HomeMy WebLinkAbout09-4141LundyLaw
BY: HERBERT L. OCKS, ESQUIRE
IDENTIFICATION NO.: 04137 ATTORNEY FOR PLAINTIFFS
19th FLOOR
1635 MARKET STREET
PHILADELPHIA, PA 19103-2297
(215) 567-3000
E-Mail Address: hocks(a,lundylaw.com
COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PA
IN RE:
ESTATE OF DAEKWON SHEPPARD, A MINOR
NO. 0 9- yI 'i t! T-?--
PETITION FOR LEAVE TO SETTLE OR
COMPROMISE MINOR'S ACTION
TO THE HONORABLE, THE JUDGES OF THE SAID COURT:
The Petition of Daekwon Sheppard, a minor, by his parent and natural guardian, Sharral Hall
Mwangi, and attorney, Herbert L. Ocks, Esquire, respectfully represents:
1. Petitioner is Daekwon Sheppard, a minor, by his parent and natural guardian, Sharral Hall
Mwangi.
2. The minor was born on 06/29/1997 and his social security number is 028-80-8500.
3. The minor resides with his parent and natural guardian, Sharral Hall Mwangi, at 825 Factory
Street, Carlisle, PA, 17013.
4. A guardian was not appointed for the minor.
5. The minor's mother and father are Sharral Hall Mwangi and James Mwangi who reside with
the minor at 825 Factory Street, Carlisle, PA, 17013.
6. The Defendant is Theresa Nist, an individual, residing at 809 Factory Street, Carlisle, PA,
17013. This case settled with the defendant's insurance company, GEICO Insurance Company.
7. On 04/19/2008 the minor sustained the following injuries at the following location: The minor
was a restrained rear passenger in a 1997 Ford Escort being operated by the Defendant which was
travelling too fast on Burgners Road in Lower Frankford Township, Cumberland County, PA. The
vehicle travelled off the roadway, overturned and came to rest on its roof in a creek. Following the
accident the minor was taken by ambulance to the Emergency Room at Carlisle Regional Medical Center.
As a result of this incident, the minor sustained acute moderate cervicothoracic sprain/strain, acute
moderate lumbosacral sprain/strain and an abrasion on the left side of the neck. The minor treated with
his physician from May 24, 2008 to August 18, 2008.
8. Attached hereto is a copy of the Emergency Room report from Carlisle Regional Medical
Center dated April 19, 2008, and copies of the Office Notes of Boland Chiropractic & Sports from
May 24, 2008 to August 18, 2008, the date of discharge.
9. Attached hereto is a statement, under oath, of the minor's parent and natural guardian certifying
the physical and/or medical condition of the minor, as well as the parent and natural guardian's approval
of the proposed settlement and distribution.
10. The minor is under sixteen (16) years of age and no written approval is necessary.
11. The following settlement has been proposed:
Daekwon Sheppard, a minor - $6,500.00
12. Counsel is of the professional opinion that the proposed settlement is fair and reasonable and
adequately compensates the minor for the injuries sustained from which he has made a full and complete
recovery. Counsel is of the professional opinion that there is no question of liability in this case as the
minor was a passenger and liability is not an issue.
13. Counsel has incurred the following expenses for which reimbursement is sought:
Court Filing Fees
Investigation, Photographs,
Police Report
Medical Records
TOTAL EXPENSES
$ 78.50
Travelling Expense 610.00
8.00
67.69
$764.19
14. The following costs have been incurred by or on behalf of the minor and must be paid from
the proceeds of the settlement:
None except those listed in Paragraph 13
15. The Department of Public Welfare does have a claim or lien against the minor
in the amount of $1,001.00. Attached hereto is a copy of a letter from the Department of
Public Welfare dated March 9, 2009, 2009, agreeing to reduce their lien and accept the
payment of $640.53.
16. Counsel requests a fee in the sum of $1,433.95 which is 25% of the net
settlement payable to the minor. A copy of the Contingent Fee agreement is attached.
17. Counsel has not and will not receive collateral payments as counsel fees for
representation involving the same matter from third parties (i.e. subrogation).
18. The net settlement payable to the minor (after deduction of costs and attorneys
fees) is $3,661.33.
WHEREFORE, Petitioner requests that he be permitted to enter into the settlement
recited above and that the Court enter an Order of Distribution as follows:
A. TO: LundyLaw
(Reimbursement for Costs)
B. TO: LundyLaw
(Counsel Fee)
C. TO: Department of Public Welfare
(Lien of $1,001.00 reduced to $640.53)
D. TO: Daekwon Sheppard, a minor,
in a restricted account not to be
withdrawn before majority or upon
prior leave of the Court.
TOTAL SETTLEMENT
LundyLaw
$ 764.19
1,433.95
640.53
3,661.33
$6,500.00
BY: L 0,A-
Herbert L. Ocks, Esquire
Attorney for Petitioner
VERIFICATION
Sharral Hall Mwangi hereby states that she is the Petitioner in the above-action and
verifies that the statements made in the foregoing Petition for Leave to Settle or
Compromise a Minor's Action are true and correct to the best of her knowledge,
information and belief. She understands that the statements therein are made subject to the
penalties of 18 Pa. C.S. §4904, relating to unworn falsification to authorities.
C?et?1?
4Sharr Hall Mwangi, as p e t and na
guardian of Daekwon Sheppard, a minor
LundyLaw
BY: HERBERT L. OCKS, ESQUIRE
IDENTIFICATION NO.: 04137
19th FLOOR
1635 MARKET STREET
PHILADELPHIA, PA 19103-2297
(215) 567-3000
E-Mail Address: hocks(a),lundylaw.com
ATTORNEY FOR PLAINTIFFS
COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PA
ORHPHANS' COURT DIVSION
IN RE:
ESTATE OF DAEKWON SHEPPARD, A MINOR I NO.
CERTIFICATION OF COUNSEL
Herbert L. Ocks, Esquire, certifies that he is counsel for Plaintiffs herein and that in
his professional opinion, the proposed settlement offer is fair and reasonable, in light of all
the circumstances in the case and there has been a complete recovery. Furthermore,
counsel is of the professional opinion that there is no question of liability in this case as the
minor was a passenger and liability is not an issue.
LundyLaw
BY: I ?'? ? , 0J.'-
Herbert L. Ocks, Esquire
Attorney for Petitioner(s)
CERTIFICATE OF SERVICE
I hereby certify that I have this date served a copy of the foregoing pleading by first
class mail, postage pre-paid, upon all counsel of record as follows:
Mr. Mark Heberger
Claims Department
GEICO Indemnity Company
One Geico Boulevard
Fredericksburg, VA 22412-0004
Tele. No.: 800-841-1003 ext. 4251
Driver: Theresa Nist
Insured: Charles Nist
Claim No.: 034426909-0101-029
LundyLaw
Herbert L. Ocks, Esquire
Attorney for Petitioners
Date: June 15, 2009
? ADMISSION
M&DICAL CII RECORD
361 Alazandar Spring Road a Q4rin,19, PA 170154,29 • (717) 249.1212 :... :: < M
P ADMIT DA /TIM ROOM N5 - F AGI: -:93.9$554. 000105738
A 04/19/2008 18:51 0000 El P 10 DAT OF BIRTH
06/2E9/1997 M 2A Ms L ATI N PROGflAM
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B25 ?,?10? ST 028-80-8500
STUDENT
HAMZLTON MPL vER N
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CUMB
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SHARRALL
,
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825 FACTORY ST HOMEMAKER
017-54-3828
A
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CARLISLE PA 17013
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(717)254-1541 LAn IP T A i
EMERGENCY C NTACT NAME
EMERGENCY CONTACT MOTHER RESP
PHONE
EMERGENCY CONTACT RELA71pNSHIP TO
PATIENT
MAANGI, JAMES (508)410-5085 FRIEND
PRIVACY
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AUTHORIZATION
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FRIERSON, PATRICIA L DR. FAMILY ! I ARE
NONSTAFF, FAMILY PRY
:0:.? CXAGN0515 i SIGNS III SYMPTOMS
?C.
MVA--MINOR INJURY ACCIDENT
NO FAULT 04/19/2008
PRINCIPAL DIAGN0619 (TM --I'- es[abllshad after study to be chiefl
otGasioninp [he "."On of the patient to the HOSPITAL for carol y roaponeibk for
.
COMPLICATIONS
COMORBIDITVIIESI
PRINCIPAL PROCEDURE
NMA7110
ml MEDICAL RECORDS COPY I??AAI?N?I?I?A?
iuvr',
- ' ` Carlisle Re Iona! Medical Center
?' fsPe e: :..
Date In:04119/2008Pros Time: 18:51 Pt#:9399554 MR#:0001057387 Triage Time 18:
51 Triage Note:
Name: SHEPHERD, DAEKWON Arrival Mode: BLS T:97.7 PO PT IN MVA. CAR FLIPPED AND
Age: 10YRS DOB: 06/29/1997 Sex: M Wt:ibs: 81 kgs: 36.8 P:94 Regular WENT INTO A CREAK.
R:20 Unlabored RESTRAINED DRIVER. NECK PAIN.
PCP:` NON-STAFF, FAMILY, PHY' LAC TO NECK. NO COMPLAINTS.
EDP:•FRIERSON_MD, PATRICIA L. BP-132/061 NO LOC. SEVERE DAMAGE TO
tCief Complaint MVA-MINOR INJURY 02 Sat 100 % NL / hypo CAR.
Pain/Location: 01Denies Paln
Wit
Level 1-9 =1-3 elsrtter4s 1.w 1614 ?{ ekm
:. , = R!ris Lave15? 5 elrftreMls
cam.. - _.
Souroe: t t family spouse EMS nsg. home other:
.................
Ltd BY poor historian dementia severity hearing intoxicated
set: m' days wks mths ago
rarity: mild mod sev 110 current _/10 max
*of Vehicle: auto s bicycle moped motorcycle auto vs. pod
s s p _y-•• .......
ai a de io ed--' reload }iekinei..................... of Collision: multi vehicle e v . fell asleep t control '
of Impact: front back right left Position in Vehicle: driver asseng t rear
cftY -- Dam otiti oderate high - minimal / e severe
er Iss m to ejected extricated assisted out of vehicle fatalities
otion painlsxs: head Few a /lower c es men
u m y: right /left lower extremity: rig
LOC ec !min remember/ personnel /transfer to ED/ remains unconscious
ociated SUS: dY ess: 511 left pares e / left
nausea / su chanoes lacaraikmnrs
r"ru ei rnsiory:
, -r , .. L'
CIL,J d/ ?J- /-, t'
............... -l
? 1
o?
C/-"
KVS: 1.1606111.4 = i syslem Le4e1 a .4 -9 sysfertis l+4ya l 15 :¦.1 W ayste?x
General Eyes ENT Respiratory Cardiovascular (;aatrointsstinal Genitourinary
Fever / chills
Weight loss Visual Changes
Redness Sore Throat
H Shortness of Breath Chest Pain Nausea / Vomiting Dysurie
General Weakness
Dryness oarse Voice
Epistaxis Cough
Con
estion Palpitations
P Diarrhea Frequency
Polyurea
Diplopia
I
4 Auditory Acuity g
Hemoptysis ND
Orthopnea Constipation
Rectal Bleeding Vaginal Bleeding
Vaginal Discharge
Polydipsia tching Nasal Drain/Gong. DOE Black Stool Penile Discharge
Musculoskelsial Neurological Psychological Skin Immunilogicai owed
Joint Pain
Joint Swelling Syncope
Headache Anxiety
Depression Rash
Pr
iti Recurrent H All other systems negativ
Neck Pain
Focal Weakness
Hallucination ur
c
Lesions HIV/AIDS
Anaphylactlc Rxn
ue to: ALOC acuity
Back Pain Paresthesia Insomnia Bruising dementia poor historian
Myaigtas Confusion Stress Bleeding
intoxicated
P"E f=smlJ '90 610/ Wx: level 1,3 w orie Levei'4 T sectloh; . , I vV11 !? 2.3 sedfons '
Past Medical History: Additional Past Medical History:
Medications:
Past Surgical History: None CABG y TSH/BSO
Other:
Family History: N CAD / MI OM CA CVA
Reproductive History: G_ P_ A_ Last Menstrual Period:
Menses History: Regular ! Irregular / Post-partum / Pre-menarch
Last Tetanus:
social Mstory. Tobacco: Y _PPD / N / Quit Living: M / S 1 D / Ak
Alcohol: Denies / Social / Heavy ! Alcoholic
Substance Abuse:
Other: _S
LRvel?t:.`5.7 s
04 8 Leve12-3: 2.4 systems yetprhs Level g`S+:sy ma . ' indicates system examined sod negattw
General: Distress: k_yffl mild moderate severe well nourished no evidence of trauma
'Elf
cachetic obese disheveled dehydrated chronic Illness nsy, home pt, malnourished other
HENT:: / AT pharynx NL ears NL nose NL
tenderness: maxillary: R / L frontal: R / L nasal drainage: clear / purulent ear canal: R / L erythema / obscured
R / L erythema bulging perforated pharynx: exudate erythema abscess other:
Eyes: • PERRL EOMI conjunctiva NL NL fundus
R pupil: _ mm L pupil: _ min conjunctiva: injected / drainage R / L other
.......vywrrar Mwuruar VCnter
Name: SHEPHERD, DAEKWON Date In:04/19/2008
MR#:0001057387 Pt#:9398554
Physical ke cont. Level 2-3:24 systems Lave) 4: 5-7 systems Level 5: 8+ systems NL• i dicat system examined and negative
Nock: NL• non-tender painless ROM ea m' ' ' non-tender ",
C•collar in place spasm muscle tender to palpation: R / L bony tender to palpation: R / L limited / painful ROM
Chest:
RL chest wall non-tender NIL excursion/ expansion no retractions
`
der to palpation: R / L chest wall sternum retractions flail chest subcutaneous emphysema other:
CV.• • RRR no murmur no gallup PMI NL pulses NL
chycardic bradycardic irregularArregular rhythm extra systoles murmur /8 systole/diastole
pulses: decreased/ absent R I L carotid femoral dorsatis pedis radial uinar other:
aspiratory .• no respiratory distress breath sounds NL effortless
unequal I decreased sounds crackles wheezes rates rhonchi labored stridor retractions cheyne stokes other
.
Abdomen: appearance NL BS NL soft non-tender rectal NL guiac negative no organomegaly
-
t
c
7
e
BS: hyper/ hypo / absent guarded tender mass/pulsatile heme + stoBS: hypo /absent guarded tender home + stool /blood
Back: ROM NL no CVAT tenderness
/ bil CVAT tenderness: bony/ muscle dorsal lumbar sacral coccyx
Exfremi'Bes: non-tender full ROM no edema / erythema pelvis stable hips non-tender
sho ened / ext. rotated: R / L effusion: R / L Omited ROM: R / L other
!dr warm dry color NL no rash
hof. cold diaphoretic cyanotic pallor edema erythema acchymosis other:
Neur'o: • AA&Ox3 CN's NL (2-12) motor l sensory NL cerebellar function NL DTRs symmetric
lethatgic somnolent obtunded disoriented R / L CN deficit other:
Psych: affect NL behavior NL
anxious hostile flat affect depressed combatative psychosis other
OU. NL• ext genitalia NL no urethral bleeding no lesion no edema deferred
urethral blood other: L=-ac A=Abraslon E-Echymosis
Medical Decision Makin
NL I except
>-< UA: NIL / except C-Spine: _ Interpreted by EDP 1 /2 / 3 Views
WBC LE - neg acute _other
ROC Blood CXR:
Interpreted by EDP _ NAD
NL !except
-
preg Screen: urinelserum: nag /pos
+-f-< NAI Infllitrete
_
Tox Screen: nag /pos
ALT Amy Trop PT
Abd:
NSBGP
obstruction
-
-
EKG: neg / pos
AST Lipase CKMB INR
Head CT:
Other / Procedures:
Consultation: Clinical Course & Re-evaluation:
Time: . Disc with Dr. Mods: Time: Improved / Worse / Unchanged
will _"a patient In office _ admit _ see in consult Time: Improved / Worse / Unchanged
Time: . Disc with Dr. IVF: p Patient re-examined
will see patient in office _ admit _ see in consult E3Cdtical care: 30-74 minutes / 75-104 minutes ?See procedure note ?See addendum
Clinical l g lon: Dls leson:
1. _t c-st?r? 'L tom. Time:
2. '\l., Discharge: Home NH PsychFac Jail
3. ,/ C, v? ?? Admit: Floor ICU PCU Obs OR Tole Psych Peds ?Orders written
4.
Transfer: Facility: Rcv Physician:
5. AMA LWOT DOA Expired gTransfer forms competed
C
diti
St
bl
on
on:
a
e Satisfactory Improved Critical Guarded Emergent Non-emergent
Instructions:
Follow up with: O Prescription(s) given: _ Follow up care discussed with: patient family spouse other.
? PMD
Additional Instructions:
? Doctor
QED
?Other
In_ day(s) 0 AM
Signatures: PA/ARN
MDlDO
k)
Pro-MED Complegow - (circb r oarwes. t naa aiasn Per ?? octo?) Rev. Wiwi
ORDAR PROCEDURE FORM
ORTHOPEDIC EMERGENCIES
Date In: 4/19/2008 Time:
Name:SHEPHERD, DAEKWON
Age: IOYRS DOB: 06129/1997 Sex: M
Carlisle Regional Medical Center
Pt#:9399554
MR#:0001057387
EMERGENCY DEPARTMENT
ONGOING NURSING ASSESSMENT Name: Carlisle Regional Medical Center
SHEPHERD, DAEKWON Pt#:9398554
Age:10YRS D08:06129/1997 Sex: M MR#:0001057387
Date: 4/19/2DDS EDP: 'FRIERSON MD, PATRICI PCP:' NON-STAFF, FAMILY, PHY'
te?a:prls?tep?t?g} :.. ..'::'•'.
Airway Clearance, Ineffective Communication Impaired Infection, Potential Self Care Deficit
Anxiety
?oping, Ineffective -injury,
- skin Integrity Impairment
Breathing Patterns, Ineffective Fluid Volume, Alteration in -`Knowledge Deficit -'ihought Processes
Im
i
-C
di
d
O
,
pa
re
ar
ac
utput, Decreased Gas Exchange, Impaired Mobility Impaired Th
fort, Alteration in Fiyperlhennie Fever ought Processes. Alteration in
N
C
an-
ompliance Tissue Perfusion, Alteration in
Other
- Other
Not Nol
Mq met Nx Met Mot lot MN Met lot
O FB REMOVAL O IMMOBILIZATION 1 PROPER ALIGNMENT O IMPROVEMENT OF BREATHING
O BLEEDING CONTROL P DECREASE 1 PREVENT SWELLING
O PAIN CONTROL AIN STABLE HOMEOSTASIS O STABILIZE PATIENT IN DISTRESS
O ALLEVIATE NN O meet ENVIRONMENTAL NEEDS
O MAINTAIN SKIN / TISSUE INTEGRITY
? meet PSYCHOSOCIAL NEEDS
O FEVER CONTROL q PREVENT FURTHER IN,1URY O meet SELF CARE ABILITY NEEDS
O DECREASE ANXIETY 13 MAINTAIN / IMPROVE CIRCULATION
O meet EDUCATIONAL NEEDS
O SAFETY IN THE ED p INFECTION CONTROL O after
Mt: N = dotxxnentalkin In nurses rotes. other 'codes' per Hospital Policy.
Tlfr?s fiut#!? Proprtrq Obs
, g
T
P
SIP'
NO /
CWdleL
- ;
K?UU LS? r L ILIW 010A L ol
I 1
LA? I J,
_ wV"-J')L' .Q ri
l
Discharged in care of: A
b
/C
m
p
13Strett3 Carried
Disch a instructions given to rbalized understanding
--- - t: Room #: to Dr. Ready for Room Time:
_v R rt tied at and given to
T ered to D Transfer Verified
R o called at and given to
a L without treatment O Left Against Medical Advise
- ndition at Disposition: ?Improv Stable aSerious DExpired
Pain Scale: Pain Location:
--- Patient nt repo rts that pa' is;?0 Im rovedR % Pnvm
Dis position Vita T 11 l ?
Dispos ition Da Nurse. Ci
Rev. U3!OSrD4 ?
EMERGENCY DEPARTMENT
SMENT SHEPHERD, DAEKWON Carlisle RegioPIC93 Medical 4 Center.
PEDIATRIC NURSING ASSES Name:
Age: 10YRS DOB: Q8129/1987 Sex: M MR#: 0001057387
Date In:4/19/2008 Time: EDP: `FRIERSON_MD, PATRICI PCP:' NON-STAFF, FAMILY, PHY'
SAectWe Notes: n 11 - ,
Quality:OSharp bibull OCramping OBuming OAching a Rating
Mode of nset: O Sudden O -Gradual O Intermittent g Scale:
Onset: Date: Time: Duration: WONGIBAKER FACES RATING SCALE
Onset > 24 hrs. medical attention was s - t90? Qp .?. ?,
ought? pNo pYes Date:
Radiating: ONo OYes (sp.?&y1
Caregiver: OParents OMother OFather OOther.
Accompanied by:
Appearance: OClean OUnkempt pother
Activity level: OAwake OPlayful ?Smlies / Laughs
oOther
ORtktlesa' . t?Ohalfetttei! OUnr.. _
aponsiti!s -
Fgpl? 'sii:e .acid (811110011;1:r
Capillary Refill. a <2 Secs (Normal)
Turgor: O Normal O Decreased
Pulses: L Radial: ? Present ? Absent
L Pedal: ? Present ? Absent
Effort
Cough: Q None
Lung Sounds:
?Clear OWheezes
OR OL OR pL
O>2 Secs (Delayed)
R Radial: ? Present ? Absent
R Pedal: ? Present ? Absent
u i.N.W.W O WMPIQry u y0veraty}, -
O Rr#rdd(ono 17 9Vldor ?? tiae`? Fiarinyl ..
O Productive a Non-Productive
?Rhonchl0Crackles [3 Diminished DAbsent
OR OL OR OL OR (31. OR 13L
Environment: O No steps O Few steps O Many steps
Nutritional status: ONormal a Cachetic O Obese
Religious / Cultural preference: ONone t%MC1fy
Best leam by: (pt / caregiver) OVerbal pwrltten ORetum demo
Learning Barriers:
Abdo oft O Flat 1 Rigid O Distended
P,ffon-Tender O Tender (Area)
Bowel Sounds: OPresent ODecreased OAbsent
Elimination: O Normal OConstipation ODiarrhea # of Stools:
Voiding: pContkrent Olncwntinent' ODiaper
ODysuria 0Frequency Color:
Other findings:
Lacerations / Abrpslons ! qo9tusIons
Location: , .
Size:
Bleeding: 13 Absent Pr ent El Scant O erate eavyOPulsating
ROM: r1WNL O Decreased OAbsent
Edema: O Absent 01+02+132+ DeformityO Yes C No
Scars: o Yes O No Distal pulses: O Absent O Present WIM -77777;77
13NEW BORN Asw o t Month ?INFANT i -12 Month. Language! ?Cries Often OSmiles ?Coos / Gurgles OBabbles
Bom at Term:OYes ONo Delivery: OVaginal OC-Section
Diet: O Breast Feed OFormula type: Uses: OBottle OSpoon OCup
Elimination: O3 - 8 stools a day Other. _
Acttvity: Lifts Head: OYes ?No Sits up: ?with help ? without help Crawls: ? Yes ? No Teething: ? Yes ? No
Observation of Interaction with caregiver is ? Appropriate OSee Nursing Assessment
?TODDLER Ao. t-s Y"m ? Pre-School Ay. a - 5 Y.ers Language: OFew Words ?Sentences ? Easily Understood
Diet: OFNer Foods ?Regular Diet OFeeds Self Uses: OBottle 0 Cup Teething: ?Yes ?No
Elimination: 01 - 2 Stools per day ODiapers OTollet trained OWets bred: O Rarely 13 Occasionally OFrequently
Activity: Walks: ? Yes ? No OWalks with assistance OWalks Independently
Observation of interaction with caregiver is OApproprbate OSee Nursing Assessment
?SCHOOL AGE A" o-11 You. ?ADOLESCENT Age +s - v Y. Reached Puberty: ? Yes ONo Learning disability: O Yes School grade:
Diet: E3 Eats 3 meals/day OEating disorder: (specify) WearsBraces pYes ONoT
Elimination: ? N bl -
o pro em reported ? Wets bred: ORarely ?Occasionally OFrequenuy
Social Habits: Smokes O Yes ? No Uses Alcohol: ? Yes ?No Uses Dru Yes ONo
?
Observation of interaction with caregiver is ? Appropriate OSee Nursing Assessment
Vital Signs: 16:51 T: 97.7 P: 94 Regular R: 20 BP: 1321061 Nurse Sionat
INITIAL ASSESSMENT FORM Carlisle Regional Medical Center
PRIORITY: 3 • Patient: SHEPHERD, DAEKWON Pt#: 9399554
Urgent DOB: 06/29/1997 AGE: 10YRS sex: M MR#: 0001057387
EDP: *FRIERSON_MD, PATRICIA L.
DATE: 04/19/2008 PCP: ' NON-STAFF, FAMILY, PHY' Worker's Comp:
Emp. Referred:
Presentation Time: 18:51 Triage Time: 18:51 Arrival Mode: BLS
Height: Weight: 81.0 Ibs. 36.8 kgs. LMP: Last Tetanus: Acc By: MOTHER
Chief MVA-MINOR INJURY
Complaint: Vital Sion
Brief PT IN MVA. CAR FLIPPED AND WENT INTO A CREAK. RESTRAINED DRIVER. NECK PAIN. LAC
Assessment: TO NECK. NO COMPLAINTS. NO LOC. SEVERE DAMAGE TO CAR.
NIGHT SWEATS NO HEMOPTYSIS NO
WEIGHT LOSS NO FEVER NO
ANOREXIA NO
SAFETY NO
TRAVEL NO
IMMIGRATION NO
RESTRAINED YES
DRIVER NO
AIRBAG DEPLOYED NO
T: 97.7 PO
P: 94 Regular
R: 20 Unlabored
BP: 1321061
02: 100 % RA
Pain intensity Scale: 0 110
Pain Location: Denies Pain
Pre-Hospital
Treatment:
Pediatric G&D App. for Age - YES, Immunization UTD • YES, Height ft. in., Head Circ. - Grade -, with MOTHER
Assessment:
Past Medical DENIES
History:
Allergies: NKDA
Medicines:
DENIES
Nurse Signature:
VLB
Rev 0518104
Carlisle Flegional Medical Center -- Emerqencv Department
361 Alexander Sprinq Rd Carlisle, PA 17013 -- (717) 960-1695 Shepherd, Daekwon
4119108 7:18pm 1057387
DISPOSITION'SUMMARY
Patient: Shepherd, Daekwon
SS #: Age/DOB.
CURRENT Address: Current Ph:
City: Zip: Medical Record: 1057387
Arrival: 4/19/08 7:18pm Disch: 4/19/08 7:19pm
Disposition:
MD ED: Kathy Ferraro, MD PMD:
ReWPA/NP: Kevin Gold, PA-C PMD Ph:
Dx #1: Motor Vehicle Accident-Passenger
ICD-9 #1: E819.1 #1 Dx Engl: MOTORVA.ESW #1 Dx Span: MOTORVA.SSW
Dx #2: Abrasion, Neck
ICD-9 #2.910.0 #2 Dx Engl.- ABRAS.ESW #2 Dx Span: ABRAS SSW
uw¦
Follow-up: YOUR FAMILY DOCTOR
F/U MD Ph:
F/U DR: as needed
Other Instr:
MY SIGNATURE BELOW INDICATES:
> I have received and understood the oral instructions regardinq my current
medical problem.
> I will arranqe follow-up care as instructed above.
> I acknowledge receipt of the written instructions as outlined on this and
any previous page(s). I will read and review these instructions. ?/
} X
anent (or Leqal Guardian) Signature F Staff ness) Si lure
PATIENT CONTACT RECORD
Emergency Contact
Please list the person(s) you would like us to contact in the event of a medical
emergency
Name:
Relationship to Patient:
Home Phone:
Work Phone:
Cell Phone:
2.
3.
Patient Right and Responsibilities 2natients Only)
I have received a statement of the Patient's Rights and Responsibilities.
(minw tan)
Patient Confidentiality (Inpatients Only)
Dear Patient,
To protect patient confidentiality, the following personal identification number has becn
assigned to you. Medical information will not be disclosed or discussed with anyone
who cannot ftimish this number to our staff;
-.qL
(Personal Identification Number)
i of Patient/Responsible Pay 0, kkA (4 Ig -()g
Date
GI?NAL . (717) 249-1212 PATiEPrr LaseL
MCDIChL crw re,
No 1609 0312008 White (Medical Record
Yellow (Patient)
Permission to discuss details of your account: Yes
Name:
Relationship to Patient:
Home Phone.
Work Phone:
Cell Phone:
Permission to discuss details of your account: Yes
No
Patient is a resident of a nursing home: _ .. no
If yes, name of facility
No
ME *1 CAL 60 k
a
351 Alaxandar Sping Road* Carts", PA 170158129 • (717) 249-1212
CONDITIONS OF TREATMENT AND ADMISSION
PATIENT'S NAME SHEPHERD, DAEKWON ATTENDING PHYSICIAN FRIERSON, PATRICIA L
ACCOUNT No. 9 3 9 9 5 5 4
DATE 6 TIME OF ADMISSION 04/19/2008 1$:51
CONSENT TO HOSPITAL CARE AND TREATMENT
I AM PRESENTING MYSELF FOR EMERGENCY SERVICES OR ADMISSION TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCH
CARE, INCLUDING DIAGNOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOYEES OF THE HOSPITAL, AND BY ITS MEDICAL
STAFF, OR THEIR DESIGNEES, AS MAY IN THEIR PROFESSIONAL JUDGEMENT BE DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING.
I ACKNOWLEDGE AND UNDERSTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL, INCLUDING THE ATTENDING PHYSICIAN(S)
NAMED ABOVE, AND RADIOLOGISTS, ANESTHESIOLOGISTS, PATHOLOGISTS AND EMERGENCY PHYSICIANS, ARE NOT EMPLOYEES OR AGENTS OF THE
HOSPITAL, BUT RATHER ARE INDEPENDENT CONTRACTORS WHO HAVE BEEN GRANTED THE PRIVILEGE OF USING THE HOSPITAL FACILITIES FOR THE
CARE AND TREATMENT OF THEIR PATIENTS. I AGREE TO ACCEPT THEIR CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE HOSPITAL.
I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY BASIS IS NOT INTENDED AS A SUBSTITUTION OR
REPLACEMENT FOR COMPLETE MEDICAL CARE.
CONSENT TO RELEASE INFORMATION
1 HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES
THAT MAY BE LIABLE FOR ALL OR PART OF THE HOSPITAL CHARGES, ALL OR PART OF MY HOSPITAL RECORDS AS MAY BE NECESSARY (INCLUDING ANY
TREATMENT FOR ALCOHOL OR DRUG ABUSE OR DEPENDENCE), TO DETERMINE BENEFITS ENTITLEMENT AND PROCESS PAYMENT CLAIMS FOR HEALTH
CARE SERVICES PROVIDED.
MEDICARE CERTIFICATION RELEASE
I CERTIFY THAT THE INFORMATION GIVEN BY ME IN APPLYING FOR PAYMENT UNDER THE TITLE XVIII AND TITLE XIX OF THE SOCIAL SECURITY ACT IS
CORRECT. 1 AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS
INTERMEDIARIES OR CARRIERS ANY INFORMATION NEEDED FOR THIS OR A RELATED MEDICARE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED
BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSIGNMENT.
PERSONAL EFFECTS AND VALUABLES
I UNDERSTAND THAT THE HOSPITAL SHALL NOT BE LIABLE FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES (MONEY, JEWELRY,
GLASSES, DENTURES, DOCUMENTS, CLOTHING, ETC.) UNLESS SUCH ITEMS ARE DEPOSITED IN THE HOSPITAL SAFE. THE HOSPITAL WILL NOT BE LIABLE
IN EXCESS OF $50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLES DEPOSITED WITHIN THE HOSPITAL SAFE.
ABOUT YOUR BILL
I UNDERSTAND THAT I WILL RECEIVE A BILL FROM THE HOSPITAL FOR PROVISION OF THE HOSPITAL SERVICES, INCLUDING STAFF AND EQUIPMENT, AND
FOR ANY SUPPLIES OR MEDICINES UTILIZED. I WILL ALSO RECEIVE A BILL FROM ANY PHYSICIAN WHO PROVIDES PROFESSIONAL CARE TO W. FOR
EXAMPLE. I MAY RECEIVE A SEPARATE BILL FROM ONE OR MORE OF THE FOLLOWING TYPES OF PHYSICIANS WHO RENDER SERVICES TO ME: MY
ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLOGIST, PATHOLOGIST, OR ANY OTHER
SPECIALIST.
INSURANCE ASSIGNMENT
I HEREBY ASSIGN TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT
(HEREINAFTER 'PHYSICIANS'), OR THEIR DULY AUTHORIZED ASSIGNS TO TAKE ALL NECESSARY STEPS, WITHOUT LIMITATIONS, TO ENSURE THAT ANY
INSURANCE BENEFITS OTHERWISE PAYABLE TO ME OR MY ESTATE ARE PAID DIRECTLY TO THE HOSPITAL OR PHYSICIANS. THIS ASSIGNMENT OF
INSURANCE BENEFITS INCLUDES BUT IS NOT LIMITED TO BILLING INSURANCE, FILING PETITIONS, FILING SUIT, IN MY NAME OR ON BEHALF OF THE
HOSPITAL OR PHYSICIANS, FILING PROOFS OF CLAIM, FILING PROBATE CLAIMS AND FILING GRIEVANCES AND ALL OTHER SIMILAR PROCEDURES, AS
MAY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. I ALSO AGREE TO PROVIDE AND SIGN ANY OTHER DOCUMENTS
THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES.
STATEMENT OF FINANCIAL RESPONSIBILITY
1 UNDERSTAND THAT 1 AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY THIRD PARTY. 1 FURTHER AGREE
THAT SHOULD I NOT PAY THE BALANCE WITHIN THIRTY 130) DAYS AFTER THE DATE OF DISCHARGE, MY ACCOUNT WILL BE CONSIDERED DELINQUENT. I
AGREE TO PAY COSTS OF COLLECTION, INCLUDING REASONABLE ATTORNEY'S FEES AND COSTS, COLLECTION AGENCY FEES AND COSTS, AND
INTEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW.
FRAUD
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURANCE COMPANY, OR FILES A STATEMENT OF CLAIM
CONTAINING FALSE, INCOMPLETE OR MISLEADING INFORMATION MAY BE SUBJECT TO PROSECUTION UNDER APPLICABLE LAW.
ADVANCE DIRECTIVE (FOR ADMISSION TO HOSPITAL ONLY)
IF I AM TO BE ADMITTED TO THE HOSPITAL, I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT TO ACCEPT OR REFUSE MEDICAL TREATMENT. 1
HAVE BEEN INFORMED OF MY RIGHTS TO FORMULATE ADVANCE DIRECTIVES. I UNDERSTAND THAT I AM NOT REQUIRED TO HAVE AN ADVANCE
DIRECTIVE IN ORDER TO RECEIVE MEDICAL TREATMENT AT THIS HOSPITAL. I UNDERSTAND THAT THE HOSPITAL AND MY CAREGIVERS WILL FOLLOW
THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW.
(INITIAL THE FOLLOWING OPTION THAT APPLIES)
• I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY OF THIS FOR MY MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME.
• I HAVE NOT EXECUTED AN ADVANCE DIRECTIVE AND DO NOT WISH TO DO SO.
• I WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION
INIT. !FOLLOW-UP DONE BY
INIT.
_ DATE
I CERTIFY THAT I HAVE READ (ORR HAVE BEEN READ) THE ABOVE CONSENTS AND CAND AGREE WITH THEM.
DATE: ls?l
CAY Y ATURE OF PATIENT 01R. LEGALL Ui RIZEO REPRESENTATI '
14 J?-
WITNESS PRINT N
RSON AOVE
HMA7110
IIINIlINANiIlIlII 939966a
i110 11111 milli
Carlisle lReglonal Medical Center -- Emergency Department
361 Alexander Spring Rd Carlisle, PA 17013 -- (717) 960-1695
Patient: Shepherd, Daekwon
MD ED: Kathy Ferraro, MD Disch: 4/19108 7:19pm
Res/PA/NP: Kevin Gold, PA-C, Medical Record: 1057387
AFTERCARE INSTRUCTIONS
We are pleased to have been able to provide you with emergency care. Please review these instructions when you return home
in order to better understand your diagnosis and the necessary further treatment and precautions related to your condition.
Your diagnoses/prescriptions today are:
DX #1: Motor Vehicle Accident-Passenper
Dx #2: Abrasion, Neck
0
General Information on MOTOR VEHICLE ACCIDENTS
Each Year in the United States, about two million people are injured in motor vehicle accidents. Fortunately, many of
these injuries are relatively minor, such as simple scrapes, sprains or bruises. However, other injuries can be more serious,
and can even result in death. In fact, each year about 50,000 Americans die as the result of motor vehicle accidents. This is
roughly the same number of Americans who died in the entire Vietnam war.
Open vehicles like motorcycles and "Alf Terrain Vehicles" are particularly dangerous. In an accident, they leave the driver
completely exposed to absorb the full force of the impact. What might have been a minor fender bender in a car can be a
fatal accident on a motorcycle.
What are the risks?
Most people involved in minor motor vehicle accidents start to feel better within a few days and do not develop any
serious medical problems. There are, however, some risks:
1. Often the aches and pains that result from a minor motor vehicle accident keep on getting worse for the first day or two.
This is uncomfortable, but not dangerous.
2. Sprains of the neck or back sometimes produce pain that lingers on and off for weeks or even months.
3. Cuts or scrapes sometimes get infected.
4. On rare occasions, serious injuries may not become apparent for several hours or even days.
INSTRUCTIONS
1) NEVER DRINK ALCOHOL AND DRIVE. About half of all motor vehicle accident fatalities are the direct result of drinking
and driving.
2) ALWAYS USE A SEAT BELT. Seat belts save livesl
3) ALWAYS MAKE SURE ANY SMALL CHILDREN ARE SECURELY FASTENED IN AN APPROPRIATE CAR SEAT (In
most states this is required by law).
4) If you ride a motorcycle, ALWAYS WEAR A HELMET when you ride, and try to wear protective clothing like a leather
jacket. Better yet, sell your motorcycle and buy a car.
5) If you are not allergic to it, you may take acetaminophen (Tylenol) to help relieve the aches and pains. Stronger pain
medication is not usually needed.
6) If you have sprained or bruised muscles, ice packs may help ease the pain for the first two days after the accident. Put
the ice in a plastic bag. Roll up the bast in a towel and try putting it on the sore spots for 5 to 15 minutes at a time. After
the first two days, warm packs usually work better.
7) If you have any cuts or scrapes, keep them CLEAN and dry. Contact your doctor if they become unusually red, swollen
or tender.
8) SEEK IMMEDIATE MEDICAL ATTENTION if you develop chest pain, difficulty breathing, pain in the belly, vomiting, a
severe headache, severe neck pain, bleeding, dizziness, confusion, difficulty walking, a fever, convulsion, blurred vision,
excessive drowsiness or pass out. In children ALSO look for poor feeding or irritability.
General lr formatlon on ABRASIONS
An "abrasion" is the medical term for an accidental scrape or scratch on the skin. Abrasions often result from auto
accidents, falls or contact with broken glass or other sharp objects. Depending on the circumstances, the abrasion may be
relatively small and insignificant, or it may be quite large.
What are the risks?
Pq 2
Most abrasions heal in one to two weeks and do not produce any serious medical problems. There are, however, some
risks:
1) When the skin is disrupted by an abrasion, perms sometimes get into the wound and start to prow and multiply,
producinq an infection. If not treated right away, these infections can be serious. Immediately cleaning the wound is best
way to help prevent an infection.
2) Deep abrasions sometimes leave a noticeable scar.
3) On rare occasions, there may be some damage to the muscles, tendons, nerves or bones underneath the abrasion.
INSTRUCTIONS
1) When you get home, You should:
A) wash the abrasion(s) thoroughly with lots of soap and water (unless this has already been done in the emergency
room),
B) if you are not allergic to it, gently apply a thin layer of antibiotic ointment and
C) cover the area with a bandage.
2) Keep the area clean and drv.
3) If the bandage pets dirty or wet, change it right away. Otherwise, you should change the bandage once a day. To change
the bandage you should:
A) remove all of the old bandage,
B) gently wash the area under running water,
C) if you are not allergic to it, gently apply a thin layer of antibiotic ointment and
D) put on a new bandage.
4) WARNING: Some antibiotic ointments can be toxic if used on large areas of skin. If your abrasion covers an area larger
than the surface of your hand, talk with your doctor before using any antibiotic ointment.
5) If you are not allergic to them, you may take acetaminophen (Tylenol) or ibuprofen (Advil) to help ease the pain.
6) Tetanus shots are good for 5 to 10 years, provided you have had all your "baby shots' as a child-
7) SEEK IMMEDIATE MEDICAL ATTENTION 'rf:
A) you develop a fever, persistent bleeding, vomiting or
B) the abrasion gets very red, swollen or tender or
C) you develop red streaks on the skin near the abrasion or
D) the abrasion develops a foul odor, or starts to drain pus.
0
Follow-up: YOUR FAMILY DOCTOR
FN MD Ph:
F/U D/T: as needed
Other Instr:
EKGs and X-Rave: If you had an EKG or X-Ray today, it will be formally reviewed by a specialist tomorrow. If there is any
change from today's Emergency Department reading, you will be notified.
IMPORTANT NOTICE TO ALL PATIENTS: The examination and treatment you have received in our Emergency Department
have been rendered on an emergency basis only and will not substitute for definitive and ongoing evaluation and medical care.
A follow-up physician has been designated for you. It is essential that you make arrangements for follow-up care with that
physician as instructed. Report any new or remaining problems at that time, because it is impossible to recognize and treat
all elements of iniury or disease in a single Emergency Department visit. Significant changes or worsening in your condition
may require more immediate attention. The Emergency Department is always open and available if this becomes necessary.
Boland Chiropractic & Sports
915 N Mountain Rd, Ste C
Harrisburg, PA 17112-1018
RE: DAEKWON D SHEPHERD
-------- - ----------
8/18/2008 Pain Level: 0
Height: Weight:
SOAP NOTES
Date: October 16, 2008
- - -------------- ----------- --------------------
req Level: 0 BP: Pulse:
Temp:
Field 1: Field 2: Field 3:
Subjective:
The patient returns to the office today for discharge evaluation stating that he feels his symptoms are mostly
resolved at this time,- he denies any exacerbations since his last visit. He has resumed all ADL without
complication.
Objective:
Spinal fixations present at C5, T4-5 and L5.
Assessment:
The patient has reached maximum chiropractic improvement.
Plan:
Full spine CMT. The patient is discharged at this time from active care. I do not anticipate: any permanent
residuals for him.
------------------
008 Pain Level: 0 Freq Level: 0 BP: Pulse:
Temp:
Height: Weight: Field 1: Field 2:
Field 3:
Subjective: .
The patient returns to the office reporting that he is doing much better at the current time. His symptoms of neck
and back pain are rated a 2 occurring between 5-25% of his day. He has returned to all of his normal activities
without complication.
Objective:
Spinal fixations at C2-3, T2-5, L5-S1.
Assessment:
The patient has nearly achieved maximum medical-chiropractic improvement.
Plan:
Full spine CMT followed by 15 mins each therapeutic exercise and dynamic activities supervised by Dr. Boland:
He is recommended to return in 4 weeks for final reassessment of his condition.
Page 1 Of 5
RE: DAEKWON D SHEPHERD
---------------- -------- ----- ---------------- ------------------------------- --------- ------ ---- ---- -- ------------ ------- - ----- -------- -- --
6/25/2008 Pain Level: 0 Freq Level. 0 BP: Pulse: Temp:
Height: Weight: Field 1: Field 2: Field 3:
Subjective:
The patient reports mild degree neck pain radiating to left arm occuring between 5-25% of his day rated at a level
3.
Objective:
Spinal fixations at C2-4, T2-8, L5 with cervical spine ROM limited in rotation.
Assessment:
Plan:
Full spine CMT followed by THREX and DYNA each 15 min. supervised by Dr. Boland
-------------------------- --------------------------------------------- --------------------- ----- ----------- ------- ----- _ ------------ ---------------------------------------------
6/19/2008 Pain Level: 0 Freq Level: 0 BP: Pulse: Temp:
Height: Weight: Field 1: Field 2: Field 3:
Subjective:
The patient returns to the office today stating his symptoms are again improving and rated his pain at a number 2
on a scale of 0-10 occurring no more than 25% of his day. His primary symptoms at this time are in his neck and
occassionally in his low back and legs. His mother interjected to state she believes he still is not himself in regard
to his activities.
Objective:
Spinal fixations at C2-4, T2-8 and L5. Cervical spine ROM limited mostly in left rotation by approximately 35%-
Assessment:
Plan:
Treatment today consisted of FS-CMT and THREX with emphasis on abdominal and low back strengthening and
DYNA for balance and coordination 15 minutes each supervised by Dr. Boland. The patient tolerated -treatment
well.
---------------------- -------
- p - : --
6/14/2008 Pain Level: 0 Freq Level: 0 BP: Pulse: - - - -- Tem -
Height: Weight: Field 1: Field 2: Field 3:
Subjective:
The patient reports his symptoms today at a level 2 occurring approximately 25% of his waking day. He believes
his treatments are helping him and he is feeling much better overall stating he has little to no pain in his chest at
this time. He continues with neck and low back pain and intermittent pain in his extremities.
Objective:
Spinal fixations at C6-7, T3-6 and L5-S1
Assessment:
Plan:
FS-CMT followed by THREX and DYNA as previously described for a combined 30 minutes, supervised by Dr.
Boland. The patient tolerated treatment well.
Page 2 Of 5
RE: DAEMON D SHEPHERD
--- ------- -------------------------- ------- --------------- -- ------------------------ -------------- --------- - --
---------------------------------------------------------------
6/7/2008 Pain Level: 0 Freq Level: 0 BP: Pulse: Temp:
Height: Weight: Field 1: Field 2: Field 3:
Subjective:
The patient reports to the office today stating his symptoms have decreased at this time occurring approximately
25% of his day and rated a 3 on a scale of 0-10 stating "its getting somewhat better but I still have pain in my
neck, back, legs and radiating to my chest".
Objective:
Spinal fixations present C2-5, T3-10, L5.
Assessment:
Plan:
Treatment today consisted of FS-CMT followed by 15 minutes each of DYNA and THREX supervised by Dr.
Boland. The patient tolerated treatment well.
----------------------- --- -- - - ------ ----------------------------------------------------------------------------------------- ------------------------- ---------------------
6/4/2008 Pain Level: 0 Freq Level: 0 BP: Pulse: Temp:
Height: Weight: Field 1: Field 2: Field 3:
Subjective:
The patient returns to the office reporting his symptoms occurring approximately 50% of his day rated at 5 on a
scale of 0-10 again occurring in his neck, upper and middle back, lower back and legs.
Objective:
Spinal fixations at C5, T3-6 and L5.
Assessment:
Plan:
FS-CMT followed by 10 minutes each DYNA for improving coordination and balance and 10 minutes THREX for
abdominal and low back strength. The patient tolerated treatment well
5/28/2008 Pain Level: 0 Freq Level 0 BP: Pulse: Temp:
Height: Weight: Field 1: Field 2: Field 3:
Subjective:
The patient returns tot he office reporting continued pain in his neck, legs and chest occurring between 25-50% of
his waking day and rated a 5 on a scale of 0-10.
Objective:
Spinal fixations were noted at C5-6, T3-8 and L5-S1.
Assessment:
Plan:
Treatment today consisted of FS-CMT followed by 15 minutes DYNA with emphasis on multiple balance
movements and THREX 10 minutes with emphasis on abdominal bracing while riding the mechanical horse.
Page 3 OF 5
RE: DAEKWON D SHEPHERD
---- --- - ------
24/2008 ----- -- ------------------------
Pain Level: 0
Freq Level: 0 BP:
Pulse:
Temp:
Height: Weight: Field 1: Field 2: Field 3:
Subjective:
ACCIDENT HISTORY.-
Master Shepherd, a 10 year old student was brought in for a consultation by his mother on May 24, 2008 for
injuries sustained in a motor vehicle accident on April 19, 2008. Master Shepherd was seated in the rear seat of
a late model station wagon which careened off the road, drove over an embankment, down and hill and ended up
in a creek flipped over on the roof. The patient stated he was wearing his seatbelt at the time, but ultimately had
to (kick out) a window to extricate himself from the vehicle. He reported that although he did not sustain any -
bleeding cuts nor loss of consciousness he was transported to the Carlisle Hospital emergency room via
ambulance on a back board with neck restraint. The patient recall having been examined at the hospital and
released under his mother's care with instructions to follow up with the family physician. Due to the family not
having lived in the area for an extended length of time, he did not have.a family physician and ultimately
consulted the Sadler Clinic whereby, he was-r.:e,c ACenter:whereby'he had
xrays taken of his neck on May 22, 2008.
Immediately following the collision the. patient reports having the following symptoms- he was scared and shaken
up and felt pain in his neck, middle and lower back, chest and arms. Later that day and the following day he
reports having the same symptoms and also experiencing pain in the backs of his knees and lower legs.
On the day of and poor to the accident; on April 19, 2008, Master Shepherd stated that he had no physical
complaints and participated in several athletic type activities as do most boys his own age. Since that time he
has been significantly restricted due to the afore mentioned symptoms.
Past medical history was non-contributory. The patient is not under doctors care nor does he take medication for
any reason. The patient uses over the counter topical cream for eczema.
SOCIAL HISTORY:
The patient is a full time student and lives with his mother and step father in Carlisle, PA.
REVIEW OF SYSTEMS:
The patient and his mother denied any other heart, lung, EENT, GI-GU, metabolic, endocrine or neurological
disorders.
CURRENT CONDITION:
On May 24, 2008, Master Shepherd presented himself to this office for an evaluation at which time he related the
following symptoms; pains in his neck, middle and lower back, pain in his chest, arms and backs of his knees
and lower legs which had not significantly improved since the accident.
Page 4 Of 5
RE: DAEKWON D SHEPHERD
Objective:
EXAMINATION:
Physical examination results were as follows: mild distress was noted during the time of consultation. The
patient often was noticed rubbing his neck where he had evidence of seat belt burn on the left side. General
neck movements were painfully limited particularly in rotation to the right side which was limited by 50%; all neck
movements were painful. Visual inspection of the patient revealed considerable head and neck tilt to the right.
Motion palpation revealed articular blockage at C2-5 with associated tenderness on the left side and spinous
tenderness at T2-8 with associated paraspinal muscle tenderness. Auscultation of the heart and lungs was with in
normal limits. Motion Palpation of the remainder of the spine revealed spinal fixations C2-C7, T2-T8 and L4-S1.
Report of xray from Walnut Bottom Radiology was negative for fractures or gross malalignment. The patient
stands 47 &1/2 inches tall and weighed 80 pounds. Muscle strength evaluation in the upper extremities was
normal however the patient could not perform resisted neck movements without pain in his neck and shoulders.
Thoracolumbar range of motion was within normal limits however did cause the patient some degree of back and
lower leg pain on both sides. Deep tendon reflexes and sensory examination were within normal limits.
These findings on examination are consistent with the type of accident described by the patient which occurred
on April 19, 2008. It is my opinion that the symptoms which the patient is currently experiencing are directly and
causally related to the same accident.
Assessment:
DIAGNOSES:
The patient initial diagnosis including:
1) motor vehicle collision with a non-vehicle object
2) acute moderate cervicothoracic sprain/strain
3) acute moderate lumbosacral sprain/strain
Total time of evaluation was 55 minutes including decision making of moderate complexity.
Plan:
MANAGEMENT:
Management of the patient's condition will include
1. Chiropractic manipulative treatment - a form of manual treatment to influence joint and neurophysiological
function.
2. Spinal decompression employing forces given in the direction of pain - free motion in order to reduce
discoradicular irritation. Decompression Therapy
3. Soft tissue mobilization and massage to relieve hypertonic musculature.
4. Ultrasound and electrotherapy to increase circulation for more rapid healing, reduce inflammation, pain and
spasm.
5_ Therapeutic exercise to develop strength and endurance, range of motion and flexibility.
6. Neuromuscular reeducation to develop balance and coordination, posture and proprioception for sitting and or
standing..
7. Therapeutic dynamic activities to improve functional performance.
8. Self-care home management training in activities of daily living to minimize the risk of re-injury..
ADDENDUM - August 1, 2008:
Spinal manipulation on 5-24-08 was rendered to the cervical, thoracic and lumbosacral regions.
Page 5 Of 5
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF PUBLIC WELFARE
BUREAU OF FINANCIAL OPERATIONS
DIVISION OF THIRD PARTY LIABILITY
CASUALTY UNIT
P.O.BOX 8486
HARRISBURG, PA 17105$486
March 9, 2009
LUNDY LAW
FRANCINE H MONTGOMERY LEGAL ASSISTANT
1635 MARKET ST 19TH FL
PHILADELPHIA PA 19103
Re: DAEKWON SHEPPARD (minor)
CIS #: 530182075
Incident Date: 04/19/2008
Dear Ms. Montgomery:
The Department of Public Welfare maintains a lien in the amount of
$1,001.00 for the above-referenced incident.
The Department has agreed to reduce its lien by 25% plus a prorata share
of expenses and accept the net payment of $640.53 to satisfy the total lien
amount.
Checks should be made payable to the Department of Public Welfare and
sent to my attention at the above address. We request that with all
transmittal of funds, you provide the Department with a copy of the final
distribution sheet.
In the event you have already brought or will bring any action resulting
in a further recovery, we reserve the right to seek recovery of any
additional unpaid portion of our medical/cash lien. This settlement in no
way affects our future rights.
Thank you for your cooperation in this matter. If you have any further
questions, please contact me.
. erely,
aren H. Peterson
Claims Investigation Agent
717-772-6615
717-772-6553 FAX
• L.PW arvinLundy
TT A
seiSells
CONTINGENCY FEE AGREEMENT
DATE: wmbe,
I hereby retain, constitute and appoint the law firm of LUNDY LAW as my counsel to prosecute a claim for personal
injuries. The cause of action arose on
I hereby agree that the compensation of the firm and my attorney for se ices shall be determined as follows:
-t ,lv l haGc to/?c ?hu-z? 33113 6
The firm and my attorney shall receive ?1?G f??Percent of gross sum secured either or whether by way of
settlement or verdict. All expenses incident to the prosecution or litigation of this case are to be borne by the client at
time of distribution unless otherwise agreed in writing. I do hereby direct and authorize my attorney and Lundy Law to
pay directly and without additional consent from any proceeds of/by settlement or verdict any unpaid balance for
treatment, services or other costs made necessary by the injuries sustained in this accident and/or the
prosecution/litigation of this claim. Expenses include, but are not limited to, such things as investigation, photos,
experts, filing fees, court costs, photocopying, research costs and a one-time $150 administrative fee. In the event no
money is recovered in this case, the client shall not be liable for any expenses or legal fees as a result. Lundy Law
may withdraw as counsel at any time, without obligation, at its sole discretion.
Client hereby acknowledges that Lundy Law has taken this representation on a contingency arrangement as stated in
this document. As a result, Lundy Law is sharing in both the risk and recovery regardless of the number of hours
invested. In consideration of Lundy Law accepting this case, and in the event that client discharges Lundy Law for any
reason, client hereby specifically agrees to waive any hourly time accounting and instruct his/her new counsel to pay the
following fee, whether this matter is settled or tried, as determined by a scheduled percentage of the total amount of
gross settlement/recovery/award which is received or offered according to the stage of the representation when the
discharge or withdrawal of Lundy Law occurs: Claim stage: 33 1/3%, Litigation stage, 40%, Within sixty (60) days of
Arbitration/Trial : 50%.
In addition, Lundy Law shall receive all costs advanced and/or expended to date before the file shall be transferred
Client agrees to keep the attorney advised of his/her whereabouts at all times and to cooperate in the preparation and trial of
the case, to appear on reasonable notice for depositions and court appearances, and to comply with all reasonable requests
made of him in connection with the preparation and presentation of his/her case.
Lundy Law, or its representative attorney, is authorized to endorse my name to any drafts, insurance drafts or settlement
drafts only for the purpose of depositing said drafts into its escrow account. My counsel is further authorized to pay directly
to any health care provider(s) any amounts due for services rendered upon receipt of said money.
No representation has been made as to what amounts, if any, client may be entitled to recover in this case
Further, I hereby state and affirm under penalty of law that the facts regarding me and my background, the accident, injuries,
participants, and witnesses are true and correct as presented to Lundy Law, and I understand that the law firm is relying upon
these facts to accept my representation for this matter.
I hereby acknowledge that I have read this fee agreement, agree to these terms and I have received a duplicate copy of this
Contingency Fee Agreement.
N E?
Revised: Pcbtuary 26, 2004
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FlL~D-C)t~rICE
LundvLaw ~~' Ta-{" PR~~'~-`~'~'~T,A~Y
BY: HERBERT L. OCKS, ESQUIItE
IDENTIFICATION NO.: 04137 ZQ ~ 0 ~~" E $ ~ ~ ' ~' ~ ATTORNEY FOR PETITIONERS
19th FLOOR
1635 MARKET STREET ~U"~ r _ ' . _; _~''~~,"~~
PHILADELPHIA, PA 19103-2297r'=' " ~`> ~ _ ,. ` ~'
(215) 567-3000
hocks(a~lundvlaw. com
~ ~~ COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PA
ESTATE OF DAEKWON SHEPPARD, A MINOR
NO. 09-4141 CIVIL TERM
AFFIDAVIT OF COMPLIANCE
I, Sharral Hall Mwangi, hereby state and affirm that I have complied with the Order issued on August
5, 2009, by the Honorable M. L. Ebert, Jr. as follows:
1. On August 21, 2009, the sum of $3,661.33 was deposited by in an insured, interest-bearing
Certificate of Deposit, No. 2055017541, in the Sovereign Bank pursuant to the Order of the Court.
2. The Certificate of Deposit, No. 2055017541, is entitled:
Daekwon Sheppard, minor, not to be withdrawn until age of majority
3. A copy of said Certificate of Deposit is attached hereto.
I verify that the statements in this Affidavit are made subject to the penalties of 18 Pa. C.S. §4904
relating to unsworn falsification to authorities.
f, , r
DATE: March 16, 2010 W ~/n
Sharral Hall Mwangi, arent natural
Guardian of Daekwon Sheppar a minor
IW4V.i~ YV..
.:, :.
~- ~ ~r:: overeign dank
., ;..
Certii~icate of Deposit Receipt
Addition to Principal !Withdrawal from Principal Transactions ONLY
This receipt is issued to:
DAEKWOI~ SHEPPAitD 4tIlr'OR
NOT TO BE wiTHI3RgyVN UNTII. ,AGE OF 1~iATORITY
825 FACTQRY ST
CARLISLE PA I7Q13.1352
The account evidenced by this receipt is subject to and further explained in the terms and
conditions as contained in the deposit account ag.~ement and the ccrtificate of deposit disclosure.
~~u~ollar Amount
Balance before AdditiontWithdrawal 53,661.33
Addition to Principal gp,pp
oa
withdrawal from Principal $o.
Penalty Amount ~~~
~~ ~'4B grace aer+oa.
New C$rttlicate of
A~ t Det i!s '•
.4ccount Number. 24 X017541 IRA Account: ^ Yes®No
Date Opened: 0 !409
Term: MO':'dTHS
MCY Date: 08:~ 1/2410
Interest Rate: 1,3g
Annual Percentage Yield: 1.40
In~erest Disbursement: MOhTI-II..Y
Interest Payment Frequency: ?vI(3NTHL.Y
Et~ortiva fJt0/02
This account is not negotiable and net transferable.
~uN f ~ zoo9~
LundyLaw
BY: HERBERT L. OCKS, ESQUIRE
IDENTIFICATION NO.: 04137
19th FLOOR
1635 MARKET STREET
PHILADELPHIA, PA 19103-2297
(215) 567-3000
E-Mail Address: hocks@lundylaw.com
ATTORNEY FOR PLAINTIFFS
COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PA
IN RE:
ESTATE OF DAEKWON SHEPPARD, A MINOR
NO. ~ - 41 y 1 Csvi !`~-m
FINAL DECREE
AND NOW, this y of , 2009, upon consideration of the petition to
compromise a minor's action, the proposed settlement having a gross value of $6,500.00,
is hereby approved, to be distributed as follows:
TO: LundyLaw ~ $ 764.19
(Reimbursement for Costs}
TO: LundyLaw 1,433.95
(Counsel Fee)
TO: Department of Public Welfare 640.53
(Lien of $1,001.00 reduced to $640.53)
TO: Daekwon Sheppard, a minor, to be placed $3,661.33
in an investment/account authorized by Pa.
RC.P. 2039(b)(2}, IN THE NAME OF THE MINOR,
Which investrnent/account shall bear the notation
"not to be redeemed or withdrawn except for renewal
in its entirety prior to June 29, 2015 except upon
Order of the Court."
Total $6,500.00
Sharral Hall. Mwangi, parent and natural guardian of Daekwon Sheppard, a
minor, is ORDERED and DIRECTED to file an affidavit of compliance regarding the
opening of the restricted investment/account with the Clerk of the Orphans' Court within
thirty (30) days.
BY THE COURT:
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