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HomeMy WebLinkAbout10-1977e- 2010 MAR 19 aM 1: 10 'Lj rr I I;',y, ?H IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: SHENDELLE L. GLEIM, ORPHANS' COURT DIVISION a minor Docket Number: I Igjj a',v i t Tem PETITION FOR APPROVAL OF SETTLEMENT OF MINOR'S CLAIM Filed on behalf of Petitioner, Safe Auto Insurance Company Counsel of Record for this Party: Jeffrey C. Catanzarite, Esquire PA I. D. #72765 Summers, McDonnell, Hudock, Guthrie & Skeel, P.C. Firm No. 911 Gulf Tower, Suite 2400 707 Grant Street Pittsburgh, PA 15219 (412) 261-3232 #17508 f qa. 00 p(s ATT"11 C092M8o1A 0*X91'78 I IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: SHENDELLE L. GLEIM, ORPHANS' COURT DIVISION a minor Docket Number: PETITION FOR APPROVAL OF SETTLEMENT OF MINOR'S CLAIM Petitioner, Safe Auto Insurance Company, by and through its attorneys, Summers, McDonnell, Hudock, Guthrie & Skeel, P.C., and Jeffrey C. Catanzarite, Esquire, files the following Petition for Approval of Settlement of Minor's Claim and avers as follows: 1. Scott and Brenda Gleim are adult individuals currently residing at 65 Hays Grove Road, Newville, Pennsylvania 17241. They are the parents and natural guardians of Shendelle L. Gleim, a minor, who was 14-years-old on the date of the subject accident. 2. On or about November 14, 2008, the minor was involved in an automobile accident when the vehicle in which she was a passenger was struck head-on while traveling west on Pine Road by a vehicle operated by the tortfeasor that failed to stop at a stop sign while traveling on Burnthouse Road. 3. As a result of the accident, the minor sustained a head contusion, right elbow abrasion, and a calf strain. 4. As a result of the accident, the minor was transported by ambulance to the hospital. A true and correct copy of her medical records from Yellow Breaches EMS are attached hereto as Exhibit "1 ". 5. As a result of the accident, the minor was treated and released on the same day at the Carlisle Regional Medical Center. A true and correct copy of the T I minor's medical records from Carlisle Regional Medical Center are attached hereto as Exhibit "2". 6. As a result of the accident, the minor was treated at Carlisle Pediatrics on November 20, 2008, with a diagnosis of a calf bruise. A true and correct copy of the medical records from Carlisle Pediatrics are attached hereto as Exhibit "3". 7. Mr. and Mrs. Gleim have entered into a settlement agreement with Safe Auto Insurance Company, the tortfeasor's insurance carrier, and have agreed to accept Safe Auto's offer of $4,000.00. A true and correct copy of the Release executed by Scott and Brenda Gleim is attached hereto as Exhibit "4". 8. The Petitioner has investigated this matter and agrees that compensation in the amount of $4,000.00 is a fair and equitable settlement in light of the injuries sustained by the minor. In addition, it is hereby averred that the settlement is in the best interests of the minor. Furthermore, Mr. and Mrs. Gleim are in agreement concerning the settlement offer. Based upon these considerations, it is Mr. and Mrs. Gleim's opinion that the settlement is in the best interests of the minor. WHEREFORE, the Petitioner respectfully requests this Honorable Court to approve the terms of the settlement pursuant to Pa. R.C.P. No. 2039. Respectfully submitted, By: Summers, McDonnell, Hudock, Guthrie "keel, P.C. (y C. Catanzarite, Esquire sel for Petitioner Auto Insurance Company VERIFICATION STATEMENT We, Scott and Brenda Gleim, aver that the statements of fact contained in the attached Petition are true and correct to the best of our information, knowledge and belief and are made subject to the penalties of 18 Pa. Cons. Stat. Ann. Section 4904, relating to unsworn falsification to authorities. Furthermore, we believe that settlement in the amount of $4,000.00 is fair and reasonable and in the best interests of minor, Shendelle L. Gleim. Date: Scott Gleim, pa ent and natural guardian of Shendelle L. Gleim .. _ k 1 l Brenda Gleim, parent and natural guardian of Shendelle L. Gleim #17508 2:27°M AMBULANCE B?LLM Nov. 11. 2008 12:18PM Pennsylvanb EMS Report 1 ?1R0 D No, D625 P. 37 :thrift Name Bwh' Umb Newt & No. PM NG. Dale Y lw_ Y anwhwEmx o1 X310110 BODII27 11/lU1At11 bdiaft Lnad8% libmick"ft a bulgy 12lr P8A! Ldd. Ne. PineIIAMOmmakmcwAd Diclo.vo IDWAri?,,17065 ML11419 Ir Caa6tk Rslpold us" comet ymbblNew y akim c Ol 1Lawy Zak 8 110616 Ad w# 69 Hays owe Rd C ill Ong, C6tbfnc S 16497 lama $ 042991 o C 13 KW 09 Oq Sate zip , a ?„ Netrrilk PA 17141 C w p feanoak l ; 4 Yfm 17/llA9l3 (11 77f6 6/91 7? ON .em w P • W Sm Pe, PL wdril 911 Dlay.lelf 21:13 lyWW60 11:1] eal.naiertfyaiei?f at..a+. AaHeaw: 21:18 Cmfacl 21:19 1nuesnlsg Anlat mhb Audit os 0111 oa,%Ww DOL IN 71675 71691 De?etl8cne 21:41 ArdVe 214 Atadnbb 22:13 OLACMe ME" c"Man a1C IJdae 5f QYetlerc ?? •? Noll kaco to aill?l dde ?ivAeed, tlRk brrer yido, rbrar?o. b,iApt eDew cmrw Mein: >tona ade)a mm PAM AWM Uva of Cmudsmmeu $Pew Nsutrado?ltstl ,t k%, Yesperaplra & COW p Cmamlow p arlo•aed: s p cote" p xoaa.*I•:a 0lby 0 ruk 0 Maalad 0 ,Aloft ? ? > t ? Iininhs ? Nte tame O Mow ? Pak ? QYMp ? i4t wile 0 cmiatiw ? saw ? SWNeck ? '9Vo1ma<+ [] D4pl.tedc ? lhua A ? Ydln. ? C-bud C) AbMW 0 cfft ? Neck Pain ? Daq 0 Alko. Cl Ofm %mwwow ?Kyda" n ?UAtW 0 OPPL-60ak-U ? I.Aira ? Agbo* Fad l D oV - L 0 It 0 O 7YfYa ® Gaol o cold O ROPIMI:07 fartaule Cardlnrucatlar Papal l?lr 0 X.C" bj* l 1t PJ Psa x ? A9+ray Pdamk Pawed 0 p chat?aim p/ No cwaN w L k Sim _ ? : L RQ ? Sytma idrA Abefs ? ? m ? s wde: _ > M Da16k VWm - L ?R? [] Latorae . Q O ? cAOawu ? l.tcasiaast a9.ted ? t wow-tic - LORD (j il.eaetlow blattdr4od ? ? ? ? 0 Hufi>,s lined CIO Bars o fepl.el ? sailer Whom" ? 0 o DWI ? M adtla W Si * DD ? Naeetrl adatj M-kWA DO ? JfA.vy ? ?• , m xWwaalre 00 Pg.- LORD c"O Rhmm ? ? Ddc6.f?e- l.plt? lea.weAfasm111f? ? A p No Ca Wbid ArPMOio C] ? ? aP All„ ,? . ? a FVO&divo.* 0 late Yee O ? Nteel cm0gow 7uml © No cagbw ? Nu"Dm6 ° ? so, n-w ? Nos& DwIatlo. - L 0 R 0 L ? R? ? DoWng [] gwdb@edcm ? ND ? 1 . ,. 1), Received TImCOIN ov, 1?PM No. a1Mys/xepaaluaa(t: 19 uw, life. • eSLImI i Pmvldax Pnsw I at 3 O O I-A w O W W 2:27°M AMBULANCE BILLING Nov. 11. 2008 12:18PM RO ?. p O Arer(e) Sffscbd ?WQ ?RVQ ?LLQ ?? [ sa ?Ph= ? oadlo? (] morel ?.mde J1tiei.t biAMW- No ® Yom O TWdr- No M Yw O q amk.l ? ld=hlal p »weigs ? "Up O bd Raddicwq - No O Yee O No. 0625 P. 38 p r,. area D ua•Ky .? ha? ? r+m p air La wmac ? Raandem ? r*Y Told oftM - RKUMidee D No ONOW" LA RA LL IL U U LL Rr. 00 0 0 IV. 00 00 ?L7 a o PWlW 00 00 PAN 00 0 0 a1cm ?'D 00 Wpvdwdve 0 NoCMA-:a Ovadmd Blades ?D""p r'".!- N. O Yet O 01M.lde r rte. _ WCA _ ?PGW MOVMMW Feel Had TO" _ Narrative min p P•n• ? Ta?ooi?NeE'•?o Dispatched for MVA in the vicinity of Pine Rd, and Burnt House Rd., Dickinson Township, Cumberland County, 17065 Advised enroute of two vehicles vAhh one overturned, unknown injuries, Co *mad by chief on scene that accident was on Me RdJMountain View Rd. AOS to find 4 people that were in the vehicles at this time of the crash sitting alongside the road in grass. One St1V overtumed,'and a dark green satum with extensive front end damage with air bags deployed. Only two of the occupants required medical attentlon. AN occupants of vehicles stated they were wearing seat behs. HPI: The first occupant (14 year old female) had a contusion on the right upper side of her forehead. She stated that she was wearing her seat belt and in Ow front side passenger seat when the vehicles collided. PE: Patient was a 14 year old female who was conscious, alert and oriented X4 with a natural patent airway with good respiratory effort. Skin was warm, pink and dry. PERL. No JVD. Trachea midfine, Patient had a contusion on the right upper side of her forehead. Patient refused to be put on the longboard, with CIM and C-collar. Patient denied any chest pain, abdominal pain, neck or bade pain. Patient had equal strength in tipper ext ernMes akmg with good movement In lower mtremitles, Padenl complained of right lower leg pain. Nothing was viable on right lower leg and patient did not eornplain when right lawer lee was palpated. Accessed patients vital sign& co 0 N w 0 N kh t.? W TIP:PaUent walked to the ambulance. Crew assisted patient to apply an Ice pack to her forehead and also Ice pack to right lower lea. Patient was placed on bendb and secured with safety lap belts for transport. Padent remained stable throughout transport with no other complaints. Monitered patients vital signs enure to hospital. Patient also signed refusal tM,7 nt with a Pwvjda ..•o ••,j?1M Q c?2:DBPM No. R Received hl N ov, s •9 pus: 2 tsw 1?spmeoo?c)194 esau-?ama. M of 3 pen"yh+'mdjL + MS Report pan. 2 ?.? Nov. 17. 200B 12:18PM Ati^3CLANCE BILLINa Pennsylvania WAS Report No-0625 P. 39 3?cNee NIA 1)011 l?k lCR Na Dtls T016W Alto" MA Inc. 01-1101101 1001127 1 U[1/2D01 lrtla d Name DNe dth7s 1led.l 9ea+Hq IWuoMr PSAP 8htaddIv Okim MOM - o1o[S[?l9 longboard, CID's and opine collar. Patient was transported to Carlisle Regional Medical Center and met by parents Ih ER, Second patienla PCR to follow, Pedants parents signed release form- Both patients were placed In ER room 1 and care was transferred to ER nurse. EON KAK 110846 ARM" : 1 .: 6: 1. , j 1000 Nash 0 31: 31:11 cad E-- Cl 1: U 16 100" U• mor k T°?0 21:53 N 16 1006® NMMI Receiver -i ec o v' ? 1."4' ; P.M., NNo, j?i7.?w.I„d OQ 0 N N v W W ri' j 7.Z I V AMBULANCE BILLING Nov. 17. 2008 12:19PM No. 0625 P. 44 ?06110?7 Yc11oK urteches tbs. blc •233 Mill Sljcd, Pb- Box 106 Mt. Holly Spemp, PA 17065 Patient Refused ot.Serniceg Th6 is io ca* &a n is Mfasiug (?it?clc oue; Tircatmcnt Tian port Other K ??,? ??a • ? ?olrkd?e Wert Ihtvobom7o6oenrodoflbe tiie?(s) lnwlvddaodLe?e't~jr ?YdlaMl "Mftbw BW• UL °°?*Mdi), tea). tba aa*ulmw =via% tic m du al wwm aqd • Phnid?eodtbs?odWtoome?ood'6ciliAy?+omell spode jrfi?r?rideIS tsw"woay • , : ?t $oca?tbis ?ioo. ISano aLo bocayco?rided vid?Ydlail?rHtoa?rs Iib(S,1acl+Iotion of ,Y ? p+Iicsi oe?..I oodtutaod teat nq upffia l l" PC OoW in6oci?tanaeay bo dwad by . apaaboax ?pct?q, t +? 7? 4°t?t+oR, PaYa?out auJUocLoal?+?wto I xq? WmndcuvM bopw6mW and tbraUb"t6 't9"Fc4; &o si*to aoas-ltatiaot; the ab?i?jr ?o aaoas and ' - ?plr m0?1?oiodloulodooo?ltoq; ?+?iclf ? Mm?ood,m?r io6otaoatlon? aed the optionto ioquast - 0f ducb=Vs; jan tbo %mks aad =Wk&m grit de nod= a *tc i7ltQl:?=, Dato Dma,?_ Blp: -Palso: Rasp: . •Tima?, B/P' _ " Pb1ao: - Reap: AVkLl bOB _qa_Sociial smudcy0 • - ? A11agi?s; - Received Time Nov.17. 2008 12:08PM No-0075 ?ipO D, E1lpAA FORM 3 CARLISLE REGIONAL MEDICAL CENTER Page ] of 2 AT O ON FOR RELEASE U E D ISC S OF AL INFORMATI N Paliant Name;t'/?d1 e ???' ?t°- !r7 Date of Birth: ? X11 Aare": Fax Number phone Numb: SSN: -J.3--1f'Sl MAccess Reiff to CoWinspect ! authorize the usa/dseiosure of health information about me as described below. 1 The Io1M*V orgpnizatlon is authorized to make the dis *". e: GtrNt e -y- Name of rwwiy Address 2. The" of inbrriation to be used or disclosed is as blows (Please include data of service) Date(s) of service:. , Nd V ?!?? ply r 1q, .too B -to r rat f n t CorrtpWe )medical Record 0 Abstract of Medial Redid (H&P, Discharge Stmmary, Gonoualtellon Reports, Operative A Procedure Reports, EKGs, Laboratory, X-ray and imaging reports) D History & Physicei (H&P) ? 01801191,98 SUMMWY Report 0 Consultation Reports 0 X-ray and imaging reports O progress Notes Laboratory Test Results 0 irrrnuNzation Record [? other- list specific items: Behavioral Health Reports: 0 Social History B Ghent Date 1=omr ReferrallTmabnent Form B Admission Evaluation NotillCation of Admission ? Trea trnerd Plan ? Academic History ? Aftercare imtrudlom Psydtotogical Evaluation D Other - list specific hems= I understand that" information in my beaith record may include information relating to sexually lrwoniBed disease, acquired immunodeficie wY ayndrane (AIDS). or human imm>nw10111ciencY virus (HNC it may also include infamation about behavioral or mental health services, and treatmer9 of alcohol abuse This information is being provided to You iron records wtwee confiderfalltY may be protented by State and/or Federal law 4 1 understand that your fWAlty, may «xeive conPmOtion for medical record copying In wxrdance vAh State law 111PAA Form 3 Vcniun I 4114!2103 Form 3 Authorixmiur, -0,'- 1 7St'W it HWAA FORM 3 Page 2 of 2 5 This information may be disclosed to and used by the following in6viduallorganizetion: ? ? S rP r /y,-1 ( C? ?.if? -r?°i_ ??„a4.rvtrJ' Act lir rtf??4tk tC Name: ! f Address: For the purpose cf: ? Further Medical Care ? Insurance EI'gibMbylBenafits Q itupet:tion/Copying of my records liff Legal lrweatigation or Action 0 Personal ? Changing Physicians ? Other (please specify):- 6 1 understand I have the right to Inspect and obtain a copy of my protected hearth inforntetiion in the designated record sets you or )our business associates maintain. I understand however I am not w0ged to Inspect or obtain a copy of any psychotherapy notes or aryl information compiled In aruictpOW of use of or fv any olvil, criminal or adrMnistra5ve aetlon or proceeding. any information not sutlect to discosure under tine Cynical Labomlcw Improvernenls Arnendmnrts of 1988. (42 U S C . sKWn 263 (3). and ce tain other rec3rdr 7. 1 understand that I may refuse to sign this aWXff Mw and that my refusal to sign will nat affect my ability to obtain treairnent or payment or my elglbatty far benefits. I may Inspect or copy any Information used or disclosed under this authorization as described in #2 above a I understand that the information disclosed pmuant to this authorization may be subject to re-disclosure by the radpient and no longer be protected under the terms of psis authorization 9 1 understand that I may revoke this authorization in writing at any Urns To understand that if 1 revoke this auti?orization. I must do so in writin5 and present my written revocation to the Health Information Management Department. i understand that the ravocafion wall not apply to infoanstion that has already been released In response to this authortzetlon This authorization expires within 90 days, unless otherwise o Patient DeW (If signed by person other than the patient. state relatiordi p and authority to do so) ? he 1 lc L -?1e r n'_ Name of Phtien (Please Print) Patient is: Minor ? Incompetent ? Disabled ? Decamod Logan Authority: Custodial Parent [I Legal Guardian Powar of Attorney for Health Care ca? sw w . Cj ExecrAor of Estate of Deceased []Authorized Legal Personal Representative -Q Date i UPAA Form 3 version 1 4!1412003 Fotr.. 3 Authorization GRt?tE ADMISSIO rfOfC; RECOR i iM MMraq/M /pfd IhN CrNW. PA f101titrftf {Tti? ?IF72t2 9418074 000075817 A 11/14/2008 22:08 0000 E1 F 14 12/15/1993 F 1 S A T 1 GLEIM, SHENDELLE L 195-74-4561 STUDENT E 65 FLAYS GROVE RD N NENVILLE PA 17241 7 US (717)776-6691 CUMBERLAN G GLEIM, SCOTT L 65 HAYS GROVE RD OVER ECHMETSBURG NAVY DEPOT BOWYER mm U 194-42-8331 CARLISLE PIKE (717)605-3595 A R NEWVILLE PA 17241 PR= omm MECHANICSBURG PA 17055 A S (717)776-6891 FATHER RESP HIWKY CONTACT NAM! not In Iwj"IpI/ ! MLAT I HEGGE, VIRGINIA (717)352-2637 GMTH o'' M" OY 3" Y RMW 1 -.? 640 RMOORT"O INS PO BOX 2655 N HARRISBURG S U Z rxm &w. WMWIJM? R A N S FAYM C E m CLOONAN, CLIFFORD C S C MVA--MINOR INJURY COMPLICATIONS 1 PRINCIPAL PROCURE ATO 58378775650 -02/]4/1951 =ffle SCOTT L&BRENDA L PA 27105 uwuwm? NONE ROSARIO, ELISEO oll INO FAULT 11/1412008 tfiMTt=D (? /47)lOT4 MEDICAL RECORDS COPY 1?? Rri rtaf wnv , n - - - -- 1 In:11f14/MPres Tima:22:08 PM:9418074 MRI1:0000756178 Tristan, Thns:a;08 Trig Nab; ia! GLEIV. SHENDELLE Anivai Modal BLS T: 96.5 PO 7F. A MUNT SEAT P t3E 14YRS DOB: QhW19% sex: F Wt:lbs: 130 was: 59.1 P:80 Regular H AIRBAG DEPLOYMENT. R; 18 Urhlabored MATOMIA TO R FOREHEAD, R :R03ARI0, ELISEO BP: f 40A077 ARM ABRAISlON, R LQWER LEG :'Ci.00NIAN M0, CLIFFORQ C FAIN f C=Ph** MVA--MINOR INJURY 02 SW:100 % NL / hypo Pain 1 Locadon: 81MUltiple Amas 4'" Laval to 1-3 elements ??"! 4 ¦ 4 elements Level S ; 5.lermarkts G U Translator Souroe: ty spouse EMS neg. Notes Re+riacw ........ home.. other: ............... ............ intaxtcatad ..................... Ltd By. poorhistorlsn demmhte sivafity hearing ... tat: min XwP days wks nwhs ago Mrily: mild Aill ?a& 110 current 110 max e Of 1/ehlCla: buck( bWibkydesmoped ..................................... 610Mde aUb Vspod . e of Collision. injx shoe vehicle: feW asleep / lest control of IrnPW'from back V9 left Position In Vehidn,: driver passenger hunt rear is Damapa: a Iow Sprats high - mWmai / modaroa / severe Cory at sane n,iecl.d exhicated assisted oul of vehicle tatafilles anon pal neck back: upper / middle !tower dmat abdomen u / left hv?. LOC ? 1 min remernbsrs impact / Pwsonnd ri?? / remains Misted S": dyspnea k--- h v /..;.?1............ ?orJit,- lt• Mr.r- t.Iz.-.......... ?oel A tt rY "+e??1e. Irk M r a&~ 40"fl.d? 44 - a molorweakness: V1Iloft parasthssi.s dpM/left V 1 #- (7-* F_ L,.? nouseelvomitin view t p ' e a hieeraYon(s) ???JI ?/ r rL?(M?K R+M? 0S: Level 14 =1 system Loft 4 ¦ 2-9 system s L&M 5 f 0• systems w Fsv denerN N ENT -1,01"" + canowwaarular Gsatroko"aw Gonftutinary =0 L parRTeas of Bnasih -Ag"sP ofn Y Van Dysurts eral wsawness Dryness Polyurea Diplopia 0 EPfsfexis Aud" camp Congesllon H A1411111010r Bolin Pa Y CIlltkm Frequency Vepinsl Bleeding Palydgosla tching Nasal DrafnJCorg. anoptysts pn D as R"w Bleedng Vaytnsl pttcwge Black Stool Penfle Dlsdw" Recunerht fNv ----- -- ' ">?ruriBs HIV/ AIDS ? s a s n NOciffla-in F ass-RL ,qo"V. ,,M tfalwrdnstion Lesbns Anaphylactic R%n unable to obtain due to. ALOC acuity P?s?estllli?s Insomnia sn"ng dementia pow historian Cerri?(Ot(- Stress Bleeding intoxicated st FaMi Social Hx: Level 1-3 - none Lewt 4 s 1 aee?iom Lem 6 + 2-3 sscUons Medical Past Ham ' Addillonml Past Medical History: NKDA Current Medicstions: NKDA Pss1 Su4cs" Matoq: None CASG AM Choty TBHJBSO Other. Family History: Nep iwe CAD / Mf DM CA CVA Allergies: Opiw. NKDA S ocial Hist r?D / N 1 Quit living M / 8 / 0 / Alone ReWoducII" Flistory: G,„ P` A_ Last MenstnW Period: AtcohoL Sodal / Heavy I Alwhofic Menses History: Regular / Irregular j Post-pwWm / Pre mensrch Strbstenpe Abusl.-V I Y : lap Tetanus: 0"W . ft lcal JExlttlt8' Level 2-3.2-4 systems level 4. s•7 systems Laval 5: B+ systems ' aidiestes system a WRIned and negative General: Distress: lid moderate severe wet nourished no evidence of trauma 9 4',,. «?/.l, •?, amcfknkrs ciXfk abase ddkhaveW d??draled dhrw illness nay. pt. malnourished '02h 'r ? av RENT: NL' NC t AT NL `i6y,? L!f'SI1 b n.•• grT7 _Aga ??.rr /.rat -04f ?/L rrCy /+y sinu C ?! r s Ivry: 1 L frontal: R / L nasal drainage: dear / purulent ear canal: R / I. erythema / obscured TM: R / L erne budging J•+?I ? P"ted E ynx: erythema abscess otlcar l ` G RAL NL kw yes. ? us R Puc7 P Pk?P? m / rap.. s?It ? mm _c`onimcWa: h%IMW / drainage R / L other ut. ?G+R 4,.Y j Name:Q( FttE Carlisle R Ions/MediCal Center Data M: t tn4rmoe d Lft XWRI: coot UnW2.3: 2.4 syswm Level 4: 6-7 s :OOOQ7l581T8 Poa:W16o74 ttfsci: . ystsma Level S: t1+ e Nl. Ys?ns NL• Mid indkoft system examb" and negative mu¦ore paJpaden: R / L G.S I'! •• craw set wa? non- tender I0 Patpa6on: R / L limited / Dakrlul ROM n: IL s4eous CV.••no emphysema other. I NL Pulses, NL PUiSM Me 4P diE bradyordic dl ardent R ""ular rhythm extra systoles murmur /t3 syatofe/dl"We s Ll I ?Ir?G •+? 4 car"d far+" dorsahs paths radial ukw Other. ?T/u i G ??'av NL• no respire sounds ernaqus! / Oecreeaay sow* oracdtlea wheezes rates rhonchf rabored suidor re Abdomen. MV tractions cnttyns stokes other recent NLtygulag negative ocse 8S: hyper / hypo / absent gu tender m Pu no slsatiJc hems.,?0??td I SF «" t Mlwwt( fink., NL• M AT Nf R/ T es,; bony l r wJdge` d?orad furt s t c?i o0ocyx 1110rtanN7e4 robs -. R f L SSUftn:1 R l alerts hlpa non tender ltdrr: NL ROM: R l L other: warm dry ootw NL no rash /v( C.."& -L-V. (4w hot coW d4ptwabc cyan t: pallor edam mylhama eoch C.P Mevno: NL' > oth?er ?4C motor Is aim Mid eomnWait pbWnded d ? e?na L DTRS eymrnetric Psych: NL' affect NL behavktr N! S other ?'lXtis anxious hwAa Qat affect E reseed n °? 4L et.' ,r r- Id OU: contbatsttva psychosis othar --------- ? jt 0-0 ML• ext ganUW NL no urethral no lesion no edema deferred urethnt blood other. GO MU.-MMM Call Peckkn Maklna? L?IaC A¦Agraskut EeEehwnej. NL / except NL / except ++? ALTAmy_ Trmp_ PT AST Lipess CKMB INR Other i Prooeduns: UA: ML / except YVBC LE RBC- Blood Pray screen: rrkmlaerum: n" / pod TO screen: nap / pas EKG: nog / nos C-Seine: InterpraNd by EDP f / 2 / 3 Views nog acute - other: CXR:- interpreted by EDP ^ NM NAi _.Ingtrete Abd: „ NS8GP - obstructlon head CT: -•...-wr w?rrw f/JIt?. - Time: . Disc with Dr, a I ro*ww/ Mads: wilt see pMient in of s...._ Whit - see in consult ?'? p ~? a e. e+ era at. Thee: Improved / Worse I Unchenged Time Disc with Dr. fVF:I - Time: improved 1 Miles I UndwVed will -See patient in Mbca? admll, sea in consult O Pariah re-examined OCNtidai care: 313 74 minutes / 75.104 minutes Mee procedure rote ?$ee addendum Clfillcal Inteliaas?el, r n..V Dlsahsr?' a Psych Fee Jap 3. C&I r- j Admit: F PCU Obs OR TaI& Psych Peds pOrders written 4. Transfer: Faeiltty: Rev Physlofan 5. AMA LWOT DOA t` Whd OTmww forms ownwed Co WUMStabts Satisfactory Improved Critical Guarded Errrargant Non-emerge Fobw O P s ption(?} iven; up can discussed with: sp p? ouse oter. h -- b? Additional insUuctions: „ QED Mew In_ dWa} 0 AM ti+pneelrea' PAIARNP e+a- ED C MDNO t vs?we.lrrrrc?,r+¦+e+enrr+es.,arw. ORDER ,PROCEDURE FORM 2HEM E -K EMERC3FN0' g date !n: 11/14/2Qp8 Time. LaboraMary 7ee1t or (sa."Oroleni rrevrous Msdlcal ReoDlda P+>? Therapy - Eva] d Tx A"J": NPWA fi3o ame Moth x0m / Dospe / Rage 0 13 a KV0 DrAce: lV F{Ad; "Gcwum I Nwsh% AsRlatuta CarJlsle RegimallNedlca/ Center t4mfie:GLEIM, SHENDELL$ P:9418074 Age- 14YRS we: 12/15/1993 sex: F kM.*0000758178 EDP: •CLOONAN-MD, CLIFFO( PCP: ROSARIO. EUSEO -- _ _ Olhan ONVINOWNG Taab - - •• -? am law Reasssesment improved O WOMB (3Uncha" tss S 0 improved p worse ? L%dw sd impro?ed p Worse 13UnchanW RnPmnrod ? worse ? UndwVW irW C3 Worse -'--- -- - D Catdlac Monitor Rate Rhythm p Spit Application 0 map ttAcwbf p Pulse oxwetry ? Ace Ba ndaQe Appliostbn p (Cold). (Mac) Applcoo n O S11% AppNoaUon (3 C-Spine Immomuzown ~ Oresw4W ? Fore4P Body Remoras D (Local), (Replonet) Anesthesia ? Conscious Safttion 13 Laceration Repair O Cast Apptlutiort El Fracture Care (open), (nosed) X14 ENCY DEPARTMT O_N_O1NQ,FS/MG M JESSMENT DMIC 11114/2008 -Anxiety Ineffective CCaedlac Ou A D ae?M&W >i? -Comfort. Alteration in ,Odw tea. ineftcove Z?krid Volume. A temdoon in Oas Exchange, lmp*w Myperthermis (Fever) no wt M.i +rn O Fs REMOVAL OSLEEOM CONTROL Q PAIN CONTROL O ALLEVIATE MV M FEVER CONTROL O DECREASE AW R7Y O SAFETY IN THE ED Carlisle Regional Medical Center Name-'OLEUW. SHENDELLE P*9418074 AUV 14YRS WB.12115/1993 Sex:F MRN:DO00758170 EDP TLOONMLMD. CLIFFOF PCP: ROSARIO. ELISEO ?1n1?rY Potential 1GtOwieeige Defidi Mobilty tmpalred -Non-Compliance Other `akin Intoprlty knpakment -'rieought Processes. In"Wed Thought Pmeeseets, Alteration in -Tissue Perk aion, A teralon in Noe no Ibt Q 1MMOBJL12AIMNI PROPER ALKaerhlENT Met me km IZ IMPROVEMENT OF BREATWNO Use Inl d bECFtEA ? t PREVENT SWELLING O STAt31L1TE PATIEW tH DISTRESS O &%MAIN STABLE WWEEAT StS On" OMRONAW.MTAL NEEDS Q MAINTAIN SKIN/ TISSUE MITEGRITY 4 meet PSYCHOSMtAL NEEDS Q PREVENT FURTHER INAIRV O neat SEW CARE ABILITY NEEDS O MAINTAW I MtPROVE CIRCULA71ON G Meet EDUCATMAL NEEDS d INFECTION CONTROL O Oaw Nit N r domawtation in rxxaq rm". ether •toose Per }tippet Peft, Tbw i Rasisaesanlerit ;3O pr. 'Rcrv,,M3 t.n -V% SIPSture ITkm I T I P I R U SP li t 1Eeraea1s1 INonibr L IDlsdrarped in extra of: o? h b o w/C 0 Stret q Carried Diediarge Instruolions given to )wverba&od understanding Admit Room 0: to Dr. Ready for Room Time Report called at and given to to o Transfer Vermed 1Raport celled at and give, to O Left without vestment p Left Agskmi Medkal Advise CMUS5011 at Disposition: 41nIPmvedWeta`bie Merious tat:apkad Pain Scala: T• o Pain Location: spit,, Patient reports that pain is: Proved O Unchanged O Worse-?- t3 c- Disposition Mimic T I a P 90 R _?JD pp '!Z J72- O2 j2 Y DEPARTMENT PE_ DIATRID NURS3 AmSSMENT Date IRA 1/14/2W8 Tune: -47-10 "faliwe Notes: rain oPatent denies pan Carlisle Regional Medical Nan"rGLEIM, SHENDELLE PO:9418074 Age:14YRS DOB: 12/15/11993 Sex: F MRCOOOO758178 EDP:'CLOONIAN_MD, CLIFFOF PCP: ROSARA EUSEO Location: rn,.L1 Ousilty:OSharp ODun OCrampinp OBwnnp OAChing O Mode of Onset: Q Suklen 0 Gradual 0 Intermittent WONGJBA1fER Fr Onse. Gate: Time: Duration: Onsets 24 hm. nreditrel attention was sought? CNo ayes Date: Radio", ONO Dyes Irseorrl CO-,iIKOW" 13MMer OFather OOlher: Ace mpan'ed by: &V M APPODWze: 0CVW OUnkwVI OOGner Aetlvfty level: Qllfiirake OPIaylul DSmites l Laughs Doom -"OW' w .fir rated OCCOPWRfivO OCrybg DLstharpi OFtestlese GDisodented Qllnresponsive Pupils size and roscilon: Skin: A** rim 139fr OC001 CIM018t 13Diaphoretia Color. 13 11* OPele 13Ashen OFlushW OCyanMic Ojourntioed Capillary Redd: D<2 Sacs (Nomad) 0s2 Secs (Odayed) Turgor: 0 Normal 0 Decreased Pulses: L Radial: ? Present ?Absenl R Re t: p Present DAbseM L Pedal: E3 Presets D Absent R Pedal: ? present D Absent Ahwsy: p`tsar 0Odor Effort: pdMabored 13 Labored OM14y D Severely p Retracborq 0 Strldor a Nasal Flaring Cough: O None 0 Productive .13 Non.Produedve Lung Sounds: Mlear OWhaezes ORhonchlOCreddes 1313"tshad oAbsent OR QL OR OL oR OL OR OL OR OL OR OL tirolaU and Davelopnwnt Weight: KG. Heigh ONEW BORN Asps - i mono OINFANT t - rt 1woom Language Rating Scab: RATING SCALE 6_ 8 t Er"'"Ment ON0 steps O Few steps O Many steps Nulritionalstatus; Wromnef 13Cadwtlc 00bese Reagious i Caiwml prof mnos: ONone Belt loam try. (pt 1 Caregiver) O Verbal OWWWO ORelurndemo Leaming Beaters: Abdomen: 0 Soft G Flat O Rigid 0 Distended O Non-Tender o Tender (Aroa) 8owe1 Sounds. fa Present O Deofe"@d O Absent Ellminatlon: O Normal OCcnsgpatlan Onjo rhea # ci Stoob: vaosg: UUMMnent Dlnoontinant DDiopw ClPotty trained CDysurla OFrequency calm Other Endings: Abrasions 1 Contusions Location: Size. Bleeding: 0 Absent a Pres*nl O Scant D Moderato 0 ileavy C PulsWng ROM: OWNL O0 Oft Edema: O Absent C 1+ 0 2+ 0 2+ Oefwmty C) Yes o Me Soars: 0 Yes 0 No Distal pulses: 0 Absent O Present L R in Head CUarnfarence: an Otkies Often OSmtie* []Coos 1Gwgles OBabbfes DE at Term:OYes ONo Ossvery: OVaginal OC-Section Diet: QBreafFeed OFormufs ": Uses: OBoltis [spoon OCnp EBminaboon: O 3 - B stools a day 011W.. Acdvfty: Llfls Mead: ayes Olio Sits UP: O*4h helP G >A OWW 11011) Crawfs. O Yes O No TeethinX 0 Yes 0 No Observation Of Interaction witll can gKw is OApproprlate US" Nursing Assessment OTODDLER Ap r-: y"re is Pro-School Av 7 - s Tana Languapr. I7FOW Worts OSenta mm q Easily Understood Diet. 1W Foods ORsgrdsr,Diet L7Pseds SO Uses: 13801116 E3 Cup Teething: Oyes ONO Elimination: 131 - 2 Stools per day OOlapars 13Toftt trolned OW0% bed: a Rarely 00c"aiorray OFrequenly Ac aviiy. Wailes: O Yes O No DWafks with assistance CMV*s Independently Observation of interaction with cwghrer Is O Appropriate OSes Nursing Aesessment EISCHOOL AGE Ass s - ii Yves 72 DOLEIfCENT Ass 12 - ra Two Reached Puberty: O Yes Olio Looming dlsab11lty D Yes $01101) gee; Oki: O Eats 3 meefsrday OEaling disorder, (apsdfy) Wears Braces QYes ONo? Elimfnetton: D No problem reporter! O Wets Iced: ORerely OQccasiortasy OFmqu*nty SOCIAI Habits: Smokes O Yes O No Uses Abohd: O Yes ONo Uses OrtW-. O Yes (]No Observation of Interaction With C"Wer Is Ap1)rW *te OSae Nursing Assessment Vital Signs: 22:08 T: 06.5 is: 80 RepWaA? R 1d eP: 140,077 Nkrrsb Slgntlturo:x1 oa . . WMIAL ASSESSMENT FORM Carlisle Regional Medical Center PRIORITY: 4 parent GLE1114, SMNDELLE PW: 9418074 Semi-Urgent D08: 12/15/1993 AGE: 14YRS Sex: F MRS: 0000758176 EDP: 'CLOONAN MD, CLIFFORD C DATE; 11114/200e PCP: ROSARIO ELISEO Worker's Camp: , ROerrS& ed: E MP. Prwantation Time: 22::0 Triage Time. 22:0a ArrhaN Mode: BLS Haight: . We19ht 130.0 lbs. 59.1 kys. LmP. Last Tetanus: Acc By: Mover Chief MVA-4ANOR INJURY Complaint V Sig s T: 96.5 PO Brief MvA FRONT SEAT PASSENGER WITH AIRBAG DEPLoyMEW. HEMATOMA TO R FOREHEAD P. 80 ROWW , Assessment: R ARM ABRAISION. R LOWER LEG PAIN R: 18 UnlabOred BP: 140/077 O2: 100 % RA NIGHT SWEATS NO HEMOPTYSIS NO Pain Intanslty Scale: 6 / 10 WEK iT LOSS NO ANOREXIA FEVER NO Pain Location: Multiple Areas NO SAFETY NQ TRAVEMVEO NO RESTRAINED YES DRIVER NO AIRBAG DEPLOYED YES Sudden Omer Pre-HOW16i Trastmad: Padlaft GAO App. for Ape • YES. Immunization UTO - YES. HdpM fl. in.. Hand Cira. - Grade • , with tilother Assessment: PAN N4dk3I NKDA History. Allergies: NKDA Medicines: NKDA Nurse Sipnskm ge 4 SEN Additional Noles: - Rev 05M 8104 Carlisle Realonal Mod" Center - Emwaewv Department Glelm. Shendelle 361 Alexander Spring Rd Carlisle. PA 17013 - (717) 96x1695 11/14/0810:32pm 768176 DISPOSITION SUMMARY Patient: Gleim. Shendelle SS #: CURRENT Address: City: Arrival: 11/14108 10:32pm Current Ph: Zip: Disch: 11/14M 10:52pm Disposition: MD ED: Jean-Paul Homes. MD PMD: Res/PA/NP: PMD Ph: Ox 01: Strain Leo (Not Otherwise Specified) ICD-9 #1: 844.9 #1 Dx Enal: SPRAINS.ESP #1 Dx Span: SPRAINS.SSP Dx #2: Head Iniury, Superficial (Unspecified) ICD-9 #2: 910.8 #2 Dx Enal: HEADINJ.ESW #2 Dx Span; HEADINJ.SSW Dx 03: Abrasion, Elbow ICD-9 N3:913.0 03 Dx Enpl: ABRAS.ESW #3 Dx Span: ABRAS.SSW a .. Follow-up: YOUR FAMILY DOCTOR F/U MO Ph: F/U DR: Other Inslr. Ice calf and forehead 30 min at a time 4-5 times a day, for 1-2 days. head iniurv precautions as instructed. MY SIGNATURE BELOW INDICATES: > I have received and understood the oral instructions regarding my current medical problem. j > I will arrange follow-up care as Instructed above. > I acknowledge receipt of the written instructions as outlined on this and any previous pave(s). I will read and review these Instructions. W ?ft the ohysicians and staff of the EmeraencV Department have made every reasonable effort to accurately determine your complete medicadw history, because of the binned knowkdae of Vouu, out-of-hospital medical care, and the creed to address snow' emmencV medical needs, we cannot be sure that a complete or tu#v accurate medication histw was provided h is fherefore necessary for you to inform Your prfnrarv care physician of your treatment in the Emewncv Department so that Your physician can proverty evaluate vow current medication needs. Age/DOB: Medical Record: 758176 X X zl2s-lr Patent or t Guardian ignature Staff (Witness) Slanature I PHYSICIAN OOC ENTATION FORM Date in: 11114/2008 Name:GLEIM, SHENDELLE Chief Complaint: MVA--MINOR INJURY Allergles:NKDA Medicines: NKDA, History: Alcohol Tobacco NKDA Wt: 59.1 KG Ht: ' " Head LMP: Carlisle eaignal Medical Conar Triage Priority: Sent-Urgent Age: 14 Yrs 0 Moe 0 MS Sex. F MR#00758176 Pt# 9419074 Wage m: T: 96.5 P: 80 R: 18 9P: 1401077 5802. 100% LDT. Imm, Status:T VA: OD OS:- PMD: ROSARIO, ELISEO Phys NotMW: EDP: •CLOONAN_MD, CLIFFORD C Exam Time: Time 2400a8t main Ordered Test It CC: to 2Z ABG EKG Pi: CXR ROS XRAY: Cec PH BMP I CMP U/A FH PT/PTT CARD PAN SH Preg CAS Exam: RAPID -A- AMYLASE HEENT: Chest Titt: Supine BP: P.. Heart: Standing 8P: P: ? Paged Dr. Time: Abdomen: ? ConsuR Dr. Time; 0 Admit to Dr: Time: Extremities: Counseling srnd Review of Dx Teat with 0 PUFemlly Neurological: ? Coordination of care Treatment: Pelvic: COURSE IN ED PROCEDURES Disposition: DIC Admit Trans Time: MOT AMA Re-Exam Time Acuity of D/C: Stable Expired DGA Coroner Autopsy Medical Decision Making: Referred to Dr. Discharge Instructions: Patient Request On Call MD Colaboraling EDP: Diagnosis; Signature: r PATDM CpNTACT MCORD Plea list die pagan f s) You w anld lice ue to conf$ct is ?e vvft Oft medical 1. NP?P to Home Phone: WO& Phone; cell PhwL. Pfoato, diacns? det n{7m fit; Yea 2 WokkPh6me: Cea phow. pto dim ofd scoonat Yeses No 3. Pebo v a sedderd of a md.S ..a • IfM nam ----Yee no „? I lava ?vod a s6at?eIlt of.Cbo Psti,t?' a Itf? ?md &,csga?'?es. - To pmtmt DeerPat? ' ' ot y? ?d?iali'ty, ?wdgeed t?° fie?oro?g PeV ? aa.WMnotbe C°? =Mbw him beam&sb. tb mar to Ow aftZ ad °r di?ose0d ?vi? an3?o (PeWand Eamon X=bca) ofP ' 0p Date (717) 249-1212 i{QdICA! C[ =k Ho t? ate O&xu t Racord) Y*UOw 0?.d • rreerc.• e>rTee Tit AArunOPr SAIIeP ROPe ? FA 1T016i/SP ? p1>ti 7121 t CONDITIONS OF TREATMENT AND ADMISSION PATENT'S Umn GLSIM, SHSNDELLE ATTENDING PHYBIC:IAN CI.OOMM, CLIFFORD C ACCOUNT ND. 9418074 DATE A TWE OF ADMISSION 11/14/2008 22: 08 CONSENT TO HOSPITAL CARE AND TREATMENT I AR . tNMUDW DIAG O MYSELF i FOR EMERGENCY SERVICES OR ADNIS910H TO THE HOSPITAL AND I VOLUNTARILY CONSENT TO THE RENDERING OF SUCH STAFF. ON THEIR DESIGNEE NOSTIC TESTS AND MEDICAL TREATMENT, BY AUTHORIZED AGENTS AND EMPLOVEES OF THE HOSPITAL, AND BY ITS MEDICAL STAFF, OR THS. AS MAY IN THEIR PROFESSIONAL JUDGEMENT Be DEEMED NECESSARY OR BENEFICIAL TO MY WELL BEING. I ACKNOWLEDGE AND UI NOEASTAND THAT MANY OF THE PHYSICIANS ON THE STAFF OF THIS HOSPITAL, IINCLUIDINNG THE ATTENDING PHYSICIAN(S) NAMED ABOVE, AND RADIOLOGISTS, ANRSTHESIOLOGISTS, 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 THEM CARE EVEN THOUGH THEY ARE NOT EMPLOYED BY THE NOSPITAL. I UNDERSTAND THAT THE EXAMINATION AND TREATMENT THAT I RECEIVE ON AN EMERGENCY aASIS IS NOT INTENDED AS A SUBSTITUTION OR REPLACEMENT FOR COMPLETE MEDICAL CARE. CONSENT TO FARMAN BUFORyATIOM I HEREBY AUTHORIZE THE HOSPITAL TO DISCLOSE TO INSURANCE COMPANIES, INCLUDING WORKERS COMPENSATION CARRIERS, OR OTHER PARTIES THAT TAEATARNT FOR ALCOHOL OR DR ABUSE OR DEPENDENCEU TOS•DMALL OR PART OF MV HOSPITAL RERDS AS RMNO OENEMTS ENTITLEMENT?AND PROCESS PAYMIEENT el Afif&AD Llc& Nru CARE SERVICES PROVIDED. MEDICARE CERT1119CATIOIN RELEASE I CERTIFY THAT THE INFORMATION GIVEN BY ME W APPLYING FOR PAYMENT UNDER THE TITLE XVMI AND TITLE XIX OF THE SOCIAL SECURITY ACT IS CORRECT, I AUTHORIZE ANY HOLDER OF MEDICAL OR OTHER INFORMATION ABOUT ME TO RELEASE TO THE SOCIAL SECURITY ADMINISTRATION OR ITS INTERMEDIARIES OR CARRIERS AMY INFORMATION NEEDED FOR THIS 011 A RELATED MEWCAAE CLAIM. I REQUEST THAT PAYMENT OF AUTHORIZED BENEFITS BE MADE ON MY BEHALF TO THE HOSPITAL OR TO THE PHYSICIAN WHO ACCEPTS ASSNGNMENT. PRSONAL EFFECTS AND VALUAIRES THE H0614YA MOT GLASSES FOR THE UNDERSTAND. DENTURES, DOCUMENTS` CLOTHING ETC JIUNLBSS SUCH LOSS non ARE DEPOSITED IN THE HOSPITAL SAFE. THEVHOSPITAL WILL NOT BEILIAB E IN EXCESS OF F50 FOR THE LOSS OR DAMAGE OF ANY PERSONAL EFFECTS OR VALUABLE$ 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. INCLUDINO STAFF AND EQUIPMENT, AND SUPPUES ON REC WHO AMPLE, I MAY RECEIVE AI SEPARIATE BILL FROM ONES OR MO E OF H FFOLLOWING TYYPEESS OF PHYSICIANS PROVIDES RENDER SERVICES TO RE: MY ATTENDING PHYSICIAN OR PERSONAL PHYSICIAN, EMERGENCY ROOM PHYSICIAN, RADIOLOGIST, ANESTHESIOLMOtr PATUn,nR-A- ..s SPECIALIST. INFJK NCS ASt1p PINT I HEREBY ASSION TO AND AUTHORIZE THE HOSPITAL AND PHYSICIANS INVOLVED IN CARE DURING THIS PERIOD OF ILLNESS OR TREATMENT HEREINAFTER AUTHOn ASSIGNS TO TAKE ALL INSURANCE BENEFITS OTHERVASE PAYABLEL TO ME RIMY ESTATE RE PAID DIRECTLY TO THE HOSPITAL OR LPHYSICIANS. TTHIS ASSIGNMENT OF ENSURE 11HAT ANY INSURANCE BENEFITS INCLUDES BUT IS NOT LAMITED TO BILUNO INSURANCE FILING PETITIONS. FILING SUIT, IN MY NAME OR ON BEHALF OF THE HOSPITAL OR PHYSICIANS, F LNG PROOFS Of CLAIM. FILING PROBATE CLAMS Me ALM GRREVANCES AND ALL OTHER SWILAR PROCEDURES, AS MAY BE AMENDED FROM TIME TO TIME WITH THE STATE DEPARTMENT OF INSURANCE. 1 ALSO AGREE TO PROVIDE AND SNiN ANY OTHER DOCUMENTS THAT MAY BE REASONABLY NECESSARY TO ACCOMPLISH ANY OF THE OTHER PURPOSES. STATEMENT OF FENAMMU RESPONSIBILITY I UNDERSTAND THAT I AM FINANCIALLY AND LEGALLY RESPONSIBLE FOR CHARGES NOT COVERED IN FULL BY ANY TFMRD PARTY, I FURTHER AGREE THAT AGREESTOUPAY Cmar OSTSYO ECOLBALANCE WITHIN THIRTY LECTION. MCLUDING REASONABLE ATTOANEYAS FEES AND COSTS, COLLECTION AGENCY FEES E AND DCOSTS. AND INTEREST WHICH SHALL ACCRUE AT THE MAXIMUM RATE ALLOWED BY LAW. FF"M ANY PERSON WH0 KNOW AMY AND WNTN INTENT TO ItNJUAE, DEFRAUO, 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, WVANIV DMIECc? NEM A?MISSIOM TO tfO$PITAL OI NLYI F 1 AM TO BE ADMITTED TO THE HOSPITAL. I HAVE BEEN GIVEN WRITTEN MATERIALS ABOUT MY RIGHT 10 ACCEPT OR REFUSE MEDICAL TREATMENT. I RIG IIAVE KEN FORM ATE ADVANCE DIRE HAVE ADVA >IR€CTIVINE O? OREC:EIVEE MEDICAL TREATMENT AT THIS HOSPITAL I U ND RSSTAND THAT THE HOSPITAL AND MY?C:AAEGIVE S WILL FOLLOW THE TERMS OF ANY ADVANCE DIRECTIVE THAT I HAVE EXECUTED TO THE EXTENT PERMITTED BY LAW. !INITIAL THE FOLLOWING OPTM THAT APPLIES) - I HAVE EXECUTED AN ADVANCE DIRECTIVE AND WILL PROVIDE A COPY OF THUS FOR MV MEDICAL RECORD WITHIN A REASONABLE AMOUNT OF TIME. - I HAVE NOT EXECUTED AN ADVANCE ORRECTIVE AND DO NOT WISH TO DO 80. hVT PIT, - i WISH TO COMPLETE AN ADVANCE DIRECTIVE DURING THIS HOSPITALIZATION. I?LLOW-UP DONE BY DATE CERTIFY THAT R N READ 10 AVE THE ABOVE CONSENTS MIA. CiAT'E: YGR _ WITMC f WATI tY i41AN1u fuill Carllsle Reofonat Medirai Center -- En ercencv Department 361 Aieriandec Spring Rd Carlisle, PA 17013 -- (717) 960-1695 Patient: Glom, Shendelle MD ED: Jean-Pau! Romeo, MD Disch; 11/14/0$10:52pm Has/PA/NP: Medical Record: 758176 AFTERCARE iNMTRLJCTiONS We are pleased to have been able to provide you with emergency care. Please review these instructions when you return home in order to better understand your diagnosis and the necessary further treatmeM and precautions related to your condition. Your diagnoses/prescriptions today are: Dx iK1: Strain Leg (Not Otherwise Specified) Dx lf2: Head injury. Superficial (Unspecified) Dx l13: Abrasion, Elbow 6 Cieneal fnfcrmation on SPRAiNs a STRAiN$ DEFINITION - Injury to ligaments that hold a joint t"0111er and in position. A strain Is a stretched muscle. A sprain is a stretched and tom ligarrment. Sprains occur most often in ankles. knees or fingers, although any jdnt can be sprained. Sprained joints can function; but only with pain. BODY PARTS INVOLVED - Any ligament (tendon) attached to any joint. SEX OR AGE MOST AFFECTED - Both sexes; all apes. SIGNS & SYMPTOMS ' Pain or tenderness in the area of injury; severity varies with the extent of injury. ' SwelNnq of the affected joint. ' Redness or bruising in the area of injury. either immediately or several hours after injury. ' Loss of normal mobility in the injured joint. CAUSES - Overuse or stress of a ligament or membrane around a joint. A sprain usually occurs when the body weight Is placed abnormally on ligaments, causing them to stretch and tear. The ankle is injured most often because of its anatomical weakness, its exposed position and the stress it sustains In athletic and recreational activities. RISK INCREASES WITH - Obesity HOW TO PREVENT - Avoid injury: ' Wrap weak joints with support bandages before strenuous activity. Stretch muscles before and after exercise. ' Strengthen weak muscles with rehabilitative exercises to prevent a recurrence. Consult your doctor or a physical therapist for exercises. Accident proof your home. WHAT TO EXPECT APPROPRIATE HEALTH CARE ' Self care it the injury is not severe. ' Doctor's treatment if the joint cannot move or bear weight normally. Cast for a severely sprained joint. ' Surgery to repair badly tom ligaments. ' Physical therapy to regain strength and normal use of the joint. DIAGNOSTIC MEASURES Your own observation of symptoms. Medical history and physical exam by a doctor. ' X-rays of the iniured area. POSSIBLE COMPLICATIONS - Permanent weakness if the sprain is severe or if a joint is sprained repeatedly. PROBABLE OUTCOME - Strains usually heal in 1 to 2 weeks. Sprains generally heal in 2 weeks without complications. HOW TO TREAT The general rule for treating sprains is R-1-C-E Pp 2 Rest: at first you will need to avoid activities that cause pain. It you have an ankle sprain or knee strain you may need crutches We: Put ice packs on the sprained area for 20-30 minutes every 3-4 hours. Do this for 2-3 days or until the sweNtng goes away. Compression: Your health care provider may recommend that you wrap an elastic bandage around your iniured joint to reduce swelling Elevation: Keep the iniumd joint above the level of your heart as much as you can until the swelling stops. MEDICATION - You may use non-prescription pain relievers such as acetaminophen or ibuprofen. If the sprain is severe. your doctor may prescribe a stronger pain reliever. ACTIVITY - Allow the Joint to rest t or 2 days. Then begin exercising the joint gently, without putting weight on it. DIET - No special diet. SEEK IMMEDIATE MEDICAL ATTENTION If You have a sprained joint that won't gear weight or move normally. Pain becomes intolerable. Swelling or bruising increases, despite treatment. General Information on HEAD Ii4,ii11RIES The term 'head IniuW refers to any injury that results from being hit on the head. Typically. there are cuts, scrapes or bruises on the lace or scalp and often there is a mild headache that gets better over one to two days. More serious head injuries can also shake the brain, resulting In a momentary loss of consciousness, confusion or amnesia. This is called a concussion. Often these more serious types of head injuries result from motor vehicle accidents, falls or lights. Are head injuries serious? They can be. Bleeding, tearing of tissues and brain swelling can occur when the brain moves Inside the skul at the time of Impact. But most people recover from head Injuries and have no lasting effects. What happens after the iniury? It Is normal to habe a headache and nausea and feel dizzy right after a head injury. Other symptoms include ringing in ears, neck pain and feeling anxious, upset, irritable, depressed or tired. The person who has had a head injury may also have problems concentrathtq, remembering things, putting thoughts together or doing more than one thing at a time, These symptoms usually go away In a few weeks, but may go on for over a year if the inliry was severe. WIN the head injury cause permanent brain damage? This depends on how bad the injury was and how much damage it did. Most head injuries don't cause permanent damage. What about memory toss? It is common for someone who's had a head injury to forget the events right before, during and after the accident. Memory of these events may never come back. Following recovery, the ability to loam and remeber new things almost always returns. Is it rue that the person must be kept awake or repeatedly awakened after the injury? No, it your doctor thinks the person needs to be watched closely, your doctor will probably put the person in the hospital. A serious head iniurv usually produces warning signs right away. On rare occasions. however, the WARNING SIGNS MAY NOT APPEAR FOR SEVERAL HOURS OR EVEN DAYS. For this reason it is important to seek immediate medical atlention N you or any one else notices any of these warning signs: t. UNCONSCIOUSNESS (passing out, blacking out). 2. Unusual drowsiness. 3. Confusion. 4. A severe headache. 5. Vomiting, 6. Slurred vision. 7. Convulsions (seizures, fits). 8. A stiff neck. 9. Areas of numbness, tingling or weakness. Pq 3 10. Stumblinq or loss of balance. 11. Unequal size of the left and right pupils. 12. In children ALSO look for a decreased activity, trouble walking, poor feeding or fussiness. INSTRUCTIONS 1) if you are not allergic to them, you may take ace medicines are not usually required taminophen (Tylenol) or ibuprofen (Advil) to help ease the pain. Stronger . 2) SEEK IMMEDIATE MEDICAL ATTENTION if you develop any of the warning signs listed above. 3) Unless instructed otherwise. FOR THE NEXT 24 HOURS, you should; A) stay with a friend or family member who has read this sheet and 13) have someone check you every 3 to 4 hours to make sure you have not developed any of the warning signs listed above At night they should wake you up about every 4 hours. n General information on ABRASIONS An "abrasion" is the medical term for an accidental serape 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 maybe relatively small and insignificant, or it may be quite (aryls. What are the risks? 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, germs sometimes fret Into the wound and start to grow and multiply, producinq an infection. It 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 Nye muscles, tendons, nerves or bones underneath the abrasion. INSTRUCTIONS 1) When you qet 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), 8) it you are not allergic to if, genlly apply a thin layer of antibiotic ointment and C) cover the area with a bandage. 2) Keep the area clean and dry. 3) if the bandage gets 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, 8) 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) pul 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 ibuprden (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 if: A) you develop a fever, persistent bleeding. vomiting or 8) the abrasion gets very red, swollen or tender or C) you develop red streaks an the skin near the abrasion or Dl the abrasion develops a foul odor, or starts to drain pus. Follow-up: YOUR FAMILY DOCTOR Fi4I MD Ph: FA) DIT: Other Instr: Ice calf and forehead 30 min at a time 4-5 times a day for 1-2 days, head injury precautions as . instructed. Pq 4 EKGs and X Revs: H you had an EKG or X-Rav today, it will be formally reviewed by a specialist tomorrow. if there is any change from todaws Emertlenev Depertment 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 essentlal that You make arrangements for follow-up care with that physician as instructed. Report any new or remaining problems at that time, because Nis impossible to recognize and treat all elements of injury or disease in a single Emergency Department visit. SbW#cant ehanpes or worsenkv In your conddor! may require more knmedlate attenfAm. The Emergency Department is atwevs open and avabble if this becwws necessary. Wfuile the Phvsicros and stall of ft Emwrwcv Department have made every t+eesonable effort to accurately deferrnMe hour cornolete medcation history, because of ft !limited knowWm of vow out a-hospdfai meabtcai care. and the need to address vow emergency meads needs, we cannot be sure that a Complete or fully amrate medkation history was provided. It is therefore necamrv for you to inform your primary care physWan of your treatment in the EmMenev Department so that your ph ys cian can Properly evaluate your cwrem medication needs. N O N Q Q OQ W r 11/23/2009 MON' 12:40 FAX 6149447924 safe auto corp One . i ? 002/Ol?- -iEv OV E D Safc Auto Claim No. - 408648 AF G AUT 8MNTS' RELEASE AND INDEMNITY AGREEMENT ?. For the consideration of the total sum of Four thousand dollars Dollars (54,000.00) the undersigned, Scott Gleim and Brenda Gleim, the parents of Shendelle Glefm, a minor, do hereby and for their heirs, executors, administrators, successors, and assigns release and forever discharge Ernauel Soto, his/her heirs, executors and assigns and Safe Auto Insurance Company, its officers, employees, agents, successors and assigns from any and every claim, demand, lice, right or cause of action, of whatsoever kind or nature that they have as the parents of Shendelle Gleim as well as all claims or rights of action for damages that the minor his or hereafter may have before reaching majority on account of or in any way relating to a traffic accident involving the minor (hereafter "the traffic accident') occurring on or about November 14, 2008 at or near the intersection of Pint Rd. in the City of Newvf ie, County of Cumberland, State of PA The undersigned acknowledge that the payment provided for above is sufficient consideration and expressly waive all claims for the payment of interest relating to the traffic accident or [his settlement. The undersigned hereby declare and represent that the injuries and/or damages sustained by the minor in connection with the traffic accident are or may be different than, greater than, or more extensive than is now known, anticipated, or expected and that recovery therefrom is uncertain and indefinite and in making this Release, it is understood and agreed that the undersigned rely wholly upon their judgment, belief, and knowledge of the nature, extent, effect and duration of the minor's injuries and/or damages and liability therefore, and this Release is made without any reliance upon any statement or representation of the parties hereby released, their insurer, their representatives, or by any person by them employed. The undersigned, for themselves, their heirs, administrators and assigns further promise to repay to Emauel Soto and Safb Auto Insurance Co., their heirs, executors, administrators and assigns any sum of money, except the sum above mentioned, that they may hereafter be compelled to pay because of injuries or damage sustained by the minor as a result of the traffic accident. It is understood and agreed that the undersigned shall satisfy from funds received from this settlement any valid and enforceable lien asserted by any lien claimant or third party payor, including but not limited to claims asserted by health care providers, health insurance carriers, Medicaid, Modicaro or other governmental entities, for benefits paid to or on b-..half of the minor as a result of the traffic accident. Further the undersigned agree to indemnify and hold harmless the,parties released hereby, their attorneys, insurers and agents from and against any and all losses, claims, liens charges, fees costs (including reasonable attorney's fees) interest or other sums incurred as a result of any lien claimant or third party payor asserting, imposing or enforcing a lien or claim related in any way to the injuries or damages for which the parties released are making payment under the terms of this Release. The undersigned hereby declare that they have the capacity and are fully authorized to enter into this Release and Indemnity Agreement, that they have read all the terms of this Release and Indemnity Agreement, have discussed them or had the opportunity to discuss them with legal counsel, fully understand them and accept them for the express purposes of settling the above described claim and forever precluding any further or additional legal action relating to the traffic accident. ? 2Pr^ !M' '_2Y ; r„ 4n447924 safe auto corp One ?M/11311 It is under tood and agreed that this is a full and final release of all claims of every nature and kind whatsoever, .and that the amount paid herein is in the nature of a compromise settlement and that the payment made is not to be construed as an admission of liability on the part of the parties ;released hereby, such liability being expressly denied. THE UNDERSIGNED HAVE READ THE FOREGOING RELEASE AND UNDERSTAND IT. IN WITNESS WHEREOF and intending to be legally bound hereby, we have signed this Release this _?O'j day of ao-O , 2001 Scott Gleim, 1ndividtu?1 y an as parent of Shendelle Glelm '6 U-t Brenda Gleim, individually and as parent of Shendelle Gleim STATE OF PA ) SS: OC)UNTY OF Cumberland ) Sworn to before me and subscribed in my presence this 6 day of 1hywbts- , 20o f. COMMONWEALTH OFPEl NMVAMA Air ` NOTAlIIIAL IM NOTTRY PUBLIC WE FL FORM TAFtf PtJK C M commission ea ices: /lloye.v kf 076 01h 1'P LCAOMjSM DO[iO M, CuM MAND CQUNf Y Y P 2 COMMM*N E WMM NCIVBMM 2A, 2012 You are noUW that Pe nsyfvama Law provlde& as follows! Am person who knowln* and with k?tent to inpue or defraud any insurer flies an application or daim oontaWng fatse, Inoomplete or misleadit information shag, upon =Mcdon, be sLMIW to ImtxLcorrnent for up to sown years and payment of a fine of up to;(Srooo. T~ , MAR232010~ t IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, -PENNSYLVANIA IN RE: SHENDELLE L. GLEIM, ORPHANS' COURT DIVISION a minor Docket Number: ORDER OF COURT ~~ ~ ~~ 7.7 C'tu, AND NOW, to-wit, this z`I' day of •r1k~l~H 2010, it is hereby ORDERED, ADJUDGED and DECREED that Shendelle L. Gleim, a minor, by and through her parents and natural guardians, Scott and Brenda Gleim, shall be permitted to settle the minor's claim against the tortfeasor, Emmanuel J. Soto, for the amount of $4,000.00, minus expenses for the minor's medical records of $40.63, with the remaining $3,959.37 to be deposited by Scott and Brenda Gleim in afederally-insured, interest-bearing account, not to be withdrawn until minor, Shendelle L. Gleim, reaches the age of majority on December 15, 2011, or by further Order of Court. Attorney Catanzarite is to provide and file a Proof of Deposit with the Clerk of Orphans' Court within sixty (60) days of the date of this Order. BY THE COURT: J. 178 ~.. r~ .• ~ ['-' W ~ ~:_ r ~~( . _ u~.... w =_ ~ C,'wa , '-'c,.~ ~.~- U . ~' -_'_ c~'v C~ ~U O /YL`aU (~~ R~~ ~ . e~ y ~~~~-~ a/zY/~~ ~~ ~-, . ill _~~ ~~ ~! a C.7 N r ~1 r~' -' -i _ :`: , ~ __.~ ~ 1'7 J (_.r