/N /ot re' Ye s o Family History Skin Cancer Yes4qo If Yes, what type: Other Symptoms (ROS ) Constipatio iarrhe eNo Unexplained weight loss Fevers ;TessA Arthritis-Joint Pain Numbnes s/Tingling Food Allergies Ye Seizures Ye o If under 18 year old: Appropriate owth d elopment Yeso u to date Ye9/No Vaccinatio s p Does the patient or anyone in the household smoke? Yes o Does the patient or anyone in the household drink alcohol? ever, ecasionally, Frequently n: clinic/forms/dermq(kfs) rev: 06102103 PENNSTATE Milton S. Hershey Medical Center College 0f Medicine PROGRESS REPORT DERMATOLOGY HPL CC.: "`RMATOLOGY NO SHOW tAynl IM BA11 1A111 . w.¦ . SH / FH / PMH (NOTES. LAB Do yo ave n -sl If Y s: ? refer to D. ?. i 11- ? OTHER EXAM/LAB: ASSESSMENT: ?L7'/ nL'i4 /,o : (Q S, EftfA RESCHE[ i related pain ? ? Yes ? Date/Time: ,c ( O /6s E EXAM NI d NI Find HEAD Rt ARM HAIR Lt ARM LIDS/CONJ Rt LEG LIPS/TEETH Lt LEG NECK NAILS CHEST GEN APPEARANCE ABDOMEN BACK ORAL MUCOSA GENT/GROIN/BUTT LYMPH NODES PLAN: Return to clinic PROCEDURE: Bx Cryo/Destroy IL-1 Location: Skin prep: Alcohol or Chlorhexidine Anesthesia: Lido w/ Epi or w/o Epi Method: Shave or mm Punch Hemostasis: AICI or Gelfoam Closure:, Open or _ -0 Suture Dressing/Wound Care: Sterile/Given Attending present for procedure: ? Referring physician contacted: ? Side effects, Risks/Benefits discussed: ? Scar, infection: ? Medication side effects: ? Handout: ? E/M: ? I saw and evaluated the patient. I agree with the findings and the plan of care as documented in the resident's note: ? Hx, PE and Rx reviewed by: Attending Signature Dr. Marks Dr. Helm Dr. Thiboutot Dr. Billingsley Dr. Miller Dr. loffreda Dr. Ammir Dr. Adams Dr. Zaengiein Dr. Anderson Dr. Mackley Attending/Resident/Student Rev- 0827103 n.'+n/rli uc/forms/pro?l.++P? (kfs) TIE MILTON S HERSHEY MEDICAL CENTER PO BOX 853 HERSHEY, PA 17033 MEDICAL RECORD COPY MR328 (REV 9/00) +-----------++-----------++----------++-------++--------++----++---++---++-+ 100095411 119043842 1107/29/05 1102M:21 AlIROOM/BEDIIEMERIJECU117RC11AI +----------++-----------++----------++-------++--------++----++---++---++-+ +-------------------------++---++----------++---++--++----++---++---++----+ ?REL NON 1 TAYLORTZACHAARY J liSmEXIIBI0/RTHDATE11/197JIIAGE33I 1SSIIMRSAl1?E11 1 +-------------------------++---++----------++---++--++----++---++---++----+ +---------------------------------++--------------------++---++------------+ (PATIENT ADDRESS (CAMP HILL (IPA 11Z17I0P11CODE 2100 CEDAR RUN DR 204 +--------------------------------++--------------------++---++------------+ +------------++---------------------------++---------------++-------------+ PT PHONE PT EMPLOYER EMPLOYER PHONE 717 612-0309 1 11 1 +-------------++---------------------------++---------------+--------------+ +--------------------------++-------------++-------------++---------------+ CONTACT (ARMSTRONG DANA 11710N612-1655 H WORK PHONE 1121 0UNTY 1 +--------------------------++-------------++-------------++---------------+ +-------------------------------------------------------------------------+ INSURANCE INFORMATION NAME POLICY # GROUP NUMBER MEDICARE 185689025A GATEWAY HEAL 22219158 SELF PAY 0 t ------------------------------------------------------------------------- + +----------------------------------------- REGISTRAR BEH I + ------------------------------------------------------------------------- + +----------------------------------------------- ICOMMENTS I +------------------------- +------------------------------------++-----------------------------------+ IA46329IRICKSYJOHN E 11ATTEND0ING PHYS 2 +------------------------------------++--------------------------------- -+ +------------------------------------++-----------------------------------+ FAMILY PHYSICIAN REFERRING PHYSICIAN BOLLARD EDWARD R PO BOX 850 UNIVERSITY HOSPITAL HERSHEY PA 17033 717 531-8161 FAX: FAX: +----- ---------------------------++-----------------------------------+ PENNSTATE Milton S. Hershey Medical Center College of Medicine AUTHORIZATION FOR TREATMENT IN THE EMERGENCY DEPARTMENT AND RELEASE OF INFORMATION The undersigned has presented for evaluation and treatment in the Emergency Department. All treatment and procedures determined to be necessary will be performed by physicians and other members of the clinical staff. Authorization is hereby granted for such treatment and procedures. The undersigned has read the above authorization and understands the same and certifies that no guarantee of assurance has been made as to the results that may be obtained. I hereby assign and authorize payment directly to the Penn State Milton S. Hershey Medical Center. I authorize any holder of medical or other information about me to release to my insurance carrier and its agents any information needed to determine these benefits or benefits for related services. I acknowledge that the Penn State Milton S. Hershey Medical Center Privacy Notice has been provided to me. INSTRUCTIONS: Please read all of the above. An authorization for treatment must be signed before treatment can be given. Authorization must be signed by the patient, or by an authorized person in the case of a minor or when the patient is physically or mentally incompetent. r DATE: SIGNED: TIME: AM PM or f/ (authorized person) Relationship to Patient: Witness: ?1_' d( k`'L For Non-emergency use of the emergency room only: Do you have access to a prima}?care physician or an outpatient clinic for non-emergency care at this time: Yes No ? Privacy Notice Given-Patient unable to sign ? Privacy Notice Given-Patient declined to sign MR 1012 12/04 AUTHORIZATION FOR TREATMENT IN THE EMERGENCY DEPARTMENT AND RELEASE OF INFORMATION ti<1 4 PENNSTATE The Milton S. Hershey Medical Center The College of Medicine Department of Emergency Medicine Record MR 818 NRME: TRYLOR, ZRCHRRY J MDr MR: 0095411 DOB: 10/11/1971 LOC: EMER OOS#: 9043842 MD#46922 SEX: M VISIT DRTE: 07/29/2005 Date, "7 7 Tern Oral Rectal (Pulse 16 7RR 7?B,P 02 sat Last dT LMP ED Pathway Room Time Physician Time Col. `,i PMH- a6f,, 07 b`c C ?tS? L -' A HPI: VII Ay a? C"tilt /, c. `-/ C?++>?Fso un"A-?!y At fc!/35 ? 1) ? 7 t7 t?f? 716,1?) /14sK3c_ C/" .. ?L _ t~ ACICA41"'r LW /JL 1?JdOi/171u+J / Med Zcd(? L4/ 1 0-eq S,-?WC ro-i a? ..? -/1 e7 7yC4--? 11100 S7,M-S AC-,-rn It_ca,.ti1 y t Allergies: Pain: Y N Location Quality Onset FHx: Cardiac Y N Diabetes Y N Radiation Quantity /10 T j Factors ROS: Unobtainab le - Y N As ted, other s st s ne ative Y Other: Constitutional: Wt. Change Y Fever Y Chills Y Weakness Y Fatigue Y Soc Hx: ETCH Y N Smoker Y N PPD Eyes: Blur vision N Y Diplopia N Y Eye Pain N Y Photophobia N Y ENT, mouth: Sore throat Y Epistaxis N Y Ear Pain N Y Rhinorrhea N Y Other: Cardiovascular Chest pain Y Pleuritic N Y Exertion N Y Palpitations N Y LAF/0i8t0 Stodfiis: - Respiratory: Cough Y Sputum (TN )Y Dypnea Y Orthopnea Wheezing Y GI: Abd. Pain Y Nausea Y Vomiting Y Constipatio Diarrhea Y _ Neutrophil GU: Hematuria Y D suria Y FrequencYM Y- Vaginal D/C N Y Incontinene N Y ? Atypicals Musculoskeletal: Arm ain Y Le ain Y Back pain N Le swellin N Y Skin- Rash Y N Lesion Y N Ca Neurological Numbness Tinglin Y Seizure Syncope Dysphasia 4 ?- Psychiatric: Suicidal Y Anxiety Y Ingestion Y Depression Y Hallucinations --N-y Mg Other: Troponin I: Myoglobin: Physical Exam: Rectal: Hemocult (+) (_) PT: PTT: ` N 1 L" V INR: T Bili: Alk Phos: ALT: Amylase: Lipase: wyijf vrY W Drug Screen: 6 1 d?1 1/ Cultures: Blood 1 2 Urine L ?AL /U !?[ / l?t S C Rad che k boo if ra tint ; relation j ? i ` Study #1: u See attached PROGRESS NOTE or additional information: ? Result: MDM I Differential Diagnosis:, 3) 6) 1) 4) 7) Study #2: 2) 5) 8) ? Result: Procedure Note: Study #3: EKG: ? Result: ED course: Treatment: - -- Consul!:/ time Coysult l Tihie Response: 1) 2) Diagnoses In tient:Pathwa Ink) U& ?^J A. Fib ? 23hr ? 4 day ? Chest Pain ? Dehydration Discharge Instructions: Please go di tly to check out secretary at waiting room desk n DVT ? 23hr ? 5 day ?Com. Acq. Penumonia ? 23hr trauma ? Cellulitis within days. Follow up with J PrescriptionsYModicat lOns: Return tc emergency department if..., 1) fit 2) 3) R sident/F /Student;Si n ture ndin Signature ton 'Number Discharge Admis lon Transfer ' ' i 1 / ... y J i v, "? ? Resolved ? proved No change Service: Time: Where: ? Cobra form 'I V Patient Visit Summa ZACHARY TAYLOR has been given the following list of patient education materials and follow-up instructions: Patient Education Materials: Injury & Illness BACK PAIN, General KIDNEY STONE Follow-Up Instructions: Follow-Up With: Address: Your Primary Care Provider When: Comments: In 10 days Follow up with your 8/812005 own doctor as needed Return to ED for blood in your urine or a significant increase in your pain. I, ZACHARY TAYLOR, have received the above patient education materials/instructions and have verbalized understanding: 7/,' '7h) Patient Si nature Dat Provider Signature Date a?? NIRN: 0095411 FIN: 9043842 Name: ZACHARY TAYLOR MRN: 0095411 Page: 5 of 5 PENNSTATE 500 UNIVERSITY DRIVE The Milton S. Hershey Medical Center HERSHEY, PENNSYLVANIA 17033 ® The College of Medicine PULMONARY DIAGNOSTICS Date: 09/09/05 Age: 33 Gender: Male Dyspnea Rest: No Dyspnea Exercise: No Name: Taylor, Zachary J. Height(in): 70 Weight(lb): 246 Cough: Yes Persistent: Yes Productive (cc): 0 Id: 95411 Race: Caucasian Smoker: No Quit: No Physician: Dr. Kevin Gleeson Diagnosis: Puknonary infiltrates How Long: Stopped: Technician: Mary C. Smith, RRT Medication: Cigarettes: No Cigars: No Pipe: No Arry Info: Occ Exposure: PBar. 756 Temp: 23 Spirometry (BTPS) Ref FVC Liters 5.32 FEV1 Liters 4.37 FEV1/FVC % 82 FEF25-75%Usec 4.51 FEF/FIF50 PEF Usec FfVC Liters 5.32 PiF Usec MW Umin Pre Pre Meas % Ref 2.72 51 2.29 52 84 3.90 86 1.74 7.10 2.05 38 2.62 58 Post Post Post Meas % Ref % Chg Flow 16 12 a- 41 0 -41 -8 T -121 -2 0 4 6 8 olume PRED Volume 8 6 4 2 0 PRE Time POST Norm Set: Crapo/Hsu Room 1 Version: NS-0101-06-2C Name: Taylor, Zachary J Lung Volumes TLC Liters VC Liters IC Liters FRC N2 Liters FRC P L Liters ERV Liters RV Liters RV/TLC % Vtg Liters Raw cmH20/Usec Comments: ID: 95411 Ref Pre Pre Post Post Post Meas % Ref Meas % Ref % Chg 6.92 4.58 66 5.32 2.72 51 3.51 2.39 68 3.41 3.41 2.19 64 1.76 0.40 23 1.69 1.86 110 24 41 2.43 1.33 Good patient effort, patient tested in sitting position. Resting Oxygen Saturation on Room Air =92 %. Interpretation: Norm Set: Crapo/Hsu Room 1 Version: IVS-0101-06-2C SEP-062005 TUE 01:11 PM HMO PSU UPG-NYFR Rn FAX NO, 7175310405 P. 01/01 NAME: TAYLOR, ZACHARY J PC*IA'CS(MMDR#: ALAM SHOAIB [..I VI V: 95411 DOB: 10/11/1971 INS: MEDICARE LOC: PUDX OOS#: 5913315 P O ARY DIAL ST HPHONE:717-531-6862 MD#: 47045 PHYSICIAN ORDER, EN N H114, P.O. BOX tX SEX: M STANDARD VISIT DATE: 09109/2005 FAX FORM , PA 1.0049 Q2;o0 MRN ' Nam MOB: CILIEYlOR 3fiCliAilY J MR# 1. pant kEVlm ' Birth Dom; 10/ 11/ 1971 1'116: MEDICARE "Attu LOC: Lft OOtiy: 67923'd1 * 00-1 1 *SENDER: ' FAX: ' PHONE: ' PAGER IFoR EmE NU AOO, 47300 SEX: M STANDARD VI8IT DATE: 00/91/2005 Instructions: Complete 11 applies fields labeled with an asterisk" including all patio t, isolation and sender Information. Check o , and all a >s). Lookon the back lieable signs and symptoms, monitoring and aN 3 I rcho :tor FlowNolume W I for test descriptions an additionatl i noses. These must be copied to front. H a I Loop is ordered, brom ilatom rn t st be held 44 hours before test. The order must ned by physician. RC NONE RESPIRATORY CO ACT DROPLET T X PEDS DESCRIPTION AND SYMPTOMS ICD 9 X PROF CODE PR OF 10 512714 if YOU want a 7394010 sc 786.59 4794375 1 04 IF Um also Check either 875 ran-snwker 786.2 47 34 NOf w oiume o0 or this GwAh am0"r 1.0 4794200 512737 One with all above 7394 pjffjjL" noel. d 786.09 794240 1 512706 tr?es Fmfomble metlt 766.3 1 47"240 512M I antes wet . ut Alternate 7394 nut 7M.49 4794720 7 Mono y H 01 47 512738 AI Mat ne with vols. 74350 tilstion 7 47ON70 5112705 e ne See 7 786.02 4794620 9 I of breath 786.06 4794680 12709 man Sae a 760.57 4794760 5 IS oxk k*w sat 2-?ft RAM2 Sal 4794761 512710 desaboatian RAIFi02 Qua& for home 02 761 2J 78 . 512712 AS Qbn Roan AN of FIO2 S bade 73 30M 0#* 1 4794782 512829 Oxi See b " 512315 treat t e 512"1 ne nebt ' V5Uj 5121W at n ed 714.2 1 512965 m T vn.a2 , CA Milt all in-tha CE 512821 ial Metho SIP V42.6 512817 Inspecim) 731575 612818 Other 2701 voloe value COMMENTS! AD DIT IO INFORM TION: • DISEASE IC04 X s DISEASE 1 co-9 X ISEASE ICD•9 X Arrt Lateral Sclerosis 92,1 dwcitv an ism) Asthma itiviN Pneumoniti rsens 4 nism 486 c _ oukenta (ALL) 204 I 518. o 425.4 eukernii1AML) 208-00 Lung Dx. 518.6 CHF 1 428.0 is fflpecifO a 1 135 w6u In nt 17.8 Chroniq Luna L 201 i 710.1 COPD 496 Rhorne L N in' :; .80 C --t us1 710. w/lunainvoNment 2)517.81 CY-sk is lung Involve 77.02 noer-girimary ;162.9 TOM lWalati in 7 OTHER: Fill in dz. From back Or other source " SIGN F ORD RING PHY ICIAN OR CLINICIAN *DATE QU T " P D NAME OF O RDERIN PHY3100 OR CU J CIAN 1- CONFI ENTIALITY ST MENT This r, contains information from The Milton S. Hershey Medical Cent r and may be confidential and/or priviled . The informs i n Is intended y for the use of the individual or entity named on this tranmift sheet. If you are not the intended recipient, u are hereby n ed that any d' c losure, copying, distribution or the taking of any action in nelian .on the contents of this information is strictly p hibited, If you h e recehred this communication in error, please notify uS imrtediately by telsPhon oollea if applicable) and return the docu t to us at the ve address via the U.S. Postal SerA,* (postage will be reimbur ). Thank you MR 886 (4/03) Page 1 a 2 NAME; TAYLOR, ZACHARY J MD: QUILLEN DAVID A MR#: 95411 DOB: 10/11/1971 • Lids and Adnexa• ? Neg ? POS INS: MEDICARE LOC; OPH1 • Slit Lamp Examination: ODs#: 5859396 O O R L n?l - ?O ?3 O nl Conjunctiva Cornea O ?^ Tear Film ?O O O? Ant. Chamber Iris ?' ? Lens MD#: 85650 SEX: M STANDARD VISIT DATE: 10/27/2005 • Gonioscopy: (9(9 Cornea Lens Lens Cornea 000 000 • Fundus Examination: R L nl abnl nl abnl vitreous LYO _ Optic Nerve _ ? Post Segment ?,- _ ¦ Optic Nerve Head: 00 ? Extended Ophthalmoscopy see additional form RESIDENT PA TICIPATION '? YES TEACHING PH SICIAN DOCUMENTATION/SUMMARY His Exam MDM &I?L (? Z /,- ?n this day I saw, examined and was physically present for the key portions PHYSICIAN Date of the services provided. I agree with the resident's plan and notes. RTC: t 7- NEXT TIME: ? Refraction J Gonio PHYSICIAN Date .J Dilated Exam J VF J other ? Dictated ? Consult requested: J Patient Instructions Given Initials MR905 Rev. 1/o5 Page 2of2 OPHTHALMOLOGY EXAM FORM White Copy - Medical Records Yellow Copy - Department 1EDICAL DECISION MAKING PENNSTATE Milton S. Hershey Medical Center College of Niedicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: PMGT, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 6472550 Tel: (717) 531-8055 1 O u t p a t i e n t L e t t e r D o c u m e n t Modified Document Electronically Signed by: Vorobeychik, Yakov M 2/28/2006 3:07:51 PM Addendum by Thompson, Virginia L on Tuesday, February 28, 2006 15:12 crossed out section should read maximal. CC: Edward R Bollard, MD, DDS Penn State Milton S. Hershey Medical Center PO Box 850 Hershey, PA 17033 Sincerely, Virginia L Thompson, CRNP Pain Management Clinic Penn State Milton S. Hershey Medical Center PO Box 850, UPC II, Suite 3300 Hershey, PA 17033 VLT February 27, 2006 Name: TAYLOR, ZACHARY J HMC Number: 0095411 DOB: 10/11/1971 Date of Service: 02/27/2006 Edward R. Bollard, M.D, OUTPATIENT LETTER Date Printed: 312 312 0 0 6 Time Printed: 5:44 AM PENNSTATE W Milton S. Hershey Medical Center College of N[edicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 1 O u t p a t i e n t L e t t e r D o c u m e n t Modified Document Electronically Signed by: Vorobeychik, Yakov M 2/28/2006 3:07:51 PM 670 Cherry Drive, Suite 104 UPG-Cherry Drive Hershey, PA 17033 Dear Dr. Bollard: Today, on February 27, 2006, we had the pleasure of seeing your patient, Mr. Zachary Taylor, in the Pain Management Clinic at Hershey Medical Center in response to your request for consultation. Zachary and his mother present today with a chief complaint of primarily axial back pain. He rates his current pain intensity as 10/10. He reports at best on rare occasions, it is a 0/10, at worse a 10/10. He describes it as constant, sharp, and aching. He denies hyperesthesia. They report motor deficit in the form of weak and shaky legs. They report sensory deficit in the form of numbness in his left foot. The patient's mother reports that this pain began after a motor vehicle accident in September 2003. The patient was an unbelted passenger who was lying asleep in the back seat, when the car was T-boned. He was treated in Washington DC where the accident occurred and found to suffer an L1 vertebral body fracture. They returned to our emergency room where this finding was confirmed. Prior to the accident, Zachary had difficulties with kidney stones and pounding and throbbing pain, but denies the presence of any of this type of back pain previous. He had no back pain prior. When explaining the history of the accident, the mother went into great detail as though reliving the accident. She reports she "disassociated" after the accident and suffers from substantial chronic pain herself. She describes that she is on "big drug". The patient notes that activity and walking will increase this pain. He is unsure if anything decreases it. Diagnostic testing most recently, the patient had a CT of the lumbar spine on September 14, 2003, immediately after the accident. This showed a right oblique anterior superior lip of L1 fracture with no significant displacement and mild anterior wedging. The bony spinal canal was patent with no retropulsion of fracture fragments. He also had multiple bilateral renal calculi noted. Previous Therapy: Medications trailed have included a hydrocodone and Tylenol, which are helpful, although the mother describes intermittent interaction with his valproic acid. He had physical therapy, which was helpful for a time. He has not had a TENS unit, biofeedback, or previous nerve blocks. Review of Systems: The patient reports he sleeps poorly. His mom states this is a chronic problem. His appetite has increased since steroid therapy. His present weight is 164 pounds. Mother states he has gained about 40 pounds in the last 2-1/2 years. He denies nausea or vomiting. He notes shortness of breath, which the mother relates to chronic atelectasis for which she follows up with our pulmonary medicine division. He denies chest pain, fever, chills, or constipation. She reports chronic intermittent bowel or bladder incontinence. Deny melena or hematuria. When asked about changes to physical activity, the patient is relatively inactive. He watches movies and will sometimes go on shopping trips with his father. The patient has been disabled permanently. There is litigation pending regarding the injuries he received in the accident. The patient admits to some mild depression, but denies significant depression. They have significant family support. Mother denied any psychiatric history. History of drug or alcohol abuse or any use of recreational drugs. Date Printed 312312006 , Time Printed: 5:44 AM PENNSTATE 100q Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 1 O u t p a t i e n t L e t t e r D o c u m e n t 1 Modified Document Electronically Signed by: Vorobeychik, Yakov M Current medications include valproic acid, Tylenol, hydrocodone, and prednisone. Allergies: The patient reports allergy to Advil and codeine. 2/28/2006 3:07:51 PM Past history and medical history are significant for ulcerative colitis, hypoxic brain injury at birth, myoclonic jerking, renal calculi, GERD, and asthma. Surgical history includes removal of multiple renal calculi as well as renal stenting. He has also had right knee surgery and an inguinal hernia repair. Family history includes a paternal history of coronary artery disease and hypertension, as well a maternal history of diabetes. Social History: The patient is single, lives with his mother. His parents are divorced. His father is also involved in his care as are siblings. The patient has no children. He denies current use of cigarettes or alcohol. Physical Exam: This is an obese, young, Caucasian male who appeared in no acute distress. He is awake, alert, and oriented x3. The patient has evidence of his hypoxic brain injury with some mental retardation. The patient is also quite hard of hearing. He is wearing hearing aids. His mother accompanies him and explains and assists Zachary with his answers. Vitals signs today are pulse of 96, respiratory rate of 20, and blood pressure 109/76. HEENT Exam: Neck demonstrates full range of motion without pain. The patient does have tenderness to palpation across his bilateral trapezius muscles. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Cardiovascular exam: Heart is regular in rate and rhythm without murmur. Respiratory exam: Lungs are clear to auscultation bilaterally. GI exam: Abdomen is obese with stria noted. It is nontender with no organomegaly and bowel sounds present. Musculoskeletal exam: Upper extremities are 5/5 in strength bilaterally with no sensory deficit identified. Lower extremities are 5/5 in strength bilaterally with no sensory deficit identified. Deep tendon reflexes are intact bilaterally. On spine exam, the patient has decreased range of motion of the lumbar spine due to pain. He is tender to palpation from approximately T12 through L2 with < -- tenderness midline at L1. Straight leg raising is negative bilaterally. Impression: 1. Vertebral fracture. History of L1 fracture- 2. Myofascial pain syndrome. Plan: 1. The patient would not be a candidate for any interventional procedures. The nature of his injury and the location of his pain does not indicate that he would benefit from epidural or facet injections. 2. It was noted, he is not taking any anti-inflammatory medications. We have recommended his primary care physician to consider adding nonsteroidal anti-inflammatory to his regimen, if this would be tolerated based on his other medications and his history of ulcerative colitis and GERD. We will leave this decision up to his primary care physician. 3. The only option we can recommend is to continue with conservative treatment including the use of Vicodin and Tylenol, which seems to be quite effective for managing his pain. If at some point in the future, this is not managing his Date Printed 312312006 Time Printed: 5:44 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t L e t t e r D o c u m e n t Modified Document Electronically Signed by: Vorobeychik, Yakov M 2/28/2006 3:07:51 PM pain, we could consider initiation of a stronger narcotic. However, the mother states the patient requires liquid medications and the longer acting agents are generally not available in a liquid preparation. 4. We have discharged Zachary from our care, as we have nothing additional to offer. He will return to the care of his primary and referring physicians. As an interventional consultative practice, we have nothing additional to offer. This plan was discussed with the patient and his mother. They verbalized understanding and agreed to the plan. Thank you very much for the opportunity to participate in Mr. Taylor's care. If you have any questions about these recommendations, please feel free to contact us at the Pain Management Center. Dr. Yakov Vorobeychik was present for the evaluation and therapeutic treatment planning of this patient. 51036 Sincerely, Yakov M Vorobeychik, MD YMV /CO DD: 02/27/06 DT: 02/28/06 06:10 Date Printed. 312312006 Time Printed: 5:44 AM PENNSTATE lop"" Milton & Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 Patient Sex: Male Date of Birth: 10/11/1971 Patient Location: LPS, , Visit Number: 6309196 Visit Type: Clinic O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Gleeson, Kevin 2/3/2006 4:36:40 PM OUTPATIENT LETTER January 25, 2006 Name: TAYLOR, ZACHARY J HMC Number: 0095411 DOB: 10/11/1971 Date of Service: 01/25/2006 Dear Doctors: I saw Zachary Taylor today with his mother. She has tapered his prednisone down to 0 over the course of the last month or so. He has been off the prednisone for a week. His back pain is much worse and his diarrhea is worse. The CT scan of his chest in late January demonstrated a resolution of the ground-glass infiltrate with some persistent atelectasis, but nothing else. On physical examination today, his weight 260 pounds, his blood pressure 100/70, and his pulse 85. Head, eyes, ears, nose, and throat are unremarkable. His chest is clear and has no rales today. Whatever the case may have been with his lung disease before, I think he just has some atelectasis now. I am going to put him back on the prednisone for a week or two, because I think it may have been tapered too rapidly. It is perhaps contributing to his overall malaise, worsening pain, and diarrhea. I plan to see him back in 6 months. No further intervention for his lung disease is needed now. Date Printed: 312312006 Time Printed: 5:44 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Gleeson, Kevin 2/3/2006 4:36:40 PM 496501 Sincerely, Kevin Gleeson, MD KG /CO DD: 01/25/06 DT: 01/26/06 10:23 Date Printed: 312312006 Time Printed: 5:44 AM PENNSTATE qP Milton S. Hershey Wdical Cuter College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: RAD, , Visit Type: Clinic PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 6285401 C h e s t - S t u d y Final CT CHEST WITHOUT CONTRAST PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 12/28/2005 EXAM NUMBER: 1108163 ORDERING PHYSICIAN: GLEESON, KEVIN UNENHANCED CT OF THE CHEST TECHNIQUE: A helical CT of the chest was performed with a multidetector CT reconstructed every 3mm using lung and mediastinal algorithms, Additional prone images were obtained through the lung bases. CLINICAL INFORMATION: Pulmonary infiltrate COMPARISON STUDY: Unenhanced CT of the thorax September 9, 2005 FINDINGS: CHEST: There is no mediastinal, hilar or axillary lymphadenopathy. There is atelectasis or scarring in the right middle lobe which remains when placed prone. There is right basilar atelectasis which has progressed slightly from the comparison study. There is no consolidation. Ground glass opacity in the right lower lobe resolves with prone placement. There is no pleural effusion. The heart is unremarkable. Included intra-abdominal contents are stable with bilateral renal calculi and calcifications as well as scarring of the left kidney. IMPRESSION: 1. Right middle and lower lobe atelectasis versus scarring slightly progressed from the comparison study. 2. Right lower lobe groundglass opacity resolves with prone placement and is therefore not hypersenstivity pneumonitis but dependent atelectasis. Dr. Edward J. Borman is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. Date Printed: 312312006 Time Printed: 5:45 AM PENNSTATE ® Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 C h e s t - S t u d y ' 1 Final DICTATED: BORMAN, EDWARD REVIEWED AND SIGNED: SARWANI, NABEEL DATE DRAFTED: 12/28/2005 11:50 AM DATE OF FINAL SIGNATURE: 12/29/2005 05:52 PM Date Printed: 312312006 Time Printed: 5:45 AM PENNSTATE 10 Milton & Hershey Medical Center College of Wicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: LPS, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 6082464 Tel: (717) 531-8055 1 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Gleeson, Kevin November 30, 2005 Name: TAYLOR, ZACHARY J HMC Number: 0095411 DOB: 10/11/1971 Date of Service: 11/30/2005 Edward R. Bollard, M.D. PSMSHMC General Internal Medicine Hershey, PA 17033 Dear Dr. Bollard: OUTPATIENT LETTER 12/8/2005 9:29:38 AM I saw Zachary today for followup of his interstitial lung disease. I have spoken with his mother on the phone on several occasions since I saw him in August. In September, we initiated prednisone 40 mg after ascertaining that his lung function was restricted and he had a ground-glass opacity in his right lower lobe. I was to see hini back in October and the appointment was canceled for some reason, and thus I am seeing him back today after essentially 2 months of prednisone 40 mg a day. His cough is better. His mother states his back continues to bother him, and between the patient and the mother, they believe that there may be some relationship between the auto accident < > lung disease. Other medications include oxycodone for pain, valproic acid, and he is currently taking some antibiotic. Date Printed: 312312006 Time Printed: 5:45 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 1 O u t p a t i e n t L e t t e r D o c u m e n t 1 Final Document Electronically Signed by: Gleeson, Kevin 12/8/2005 9:29:38 AM On physical examination, his weight is 255, his blood pressure is 98/68, and his pulse is 108. He ascends and descends the examining table with the assistance of his mother. His chest is pretty clear. I cannot tell if he has rales or not since he does not inhale consistently when I ask him to. A 2-month trial of prednisone at 40 mg is certainly sufficient to determine if his condition is steroid responsive. If symptoms are better; I think we should repeat the CT scan to determine if the lung infiltrate is better. If it is, or is not, then we will proceed from there. Otherwise, I would like to reduce the prednisone to 30 mg and then to 20 within a month. I will see him back in 4 weeks. I will be in further touch with you. 410921 CC: Edward R Bollard, MD PSMSHMC Medicine Sincerely, Kevin Gleeson, MD KG /CO DD: 11/30/05 DT: 12/01/05 07:47 Date Printed: 312312006 Time Printed: 5:45 AM PENNSTATE Milton S. Hershey Medical Ceder College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: LAB, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 6040024 Tel: (717) 531-8055 I C B c Procedure WBC Hgb Hct RBC MCV MCHC MCH Units K/uL g/dL % M/uL fL g/dL pg Ref Range [4.8-10.8] [14-18] [42-52] [4.6-6.2] [82-96] [32-36] [28-33] 10/13/2005 Thu 0 12:47:00 PM 14.4 15.2 46.1 4.86 94.9 33.0 31.3 Procedure RDW Plts MPV Type of Diff: Neut% Lymph% Units % K/uL fl, % % Ref Range [12.0-16.4] [140-34 0] [8.7-12.5] [35-71] [25-45] 10/13/2005 Thu 0 12:47:00 PM 13.6 245 9.6 MANUAL 88 10 10/13/2005 12:47:00 PM Plts: CHECKED Procedure Mono% Baso% Eos% Neut, Abs Lymph, Abs Mono, Abs Units % % % K/uL K/uL K/uL Ref Range [0-10] [0-2] [0-6] [1.7-7.7] [1.2-4.9] [0.0-1.1] 10/13/2005 Thu 0 12:47:00 PM 2 0 0 12.7 1.4 0.3 Procedure Baso, Abs Eos, Abs RBC Morphology Units K/uL K/uL Ref Range [0.0-0.2] [0.0-0.7] 10/13/2005 Thu 0 12:47:00 PM 0.0 0.0 NORMAL Date Printed: 312312006 Time Printed: 5:45 AM PENNSTATE lp"'q Milton S. I?Y Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 C h e m i s t r 10/13/2005 Thu 0 10/13/2005 Thu 0 Procedure Na Units mmol/L Ref Range [135-145] 12:47:00 PM 140 Procedure Ca Units mg/dL Ref Range [8.5-10.0] 12:47:00 PM 9.3 K Cl- HCO3 BUN Cret Glu mmol/L mmol/L mmol/L mg/dL mg/dL mg/dL [3.5-5.0] [98-110] [22-32] [8-22] [0.8-1.4] [70-120] 3.8 98 33 13 1.1 76 Date Printed: 311311006 Time Printed: 5:45 AM PENNSTATE UP Mon & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 L i v e r / G 1 -1 Procedure ALT T Bili Alk Phos AST Units unit/L mg/dL unit/L unit/L Ref Range [10-50] [0.1-1.0] [40-110] [10-40] 10/13/2005 Thu 0 12:47:00 PM 21 0.4 60 15 Date Printed 312312006 Time Printed: 5:45 AM PENNSTATE 10 Milton S Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 I D r u g M o n i t o r 10/13/2005 Thu 0 Procedure Valproate Units ug/mL Ref Range [50-100] 12:47:00 PM 108 Date Printed:' 312312006 Time Printed: 5:45 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 I C a r d i a c / L i D i d 1 Procedure Chol LDL HDL Chol/HDL TG Units mg/dL mg/dL mg/dL mg/dL Ref Range [125-200] [50-130] [>35] [30-250] 10/13/2005 Thu 0 12:47:00 PM 223 126 65 3.4 158 Date Printed: 312312006 Time Printed: 5:45 AM PENNSTATE 40 Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 N u t r i t i o n Procedure Alb Prot Units g/dL g/dL Ref Range [3.5-5.5] [6.5-8.3] 10/13/2005 Thu 0 12:47:00 PM 3.8 6.8 Date Printed: 312312006 Time Printed: 5:45 AM PENNSTA?TE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: PUDX, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 5913315 Tel: (717) 531-8055 P u l m o n a r y R e p o r t D o c u m e n t Final Document Electronically Signed by: Alam, Shoaib PULMONARY PROCEDURE Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 09/09/2005 33-year-old male with pulmonary infiltrates. Studies Performed: 1. Spirometry with flow volume loop. 2. Lungs volumes by body plethysmography. 3. Oxyhemoglobin saturation. 9/23/2005 11:02:31 AM Results: Good patient effort. Resting oxyhemoglobin saturation on room air was 92%. Spirometries show an FEV1 of 2.29 liters which is 52% of predicted, FVC of 2.72 liters which is 51% of predicted, and an FEV1/FVC of 84% compared to a predicted of 82%. Total lung capacity measures 4.58 liters which is 66% of predicted. Interpretation: 1. Mild oxyhemoglobin desaturation. 2. No evidence of an obstructive ventilatory impairment. 3. Mild restrictive ventilatory defect is present. 4. Compared to a prior study done January 13, 2005 there has been a 330 cc decrease in FEV1. Date Printed: 312312006 Time Printed: 5:46 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 I P u l m o n a r y R e p o r t D o c u m e n t Final Document Electronically Signed by: Alam, Shoaib #286513 Review/Sign: Dorothea T Direso, DO Review/Sign: Shoaib Alam, MD DTD /GC DD: 09/09/05 DT: 09/12/05 16:08 9/23/2005 11:02:31 AM Date Printed: 312312006 Time Printed: 5:46 AM PENN5TATE No" Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 P F T - S t u d y Final PULMONARY PROCEDURE Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 09/09/2005 33-year-old male with pulmonary infiltrates. Studies Performed: 1. Spirometry with flow volume loop. 2. Lungs volumes by body plethysmography. 3. Oxyhemoglobin saturation. Results: Good patient effort. Resting oxyhemoglobin saturation on room air was 92%. Spirometries show an FEV1 of 2.29 liters which is 52% of predicted, FVC of 2.72 liters which is 51 % of predicted, and an FEV1/FVC of 84% compared to a predicted of 82%. Total lung capacity measures 4.58 liters which is 66% of predicted. Interpretation: 1. Mild oxyhemoglobin desaturation. 2. No evidence of an obstructive ventilatory impairment. 3. Mild restrictive ventilatory defect is present. 4. Compared to a prior study done January 13, 2005 there has been a 330 cc decrease in FEV1. Date Printed: 312312006 Time Printed: 5:46 AM PENNSTATE ® Milton & Hershey Medical Center NOR College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 I P F T - S t u d v 1 Final #286513 Review/Sign: Dorothea T Direso, DO Review/Sign: Shoaib Alam, MD DTD /GC DD: 09/09/05 DT: 09/12/05 16:08 Date Printed: 312312006 Time Printed.- 5:46AM PENNSTATE Milton & Hershey Medical Center 10 College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 Patient Sex: Male Date of Birth: 10/11/1971 Patient Location: LPS, , Visit Number: 5792321 Visit Type: Clinic O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Gleeson, Kevin 9/19/2005 2:15:31 PM OUTPATIENT LETTER August 31, 2005 Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 08/31/2005 Edward R. Bollard, M.D. UPG-Internal Medicine 670 Cherry Drive Hershey PA 17033 Dear Dr. Bollard: I saw your patient Zachary Taylor today for evaluation of interstitial lung disease. Thanks for sending him here. He is the son of a mutual patient of ours, Dana Armstrong. As you know, he had a cough for something like 6 months. A chest x-ray in February was normal. A CT scan in March showed a lung infiltrate and a CT scan in June showed progression of the lung infiltrate. He had been on nitrofurantoin for about 11 years for urinary tract difficulty until about March of 2005. Evidently, cough is his only symptom. He grew up in State College has no particular exposure to agricultural products or silage. He has never worked in a mine. He has taken a number of medications, but none of them suggestive of pulmonary toxins. He is actually retarded man who must be disabled. He had a car accident in 2003, which has caused back pain and myriad doctor and surgeon visits. Date Printed: 312312006 Time Printed: 5:46 AM PENNSTATE KA" IV Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Gleeson, Kevin 9/19/2005 2:15:31 PM He takes oxycodone as needed: if he takes too much of it, he gets some kind of myoclonic jerking and then he takes valproic acid. I will not dwell on those things further. Evidently, you gave him an Advair to treat him that made his cough worse. He had spirometry done demonstrating restriction, but poor technical quality. His review of systems is otherwise noncontributory. On physical examination, he is a retarded pleasant man. His weight is 240, his height 5 feet 10 inches, his blood pressure 130/70, and his pulse is 72 and regular. Head, eyes, ears, nose, and throat are unremarkable. His upper airway looks normal. His chest is totally clear. I can hear no rates. He has no rhonchi. He has no wheezing. Heart tones are normal. His abdomen is obese. Extremities are normal. I can see no rash anywhere. He has no clubbing. I have the reports of the CT scans of his chest demonstrating lower lobe ground glass infiltrates. His spirometry is as mentioned above. Mr. Taylor has these lung infiltrates which probably nitrofurantoin lung disease. This conclusion is based as much on the fact that it is hard to imagine what else they could be as the fact that this would be reasonably difficult for nitrofurantoin lung disease. The next issue is, whether his lungs are shrinking. If he has restricted lung dysfunction, then spare or especially progressive restricted lung dysfunction, he needs some interventions. I have taken the liberty of organizing a repeat CT scan and lung volumes by helium dilution. We will see based on this information what to do next. I am not great; I do not believe he has progressive pulmonary fibrosis and doubt if this is a huge matter. As we know, since the mother is very inquisitive about all this and can draw some inappropriate conclusions, but I have spoken in detail with her today and I think everything would be all right. I will be in touch with you after I see him again. Date Printed: 312312006 Time Printed: 5:46 AM PENNSTATE 10 Milton I Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Gleeson, Kevin 9/19/2005 2:15:31 PM 273936 Sincerely, Kevin Gleeson, MD KG /MSH DD: 08/31/01 DT: 09/04/05 21:59 CC: Edward R Bollard, MD PSMSHMC Medicine Date Printed: 312312006 Time Printed: 5:46 AM PENNSTATE Milton & Hershey Medical Center College of Wdicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: RAD, , Visit Type: Clinic PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 5927827 I C h e s t - S t u d v 1 Final CT CHEST WITHOUT CONTRAST PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 09/09/2005 EXAM NUMBER: 972738 ORDERING PHYSICIAN: GLEESON, KEVIN UNENHANCED CT OF THE CHEST TECHNIQUE: A helical CT of the chest was performed reconstructed every 5mm using lung and mediastinal algorithms. CLINICAL INFORMATION: chronic cough and nitrof irantoin used in the past, previous CT showed inflammatory lung disease. COMPARISON STUDY: Comparison is made with enhanced CT of the thorax 17 Jun 2005 FINDINGS: CHEST: The subtle patchy ground glass opacity in the right lower lobe has persists. There are milder similar findings in the left lower lobe. There is sparing of the upper lobes and right middle lobe. There are no pleural effusions. There is no mediastinal or hilar adenopathy on this unenhanced CT. There is no pericardial fluid or thickening. Soft tissues and bones are unremarkable. One included portion of the abdominal contents there are bilateral renal parenchymal calcifications and mild lobulation of the right upper renal pole which may be post inflammatory in nature. IMPRESSION: 1. Subtle patchy ground glass opacity predominantly involving thelower lobespersists and although this could be inflammatory given the confinement to the dependent portion of the lung this is more likely atelectatic. If the patient is scanned again in the future recommend adding additional prone images through the lung bases. 2. Bilateral renal calcifications, some appear to be dystrophic parenchymal calcifications, probably post inflammatory in nature. Dr. Edward J. Borman is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. Date Printed. 312312006 Time Printed: 5:46 AM FENNSTATE IV Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 C h e s t - S t u d y 1 Final DICTATED: BORMAN, EDWARD REVIEWED AND SIGNED: LOBELL, MARK DATE DRAFTED: 09/09/2005 04:20 PM DATE OF FINAL SIGNATURE: 09/09/2005 06:18 PM Date Printed: 312312006 Time Printed: 5:46 AM PENNSTATE ® Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: EMER, , Visit Type: Emergency Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 9043842 E m e r g e n c y D e p a r t m e n t N o t e D o c u m e n t Final Document Electronically Signed by: Ricks, John E ED SUMMARY Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 07/29/2005 CHIEF COMPLAINT: Right flank pain. 8/1/2005 2:43:54 PM HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old male history of chronic back pain since an L1 fracture several years ago. Also known to have kidney stones, comes in with slight increase in his back pain. He is getting physical therapy for the pain, and mother feels that that may have exacerbated his pain. He states that the right flank posterior axillary line stabbing and goes up and down the side. No radiation to the groin. He has had no dysuria, frequency, nocturia, or gross hematuria. Past history significant for ulcerative colitis, mental retardation, L1 fracture, and kidney stones. Current medications include Valproic acid, Tylenol, and Vicodin, which he uses for his back pain. No known allergies. FAMILY HISTORY: Negative for premature cardiac disease and diabetes. SOCIAL HISTORY: Does not smoke or drink alcohol. REVIEW OF SYSTEMS: Constitutional: No recent weight change, fevers, sweats, or chills. Cardiac no chest pain, pleuritic, or exertional. No palpitations. Respiratory no cough, sputum production, dyspnea, orthopnea, or wheezing. GI no abdominal pain, nausea, vomiting, constipation, diarrhea. OBJECTIVE: The temperature is 36.7, pulse 88, respiratory rate 20, blood pressure 129/91, 02 sate 98%. The patient is awake, alert, in no acute distress. Mother states he is in his normal mental condition. Skin is clear, warm and dry. HEENT: Pupils are equal, react to light, EOMs intact. Oropharynx unremarkable. Neck supple. Lungs are clear to percussion, auscultation. Cardiac exam: Regular rhythm, no gallop or murmur. Abdomen is soft, slightly tender to Date Printed: 312312006 Time Printed: 5:47 AM PENNSTATE NWton & Hershey Medical Center College of WAcine If Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 E m e r g e n c y D e p a r t m e n t N o t e D o c u m e n' t Final Document Electronically Signed by: Ricks, John E 8/1/2005 2:43:54 PM palpation generally without any focal tenderness, without guarding or rebound. Normal bowel sounds, tender to palpation over the right mid back. No CVA tenderness. Extremities: No cyanosis, clubbing, or edema. LABORATORY EVALUATION: Includes a KUB, which shows stones in his kidneys, similar to before and no stones in the course of the ureter. Trace positive hemoglobin, 5-10 red cells per high power field, negative for nitrite and leukocyte esterase. IMPRESSION: Right flank pain musculoskeletal. PLAN: Followup PCP within 10 days if needed. Continue physical therapy. Return to the emergency department for any gross hematuria, temp greater than 102 or significant increase in pain. # 514383 Review/Sign: John E Ricks, MD JER /BJC DD: 07/29/05 DT: 07/29/05 07:48 CC: Edward R Bollard, MD PSMSHMC Medicine Date Printed: 312312006 Time Printed: 5:47 AM PENNSTATE 1OW" Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 A b d o m i n a l / G I D o c u m e n t s Document Electronically Signed by: X-RAY ABDOMEN 1 VIEW PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 07/29/2005 EXAM NUMBER: 914367 ORDERING PHYSICIAN: RICKS, JOHN KUB Clinical History: Hematuria, renal calculi Discussion: Comparison is to April 6, 2005 Final Findings: The radiograph of the upper abdomen is limited due to motion artifact. Three to four left renal calculi are again identified. Three right renal calculi remained identified. The previously noted on 1 cm calculus at the right mid to upper pole is no longer identified. There are no obvious calculi overlying the expected course of the ureters. The visualized bony structures are appropriate for age. Impression: Bilateral renal lithiasis. The previously noted on 1 cm calculus at the right mid to upper pole is no longer identified. There are no obvious calculi overlying the expected course of the ureters. A CT could be obtained if there is a strong clinical suspicion of obstruction. Dr. Douglas J. Martin is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: MARTIN, DOUGLAS REVIEWED AND SIGNED: MARTIN, DOUGLAS / STECHER, ROBERT ATTENDING DATE DRAFTED: 07/29/2005 04:26 AM DATE OF FINAL SIGNATURE: 07/29/2005 08:27 AM Date Printed: 311311006 Time Printed: 5:47 AM PENNSTATE Milton S. Hershey Medical Center UP College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 Procedure Color (u) Appear (u) Glu (u) Bili (u) Ketones Units mg/dL mg/dL Ref Range [NEG] [NEG] [NEG] 7/29/2005 Fri 0 3:32:00 AM YELLOW CLEAR NEGATIVE NEGATIVE NEGATIVE 7/29/2005 3:32:00 AM Complete Urinalysis (Basic&Micro): [[Urine, sterile container]] 7/29/2005 Fri 0 7/29/2005 Fri 0 Procedure Hgb (u) pH (u) Units unit Ref Range [NEG] [4.5-8.0] 3:32:00 AM TRACE 6.5 Procedure WBC (u) RBC (u) Units /HPF /HPF Ref Range [0-4] [0-4] 3:32:00 AM 1-4 5-9 SG 1.025 Prot (u) Urobili Nitrite (u) Leuk Est mg/dL EU/dL [NEG] [0.1-1.0] [NEG] [NEG] NEGATIVE 0.2 NEGATIVE NEGATIVE Bact (u) Crystal [NONE] FEW MODERATE CALCIUM OXALATE Date Printed: 312312006 Time Printed: 5:47 AM PENNSTATE 10 Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 I A b d o m e n - S t u d y Final X-RAY ABDOMEN 1 VIEW PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 07/29/2005 EXAM NUMBER: 914367 ORDERING PHYSICIAN: RICKS, JOHN KUB Clinical History: Hematuria, renal calculi Discussion: Comparison is to April 6, 2005 Findings: The radiograph of the upper abdomen is limited due to motion artifact. Three to four left renal calculi are again identified. Three right renal calculi remained identified. The previously noted on 1 cm calculus at the right mid to upper pole is no longer identified. There are no obvious calculi overlying the expected course of the ureters. The visualized bony structures are appropriate for age. Impression: Bilateral renal lithiasis. The previously noted on 1 cm calculus at the right mid to upper pole is no longer identified. There are no obvious calculi overlying the expected course of the ureters. A CT could be obtained if there is a strong clinical suspicion of obstruction. Dr. Douglas J. Martin is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: MARTIN, DOUGLAS REVIEWED AND SIGNED: MARTIN, DOUGLAS / STECHER, ROBERT ATTENDING DATE DRAFTED: 07/29/2005 04:26 AM DATE OF FINAL SIGNATURE: 07/29/2005 08:27 AM Date Printed: 312312006 Time Printed: 5.47 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 Patient Sex: Male Date of Birth: 10/11/1971 Patient Location: LAB, , Visit Number: 5693632 Visit Type: Clinic C h e m i s t r 6/22/2005 Wed 0 Procedure Glu Units mg/dL Ref Range [70-120] 3:13:00 PM 63 Date Printed: 311312006 Time Printed: 5:48 AM PENNSTATE Mon S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 I H e m e / O n c Procedure B 12 Folate Units pg/mL ng/mL Ref Range [200-900] [3-20] 6/22/2005 Wed 0 3:13:00 PM 701 4.0 Date Printed. 312312006 Time Printed: 5:48 AM PENNSTA?TE Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: RAD, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 5681695 I C h e s t - S t u d v 1 Final CT CHEST WITH CONTRAST PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 06/17/2005 EXAM NUMBER: 825723 ORDERING PHYSICIAN: BOLLARD, EDWARD ENHANCED CT CHEST CLINICAL HISTORY: 33 y/o male with chronic cough for 3 months. Pt has history of nitrofurantoin use and inflammatory changes on prior CT scan. TECHNIQUE: Routine, IV enhanced CT of the chest was performed. DISCUSSION: Comparison CT scan from 6/17/2005. The heart and great vessels are unremarkable. There is bilateral apical adipose capped appearance is unchanged. There is no focal infiltrate or focal mass. There is worsened ground glass opacities and interstitial changes bilaterally but most prominent along the right major fissure and within the right lower lobe.There is interstitial thickening with mild dilation of the airways, most visible in the bilateral lower lobes. There is no focal consolidation. There is a 5 mm right upper pole non-obstructing renal calculus. On the left, there is a 4mm upper pole calcification with thinning of the parenchyma. An additional smaller calculus is seen posteriorly at the same level, either nephrolith or vascular calcification. There is no acute bony abnormality. IMPRESSION: Worsened right lower lobe groundglass opacities consistent with hypersensitivity pneumonitis/ drug induced interstitial lung disease.. This is likely related to nitrofurantoin use. Follow-up imaging or PFT""s may be useful to assess response to therapy. Dr. Scott J. Habakus is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. Dale Printed: 312312006 Time Printed: 5:49 AM PENNSTATE Ni~ilton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 DICTATED: HABAKUS, SCOTT C h e s t - S t u d y Final REVIEWED AND SIGNED: MAHRAJ, RICKHESVAR DATE DRAFTED: 06/17/2005 05:00 PM DATE OF FINAL SIGNATURE: 06/18/2005 11:46 AM Date Printed: 312312006 Time Printed: 5:49 AM PENNSTATE Milton S. Hershey Medical Center 10 College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 Patient Sex: Male Date of Birth: 10/11/1971 Patient Location: RAD, , Visit Number: 5534166 Visit Type: Clinic P e I v i s/ G U - S t u d y Final ULTRASOUND SCROTUM PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 04/29/2005 EXAM NUMBER: 769088 ORDERING PHYSICIAN: GILBERTHILLS, REBECCA SCROTAL SONOGRAM CLINICAL HISTORY. 33-year-old male with hard nodule in left groin I scrotal region. FINDINGS: The right testicle was not visualized in the right scrotal sac. Only the left testicle was imaged. There is no evidence of intratesticular mass or other testicular abnormality. Vascular testicular flow is noted. There is a 0.2 by 0.2 cm by 0.3 cm cyst in the head of the left epididymis likely representing a spermatocele or epididymal cyst. Adjacent to the head of the epididymis and attached to the tunica vaginalis is a4mm avascular soft tissue density nodule, possibly post inflammatory. There is a small amount of extratesticular fluid.A left varicocele is noted. There is a left sided varicocele. IMPRESSION: 1. No significant testicular or scrotal mass 2. Left varicocele. 3. The left testicle is unremarkable. 4. The right testicle was not visualized in the scrotal sac. Has the patient had prior right orchiectomy? Dr. Ritu Rajwar is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. Date Printed: 312312006 Time Printed: 5:49 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 P e I v i s/ G U - S t u d v Final DICTATED: RAJWAR, RITU REVIEWED AND SIGNED: KAPLAN, STEVEN DATE DRAFTED: 04/29/2005 01:37 PM DATE OF FINAL SIGNATURE: 04/29/2005 03:43 PM Date Printed: 312 312 0 0 6 Time Printed: 5:49 AM PENNSTATE 4F Milton & Hershey Medical Center College of Wdicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 1 703 3-08 50 Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: LPS, , Visit Type: Clinic PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 5313657 1 O u t p a t i e n t N o t e D o c u m e n It 1 Modified Document Electronically Signed by: Mahon, Frank B OUTPATIENT NOTE Name: TAYLOR, ZACHARY, HMC Number: 95411 DOB: 10/11/1971 Date of Service: 04/06/2005 4/14/2005 11:35:42 AM This is a 33-year-old patient who presents in followup of bilateral renal calculi. He has a KUB today. He has previously been followed by Dr. Erickson and then by Dr. Reese. He has known stones in both kidneys, which he and his mother have elected to follow. He has occasional pain in the midback, which resolves when he drinks lot of fluids. It is unclear whether this is related to his stones or from a back injury, which he suffered sone years ago as a result of automobile accident. On physical examination, he has no CVA tenderness. His abdomen is soft and nontender. His urinalysis shows a trace blood and trace hemoglobin. It does not show any leukocyte esterase or nitrite. His KUB today reveals a 10-mm stone in the right upper pole and another smaller stone in the right upper pole. There are some small stones in the right lower pole. There are 3 stones in the left kidney in the upper mid and lower pole, which measure between 4 mm and 6 mm. After much discussion with Zachary and his mother, they have elected to continue to follow the stones for another 6 months and will return at that time with the KUB. We discussed possibly having an ESWL if there is any change in the stones or if they should at some point desire to do that, however, for the time being there are comfortable to continue watching the stones. He is going to continue taking his trimethoprim. He was, however, unable to tolerate Urocit-K and is not taking that. He was encouraged to drink plenty of fluids and we will see him back in 6 months. I Dr. Mahon, saw and evaluated the patient and agree with the resident's findings and plans as written. Date Printed: 312312006 Time Printed: 5:50 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t N o t e D o c u m e n t Modified Document Electronically Signed by: Mahon, Frank B 4/14/2005 11:35:42 AM 63453 Review/Sign: Daniel M Altstatt, MD Review/Sign: Frank B Mahon, MD DMA /MSB DD: 04/13/05 DT: 04/13/05 20:11 Date Printed: 312 3 12 0 0 6 Time Printed: 5:50 AM PENNSTATE ® Milton S. Hershey Medical Center • College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 1 O u t p a t i e n t N o t e D o c u m e n t 1 Final Document Electronically Signed by: Mahon, Frank B 4/8/2005 1:44:24 PM OUTPATIENT NOTE Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 04/06/2005 This is a 31-year-old white male who has a history of bilateral renal calculi. He is actually been followed by Dr. Erickson and more recently Dr. Reese. This patient has had no pain, chills or fever. He has no irritated bladder symptoms. We got a KUB today, and it shows a persistence of a 10 mm calculus in the upper pole of the right kidney and 2 to 3 mm smaller stones in the lower pole of the right kidney. On the left, he has a 3 mm, 6 mm, 5 mm calculus that really appears unchanged from the previous report. The old films are not available. Dr. Altstatt and myself saw the patient. It looks to me like the patient may have medullary sponge kidney with stones in the dilated collecting tubules. I would just observe them. This is what he would like to do. I encouraged him to drink lots of fluids. He knows that if his chills, fever, flank pain, nausea, and vomiting should come back, he will come in one year, we will get a KUB before that. This patient has previously been followed by Dr. Erickson who has given the patient Urocit-K. His pH is 6. Certainly, the stone burden seems very stable and I would just follow them as they are. IMPRESSION: Bilateral renal calculi unchanged. This patient reports that he has had 24 hour urine collections in the past. Review/Sign: Frank B Mahon, MD FBM /BAA DD: 04/06/05 DT: 04/08/05 12:16 Date Printed: 312312006 Time Printed: 5:50 AM PENNSTATE KL" UP Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 I A b d o m i n a l / G 1 D o c u m e n t( s) Document Electronically Signed by: Final NYES X-RAY ABDOMEN / KUB / FLAT PLATE-I VIEW PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 04/06/2005 EXAM NUMBER: 745518 ORDERING PHYSICIAN: MAHON, FRANK KUB History: Renal calculi. Discussion: There are no comparison studies currently available. There is a nonspecific bowel gas pattern, without evidence of bowel dilatation or intestinal obstruction. Multiple calcifications projecting over the renal beds bilaterally, the largest on the right measuring 7 mm in largest of the left measuring 5 mm. These are most consistent with renal calculi. There are no calcifications along the project course of the ureters. The soft tissues and bony structures are otherwise unremarkable. Impression: 1. Calcifications projecting over the renal beds bilaterally most consistent with renal calculi as described above. Dr. Scott W. Michelitch is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: PRABHU, PILAR REVIEWED AND SIGNED: PRABHU, PILAR / MICHELITCH, SCOTT DATE DRAFTED: 04/06/2005 03:22 PM DATE OF FINAL SIGNATURE: 04/06/2005 04:32 PM Date Printed: 312312006 Time Printed: 5:50 AM PENNSTATE 10 Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 I A b d o m e n - S t u d v 1 Final NYES X-RAY ABDOMEN / KUB / FLAT PLATE-1 VIEW PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 04/06/2005 EXAM NUMBER: 745518 ORDERING PHYSICIAN: MAHON, FRANK KUB History: Renal calculi. Discussion: There are no comparison studies currently available. There is a nonspecific bowel gas pattern, without evidence of bowel dilatation or intestinal obstruction. Multiple calcifications projecting over the renal beds bilaterally, the largest on the right measuring 7 mm in largest of the left measuring 5 nun. These are most consistent with renal calculi. There are no calcifications along the project course of the ureters. The soft tissues and bony structures are otherwise unremarkable. Impression: 1. Calcifications projecting over the renal beds bilaterally most consistent with renal calculi as described above. Dr. Scott W. Michelitch is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: PRABHU, PILAR REVIEWED AND SIGNED: PRABHU, PILAR / MICHELITCH, SCOTT DATE DRAFTED: 04/06/2005 03:22 PM DATE OF FINAL SIGNATURE: 04/06/2005 04:32 PM Date Printed: 311311006 Time Printed: 5:50 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: RAD, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 5373325 I C h e s t - S t u d y i Final CT CHEST WITH CONTRAST PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 03/11/2005 EXAM NUMBER: 678741 ORDERING PHYSICIAN: BOLLARD, EDWARD ENHANCED CT CHEST CLINICAL HISTORY: Chronic cough. Nitrofurantoin. TECHNIQUE: Routine, IV enhanced CT of the chest was performed. DISCUSSION: Correlation is to prior plain film exam of the chest February 14, 2005. The heart and great vessels are unremarkable. There is bilateral apical hypertrophy of adipose tissue producing a pronounced capped appearance. There is no focal infiltrate or focal mass. There is a small patch of ground glass density along the right major fissure in the right lower lobe.. However, there are no findings to suggest amore diffusepneumonitis. Review of the upper abdominal contents is unremarkable. There is no acute bony abnormality. IMPRESSION: Biapical adipose hypertrophy without evidence of interstitial fibrosis.. Minimal right mid-lung groundglass opacities consistent with inflammatory change. Follow-up is recommended to assess significance and progression of these changes. Dr. James H. Birkholz is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: MAHRAJ, RICKHESVAR REVIEWED AND SIGNED: MAHRAJ, RICKHESVAR / DATE DRAFTED: 03/11/2005 05:01 PM DATE OF FINAL SIGNATURE: 03/11/2005 10:45 PM Date Printed. 312312006 Time Printed: 5:51 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: PT, , Visit Type: Recurring Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 5364562 Tel: (717) 531-8055 1 O u t P a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 8/25/2005 1:42:44 PM OUTPATIENT THERAPY NOTE MEDICARE 701 FORM Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 05/06//2005 DATE OF PRESCRIPTION/ RECERTIFICATION : 516/05-6/6/05 DIAGNOSIS: Low back pain. ONSET DATE: April 9, 2003. DATE OF TREATMENT STARTED: October 12, 2004. DATE OF PLAN ESTABLISHED: October 12, 2004. FREQUENCY: 1 to 2 times weekly. ATTENDANCE: Sporadic. TOTAL VISITS: 16. PATIENT STATUS: Zachary continues to be seen in Physical Therapy for manual techniques along with back stabilization exercises to improve his capabilities to maintain stability in the low back while using his lower extremities. He continues to have transportation issues due to his mother's physical condition, so his attendance continues to be irregular. He continues doing back stabilization exercises 4 times a week and has had an exacerbation of his pains indicating pain levels that are higher than they previously were. His mother has taken him off the pain medications that he was on in order to assess his activity level regarding the therapy provided. She does note that he is less mobile that he used to be with the pain medication and that his complaints are more frequent. He has difficulty expressing his condition due to his Date Printed 312312006 Time Printed: 5:51 AM PENNSTATE UP Milton & Hershey Medical Center College of Medidne Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 8/25/2005 1:42:44 PM mental retardation. We will have an orthopedic therapist review his case looking for a hypermobile segment in the next few sessions. PROGRESS TOWARD TREATMENT GOALS: 1. Zachary continues to move from sit to stand by forward flexing of his spine into an anterior tilt prior to standing. Goal not achieved. 2. Zachary continues to be less than compliant in his lumbar stabilization exercises. Goal moderately achieved. Mother will be encouraged to supervise his activity with the exercises. 3. Zachary is able to ambulate 100 feet with facilitation to the abdominals and pelvis maintained in a neutral position Goal achieved. 4. We continue to have increased complaints of pain and so bicycle exercises have not been tried. Goal not achieved. CONTINUED PROBLEMS: 1. He continues to complain of pain at L5-S1 area with a consistency. 2. Decreased generalized endurance. 3. Poor abdominal and hip strength. 4. Increase in restriction of left SI joint. 5. Poor comparative judgment skills regarding pain and dysfunction. CURRENT TREATMENT GOALS: 1. Zachary will be able to move from sit to stand keeping hips and shoulders in good alignment without forward flexion of the trunk in the next 4 weeks. 2. Zachary's mother will review exercises with Zachary in order to provide consistency with the home exercise program over the next month. 3. Zachary will report decreased pain after extension exercises done 2 to 3 times a day in the next 4 weeks. PLAN: 1 to 2 times weekly physical therapy for 4 weeks to include back stabilization exercises, muscle energy strength, counterstrain advanced strain-counterstrain, myofascial release with visceral myofascial release and neural tissue tension technique , back stabilization exercise. TIME SPENT: 15 minutes evaluation and 15 minutes treatment. Date Printed: 312312006 Time Printed: 5:51 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 1 O u t p a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 228303 Review/Sign: Laura S Hamann LSH /TBL DD: 05/06/05 DT: 08/10/05 16:43 8/25/2005 1:42:44 PM Date Printed: 312312006 Time Printed: 5:51 AM PENNSTATE Milton & Hershey Medical Center College of Ntedicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 5/16/2005 11:09:18 AM OUTPATIENT THERAPY NOTE MEDICARE 701 FORM Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 04/05/05 CURRENT DATE OF PRESCRIPTION/RE-CERTIFICATION: 04/05/2005 - 05/05/2005 DIAGNOSIS: Low back pain. ONSET DATE: 04/09/2003 DATE TREATMENT STARTED: 10/12/2004 DATE PLAN ESTABLISHED: 10/12/2004 FREQUENCY: 1 to 2 times weekly. ATTENDANCE: Sporadic. TOTAL VISITS: 13. PATIENT'S STATUS: Zachary continues to be seen in Physical Therapy for back stabilization exercises to improve his capability to maintain stability in the low back while using his lower extremities for mobility. He continues to have problems with transportation due to his mother's fibromyalgia and so his attendance is irregular. He is doing back stabilization exercises 4 times a week and making progress with maintaining good alignment while doing so. Mother does indicate that he is more mobile in the home setting with less complaint of pain. He does have difficulty expressing his condition due to his mental retardation. He continues to need skill care in order to improve his strength in the abdominal and low back areas, which will decrease the strain on L5-S1. PROGRESS TO TREATMENT GOALS: 1. Zachary is able to flex forward to 25 degrees of lumbar flexion. Goal not achieved. 2. Zachary is compliant with the lumbar stabilization exercises over this last month according to his mother. Goal achieved. 3. We have not begun the stationary bicycle due to his complaint of increased pain over the last month. Date Printed. 312312006 Time Printed: 5:51 AM PENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t 1 e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 5/16/2005 11:09:18 AM CONTINUED PROBLEMS: 1. Continued irritation at L5-S1. 2. Continued decreased generalized endurance. 3. Poor abdominal and hip strength. 4. Poor comparative judgment skills regarding pain and dysfunction. CURRENT TREATMENT GOALS: 1. Zachary will be able to move from sit to stand and maintain hips and shoulders in good alignment without forward flexion of the trunk in the next 4 weeks. 2. Zachary will continue with compliance in lumbar stabilization exercises in the home setting over the next month. 3. Zachary will be able to ambulate a 100 feet with facilitation to abdominals and pelvis maintained in a neutral position over the next month. 4. Zachary will be able to ride the bicycle for 3 minutes after doing back stabilization exercises and therapy over the next 4 weeks. PLAN: One to two times weekly physical therapy for 4 weeks to include muscle energy strain/counterstrain, advanced strain/counterstrain, myofascial release, visceral myofascial release, and neural tissues tension technique. A back stabilization exercises and generalized stretching. TIME SPENT: 15 minutes evaluation, 15 minutes treatment. 113083 Review/Sign: Laura S Hamann LSH /MSH DD: 05/11/05 DT: 05/12/05 23:05 Date Printed: 312312006 Time Printed.- 5:51 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 3/30/2005 10:57:41 AM OUTPATIENT THERAPY NOTE MEDICARE 701 FORM Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 02/03/2005 CURRENT DATE OF PRESCRIPTION RECERTIFICATION: 2/3/05-3/3/05 DIAGNOSIS: Low back pain. ONSET DATE: September 3, 2004. DATE TREATMENT STARTED: October 12, 2004. DATE PLAN ESTABLISHED: October 12, 2004. FREQUENCY: One to two times weekly. ATTENDANCE: Sporadic. TOTAL VISITS: 8. PATIENT STATUS: Zachary continues to be seen sporadically in Physical Therapy for treatment. He is transported by his sister and mother and has been ill recently, so he has not been able to attend therapy on a regular basis. He continues to do relatively well with low back pain and mother indicates improving mobility skill at home. TREATMENT GOALS: Zachary has not been seen over this time period due to illness. CONTINUED PROBLEMS: 1. Continued irritation at L5-S1. 2. Continued decreased generalized endurance. 3. Decreased general strength. 4. Poor abdominal strength. 5. Poor comparative judgment skills regarding pain and dysfunction. CURRENT TREATMENT GOALS: Date Printers: 312312006 Time Printed: 5:51 AM PENNSTATE ® Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t T h e r a p y N o t e D o c u m e n t Final Document Electronically Signed by: Hamann, Laura S 3/30/2005 10:57:41 AM 1. Zachary will show alignment of the pelvis through the next 4 weeks. 2. Zachary will flex forward to 30 degrees of lumbar flexion within the next 4 weeks (uncompensated). 3. Zachary will be able to get on and off the floor independently with no complaint of pain as per mother's report in 4 weeks. 4. Zachary will begin exercising on a stationary bicycle for 3 minutes with minimal increase in pain during treatment. PLAN OF CARE: One to two times weekly physical therapy for 4 weeks to include muscle energy, strain-counterstrain, advanced strain-counterstrain, myofascial release, visceral myofascial release, neural tissue tension, back stabilization, and generalized strengthening. TIME SPENT: 30 minutes treatment, 25 minutes evaluation. 23771 Review/Sign: Laura S Hamann LSH /MSB DD: 03/10/05 DT: 03/13/05 22:25 Date Printed: 312312006 Time Printed: 5:51 AM PFNNSTATF Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: DRM 1, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 1 703 3-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 5161407 Tel: (717) 531-8055 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Adams, David R 2/25/2005 12:48:43 PM OUTPATIENT LETTER February 7, 2005 Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Edward Bollard, MD PSMSHMC Medicine General Internal Medicine Hershey, PA 17033 Dear Dr. Bollard: We saw Zachary Taylor in consultation in the Dermatology Clinic on February 4, 2005 for evaluation of verruca vulgaris of the right index finger above the matrix of the nail. The history of present illness, past dermatologic and medical histories, review of systems, social history, and skin examination were accomplished. We prescribed the following therapy: Podophyllin (a blistering agent from the May Apple plant) which will cause a blister. We will avoid liquid cryotherapy at this time due to the concern for nail dystrophy secondary to possible ablation of the matrix. We recommended a follow-up appointment in 1 month and hope you will approve. If you need any further information, please do not hesitate to call. Thank you very much for allowing us to participate in the care of this pleasant patient. Date Printed: 312312006 Time Printed: 5:51 AM FENNSTATE 4p Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Adams, David R 2/25/2005 12:48:43 PM 266744 Sincerely, Gregory J Fulchiero, MD Review/Sign: David R Adams, MD, PharmD Assistant Professor of Dermatology Penn State Milton S. Hershey Medical Center Department of Dermatology, UPC II Suite 4300 PO Box 850, Hershey, PA 17033 (717) 531-6820 GJF /MSH DD: 02/07/05 DT: 02/16/05 23:23 CC: Edward R Bollard, MD PSMSHMC Medicine Date Printed: 312312006 Time Printed. 5:51.4M PENNSTATE Milton & Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 Patient Sex: Male Date of Birth: 10/11/1971 Patient Location: S200, , Visit Number: 5154069 Visit Type: Clinic O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Colt, Erica D OUTPATIENT LETTER February 7, 2005 Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Edward Bollard, MD PSMSHMC Medicine General Internal Medicine Dear Dr. Bollard: 2/15/2005 4:04:55 PM I had the pleasure of seeing your patient, Zachary Taylor, for an audiologic reevaluation. A previous audiologic evaluation conducted on November 11, 2003, revealed a severe to moderately severe sensorineural hearing loss with good word recognition ability bilaterally. Zachary currently wears 2 Danavox 163S behind the ear hearing aids. He was accompanied today by his mother who stated that she is interested in pursuing new hearing aids for Zachary. She feels as though he is not hearing as well as he has it had in the past. Zachary was involved in a severe motor vehicle accident approximately a year and half ago. Zachary's mother feels as though he has not been hearing as well since that time. Test Results: Pure tone air conduction thresholds averaged 80 dBHL for the right ear and 73 dBHL for the left ear. Speech reception thresholds were obtained as 70 dBHL for the right ear and 65 dBHL for the left ear. Word recognition was 84% at an 85 dBHL presentation level bilaterally. Bone conduction scores were essentially similar to air conduction scores bilaterally. Tympanometry was consistent with normal tympanic membrane mobility with normal middle ear pressure bilaterally. Ear canal volume for within normal limits for each ear. Test results indicate a moderately severe to severe sensorineural hearing loss bilaterally. Word recognition ability was judged to be good bilaterally. There has been no significant change in the hearing since November 11, 2003. Zachary's hearing aids were evaluated through electroacoustic analysis, which revealed them to be functioning appropriately. Zachary and his mother were informed that since his hearing aids were functioning appropriately, he could continue to use them. However, there have been more recent advances to hearing aid technology, which Zachary could take advantage Date Printed. 312312006 Time Printed: 5:52 AM PENNSTATE Olpq 14iilton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 1 O u t p a t i e n t L e t t e r D o c u m e n t Final Document Electronically Signed by: Colt, Erica D 2/15/2005 4:04:55 PM of if he did decide to pursue new amplification. They were informed that if Zachary wishes to pursue new amplification, he could set up hearing aid evaluation appointments. They did so upon leaving today. It is recommended that Zachary return for an audiologic reevaluation annually or sooner if concerns arise to monitor the stability of his hearing loss. Thank you for allowing me to participate in the care of your patient. 266904 Sincerely, Erica D Colt, MS Clinical Audiologist - Otolaryngology - Head and Neck Surgery PO Box 850, MCH091, Hershey, PA 17033 (717) 531-7171 phone, (717) 531-0919 fax EDC DD: 02/07/05 DT: 02/09/05 23:19 CC: Edward R Bollard, MD PSMSHMC Medicine Date Printed: 312312006 Time Printed: 5:52 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: PUDX, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 5149643 Tel: (717) 531-8055 I P u l m o n a r y R e p o r t D o c u m e n t 1 Final Document Electronically Signed by: Alam, Shoaib PULMONARY PROCEDURE Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 01/13/2005 This is a 33-year-old male. TESTS ORDERED: Spirometry with flow volume loop. 1/24/2005 3:24:25 PM RESULTS: Good patient effort. Oxygen saturation on room air is 91-93% . Bronchodilator not given as patient did not quality due to an FEV1/FVC ratio within 8.3 of predicted value. ATS criteria not met for end of spirometry. The FVC is 2.95 liters, which is 55% of predicted. The FEV1 is 2.62 liters, which is 60% of predicted. The FEV1/FVC ratio is 89%. INTERPRETATION: There is no evidence of an obstructive ventilatory defect. Decreased FVC suggests a restrictive ventilatory impairment. Suggest total lung volumes if clinically indicated. #235665 Review/Sign: Patrick F Walsh, MD Review/Sign: Shoaib Alam, MD PFW /PSC DD: 01/13/05 DT: 01/15/05 10:13 Date Printed: 312312006 Time Printed: 5:52 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 P F T - S t u d y Final PULMONARY PROCEDURE Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 01/13/2005 This is a 33-year-old male. TESTS ORDERED: Spirometry with flow volume loop. RESULTS: Good patient effort. Oxygen saturation on room air is 91-93% . Bronchodilator not given as patient did not quality due to an FEV1/FVC ratio within 8.3 of predicted value. ATS criteria not met for end of spirometry. The FVC is 2.95 liters, which is 55% of predicted. The FEV1 is 2.62 liters, which is 60% of predicted. The FEV1/FVC ratio is 89%. INTERPRETATION: There is no evidence of an obstructive ventilatory defect. Decreased FVC suggests a restrictive ventilatory impairment. Suggest total lung volumes if clinically indicated. #235665 Review/Sign: Patrick F Walsh, MD Review/Sign: Shoaib Alam, MD PFW /PSC DD: 01/13/05 DT: 01/15/05 10:13 Date Printed: 312312006 Time Printed: 5:52 AM q',5- 1 ¦ 209 State Street Harrisburg, Pennsylvania 17101 717.232.6300 SchmldtKramer FAX 717.232.6467 www.schmidtkramer.com I N J U R Y L A W Y E R S September 25, 2007 Hershey Medical Center Health Information Services HU24 P.O. Box 850 Hershey, PA 17033 Re: Patient: Zachary Taylor DOB: 10/11/71 SS#: 185-68-9025 Requested Records: 02/28/06 to present including Dr. Bollard's records. Requested Bills: 02/03/06 to present Dear Sir or Madam: I requested records by letter dated September 7, 2007 and you returned my letter asking for a Power of Attorney. I enclose my September 7, 2007 letter with your comments. I enclose a copy of an Order dated November 8, 1994, appointing his mother, Dana Armstrong, his guardian. Please forward to my attention the records as requested. If you have any questions, please feel free to call me at any time. Very truly yours, SCHMIDT KRAMER PC X Z C. Kramer Attorney at Law GCK/det Enclosures CHARTONE Date Request # Pages Asso ?. Z' c lion pro cm ZC ' ?c??lol E' t t,r tt f r -,? - r 209 State Street Harrisburg, Pennsylvania 17101 717.232.6300 SchmidtKra er FAX 717.232.6467 www.schmidtkramer.com I N J U R Y September 7, 2007 Hershey Medical Center Health Information Services HU24 {_ 1 P.O. Box 850 4 Hershey, PA 17033 Re: Patient: Zachary Taylor DOB: 10/11/71 SS#: 185-68-9025 Requested Records: 02/28/06 to present including Dr. Bollard's records. Requested Bills: 02/03/06 to present Dear Sir or Madam: Please be advised this firm represents the above-referenced patient for injuries received as a result of an automobile accident. Please forward to me copies of all medical records and itemized billing statements relating to the care and treatment of the patient for the above-referenced dates of treatment. I have enclosed an executed medical authorization permitting the release of this information. If you have any questions, please feel free to call me at any time. Very truly yours, SCAxTA 'ADT Kp.A.MEEI PC" Gee' rand C. Kramer Attorney at Law GCK/det Enclosure cc: Billing Department Y F VCK- _G, L A W Y E RS %- NX7", Nfilton S. Hershey Medical Center- The Milton S. Hershey W College of "Medictrre Medical Center vor AUTHORIZATION FOR RELEASE OF HOSPITAL RECORDS Health Information Services, P.O. Box 850, Hershey, Pennsylvania 17033 C Name of Patient TA !6 r Social Se: irity -, A-3-? _ Date of birth Medical Record --- Phone ?--_.-__-- THIS AUTHORIZATION WILL NOT BE ACCEPTED UNLESS ALL ITEMS ARE COMPLETED. THE INFORMATION BEING DISCLOSED MAY INCLUDE HIVIAIDS, DRUG/ALCOHOL ABUSE & MENTAL HEALTH DATA. I HEREBY AUTHORIZE HERSHEY MEDICAL CENTERIUNIVERSITY HOSPITAL TO RELEASE TO^ OR B. RECEIVE FROM L_ - - (Circle One) (Narne of ^uthorized person. agency, intitution, cr o;heri _L _?? _? - - (Street) (City) (State) (Zip Code) Reason for Request: -- Type of information to be released consists of: DISCHARGE DATE(S) OUTPATIENT VISIT DATE(S) Discharge Summary; (ies i History + Physical Operative Report Diagnostic Testis) _ y Indicate Type of Test 3 Date ?/J?. ??:IG?uI? Other (please specify) rrdC us(?1 j. /? i t., ?!l ?U ?G'L/u1?1_ c This consent is subject to revocation at any time except to the extent that the person who is to make the disclosure has already taken action in reliance on it. If you wish to revoke this authorization, you must do so in writing to the address at the top of this form, to the attention of the HNIC Privacy Officer. If not previously revoked. this consent will terminate ninety (90) days from the date of signature. Failure to sign this form will not impact your right to receive care at Hershey Medical Center. Neither our treatment nor your payment is conditioned upon your signature on this fcrm. I hereby release the provider of said records from any legal responsibility or liability in connection with the release of the records indicated and herein. 7/ 0 S 9n2 are of Parent )r n'P 1.a.1 e -- €. ?e-vim" Gate f ?P,417 2I??!i?r,si;q? ?i ?igr.ed ?y caner ihan Pauinil ^ s e7 - MUST BE SIGtOD PHONE Note to recipient of information: iris ^iOrmaiicn has :)-Pen . /ol, r0 ^e ec res ., ?I@C;eG `)V P -nns`:ivaniiDi Lc. ;JrOIiIG IIS '-or" n.: k.r:r; an'. rc' 71sc Csure f?:.rll_ J1'J^ _5 ?,.^c; 7rSCIOSUf° !S d?(frj5i`J --:y .nd i:'(ii,e 'l •:C'15?;1', (ii persnn ,o ;;r,cm ;i MR 542 Rev. *3 :03 .AUTHORIZATION FOR RELEASE OF HOSPITAL RECORDS ij j IN THE COURT OF COMMON PLEAS OF CENTRE COUNTY, PENNSYLVANIA IN RE: Zachary Taylor No. 14-94-0153 ORDER C O U W cc O U- d U j _! U- i. j li 1! N 10 H T IjCCD ?J i' ii AND NOW, this 8th day of November, 1994, after conference' with all counsel in the above matter, it is ORDERED that r Paragraph 7 of the Court's previous Order of September 8, 1994, is Amended to read as follows. This Decree assumes that both natural parents, Dana Taylor and John Taylor, will provide custodial care for Zachary Taylor with his father having up to six (6) months per year based upon the best interest of Zachary. During that period of time that Zachary is with his mother, Dana Taylor, she shall be Zachary's limited guardian. During that period of time that Zachary is with his father, John Taylor, the father shall be Zachary's limited guardian. If there is any conflict in terms of the amount of time that Zachary will spend with his mother or with his father the Court will review this matter upon petition of any party. C O U cn cf) -j ti CX- c? C) ? - Q j Of j y 41 LL1 - Cr t- v O W = LU J I Certified from the records this ........A?••••... 40 of .......7..., i 9.. Divis on tf Common Plecs IN THE COURT OF COMMON PLEAS OF CENTRE COUNTY, PENNSYLVANIA ORPHANS' COURT DIVISION IN RE: ZACHARY TAYLOR No. 14-94-0153 FINAL DECREE AND NOW, this day of September, 1994, upon consideration of the annexed petition and after hearing held following due notice, it is hereby ORDERED and DECREED that, based upon a finding that Zachary Taylor suffers from mental retardation as well as kidney disease and, as a result, is so severely mentally impaired that he is unable to make, communicate, or participate in certain-decisions relating to his estate and person, Zachary Taylor is adjudged partially incapacitated in the following areas: Zachary Taylor needs a limited guardian to help with his general care, maintenance, and therefore-it is hereby ORDERED that Zachary Taylor reside with his natural mother and proposed guardian,. Dana Taylor, at the natural mother's residence, subject to periods of time with his natural father, John Taylor, co-guardian of Zachary. It is found that Dana Taylor and John Taylor must ensure that Zachary Taylor receive the proper training, education, medical care, psychological, social or any other vocational services that Zachary may need in order to function in the manner that he is now functioning. Therefore, Dana Taylor and John Taylor are appointed limited guardians of the person of Zachary Taylor with authority to handle the following specific areas relating to the person of the incapacitated person: to ensure Zachary's general care-; maintenance, residence and habitation, educational, medical, and psychological and vocational areas. Further, it is found that Zachary Taylor is in need of a limited guardian of his estate and therefore Dana Taylor and John Taylor are appointed limited guardians of the estate of Zachary Taylor with the authority to handle the following specific areas relating to the estate of the incapacitated person, Zachary Taylor: Aside from the above general care ordered the limited guardians are responsible to manage Zachary Taylor's finances to include disposition of social security funds, any earnings from employment, payment of all necessary bills, accounting to this Court on a yearly basis.for all of the partially incapacitated person's income and expenses. Within twelve months from the date of this decree and at least annually thereafter, the respective guardians shall file with this Court a report as required by the Register's Office Zachary Taylor's social security income will be pro-rated between the parents and guardians based upon the time spent with each parent. This Decree assumes that both natural parents, Dana Taylor and John Taylor, will provide custodial care for Zachary with each parent having him for a period of as close to six (6) months each year as possible. During those six (6) months that Zachary is with his mother, Dana Taylor, she shall be Zachary's limited guardian. During those six (6) months that Zachary is with his father, John Taylor, he shall be Zachary's limited guardian. Either parent may petition this Court to appoint him/herself as sole limited guardian in the event that- the other parent does not maintain custodial care for an approximately six month period during the calendar year. Zachary Taylor has ten (10) days from the date of this Decree to file exceptions. Failure to file exceptions within that time will result in this Decree becoming final. Zachary Taylor has been advised of his right to appeal and to petition to modify or terminate the guardianship by copy of this Decree and by the Statement of Rights thereto. ? ? r- m o c.n M C-3 n _TI cn Cf) f . --I r'T1 rn ? CD M >. --a Cy CD O T CO C:) - - . n -3 m z r- _Tj ? cn cn o n s? ? o CZ) o c crt CertMed from the records this .........../... :'; Liay of ....... ..., 9.9' STATEMENT OF RIGHTS AN ORDER HAS BEEN ENTERED WHEREBY YOU HAVE BEEN ADJUDICATED A PARTIALLY INCAPACITATED PERSON AND UNABLE TO CARE FOR YOURSELF AND/OR MANAGE YOUR PERSONAL AFFAIRS. YOU HAVE THE RIGHT TO FILE EXCEPTIONS TO THE COURT'S DECISION WITHIN TEN (I0) DAYS OF THE DATE OF THE COURT'S ORDER. IF YOU FAIL TO FILE EXCEPTIONS, THE ORDER WILL BECOME FINAL. IN THE EVENT THAT YOU FILE EXCEPTIONS AND THEY ARE DENIED, YOU HAVE A RIGHT TO FILE AN APPEAL TO THE SUPERIOR COURT WITHIN THIRTY (30) DAYS OF THE DATE OF THE DENIAL OF THE EXCEPTIONS. IN ADDITION, YOU MAY' PETITION THE COURT AT ANY FUTURE TIME TO MODIFY OR TO TERMINATE THE LIMITED GUARDIANSHIP IF THERE IS A SIGNIFICANT CHANGE IN YOUR CAPACITY OR IF YOUR LIMITED GUARDIAN FAILS TO PERFORM HIS/HER DUTIES IN ACCORDANCE WITH THE COURT'S ORDER. IF YOU WISH TO APPEAL THE ORDER OR TO PETITION THE COURT TO MODIFY OR TERMINATE THE LIMITED GUARDIANSHIP, YOU MAY BE REPRESENTED BY AN ATTORNEY. IF YOU DO NOT HAVE AN ATTORNEY, YOU MAY REQUEST THAT THE COURT APPOINT ONE TO REPRESENT YOU. IF YOU CANNOT AFFORD AN ATTORNEY, THE SERVICES OF AN ATTORNEY WHOM THE COURT MAY APPOINT WILL BE PROVIDED AT NO COST TO YOU. PENNSTATE 40 Milton S. Hershey Medical Center College of Medicine PATIENT HISTORY AND REVIEW OF SYSTEMS VAME: TAYLOR, ZACHARY J MD: THOMPSON VIRGINI MR#: 95411 DOB: 10/11/1971 INS: GATEWAY ASSURED LOG: PMGT UOS#: 6472550 MD#: 12911 SEX: M STANDARD VISIT DATE: 02/27/2006 Reason for today's vi .&414 Lyl Who referred you to our p Please list the medications, vitamins 4 herbal treatments you currently use: Do you take aspirin, coumadin, herbal treatments or any medication that may thin your blood? Yes No Please list: Allergies: Do you smoke tobacco? Yes 'S- how many? Do you drink alcohol? Yes& type List previous operations: Procedure Date Hospital Complications ---- Have you or any relatives had any complications from s gery or anesthesia?s No If yes, what was the complication? Family History: Heart Disease: Yes /?9 High Blood Pressure:'jp / No x"60 Other: Are you currently e eriencing any paint / No Is the pain related to your reason for visiting the doctor today? Ye / No Please rate your pain on a 0-10 Scale. IC) Example: 0 =No lz 5 = Moderate Pain, 10 =Worst Pain Imaginable Your Pain Rating: /0 Do you have any special needs that we should be awaXf f s o that we can serve you better? (for example - wheelchair, language barrier) Ao?-?l MR 846 Rev 11/01 Pg 1 of 2 PATIENT HISTORY AND REVIEW OF SYSTEMS years smoking drinks per day PAST MEDICAL HISTORY/REVIEW OF SYSTEMS Y N Problem/Comments Y N Problem/Comments Asthma, Wheezing / Stroke/TIA Bronchitis Unusual Muscle Weakness Emphysema / Kidney Failure Pneumonia Kidney Stonesor Urinary Disease Cald,_Qough, Nasal Congestion epatf fs y?gr--Sse?',?ontact Lenses, Hean I , Liver Disease / Loo / Difficulty swallowing or Chewing / Dentures, Caps, or Bridges Unintentional .Weight Loss / Stiff Neck, Jaw Persistent Nausea/Diarrhea 1 / Snoring Persistent Decreased Appetite / Home Oxygen / !LHeartbur Obese (Weight >1 OOKg) / Hiatal Hernia Rheumatic fever Gastric Reflux Heart Murmur Uses SBE Prophalaxis for heart/implant Palpitations/Irregular Heart Beat Bleeding Tendency Heart attack Sickle Cell Anemia Chest Pain Diabetes / Heart Failure Thyroid Disease / Hypertension (High Blood Pressure) Steroid Therapy / Fainting f Could you be pregnant? / Seizures LM P? / Arthritis Cancer / Glaucoma Children, Immunizations up to date? Any health problems not listed above? Patient or Parent Signature Signature of of Physician Date ? d' V NICK C_ bon copy nfor. MR 846 Rev 11/01 Pg 2 of 2 PATIENT MEDICAL HISTORY/REVIEW OF SYSTEMS PENNSTATE Milton S. Hershey Medical Center College of Medicine PROGRESS REPORT N:+ME: TAYLOR, ZACHARY J MO: GORDIN VITALY MRN: 95411 DOB: 10/11/1971 INS: GATEWAY ASSURED LOG: PMGT OOS4: 6472550 MD#: 12915 SEX: M STANDARD VISIT DATE: 02/27/2006 f? DateMme PROGRESS NOTES: (Include Name, Title) ?. I IN MANAGEMENT CLINIC V INITIAL PAIN ASSESSMENT Assessment of Pain y\ n S 1\a - ? 0 " _, Location _ . ) Intensity (Scale 0-10): v f C Characteristics/Patient Description: a Typ Sharp' Dull Bumin Aching Throbbing ? ermittent Constan ?' - ? y 'I Hypere thesis Motor Deficit, Sensory Deficit-' k i ` [ Onset: "0 / ` Activities Which Increase Pain:-'t Activities Which Decrease Pain:--` ., ' uoA Diagnostic Testing: -?r Previous Therapy Effect „-?- Medications: uku-tt T4 I 9A 4L, 1 4% 41J - (a Physical Thera py/Exercisu- ?, TENS: Biofeedbac Relaxation: \ Nerve Blocks: Other: Sleep: cJ ? 4( O P( jf ( ?L Appetite:71 ?v:% Chanaes in hvsical Activitv__ Litigation/Compensation: J W U-L Emotional Attitudes: ?5 ? !PROGRESS REPORT P t ,> Nr\ (A,/A- Date/Time I PROGRESS NOTES: (Include Name, Title Current edications: 4 d ck- Allergie ,. _ U Past History: Medical: r . VI Lt ki WA Surgical: t Family: fVA Social: Learning needs assessment (does patient have visual, hearing, cognitive or other deficits which impair ability to learn?) i ne aPove plan was ?iscusseld with the patient. He/She verbalizes understanding and PROGRESS REPORT- Milton & Hershey Medical Center College of Medicine Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: RAD, , Visit Type: Clinic PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 07997396 1 A b d o m i n a l / G I D o c u m e n t( s) Document Electronically Signed by: CT ABDOMEN WITHOUT CONTRAST PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 02/01/2007 EXAM NUMBER: 1788811 ORDERING PHYSICIAN: MAHON, FRANK Final NONCONTRAST CT SCAN OF THE ABDOMEN AND PELVIS TECHNIQUE: A noncontrast helical CT of the abdomen and pelvis was performed with axial 3 mm images displayed using soft tissue and lung algorithms. HISTORY: 35-year-old male with renal calculi. COMPARISON: Abdominal radiographs dating back to April 6, 2005 and chest CT dated 3/11/05. Report from CT abdomen and pelvis dated August 28, 2002 was reviewed. ABDOMEN: There is some mild atelectasis noted in the right middle lobe and dependent atelectasis in the lower lobes. There are multiple subcentimeter renal calculi scattered throughout the left kidney, the largest measures approximately 8 mm in the lateral aspect of the lower pole. There is a small crescentic calcification in the periphery of the lower pole of the left kidney, possibly a diverticulum with milk of calcium. There is cortical thinning and multiple areas of parenchymal scarring scarring of the left kidney. The right kidney contains multiple small, mostly punctate calculi. The largest calculus on the right measures approximately 5 mm in the interpolar region of the right kidney. There is cortical thinning and scarring in the right kidney as well. There is no hydronephrosis or hydroureter. There are no ureteral calculi. There is mild fatty change of the liver with some focal sparing in the gallbladder fossa. There is no biliary dilation. The gallbladder, spleen, and adrenal glands are normal. The pancreas is normal. No bowel abnormality is identified. PELVIS: There is a surgical clip in the left spermatic cord region. There are no distal ureteral or bladder calculi. There is no pelvic mass, fluid, or lympadenopathy. There are minimal degenerative changes of the spine. IMPRESSION: Multiple nonobstructing subcentimeter bilateral renal calculi as above. Date Printed: 1011512007 Time Printed: 5:44 AM PENNSTATE Milton S. Hasl>tey Medical Center College of Meffldne Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 A b d o m i n a l / G 1 D o c u m e n t( s) Document Electronically Signed by: Final Possible calyceal diverticulum in the periphery of inferior left renal pole. Dr. Marlo M. Pagano is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. DICTATED: PAGANO, MARLO M REVIEWED AND SIGNED: PAGANO, MARLO M / DYKES, THOMAS DATE DRAFTED: 02/01/2007 04:04 PM DATE OF FINAL SIGNATURE: 02/02/2007 08:45 AM Date Printed: 1011511007 Time Printed: 5:44 AM Milton S. Hershey Medical C rater College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 P e I v i s/ G U - S t u d y Final CT PELVIS WITHOUT CONTRAST PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 02/01/2007 EXAM NUMBER: 1788812 ORDERING PHYSICIAN: MAHON, FRANK NONCONTRAST CT SCAN OF THE ABDOMEN AND PELVIS TECHNIQUE: A noncontrast helical CT of the abdomen and pelvis was performed with axial 3 mm images displayed using soft tissue and lung algorithms. HISTORY: 35-year-old male with renal calculi. COMPARISON: Abdominal radiographs dating back to April 6, 2005 and chest CT dated 3/11/05. Report from CT abdomen and pelvis dated August 28, 2002 was reviewed. ABDOMEN: There is some mild atelectasis noted in the right middle lobe and dependent atelectasis in the lower lobes. There are multiple subcentimeter renal calculi scattered throughout the left kidney, the largest measures approximately 8 mm in the lateral aspect of the lower pole. There is a small crescentic calcification in the periphery of the lower pole of the left kidney, possibly a diverticulum with milk of calcium. There is cortical thinning and multiple areas of parenchymal scarring scarring of the left kidney. The right kidney contains multiple small, mostly punctate calculi. The largest calculus on the right measures approximately 5 mm in the interpolar region of the right kidney. There is cortical thinning and scarring in the right kidney as well. There is no hydronephrosis or hydroureter. There are no ureteral calculi. There is mild fatty change of the liver with some focal sparing in the gallbladder fossa. There is no biliary dilation. The gallbladder, spleen, and adrenal glands are normal. The pancreas is normal. No bowel abnormality is identified. PELVIS: There is a surgical clip in the left spermatic cord region. There are no distal ureteral or bladder calculi. There is no pelvic mass, fluid, or lympadenopathy. There are minimal degenerative changes of the spine. IMPRESSION: Multiple nonobstructing subcentimeter bilateral renal calculi as above. Possible calyceal diverticulum in the periphery of inferior left renal pole. Dr. Marlo M. Pagano is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. Date Printed: 1011512007 Time Printed: 5:44 AM PENNSTATE bMton & Hershey Medical Canter College of Med idne Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 P e l v i s/ G U - S t u d y Final DICTATED: PAGANO, MARLO M REVIEWED AND SIGNED: PAGANO, MARLO M / DYKES, THOMAS DATE DRAFTED: 02/01/2007 04:04 PM DATE OF FINAL SIGNATURE: 02/02/2007 08:45 AM Date Printed. 1011512007 Time Printed: 5:44 AM FENNSTATE Milton S. Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 A b d o m e n - S t u d y Final CT ABDOMEN WITHOUT CONTRAST PATIENT NAME: TAYLOR, ZACHARY J PATIENT MRN:00095411 PATIENT DOB: 10/11/1971 EXAM DATE OF SERVICE: 02/01/2007 EXAM NUMBER: 1788811 ORDERING PHYSICIAN: MAHON, FRANK NONCONTRAST CT SCAN OF THE ABDOMEN AND PELVIS TECHNIQUE: A noncontrast helical CT of the abdomen and pelvis was performed with axial 3 mm images displayed using soft tissue and lung algorithms. HISTORY: 35-year-old male with renal calculi. COMPARISON: Abdominal radiographs dating back to April 6, 2005 and chest CT dated 3/11/05. Report from CT abdomen and pelvis dated August 28, 2002 was reviewed. ABDOMEN: There is some mild atelectasis noted in the right middle lobe and dependent atelectasis in the lower lobes. There are multiple subcentimeter renal calculi scattered throughout the left kidney, the largest measures approximately 8 mm in the lateral aspect of the lower pole. There is a small crescentic calcification in the periphery of the lower pole of the left kidney, possibly a diverticulum with milk of calcium. There is cortical thinning and multiple areas of parenchymal scarring scarring of the left kidney. The right kidney contains multiple small, mostly punctate calculi. The largest calculus on the right measures approximately 5 mm in the interpolar region of the right kidney. There is cortical thinning and scarring in the right kidney as well. There is no hydronephrosis or hydroureter. There are no ureteral calculi. There is mild fatty change of the liver with some focal sparing in the gallbladder fossa. There is no biliary dilation. The gallbladder, spleen, and adrenal glands are normal. The pancreas is normal. No bowel abnormality is identified. PELVIS: There is a surgical clip in the left spermatic cord region. There are no distal ureteral or bladder calculi. There is no pelvic mass, fluid, or lympadenopathy. There are minimal degenerative changes of the spine. IMPRESSION: Multiple nonobstructing subcentimeter bilateral renal calculi as above. Possible calyceal diverticulum in the periphery of inferior left renal pole. Dr. Marlo M. Pagano is the dictating resident. Attending radiologist signature indicates review of both the images and the report and that the attending radiologist agrees with the interpretation. Preliminary reports may not have been reviewed as yet by the attending radiologist. Date Printed: 1011512007 Time Printed: 5:44 AM PENNSTATE Milton S. Hershey Medical Center College of Medidne Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 A b d o m e n - S t u d y Final DICTATED: PAGANO, MARLO M REVIEWED AND SIGNED: PAGANO, MARLO M / DYKES, THOMAS DATE DRAFTED: 02/01/2007 04:04 PM DATE OF FINAL SIGNATURE: 02/02/2007 08:45 AM Date Printed. 1011512007 Time Printed: 5:44 AM PENNSTATE Milton S. Hershey Medical Center VO College of Medicine Patient Name: TAYLOR, ZACHARY J Patient Sex: Male Patient Location: NEUR, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Tel: (717) 531-8055 Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 07209440 E M G S t u d y D o c u m e n t Final Document Electronically Signed by: Kothari, Milind J 7/17/2006 11:12:00 AM EMG STUDY Name: TAYLOR, ZACHARY J HMC Number: 95411 DOB: 10/11/1971 Date of Service: 07/12/2006 Name: Taylor, Zachary Gender: Male Pt. ID 95411 Date of Birth: 10/11/1971 OOS # 7209440 Age: 34 Technician: MB Hei ht: 5'10" Examining Physician Dr. Milind Kothari Tern 34 de C Referring Physician: Dr. Edward Bollard Weight: 250 Ibs Cc: Physicians Date of Stud 7/12/06 Patient History: 34 year old male with left lower extremity pain and numbness. This study is being performed to exclude a focal neuropathy, plexopathy or lumbar radiculopathy. Motor Nerve Conduction: Nerve and Site Latency Amplitud egment Latency , Distance Conductio e r Different n e Velocit Date Printed: 1011512007 Time Printed: 5:46 AM PENNSTATE Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 n I I Ankle v~ 3.8 ms 6.98 mV ms mm m/s Fibula head 10.3 ms 5.12 mV Ankle-Fibula head 6.5 ms 290 mm 44.6 m/s Popliteal fossa 12.0 ms 4.62 mV Fibula (head)-Popliteal fossa 1.7 ms 100 mm 57.4 m/s Tihical I Ankle 4.4 ms 12.89 mV ms mm m/s Popliteal fossa 13.1 ms 10.09 mV Ankle-Po liteal fossa 8.7 ms 450 mm 51.7 m/s F-Wave Studies Nerve M-Latency F-Latency Peroneal.L 3.7 49.2 Tibial.L 4.4 46.4 Sensory Nerve Conduction: Nerve and Site Peak Amplitu Segment Latency Distanc Conductio Latency de Differen e n ce Veloci Sural.L Mid calf 3.6 ms 12.4 [IV Ankle-Mid calf 2.9 ms 140 mm 48.6 m/s Needle EMG Examination: Insert Spontaneous and/or Volitional Maximum Volitional Activity Max Vol Activity Activit Activity Muscle Insert Fibs +Wav Fasc' Other Amp Dur Recruit Polys Effort es s Tibialis anterior.L Normal None None None None Norm Norm Normal None Max. al al Gastrocnemius Normal None None None None Norm Norm Normal None Max. Medial head .L al al Vastus Iateralis.L Normal None None None None Norm Norm Normal None Max. al al Vastus medialis.L Normal None None None None Norm Norm Normal None Max. al al Tensor fasciae Normal None None None None Norm Norm Normal None Max. Iatae.L al al Date Printed: 1011512007 Time Printed: 5:46 AM FENNSTATE Im Milton S. Hershey Medical Center College of Miedidw Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 E M G S t u d y D o c u, m e n t Final Document Electronically Signed by: Kothari, Milind J 7/17/2006 11:12:00 AM Summary: Left sural sensory study was normal. Left peroneal and tibial motor studies and F responses were normal. Needle exam was performed with a disposable concentric electrode. Exam of selected muscles of the left lower extremity was normal. The patient did not want the lumbar paraspinais tested. Interpretation: Normal study. There was no electrodiagnostic evidence of a focal neuropathy, plexopathy or radiculopathy. CC: Edward R Bollard, MD, DDS Penn State Milton S. Hershey Medical Center PO Box 850 Hershey, PA 17033 Review/Sign: Milind J Kothari, DO Professor of Neurology MJK /DM DD: 07/12/06 DT: 07/13/06 16:23 Date Printed. 1011512007 Time Printed: 5:46 AM Milton & Hershey Medical Center College of Medicine Patient Name: TAYLOR, ZACHARY 3 Patient Sex: Male Patient Location: LAB, , Visit Type: Clinic Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 PSUHMC MRN: 0095411 Date of Birth: 10/11/1971 Visit Number: 07318707 C h e m i s t r Procedure P04 Units mg/dL Ref Range [2.4-4.6] 7/12/2006 Wed 0 12:33:00 PM 3.4 Tel: (717) 531-8055 Date Printed: 1011512007 Time Printed; 5:47 AM PENISTATE W Nlil#on Hhey Medical Ceanter College of Medicine Patient Name: TAYLOR, ZACHARY J PSUHMC MRN: 0095411 D r u Q M o n i t o r 1 Procedure Valproate Units ug/mL Ref Range [50-100] 7/12/2006 Wed 0 12:33:00 PM 65 Date Printed: 1011511007 Time Printed: 5:47 AM PENNSTATE Mw" Milton S. Hershey Medical Center College of Medicine May 17, 2007 Name: TAYLOR, ZACHARY HMC Number: 95411 DOB: 10/11/1971 Date of Service: 05/16/2007 Gerard C. Kramer, Esq. Schmidt Kramer, PC 209 State Street Harrisburg, PA 17101 Dear Mr. Kramer: Internal Medicine Associates Penn State Milton S. Hershey Medical Center Tel: (717) 531-5160 Penn State College of Medicine Fax: (717) 531-2034 Internal Medicine Associates, HS04 670 Cherry Drive Hershey, PA 17033 1 am writing this correspondence to make you aware of a recommendation I am making for Mr. Zachary Taylor concerning his chronic back pain secondary to a lumbar 1 vertebra burst fracture related to his motor vehicle accident, in which he was a passenger during September of 2003. As you know, Zach has continued with chronic back pain related to this burst compression fracture of the L1 vertebra. We currently have him on a medical regimen including hydrocodone, acetaminophen, nortriptyline, and Naprosyn. Zach has continued with back pain, particularly at night. It tends to impede his sleep. He and his mother report that recently they were shopping for a bed, and Zach tried a number of these to see if they would allow him some comfort. He was able to find one, and was able to sample the bed for approximately a half-an-hour in a retail store. He found it alleviated a significant amount of his pain. He was able to adjust both the height and firmness of the bed, which seemed to offer him the most benefit. Given my concerns of increasing numbers and amounts of analgesic medications, particularly narcotics, I would like to support the purchase of such a bed to help Zach's pain relief at night. The name of this bed is "The Sleep Number Bed, model 5000, full size." I do not have the exact cost of this, but looking at the retail information, it seems to range in the area of $1,425.00. Again, I believe the purchase of such a piece of equipment is necessary in order to allow Zach some pain relief at night, as well as maintaining or reducing his current need for analgesic medications on a daily basis. If you have any questions or concerns about this matter, please do not hesitate to contact me at your convenience. Signature Line CC: Forward to Addressee: S{ncerely, } 1 ?) 0 L?-QkJLV)l V?-? Edward R Bollard, D, DDS Assoc Professor of Medicine Program Director, Internal Medicine Residency Div of General Internal Medicine Penn State Hershey Medical Center "^ n_., ncn unon U-V- o , DA 17n i q (7171?i I? -6390 An Equal Opportunity University JOINDER I, John Taylor, am the father of Zachary Taylor, an incapacitated person, and hereby state that I have read the foregoing Petition for Settlement of a Personal Injury case for an Incompetent Person in Accordance with Pa. Rules of Civil Procedure 206.4 and that I understand, agree, and approve the contents thereof and join in the Petition. Date: ?Wn-Taylor FiLFD. -0,--' :'CE OF THE PP"', M9 APR 21 AM 8, 25 r 4,M .,5o po ATTY Cv-* 11-701 Q`t'y` a1o3o 4000 BY C J. IN RE: ZACHARY TAYLOR, an Incapacitated person by DANA : ARMSTRONG, guardian, Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA ORPHAN'S COURT DIVISION NO.: RULE TO SHOW CAUSE AND NOW, this )'I day of 2009, a RULE is hereby issued on the (11?j I Parties of Interest, to show cause why the Petition for Settlement of a Personal Injury Case for an Incapacitated Person in Accordance with Pa. Rules of Civil OL4- C' W4 Procedure 206.4 should not be granted. Rule returnable w4 a M? cb?- 94 5 A •M•? ova 3 15, ,2004. r- ?--??A'.'?tp- {?t.1 IN RE: ZACHARY TAYLOR, IN THE COURT OF COMMON PLEAS OF an incapacitated person by CUMBERLAND COUNTY, PENNSYLVANIA DANA ARMSTRONG, guardian CIVIL ACTION-LAW 09-2496 CIVIL TERM ORDER OF COURT AND NOW, this day of May, 2009, this case having been called for a hearing on May 15, 2009, IT IS ORDERED: (1) The settlement in the total amount of $22,500, IS APPROVED. (2) Distribution of the proceeds shall be as follows: (a) Schmidt Kramer PC - costs $1,850.09 (b) Schmidt Kramer PC - attorney fee $5,625 (c) Estate of Zachary Taylor - $15,024.91 (3) The proceeds of $15,024.91 shall be paid to Dana Armstrong and John Taylor as co-plenary guardians of the estate of Zachary Taylor, an incompetent person. (4) Dana Armstrong is authorized to execute the release and any other documents necessary to effectuate this settlement. erard C. Kr For Petitione :sal J By th Edgar B. Bayley, J. ?Y' ?1??a???r?,??. 2??9 ??'? 1 ? P?1 ??? ? ? ?? ??' ? ? f 3 ?? r ?.:_ ? ,