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Home My WebLink About12-2135 1j r 0 !?o rAk f? ADi R --4 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLNM L A N D C 0 UN Ty PENNSYLVANIA IN RE: VINCENT S. TERMIN, a Minor NO. abg'a I35 civl\ PETITION FOR COURT APPROVAL OF MINOR'S SETTLEMENT PETITION FOR COURT APPROVAL OF MINOR'S SETTLEMENT COMES NOW, Petitioners, Mickey S. Termin and Monique S. Termin, as parents and natural guardians of Vincent S. Termin, by and through Griffith, Strickler, Lerman, Solymos & Calkins, and Michael B. Scheib, Esquire, and files a Petition for Court Approval of Minor's Settlement, and in support thereof avers as follows: Vincent S. Termin ("Vincent") is a minor who has a date of birth of April 23, 1994, and is currently 17 years of age. 2. Vincent resides with his parents, Mickey S. Termin and Monique S. Termin, at 5835 Spring Tree Court, Enola, PA 17025. 3. This matter arises out of a motor vehicle accident that occurred on October 22, 2010 at which time Vincent was 16 years old. 4. On the aforesaid date, Vincent was a restrained front seat passenger in a motor vehicle driven by Christopher M. McCleerey and owned by Jamie A. McCleerey. 5. The accident occurred on Wertzville Road, Silver Spring Township, Cumberland County in which Christopher M. McCleerey did not notice that the vehicle in front of him being operated by Darlene Sponsler was stopped waiting to make a left hand turn onto Beard Road. McCleery's vehicle struck Sponsler's vehicle and then entered the opposite lane of travel and C? x)03. ?S1 Ckwsi19o, 91;?, 'Fa-733 ss was struck by a third vehicle operated by Gina Harris-Franke who was driving in the opposite direction. 6. As a result of the aforementioned accident, Vincent was taken by Silver Spring EMS to Hershey Medical Center. 7. At Hershey Medical Center, Vincent was evaluated with head injury, cervical spine injury, internal hemorrhage, solid organ injury, hollow organ injury, abrasion, contusion, sprain, closed fracture. A true and correct copy of the ED Triage Form and ED Summary of Hershey Medical Center is attached hereto as Exhibit "A". 8. Vincent was admitted to Hershey Medical Center for observation and was stable enough for discharge on October 23, 2010 with a discharge diagnosis of pulmonary contusion, hematuria. A true and correct copy of the Discharge Summary is attached hereto as Exhibit "B" 9. Vincent was seen by James W. Eash, LSW of Riegler, Shienvold & Associates on October 27, 2010, November 4, 2010 and November 30, 2010 for psychiatric evaluation. A true and correct copy of the records of Riegler, Shienvold & Associates is attached hereto as Exhibit «C„ 10. Vincent does not currently have any doctor appointment scheduled due to the accident and has not received any additional medical treatment as a result of the accident. 11. At the time of the accident, Jamie A. McCleerey was insured under the Encompass Insurance Company Insurance policy of Earl McCleerey, with bodily injury limits in the amount of $100,000.00 per person and $300,000.00 per accident. A true and correct copy of Earl McCleerey's declarations page is attached hereto as Exhibit "D" 12. Mickey S. Termin and Monique S. Termin, as the parents and natural guardians of Vincent, have presented a claim to Encompass Insurance Company. 16. Mickey S. Termin and Monique S. Termin, as the parents and natural guardians of Vincent, and Encompass Insurance Company, have agreed to a settlement of the claim in the amount of $14,000.00, which shall be made payable in the following payments: a. A payment in the amount of $14,000.00 shall be paid by Encompass Insurance Company to Mickey S. Termin and Monique S. Termin as parents and natural guardians of Vincent Termin to be deposited in a savings account in the name of Vincent Termin, a minor. 18. Pursuant to Pa.R.C.P. 2039(2) the amount $14,000.00 is to be deposited in a savings account in the name of Vincent Termin, a minor, with proof of deposit to be filed within fourteen (14) days from the date of the approved settlement. 21. Mickey S. Termin and Monique S. Termin, as parents and natural guardians of Vincent, understand that Attorney Michael B. Scheib was retained by Encompass Insurance Company to obtain court approval of the minor's settlement. Attorney Scheib was not involved in the decision to settle this claim. Attorney Scheib will not be paid from the settlement funds. 22. Mickey S. Termin and Monique S. Termin, as parents and natural guardians of Vincent, believe that this settlement is fair and reasonable compensation for the injuries suffered by their son, Vincent. 23. Mickey S. Termin and Monique S. Termin, as parents and natural guardians of Vincent, understand that if the Court approves the settlement, Vincent will be barred from filing any other type of claim or lawsuit as a result of the October 22, 2010 accident. 24. Mickey S. Termin and Monique S. Termin, as parents and natural guardians of Vincent, understand that if the Court approves the settlement, they will be required to execute a document which releases Jamie A. and Earl W. McCleerey, Jr., and Encompass Insurance Company as a result of the October 22, 2010 accident. 25. Mickey S. Termin and Monique S. Termin, as parents and natural guardians of Vincent, believe that the approval of this settlement is within the best interest of their son, Vincent. WHEREFORE, Petitioners, Mickey S. Termin and Monique S. Termin, as parents and natural guardians of Vincent Termin, respectfully requests this Honorable Court approve the minor's settlement of this matter. GRIFFITH, STRICKLER, LERMAN, SOLYMOS & CALKINS By: .a MICHAEL B. SCHEIB, ESQ IRE Supreme Court I.D. No. 63868 110 South Northern Way York, PA 17402-3737 Telephone: (717) 757-7602 s VERIFICATION Mickey S. Termin and Monique S. Termin as parents and natural guardians of Vincent S. Termin, a minor, verify that the statements made in the foregoing Petition For Court Approval of a Minor's Settlement are true and correct, upon their personal knowledge or information and belief. This verification is made subject to the penalties of 18 Pa.C.S. §4904, relating to unswom falsification to authorities. Date: , 2012 ----- Mickey S. Termin, as parent and natural guardian of Vincent S. Tegpi }n J/7 , 2012 ' Date: Monique S. 'Armin, as parent and natural guardian of Vincent S. Termin J Q 111 J ~ A J J Q PENNSTATE HERSHEY FM Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S MRN: 1945368 Date of Birth: 4/23/1994 Patient Gender: Male DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: ED Triage Form Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Visit Number: 15129887 Visit Type: Observation Patient Location: 7MBS; 7238; 01 ED Triage Form Final English,Lori A (1 0/22/201 0 09:31 EDT) 10/22/2010 09:31 EDT ED Triage Form 10/22/10 09:31 am Performed by English, Lori A Entered on 10/22/10 09:35 am ED Triage Complaint Chief Complaint pt involved in multiple patient accident. pt the reported front seat passenger, restrained. had to have seatbelt cut to be extricated. possible loss of consciousness. + airbag, headache, right hip/bicep pain. pt in NO Cspine precautions. Mechanism of Injury Airbag, Auto, Passenger, Restraint Mode of arrival-ED Ambulance Pre-Hospital treatments? Yes Abuse No Pregnancy Status N/A Last Tetanus <5 Years Nursing Home Resident No ED Physician Notified-abuse No During last month felt down or depressed No Allergy Reaction 1. NKA Triage Vital Signs Temperature Route Temperature Heart Rate Respiratory Rate SpO2 Pain Intensity Pain scale used primary Visual Acuity ED Vital Signs Patient Weight Oral 36.8 DegC 68 bpm 16 br/min 98% 4 0-10 Pain scale No 80.000 kg Date/Time Printed: 2/26/2011 16:45 EST Printed By: Twigger,Barbara Page 1 of 10 PENNSTATE HERShr_Y Owt! Milton S. Hershey qP Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 ........................ ....... ........... »,...., ,. ED Triage Form Systolic Blood Pressure 136 mmHg Diastolic Blood Pressure 72 mmHg BP Location # 1 Left Arm Weight 80.000 kg Weight Method Patient stated Glasgow Coma Scale/ED Eye Opening Response Peds Coma Spontaneously Best Verbal Response Peds Coma Oriented and converses Best Motor Response Peds Coma Spontaneous Pediatric Coma Score 15 Surgical / Procedure History ---------------------------- Surgical History Grid 1. Surgical/Procedure History Description None Functional Assessment Have You Fallen Twice in Six Months Peds Medical Hx I ----------------- Peds Medical HX I HEENT Denies: Patient Peds Medical HX I Gastrointestinal Grid Denies: Patient Peds Medical HX I Cardiovascular Denies: Patient Peds Medical HX I Gent Grid Denies: Patient Peds Medical HX I Respiratory Denies: Patient Peds Medical HX I Musc Grid Denies: Patient Peds Medical Hx II ------------------- `NOT VALUED` Denies: Patient Peds Medical HX II Hemat Grid Denies: Patient Peds Medical HX 11 Neuro Grid Denies: Patient Peds Medical HX II Behavioral Grid Denies: Patient Date/Time Printed: 2/26/2011 16:45 EST Printed By: Twigger,Barbara No Page 2 of 10 . PENNSTATE HERSHEY WTI Milton S. Hershey W Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 ED Triage Form *NOT VALUED" Denies: Patient Peds Medical HX II Onc Grid Denies: Patient ED Triage Tracking DCP Generic Code Tracking Acuity Tracking Reg. Status Triage Time Visit reason Tracking Group Ambulance List -------------- Ambulance List 2 Start 10/22/10 09:35 MVC EMER Trk Gp Other: silver spring Date/Time Printed: 2/26/2011 16:45 EST Page 3 of 10 Printed By: Twigger,Barbara PENNSTATE HERSHty PO' TI Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 IER Trauma Form DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: IER Trauma Form 10/22/10 08:45 pm Performed by Norman, Kristin Entered on 10/22/10 10:31 pm Education IER Trauma Form Final Norman,Kristin (1 0/22/201 0 20:45 EDT) 1 0/22/201 0 20:45 EDT Educational Needs Assessed Yes Barriers to Learning None evident Learning Preferences Verbal Explanation, Printed Instructions IER Safety Topic 000000001 Hand Hygiene as an important infection deterrent IER Safety Taught 000000001 Patient IER Safety Topic 000000002 Respiratory Hygiene decreases the spread of airborne germs IER Safety Method 000000002 Verbal Explanation IER Safety Taught 000000002 Patient IER Safety Topic 000000003 Two patient identifiers are used for safe procedure and drug administration IER Safety Method 000000003 Verbal Explanation IER Safety Taught 000000003 Patient IER Safety Topic 000000004 Contact Isolation may be necessary for cer tain cultured germs IER Safety Method 000000004 Verbal Explanation IER Safety Taught 000000004 Patient IER Safety Topic 000000006 Falls can occur to any patient during hospitalization IER Safety Method 000000006 Verbal Explanation IER Safety Taught 000000006 Patient IER Safety Topic 000000008 Significance of the colored armbands IER Safety Method 000000008 Verbal Explanation IER Safety Taught 000000008 Patient General Topics -------------- IER General Topic 000000001 IER General Method 000000001 IER General Evaluation 000000001 IER General Taught 000000001 IER General Topic 000000002 ivfluids IER General Method 000000002 Date/Time Printed: 2/26/2011 16:45 EST plan of care review Verbal Explanation Verbalizes understanding Patient, Mother to continue to drink or well restart Verbal Explanation Page 4 of 10 Printed By: Twigger,Barbara PENNSTATE HERSHEY WTI Milton S. Hershey iW Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 IER Trauma Form IER General Evaluation 000000002 IER General Taught 000000002 IER General Topic 000000003 noted in e.r. IER General Method 000000003 IER General Evaluation 000000003 IER General Taught 000000003 IER General Topic 000000004 IER General Method 000000004 IER General Evaluation 000000004 IER General Taught 000000004 Date/Time Printed: 2/26/2011 16:45 EST Verbalizes understanding Patient, Mother need to check urine since some blood Verbal Explanation Verbalizes understanding Patient, Mother pain meds and when to let me know Verbal Explanation Verbalizes understanding Patient, Mother Page 5 of 10 Printed By: Twigger,Barbara .PENN STATE HERSHEY FIM- Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 Interdisciplinary Narrative Form DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Selgas,Christopher J (10/ 22/2010 09:35 EDT) 10/22/2010 09:35 EDT Interdisciplinary Narrative Form 10/22/10 09:35 am Performed by Selgas, Christopher J Entered on 10/22/10 10:21 am Interdisciplinary Narrative --------------------------- Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text 0925 - Pt into room 10 via BLS litter, sitting up, NAD. Pt assessed by RN and ED resident Dr. Gohzansky. Pt moved onto ED litter and evaluated. Pt AA, c/o pain in front of head, states was in MVC with the 4 other trauma pts in ED currently, self extricated after short LOC, sat in back of police car for 30-40 minutes before assessed by BLS. Pt's father on scene after crash. Pt layed down, no collar on, head and neck assessed, front h/a, no obvious head trauma. Pt w/o neck pain or obvious injury. Chest assessed, lung sounds clear, no ovious trauma. abd soft, pt w/ bruising on both hips, more so on right, appears as seat belt marking. C.Selgas RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Selgas,Christopher J (10/22/2010 09:40 EDT) 10/22/2010 09:40 EDT Interdisciplinary Narrative Form 10/22/10 09:40 am Performed by Selgas, Christopher J Entered on 10/22/10 10:23 am Interdisciplinary Narrative --------------------------- Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text 0935 - FAST u/s by ED resident Tony, Date/Time Printed: 2/26/2011 16:45 EST Page 6 of 10 Printed By: Twigger,Barbara . PENNSTATE HERShtY WMI Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 Interdisciplinary Narrative Form negative results. Pt evaluated by ED attending Dr. Luckey. C.Selgas RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Selgas,Christopher J (1 0/22/201 0 09:47 EDT) 1 0/22/201 0 09:47 EDT Interdisciplinary Narrative Form 10/22/10 09:47 am Performed by Selgas, Christopher J Entered on 10/22/10 10:26 am Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text 0943 - 20g placed in left forearm, labs drawn, RN explained to pt care plan. Pt asked about his friends, RN advised that they were all being treated in department, some were injured severely, pt understood. ED nurse Jenn at bedside, updating pt on his friends. C.Selgas RN 0945 - Pt stating he doesn't feel good after hearing about his friends, pt pale, b/p cycling and dorpped @ 40 points systolic. Pt layed back, NSS 1 liter attached after blood drawn, opened wide for bolus. Pt monitored and calmed by RN. Pt starting to regain color and feel better. ED attending Dr. Luckey advised of pt's response. C.Selgas RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Selgas,Christopher J (1 0/22/201 0 09:55 EDT) 1 0/22/201 0 09:55 EDT Interdisciplinary Narrative Form 10/22/10 09:55 am Performed by Selgas, Christopher J Entered on 10/22/10 10:26 am Interdisciplinary Narrative --------------------------- Date/Time Printed: 2/26/2011 16:45 EST Page 7 of 10 Printed By: Twigger,Barbara . PENNSTATE HERSHLY Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 Interdisciplinary Narrative Form Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text 0950 - Report to ED nurse Jenn, pt care transferred. C.Selgas RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Mason,Jennifer L (10/22/2010 10:57 EDT) 10/22/2010 10:57 EDT Interdisciplinary Narrative Form 10/22/10 10:57 am Performed by Mason, Jennifer L Entered on 10/22/10 10:57 am Interdisciplinary Narrative --------------------------- Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text pt taken and returned from CT. pt states that he feels better. resting in NAD at this time. j.mason RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Mason,Jennifer L (10/22/2010 11:33 EDT) 1 0/22/201 0 11:33 EDT Interdisciplinary Narrative Form 10/22/10 11:33 am Performed by Mason, Jennifer L Entered on 10/22/10 11:34 am Interdisciplinary Narrative --------------------------- Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text pt ambulated to the bathroom without assistance. urine sample collected and noted to have blood in urine. attending made aware. will monitor. j.mason RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Mason,Jennifer L (10/22/2010 12:37 EDT) 10/22/2010 12:37 EDT Date/Time Printed: 2/26/2011 16:45 EST Page 8 of 10 Printed By: Twigger,Barbara PENNSTATE HERSHLY Milton S. Hershey qP Meclical Center Patient Name: TERMIN, VINCENT S MRN 1945368 Interdisciplinary Narrative Form Interdisciplinary Narrative Form 10/22/10 12:37 pm Performed by Mason, Jennifer L Entered on 10/22/10 12:37 pm Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text pt resting on litter. aware of POC for admission r/t pulmonary contusion. will monitor. j.mason RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Mason,Jennifer L (10/22/2010 14:41 EDT) 10/22/2010 14:41 EDT Interdisciplinary Narrative Form 10/22/10 02:41 pm Performed by Mason, Jennifer L Entered on 10/22/10 02:41 pm Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text no change in status. pt resting in NAD at this time. family at bedside. will monitor. j.mason RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form 10122110 03:34 pm Performed by Mason, Jennifer L Entered on 10/22/10 03:34 pm Updated on 10/22/10 04:23 pm by Mason, Jennifer L Interdisciplinary Narrative Interdisciplinary Narrative Form Modified Mason,Jennifer L (10/22/2010 15:34 EDT) 10/22/2010 15:34 EDT Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text trauma admission completed. pt up and ambulated around room. resting in NAD Date/Time Printed: 2/26/2011 16:45 EST Page 9 of 10 Printed By: Twigger,Barbara PENNSTATE HERSHEY M. Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 .............................. Interdisciplinary Narrative Form at this time. j.mason RN 1534- pt brought to 7th floor with paperwork and RN present. pt states that he feels slightly lightheaded. will monitor. j.mason RN report given to pediatric floor. (modified) Date/Time Printed: 2/26/2011 16:45 EST Page 10 of 10 Printed By: Twigger,Barbara . PENNSTATE HERSHEY OWLI Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 ED Summary RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Final Motor vehicle crash - major Luckey,Thomas J (11/5/2010 10:19 EDT) Motor vehicle crash - major Patient: TERMIN, VINCENT S MR N: 1945368 Age: 16 years Sex: Male DOB: 4/23/1994 Associated Diagnoses: None Author: Luckey, Thomas J OOS: FIN: 15129887 Basic Information Time seen: Immediately upon arrival. History source: Patient, EMS. Arrival mode: Ambulance. History limitation: None. Additional information: Chief Complaint from Nursing Triage Note : Visit Reason. 10/22/2010 09:31 visit reason MVC History of Present Illness The patient presents following motor vehicle collision. The onset was just prior to arrival. The Collision was front impact. The patient was the passenger. There were safety mechanisms including seat belt and airbag. Type of injury: direct blow and deceleration. Patient is complaining of a headache and right arm pain.. The degree of pain is minimal. The degree of bleeding is none. Risk factors consist of none. The dominant hand is the right hand. Therapy today: emergency medical services. Associated symptoms: none. Additional history: Patient was the front seat passenger in a severe motor vehicle collision that resulted in one fatality on the scene and four other critically injured patients. This patient self extricated and was ambulatory at the scene. He was initially amnestic to the event, but now recalls the details. He states the driver initially did not notice the car in front of them had come to a stop while waiting to turn left. The driver swerved left to avoid hitting that car when he crossed into oncoming traffic. The right side of the car hit the car that was stopped in front of them and the car hit head on another car going in the opposite direction on the other side of the road. Four of the patients from the scene were flown here to HMC in critical condition.. Review of Systems Constitutional symptoms: Negative except as documented in HPI. Skin symptoms: Negative except as documented in HPI. Eye symptoms: Negative except as documented in HPI. ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI. Genitourinary symptoms: Negative except as documented in HPI. Musculoskeletal symptoms: Negative except as documented in HPI. Neurologic symptoms: Negative except as documented in HPI. Psychiatric symptoms: Negative except as documented in HPI. Health Status Date/Time Printed: 2/26/2011 16:43 EST Page 14 of 47 Printed By: Twigger,Barbara . PENNSTATE HERSHL'Y PX11- Milton. S. Hershey 1W Medical Center Patient Name: TERMIN, VINCENT S ED Summary MRN 1945368 Allergies:. Allergic Reactions (All) NKA Past Medical/ Family/ Social History Medical history Negative. Family history: Not significant. Social history: Not significant. Physical Examination Vital Signs Vital Signs. 10,122/2010 09:31 Temperature 36.8 DegC Temperature Route Oral Heart Rate 68 bpm Respiratory Rate 16 br/min Systolic Blood Pressure 136 mmHg Diastolic Blood Pressure 72 mmHg BP Location # 1 Left Arm Sp02 98 0 General: Alert, no acute distress. Skin: Warm, dry. Head: Normocephalic, small abrasion to left cheek. small amount of dry blood on the right pinna. Neck: Supple, trachea midline, no tenderness. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact. Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate. Cardiovascular: Regular rate and rhythm, No murmur. Respiratory: Lungs are clear to auscultation. Chest wall: No tenderness. Back: Nontender. Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity, Tenderness to right upper extremity. Gastrointestinal: Soft, Nontender, Non distended. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed. Lymphatics: No lymph adenopathy. Psychiatric: Cooperative, appropriate mood & affect. Medical Decision Making Differential Diagnosis: Motor vehicle collision, head injury, cervical spine injury, internal hemorrhage, solid organ injury, hollow organ injury, abrasion, contusion, sprain, closed fracture. Results review: Lab results : Laboratory. 10/22/2010 09:54 Na 141 mmol/L K 3.5 mmol/L Cl- 103 mmol/L Date/Time Printed: 2/26/2011 16:43 EST Page 15 of 47 Printed By: Twigger,Barbara . PENNSTATE HERShEY 1PM Milton S. Hershey Rp Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 ED Summary HC03 28 mmol/L Anion Gap 10 mmol/L BUN 19 mg/dL Cret 0.73 mg/dL Estimated GFR, Black Race Not Available, GFR estimation 3 to 10/22/201 Estimated GFR, non-Black Race Not Available, GFR estimation not validated for patients under the age of 18 mL/m.in/1.73 m2 not validated for. patients under the age of 18 mL/min/"1 73 m2 Glu Ca ,NBC Hgb :act RBC 114C V MCHC MCH RDW Plts MPV Type of Diff: Immature Gran% Neut% Lymph% Mono% Baso% Eos% Immat Gran, Abs Neut, Abs Lymph, Abs Mono, Abs Baso, Abs Eos, Abs PT INR PTT Amylase Green (Lithium Heparin) days based on specimen stability. Please order testing. 0 09:50 ABO/Rh A.BO Recheck Antibody Scr Expires at 0600AM on P. Number Component 97 mg/dL 10.1 mg/dL 10.4 K/uL 17.4 g/dL 48.9 % 5.63 M/uL 86.9 fL 35.6 g/dL 30.9 pg 11.7 % LOW 203 K/uL 10.1 fL AUTO 0 % 81 % HI 13 % LOW 6 % 0 % 0 0 0.0 K/uL 8.2 K/uL HI 1.4 K/uL 0.7 K/uL 0.0 K/uL 0.0 K/uL 14.4 second 1.07 28 second 68 unit/L Specimen available from 0 to use addon order if you wish ABO/Rh ABO Recheck NEGATIVE 10/25/2010 808476 RED CELLS Date/Time Printed: 2/26/2011 16:43 EST Page 16 of 47 Printed By: Twigger,Barbara PENNSTATE HERSHLY FXTI Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S ..........._ ...........:......:............ ED Summary 10/22/2010 09:43 Defined] mg/dLI # Units 0 Urine color urine dipstick MRN 1945368 U Appear Clear U Gluc Negative Glucose Urine Dipstick Ref Range U Bili Negative Bilirubin Urine Dipstick Ref Range U Ketones Negative Ketones Urine Dipstick Ref Range U Spec Grav 1.005 Specific Gravity Urine Ref Range U Blood Large Blood Urine Dipstick Ref Range U pH 5 p:3 Urine Dipstick Ref Range U Protein Negative Protein Urine Dipstick Ref Range U Urobilinogen 0.2 mg/dl Urobilinogen Urine Dipstick Ref Range U Nitrite Negative Nitrites Urine Dipstick Ref Range U Leuk Est Negative Leukocytes Urine Dipstick Ref Range Head Computed Tomography: No acute disease process. Radiology results: Computed tomography, C-spine, reveals no acute disease process. Pale yellow [negative] [negative] [negative] [No Normal [negative] [4.5 - 8.0] [negative] [0.2 - 1.0 [negative] [negative] Radiology results: Computed tomography, Chest, Abdomen, Pelvis, 1. Areas of groundglass opacity within the left lower lobe and right lung base, likely contusion. Less likely atelectasis. 2. No findings to suggest trauma to the abdomen or pelvis. Notes: Due to the severity of the mechanism it was decided to image the patient's head, c-spine, chest, abdomen, and pelvis. The only positive from the imaging was a pulmonary contusion. The patient continued to complain of a headache. He had some hematuria on his labs. As the observation in the ED progressed the patient began feeling somewhat dizzy. It was decided that the patient would best be served as an observation admission on the pediatric trauma surgery service.. Procedure Procedure: Bedside ED ultrasound Indication: Abdominal, thoracic trauma Study: I performed a limited abdominal ultrasound and a limited transthoracic echocardiogram (FAST). Date/Time Printed: 2/26/2011 16:43 EST Page 17 of 47 Printed By: Twigger,Barbara . PENNSTATE HERSHEY Milton S. Hershey Medical Center Patient Name: TERMIN, VINCENT S ED Summary Findings: No Intra-abdominal free fluid, No pericardial fluid Interpretation: Negative Impression and Plan Diagnosis Head injury 959.01 (ICD9 959.01) Pulmonary contusion Plan Disposition: Admit: to Inpatient Unit. Addendum MRN 1945368 Teaching-Supervisory Addendum-Brief Notes: I saw and examined the patient and agree with the resident's findings and plan as written. I supervised the above FAST ultrasound. TL. Signatures: Electronically Reviewed/Signed (23-OCT-2010 06.56.00) bv• Dan Gozhansky, MD Electronically Reviewed/Signed (05-NOV-2010 10:18:00) by: Thomas J. Luckey, MD Electronically Reviewed/Signed (05-NOV 2010 10:18:00) by_ Thomas J. Luckey, MD Date/Time Printed: 2/26/2011 16:43 EST Page 18 of 47 Printed By: Twigger,Barbara PENNSTATE HERSHCY _ F;M Milton S. Hershey ® Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 Pediatric Admission Assessment 11 Form DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Pediatric Admission Assessment II Form Final Renninger, Kristen M (10/22/2010 16.00 EDT) 10/22/2010 16:00 EDT Pediatric Admission Assessment II Form 10/22/10 04:00 pm Performed by Renninger, Kristen M Entered on 10/22/10 04:53 pm Admission History ----------------- Admitted From Emergency Department Transport Mode Wheelchair Accompanied by Names mom and dad Isolation Precautions None Patient admitted to hospital with Not Applicable Contact Person Phone Number Mickey and Monique- 443-7987 Chief Complaint pt involved in multiple patient accident. pt the reported front seat passenger, restrained. had to have seatbelt cut to be extricated. possible loss of consciousness. + airbag, headache, right hip/bicep pain. pt in NO Cspine precautions. Clinical Height/Weight ---------------------- Height 172.00 cm Patient Weight 78.400 kg Weight 78.400 kg Height Method Standing Body Mass Index 27 kg/m2 Weight Method Standing Scale Allergy Allergy Reaction 1. NKA Primary Pain ------------ Adequate Pain Control Primary No Pain scale used primary 0-10 Pain scale Pain Intensity 4 Pain Location Head General Info Date/Time Printed.- 2/26/2011 16:47 EST Page 4 of 24 Printed By: Twigger,Barbara PENNSTATE HERSHEY M. Milton S. Hershey qV Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 ..::. Pediatric Admission Assessment 11 Form Accompanied by Who has Residential Custody? Information Given by Parent/Primary Caregiver Parent's Marital Status Current Medications ------------------- No Historical Medications Health Habits Pediatrics Cigarette Smoking Smoker in House Alcohol Type Recreational Drug Type Peds Medical Hx I Mother, Father, Grandparent Mother, Father Mother, Father Mickey and Monique Married None No No Denies Denies ----------------- Peds Medical HX I HEENT Denies: Patient Peds Medical FIX I Gastrointestinal Grid Denies: Patient Peds Medical HX I Cardiovascular Denies: Patient Peds Medical HX I Gent Grid Denies: Patient Peds Medical HX I Respiratory Denies: Patient admitted with urinary catheter in place Peds Medical HX I Musc Grid Denies: Patient Peds Medical Hx II ------------------- *NOT VALUED* Denies: Patient Peds Medical HX II Hemat Grid Denies: Patient Peds Medical FIX II Neuro Grid Denies: Patient Peds Medical HX II Behavioral Grid Denies: Patient *NOT VALUED* Denies: Patient Peds Medical HX II Onc Grid Date/Time Printed: 2/26/2011 16:47 EST Printed By: Twigger,Barbara No Page 5 of 24 - PENNSTATE HERSHLY Fwtl Milton S. Hershey IV Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 Pediatric Admission Assessment 11 Form Denies: Patient Peds Medical Hx Ill -------------------- Injuries Peds Health History None Infectious Diseases Peds Health History None Infectious Disease Exposure Last 4 weeks No Medical Devices None Immunizations Current Yes Surgical / Procedure History ---------------------------- Surgical History Grid 1. Surgical/Procedure History Description None Psychosocial ------------ Domestic Concerns None Emotional Support Available Yes Financial Concerns Re Hospital/Disch No Security Object None Psychiatric Admission No Chronic/Terminal Illness Freq Visits No During last month felt down or depressed No Parental Involvement -------------------- Parent/Caregiver Present Yes Parent/Caregiver Involvemnt Child's Care Actively participates Parent/Caregiver Interaction with Child Frequent interaction Parent/Caregiver Interact w/Care Team Discusses care, feelings, concerns Parental concerns addressed Yes Nutrition Home Diet Regular Peds High Risk Nutrition Persistent N/V/D in Infant (0-12mo) >1 week: No Persistent N/V/D in Child (> 1 yr) > 2 weeks: No Tube Feedings Assessment: No Total Parenteral Nutrition (TPN): No High Risk Dx: Short Gut, FTT, Vented Pts: No High Risk Dx: Cystic Fibrosis, Malnutrition: No Difficulty Swallowing or Chewing: No Modified Diet (Other than Regular Diet or Infant Formula): No Feeding Ability Complete independence Weight Change No Date/Time Printed: 2/26/2011 16:47 EST Printed By: Twigger,Barbara Page 6 of 24 . PENNSTATE HERSHEY WMI Milton S. Hershey VP Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 Pediatric Admission Assessment 11 Form Appetite Good Education Educational Needs Assessed Yes Barriers to Learning None evident Learning Preferences Verbal Explanation, Printed Instructions IER Safety Topic 000000001 Hand Hygiene as an important infection deterrent IER Safety Taught 000000001 Patient IER Safety Topic 000000002 Respiratory Hygiene decreases the spread of airborne germs IER Safety Method 000000002 Verbal Explanation IER Safety Taught 000000002 Patient IER Safety Topic 000000003 Two patient identifiers are used for safe p rocedure and drug administration IER Safety Method 000000003 Verbal Explanation IER Safety Taught 000000003 Patient IER Safety Topic 000000004 Contact Isolation may be necessary for cer tain cultured germs IER Safety Method 000000004 Verbal Explanation IER Safety Taught 000000004 Patient IER Safety Topic 000000006 Falls can occur to any patient during hospitalization IER Safety Method 000000006 Verbal Explanation IER Safety Taught 000000006 Patient IER Safety Topic 000000008 Significance of the colored armbands IER Safety Method 000000008 Verbal Explanation IER Safety Taught 000000008 Patient Pediatric Falls Assessment -------------------------- Peds Falls Age 13 years old and above Peds Falls Gender Male Peds Falls Diagnosis Other diagnosis Peds Falls Impairments Oriented to own ability Peds Falls Environmental Patient placed in bed Peds Falls Response to Surgery More than 48 hours/none Peds Falls Medication Usage Other medications/none Peds Falls Score 9 Peds Falls Humpty Dumpty Credit The Miami Children's Hospital Humpty Dumpty Falls Prevention Program (TM) Date/Time Printed: 2/26/2011 16:47 EST Page 7 of 24 Printed By: Twigger,Barbara PENNSTATE HERSHEY F;M Milton S. Hershey qW Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 _.,,... _... ,.,. Peds Seasonal Flu Vaccine Assess Form DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Peds Seasonal Flu Vaccine Assess Form Final Ren ninger, Kristen M (10/22/2010 16:00 EDT) 1 0/22/201 0 16:00 EDT Peds Seasonal Flu Vaccine Assess Form 10/22/10 04:00 pm Performed by Renninger, Kristen M Entered on 10/22/10 04:53 pm Peds Influenza Vaccine Assessment --------------------------------- Influenza in ICU No Peds Influ Vac contraindications Patient/Power of Attorney refuses vaccine (Give Reason) and contact the patient's physician Reason for Refusal of Peds Influ Vaccine Don't do flu vaccines Date/Time Printed: 2/26/2011 16:47 EST Page 8 of 24 Printed By: Twigger,Barbara J a ul w J Q H J J a PENNSTATE HERS1- cY PX7 Milton S. Hershey 4P Medical Center Patient Name: TERMIN, VINCENT S MRN: 1945368 Date of Birth: 4/23/1994 Patient Gender: Male Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Visit Number: 15129887 Visit Type: Observation Patient Location: 7MBS; 7238; 01 .. Discharge Summary RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Final Updegrove,Gary (10/25/2010 12:14 EDT); Engbrecht,Brett W (10/25/2010 09:10 EDT) DISCHARGE SUMMARY Name: TERMIN, VINCENT S HMC Number: 1945368 DOB: 04/23/1994 Date of Admission: 10/22/2010 Date of Discharge: 10/23/2010 Reason for Discharge: Stable for Discharge Physician: Engbrecht, Brett W Service: Peds Surgery Discharge Diagnosis: Trauma MVA Closed Head Injury Other Diagnoses: Pulmonary contusion, hematuria Surgical Procedures: None Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Brief History of Present Illness: Vincent was a passenger involved in a major motor vehicle collision. He was initially found walking around on scene. He was monitored in a police car. Upon noting increased confusion he was brought to HMC as an ED patient for evaluation. Hospital Course: Vincent was evaluated upon arrival to the ED. A CT of the head, chest, abdomen, and pelvis were performed. Pediatric surgery was consulted for pulmonary contusions and hematuria. He was admitted to the floor as an observation status. X-rays were also obtained of his arms. Overnight his diet was advanced. He was tolerating a regular diet and ambulating. Date/Time Printed: 2/26/2011 16:43 EST Page 1 of 3 Printed By: Twigger,Barbara PENNSTATE HERSHLY PO' TI Milton S. Hershey W Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 Discharge Summary ambulating. A repeat chest ray was obtained in the morning. Vincent was stable and discharged. He will follow up in the pediatric surgery clinic in 4 weeks. Exam on Discharge: Vitals Temp Pulse BP RR Sp02 10/23 04:50 37.2 66 122/68 22 98 10/23 01:15 37.0 52 112/62 18 98 10/22 20:46 37.7 70 128/67 20 99 10/22 16:00 37 70 136/87 18 97 -- 10/22 15:34 ---- 83 131/66 20 97 - 24 Hr Tmax: 37.7 at 10/22 20:46 F102 Date Wt(kg) Wt(lb) --- 10/22 78.4 172 --- 10/22 78.4 172 --- 10/22 80.0 176 10/22 80.0 176 General: Alert, no acute distress. Skin: Warm, dry. Head: Normocephalic, small abrasion to left cheek. Neck: Supple, trachea midline, no tenderness. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact. Ears, nose, mouth and throat: Oral mucosa moist, no pharyngeal erythema or exudate. Cardiovascular: Regular rate and rhythm, No murmur. Respiratory: Lungs are clear to auscultation. Chest wall: No tenderness. Back: Nontender. Musculoskeletal: Normal ROM, normal strength, no swelling, no deformity, Tenderness to right and left upper extremity. Gastrointestinal: Soft, Nontender, Nondistended. +BS Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed. Care Instructions: 1. May use over the counter Tylenol or ibuprofen as needed for pain. 2. See the head injury care instructions. The key to getting better after a head injury is to rest when tired. Avoid overstimulation and overtiredness, as may increase symptoms. If ANY activity increases symptoms, stop and rest in a quiet area. Diet Guidelines: Resume your regular diet - encourage plenty of liquids. Activity Guidelines: No sports, PE class, recreational vehicles (ATV, motorcycle, bicycle, etc.), skate boarding, gym class, manual labor, driving or any other activity that increases your chances bumping your head for at least 2 weeks. Return to school - at parents' discretion once no longer symptomatic at rest at home, likely up to a week. Upon return, parents, pt, school staff should monitor for increased/returned symptoms (headaches, fatigue, difficulty processing information or concentrating). If this occurs, it may signal that it is too soon to return, or a modified school attendance schedule may be needed. Please call to let us know if this occurs. Call your doctor it: Date/Time Printed: 2/26/2011 16:43 EST Page 2 of 3 Printed By: Twigger,Barbara . PENNSTATE HERS1-i,y PX7. Milton S. Hershey qP Medical Center Patient Name: TERMIN, VINCENT S MRN 1945368 .............,.. ,...,,., Discharge Summary Please call 717-531-8521 (operator- ask for the pediatric surgery resident on call): fever, increased pain, vomiting, sudden weakness/dizziness, excessive sleepiness/agitation. For routine questions during the weekdays, please call the pediatric surgery office at 717-531-8342. Please follow up with your primary care physician in 1-2 weeks. Follow-Up Appointments: No Follow-Up Appointments have been scheduled. #343470 Electronic Signature on File Electronically Reviewed/Signed by. Gary Updegrove, MD Author Signature Dt/Tm:25.10.2010 12:14 PM Electronically Reviewed/Signed by: Brett IN Engbrecht, MDCosigner Signature Dt/Tm. 25.10.2010 09.10 AM Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Brett Engbrecht, Kerry Fagelman, Dorothy Rocourt, Mary Santos Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC Lynn Simmons MSN CRNP GU /JLH DD: 10123110 DT: 10125110 08:48 Date/Time Printed: 2/26/2011 16:43 EST Page 3 of 3 Printed By: Twigger,Barbara J Q w W J Q F J J Q Riegler, Shienvold Print Form & Associates (717) 540-1313 ? 2151 Linglestown Road, Su+te 200 ? Harrisburg, Pennsylvania 17110 V.nitial AssESS-ncnt Patient Name: Termin Vincent _ Initial Assessment Date 10-27-2010 Last Name: First Name: M.I. Jr./Sr. Patient DOB: 4-23-1994 Age: 16 Gender: Male Patient ID#: Insurance: Hicrhmark Physician: Francis Brescia -MULTIAXIAL ASSESMN - Axis I: Axis II: Code: Diagnosis: 309.9 Ad"ustment disorder NOS V71.09 NO DIAGNOSIS ON AXIS H unent's Presenting concerns?5ymptoms: Patient was recently in a car accident in which the four other passenger in the vehicle were critically injured. The patient was the only one who received relatively minor injuries and was released from the hospital. Patient reports that he is having difficulty dealing with the accident and the aftermath. He feels overwhelmed with guilt by the "insignificance" of his injuries and feels somehow responsible for his friends even though it was not him that was driving the car. Axis III: Condition concussive injury in car accident Axis IV: Psychosocial Problems victim of car accident Mild Q Moderate Severe O Axis V: (GAF) Current 60 Past Year 85 Treatment Recommendations: Treatment Type: Frequency Time to Complete Outpatient Therapy Biweekly unknown Clinician Signature: Date: Nov 3, 2010 Name/Degree: James W. Eash. LSW x0 Client consents, and copy of this initial assessment sent to physician Date Sent: ? Client consents, no copy of this initial assessment sent to physician , F? Client declines consent, no initial assessment sent to physician J Patient Name: Vincent Termin ID #: Mental: Status: Exam: ?x Check boxes where appropriate. Categories when areas are unchackad a e assumed try be within normal limits at time of intake. erieial. Descri" tion: Jeep ,,," 6e e h. ensorium Co n Appearance: ?x Normal S eech Quality Orientation: Weight ? Insomnia Z Appropriate Time disorientation ? Obese ? Hypersomnia ? Hesitant ? Place disorientation ? Over-weight ? Freq Awakening ? Emotional ? Person disorientation ? Under-weight ? Nightmares ? Monotonous one n ration: ? Emaciated etita ? Mumbled ?x Good Grooming x Normal ? Slurred ? Variable 0 Well-Groomed ? Increased ? Stuttered ? Easily distracted ? Underdressed ? Decreased ? Echolalia ? Often distracted ? Overdressed ? Binging !Speech Quantity I Memory: ? Disheveled ? Purging x Responsive 0 Intact ? Bizarre ? gain/loss of pounds ? Verbose Impaired ? Soiled/body odor _ ood and-Af e-6t ? Brief Attention: Other Features Mood: ? Nonresponsive ?x Attentive ? - Wounds ? Normal ou ht=Process'" ? Inattentive r 1 Visible scars ? Euphoric es ? Selective attention ? Tattoos ? Expansive ? Normal ntelli ence: ? OlderNounger ? Elevated ? Tangential ? Mild retardation ? Glasses x? Depressed ? Circumstantial ? Moderate retardation ? Dental braces ? Dysphoric ? Flight of Ideas ? Dementia ehav'or r-1 Anhedonic ? Loose Associations erce"ton Walk x? Normal gait ? Grieving gontent: allucinations: Other Emotions: A Normal Auditory ? Limp ? Panicked ? Obsessions ? Visual ? Shuffle ? Fearful ? Poverty of thought ? Olfactory ? Assisted ?x Anxious ? Overvalued idea ? Tactile Motor Activity: ? Tense ? Delusions ? Gustatory ? Calm ? Apathetic ? Phobias issociation: ? Hyperactive ? Irritable hou ht form: ? Depersonalization ? Agitated E] Angry x El Derealization ? Tremors/Tics Other Signs: ? Psychotic E] Fugue ? Muscle Spasms Spasms [_1 Ambivalence ? Illogical thinking El Multiple Personality ? Tense/Rigid Ej Mood swings ? Autistic thinking nslig ?, ? Underactive A res i ffective x ression El Magical thinking ? Denial of disorder gg s ve x? Cheerful ? Concrete thinking ? External locus Attitude to Examiner ? Flat ? Incoherent ? Impaired x? ? Friendly Seductive ? Blunted ? Tangential ther ? Constricted ? Perseveration ? Ingratiating Ap propriateness udgemeht ? ? Indifferent F x] x? Intact ? ? ? Evasive Defensive ? Labile ? Critical ? ? Hostile ? Inappropriate ? Impaired ? sing the following scale: 0=none- 1=yes' 2=suspected 3=unknown Evidence of suicidal 0 ideation 0 intent 0 plan 0 current attempt 0 history of attempt Describe: Evidence of homicidal 0 ideation 0 intent 0 plan 0 current attempt 0 history of attempt Describe: Page 2 Patient Name: Vincent Termin ID #: PSYCHIATRIC HISTORY T` Previous Mental Health and Substance Abuse Treatment. Date of Service Provider Name Type of Treatment Duration Outcome NONE CURRENTPSYC'tIATRICMED.ICATl :-. ONS at Medication Condition Dose Fre uenc Compliant? es/No NONE List known allergies and untoward reactions to drugs: None reported SUBSTANCE USE HISTORY (check all that apply for.-:Patient} s ' r - - ubstance use status: reatlnent history:: onseguences.of substance abuse (check all that apply): " 0 no history of abuse 0 outpatient 0 withdrawal symptoms 0 binges 0 active abuse 0 inpatient 0 medical conditions 0 hangovers 0 early full remission 0 12-step program 0 sleep disturbance 0 seizures 0 early partial remission 0 stopped on own 0 assaults 0 blackouts 0 sustained full remission 0 other 0 suicidal impulse 0 overdose history 0 sustained partial remission 0 no prior treatment 0 relationship conflicts 0 tolerance changes 0 arrests 0 loss of control 0 job loss 0 other substances used: Age of Age of Current Use C.ww...,..... ..v____.. icompiete an mat app y) list use last use es/NO ' ' `4uu'"'y r?nwun[ Is there evidence that an active addict lives in the house? ? Yes ? No Are there non-chemically dependent social contacts who can provide meaningful support during recovery? ? Yes ? No Other Relevant information Page 3 Patient Natne: Vincent Termin ID #: PSYGHO-SOCIAL STRESSORS (check all that,apply for pat4nt) None Mild Moderate; Severe' Descrbe ? ? ?. . ulturaVspiritual/recreational history: ?X (Check all that are true) x? currently active in community/recreational activities? ? lost interest in community/recreational activities? x? currently engage in hobbies? x? currently participate in spiritual activities? How impaired are patient's current relationships (family for child/adol)? ® None ? Mild ? Moderate ? Severe Describe: What is the attitude of the patient's social supports re: treatment? ? N/A ® Supportive ? Willing to be involved ? Passively Opposed ? Actively Opposed Additional Relevant Psychological/Social History lives with his biological parents. He has an older brother who is 20 years of age. His brother is in college. Page 5 Patient Name: Vincent Termin ID #: FAl171iLY,RFSTOFtY (child or adolescent) MMEDIATE' FAMILY ? Information' u.nkriown j? Information not applicable Present Present Not Alcohol Drug Mental entire part of present Abuse Abuse illness Describe childhood childhood at all father ? ? ? ? ? mother ?x ? ? ? ? ? stepfather ? ? ? ? ? ? stepmother ? ? ? ? ? ? sibling(s) ® ? ? ? ? ? other(s) ? ? ? ? ? ? arents Current Marital Status: ? single, never married ? mother remarried ? engaged ? father remarried x? married to each other ? mother involved with someone ? divorce in process ? father involved with someone ? separated ? mother deceased ? divorced ? father deceased ist all 'persons currently livin in "'atient's household: Age Sex Relabonshi to patient 20 male brother Note: If patient lives in more that one household, please list second household in the additional space provided. escribe arents: atients'under 18 full name occupation Father Mickev _ Mother Moniaue Step-father Step-mother ist children not living in same household as patient: Name Frequency of visitation: Current Grade of Patient: Current School attended: Cumberland Valley HS Does the patient currently have a(n) ? IEP ? 504 plan ? Identified learning/physical disability Additional Relevant Psychological/Social History Patient is an eleventh grade student at Cumberland Valley High School. He is reported to be a good student and states that he likes school and most of his classes. Troubled recently by students spreading rumors about the causes of the accident and things that they are saying about his friends who are in the hospital. Riegler Shienvold & Associates 2151 Linglestown Road, Suit-6 20C Hanisburg, Ptnnsylvania.1711( (717) 530-1313 Fax: (717) 540-1416 W .? w :?,,w.r*eglersYAnvo:d.com Progress Note Name: Provider: James NWLI?sh, LSW Vr?. e c , Ur M7 - Date of service: 11704-2010 Session # Participants: Type of Service: x? Individual ? Family ? Couples ? Group ? Other ?t ?i? S 40 ,._._7 , xc- ,VGd Y C- o a (Continue on back, if needed) Therapist S Riegler Shienvold & Associates 2151 Linglestown Road, Suite 200 Han-Uurg, Penns, vania 1711(' (717) 530-1313 Fax: (717) 540-1416 _ V%w.r4glers,'i en*oJ6.com N ote Name: Vincent. Termin Date of service: 1-1-30-2010 Provider: James'IN,Eash, LSW Session # Participants: Type of Service: ?x Individual ? Family ? Couples ? Group ? Other ;/- 012- C (Continue on back, if needed) Therapist s RIEGLER, GRIENVOLD & ASSOCIATES 2151 LINGLESTOWN ROAD SUITE 200 HARRISBURG, PA 17110-9455 (717)54(-A1 tI3 Bill To: VINCENT TERMIN 5835 SPRING TREE COURT ENOLA, PA 17025 CLAIM #: Z01 681 34 HE Bill as of : Mar 1, 2011 Bill For: VINCENT TERMIN Date Transaction CPT Code Charge Total Amounts Previous Balance $0.00 10/27/2010 Initial Psychological Evaluation 90801 $125.00 $125.00 11/4/2010 Individual Psychotherapy 90806 $110.00 $110.00 11/30/2010 Individual Psychotherapy 90806 $110.00 $110.00 $345.00 $345.00 Please Pay this Amount: $345.00 This is a statement indicating PAYMENTS made on this account. The payor is indicated to the right of "payment'. Adjustments are to the insurance allowance. Please note that THIS IS NOT A BILL. Please call Joni if you have any questions. JAMES EASH, L.S.W. Licensed Social Worker License Number: SW-000735-E Tax Id: 23-2140660 ¦ J Q W J W F D J Q s -- LISP Package ( Encompasses Creating protection around you Amended Policy Coverage Summary Policyholder: Agent: EARL W MCCLEEREY JR MOTOR CLUB AGENCY, INC. T/A AAA INS. 5845 ASPEN LN PO BOX 1354 ENOLA PA 17025-3308 HARRISBURG PA 17110 PHONE: 800-853-8915 470-020698-0000 Policy Number: Policy Period: Policyholder Since: 280943453 03/26/2010 to 03/26/2011 12:01 AM Standard Time 03/2006 Insurance Provided By: Encompass Indemnity Company 24 HOUR CLAIM REPORTING 800-588-7400 2775 Sanders Rd.; Northbrook, IL 60062-6127 YOUR POLICY HAS BEEN CHANGED A change in insurance coverage for your 2006 LINCOLN LS Added Stacking to Uninsured & Underinsured Motorists coverage Revised Annual Policy Premium $ 3,744.00 Additional Premium for Coverages From 05/07/2010 to 03/26/2011 $ 48.00 -- This Coverage 5UhlMal providgs you With Complete policy.jnformatiorr including the above change, and represents your c>`,%r currgptty in efftcf IMPORTANT INFORMATION ABOUT YOUR POLICY WE PROVIDE COLLISION COVERAGE FOR A NON-OWNED PRIVATE PASSENGER MOTOR VEHICLE RENTED BY YOU, DURING THE TERM OF THIS POLICY, IF AT LEAST ONE OF YOUR AUTOS SHOWN BELOW HAS COLLISION COVERAGE. (THE COLLISION COVERAGE WE PROVIDE IS SUBJECT TO THE LOWEST APPLICABLE DEDUCTIBLE.) PLEASE REVIEW YOUR POLICY FOR COVERAGE DETAILS. There is not a trampoline located on your property: You do not have a woodburning stove. MOTOR VEHICLE PROTECTION - DELUXE (Coverage applies only if a premium or limit is shown) Description: VIN: Rated Driver: Use: Class Code: COVERAGES BODILY INJURY (per person/per accident) PROPERTY DAMAGE (per accident) LIMITED TORT OPTION 280943453 Vehicle 2 Vehicle 3 2006 LINCOLN LS 2010 FORD FUSION 1LNHM87A36Y600229 3FAHPODC6AR115597 EARL W MCCLEEREY JR JAMIE A MCCLEEREY Pleasure Work 3.1-9.9 2300 2302 LIMITS PREMIUMS LIMITS PREMIUMS!. $ 100,000/300,000 $ 99.00 $ 100,000/300,000 $ 110.00 $ 50,000 $ 84.00 $ 50,000 $ Applies Applies Cf7?'-- Al' Y_k-? tt President Secretary 92.00 Continued on Next Page P.- ni ?f nQ IiSP Package Amended Policy Coverage Summary MOTOR VEHICLE PROTECTION - DELUXE (Coverage applies only if a premium or limit is shown) Vehicle 2 Vehicle 3 COVERAGES LIMITS PREMIUMS LIMITS PREMIUMS' UNINSURED MOTORISTS - $- 100,000/300,000 $ 25.00 $ 100,000/300,000 $ 25.00 STACKED LIMITS (per person/per accident) UNDERINSURED MOTORISTS - $ 100,000/300,000 $ 76.00 $ 100,000/300,000 $ 76.00 STACKED LIMITS (per person/per accident) FIRST PARTY BENEFITS (FPB) COVERAGE: ADDED FPB COVERAGE Medical Expense Benefit $ Work Loss Benefit $ (per month/maximum) Funeral Expense Benefit $ Accidental Death Benefit COMPREHENSIVE (Comp) $ COLLISION (Coll) $ AIR BAG REPLACEMENT $ 24.00 10,000 $ 1,000/5,000 $ 1,500 $ Excluded 100 Deductible $ 78.00 $ 500 Deductible $ 259.00 $ Per Endorsement $ Included COVERAGE ACCIDENTAL DEPLOYMENT DEDUCTIBLE WAIVER Deductible will be waived if your windshield is repaired, not replaced. REPAIR/REPLACEMENT VALUE TOWING $ EXTENDED TRANSPORTATION Rental Reimbursement $ Trip Interruption $ Emergency Transportation $ Premium Per Vehicle Description: VIN: Rated Driver: Use: Class Code: COVERAGES BODILY INJURY (per person/per accident) PROPERTY DAMAGE (per accident) LIMITED TORT OPTION 280943453 50 $ 11.00 $ 30/900 $ Per Day/Maximum $ 30.00 100/500 $ Per Day/Maximum $ Included 20 $ Included $ $ 686.00 Vehicle 4 $ 33.00 10,000 1,000/5,000 1,500 Excluded 100 Deductible $ 121.00 500 Deductible $ 398.00 Per Endorsement $ Included Per Endorsement $ Included 50 $ 11.00 30/900 Per Day/Maximum $ 30.00 100/500 Per Day/Maximum $ Included 20 $ Included $ 896.00 Vehicle 2001 VOLKSWAGEN JETTA 3VWSK69M11M098236 CHRISTOPHER M MCCLEERE Pleasure 2100 LIMITS FREW Ms LIMITS PREMIUMS' $ 100,000/300,000 $ 271.00 $ 50,000 $ 218.00 Applies Continued on Next Page Paae 02 of 08 tP Package ( Encompass- Creating protection around you Amended Policy coverage Summary MOTOR VEHICLE PROTECTION - DELUXE (Coverage applies only if a premium or limit is shown) Vehicle 4 Vehicle COVERAGES LIMITS PREMIUMS LIMITS UNINSURED MOTORISTS - $ 100, 000/300,000 $ 25.00 STACKED LIMITS (per person/per accident) UNDERINSURED MOTORISTS - $ 100, 000/300,000 $ 76.00 STACKED LIMITS (per person/per accident) FIRST PARTY BENEFITS (FPB) COVERAGE: ADDED FPB COVERAGE $ 71.00 Medical Expense Benefit $ 10,000 Work Loss Benefit $ 1,000/S,000 (per month/maximum) Funeral Expense Benefit $ 1,500 Accidental Death Benefit Excluded COMPREHENSIVE (Comp) $ 500 Deductible $ 66.00 COLLISION (Coll) $ 750 Deductible $ 471.00 AIR BAG REPLACEMENT Per Endorsement $ Included COVERAGE ACCIDENTAL DEPLOYMENT DEDUCTIBLE WAIVER Deductible will be waived if your windshield is repaired, not replaced. TOWING $ 50 $ 11.00 EXTENDED TRANSPORTATION Rental Reimbursement $ 30/900 Per Day/Maximum $ 30.00 Trip Interruption $ 100/500 Per Day/Maximum $ Included Emergency Transportation $ 20 $ Included Premium Per Vehicle $ 1,239.00 PREMIUMS DISCOUNTS ARb CHARGES Vehicle 2 Vehicle 3 Vehicle 4 Loss Free Discount Applied Applied Youthful Good Student Discount Anti-Lock Brake Discount Applied Passive Restraint Discount (Driver and Applied Passenger side) Anti-Theft Discount (Passive Device) Applied Encompass Easy Pay Plan Discount Applied TOTAL VEHICLE(S) PREMtUi4 _Alttl J C Discounts And Charges For All Vehicles Package Discount Applied Your Total Premium For All Vehicles $ 2,821.00 280943453 Applied Applied Applied Applied Applied Applied Applied Applied Applied _.....- ---------......- .................... .. Continued on Next Page Paqe 03 of 08 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: VINCENT S. TERMIN, a Minor NO. a0?'a-- v113S C? y? l PETITION FOR COURT APPROVAL OF MINOR'S SETTLEMENT ORDER AND NOW, this 4?1A day of 2012, a hearing on the Petition for Court Approval of Minor's Settlement is hereby scheduled before the undersigned Judge on (-w0 #M Alto, 6 of the Cumb 2012, beginning at //W d , 4 .m. at erland County Courthouse. BY THE Distribution List /Michael B. Scheib, Esq. 110 S. Northern Way York, PA 17402 ? Mickey S. Termin V Monique S. Termin 5835 Spring Tree Court Enola, PA 17025 40P, e6 fKa • Im 0010 wt TI OOPS H. ridV.ey J. Common Pleas Judge CD j? to c IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: VINCENT S. TERMIN, a Minor ORDER : NO.?Ojg?'a?3s Ck\j\\ PETITION FOR COURT APPROVAL OF MINOR'S SETTLEMENT 1 M?- AND NOW, this day of 2012, it is hereby ORDERED that: 1. The Court APPROVES the Petition for Approval of Minor's Settlement. 2. A payment in the amount of $14,000.00 shall be paid by Encompass Insurance Company to Mickey S. Termin and Monique S. Termin as parents and natural guardians of Vincent S. Termin to be deposited in a savings account in the name of Vincent S. Termin, a minor. 3. There shall be no counsel fees or costs deducted from the settlement. 4. Counsel shall file an affidavit within fourteen (14) days of the date of this ORDER certifying that said payment was deposited into a savings account in the name of Vincent S. Termin, a minor. JUDGE f Distribution List C= ? Michael B. Scheib, Esq. ? 110 S. Northern Way rn? -r M:- York, PA 17402 V Mickey S. Terrain r-- v Monique S. Termin 5835 Spring Tree Court 20 Enola, PA 17025 COT'. e,5 U ,ve,t b1i J 4? fv I f IN THE COURT OF COMMON PLEAS OF CUMBERLAND CONY; PENNSYLVANIA k, i i F-11-11 11, ?: IN RE: VINCENT S. TERMIN, a Minor ?LLLf1_.&t{m?`l6UJt: NNSYL?,?ANIA NO. 2012-2135 Civil PETITION FOR COURT APPROVAL OF MINOR'S SETTLEMENT AFFIDAVIT OF DEPOSIT OF MINOR FUNDS The undersigned, hereby certifies that on May 15, 2012, payment in the amount of $14,000 was issued by Encompass Insurance Company to Mickey S. Termin and Monique S. Termin as parents and natural guardians of Vincent S. Termin to be deposited in a savings account in the name of Vincent S. Termin, a minor, pursuant to this Court's Order. Proof of payment is attached hereto as Exhibit "A". The undersigned further certifies that reasonable efforts were made to obtain proof from Mickey S. Termin and Monique S. Termin that the $14,000 was deposited into a savings account in the name of Vincent S. Termin, within the fourteen (14) days of the date of the Order, but was unable to do so until today, May 31, 2012. A print-out of the account information is attached as Exhibit "B". GRIFFITH, S SOLYMOS4 Date: May 31, 2012 BY: ERICK . VI G( Attorney I.D. 02344 Attorney for Plaintiff 110 S. Northern Way York, PA 17402 (717) 757-7602 LERMAN, ESQUIRE 05/15/2012 14:04 61,04012371 ENCOMPASS INSURANCE PAGE 01/01 pZ - RAYM ENT .T.Nr-PRp.?nTS ON nLC Ze CL-Ay"- z9, 9e1 ?4 vFSiK.. ZM SN/Pcan MCCLL?L'fSGr .JR EARL N LN xC=r7Ar PnYEE AMOUNT C/C ,/DRAFT.. uar-R/z0 4?g O4 O? 1 ?, ^ MR Q MRH Tr'R"X" PARGNT"S .h 1 aOAra c7n gzc7PPEc °q'?EE MR Ba MR:.i TERMTN pgRENTB Br Gu ARPT nplg M2NVR VSNCENT 7 'TERM2N Moon'- 7 r'90Z EDRXNM TREE Co%l RT GSTV ENOUA mr can r_xa ,-v2s lien A n n R E 8 8 G S T Y 8r ?= P R/C R8td CLAM" cOR nDVZtY 2?.IJ U/2v 8FM CVCO Pr PROM THRU C rE Dc TR iIf„ BODx R ? 14 E L E C T C LM T RUTH/2o ?,?7-l ee` REV AMT V G N O O R- T Y N E X P E N S E rYR1= C ACG'Y mee nT A PMr/AMOUNT ".,A QRO$'/m=l_l_ NTr I ?a9e, ee P14A A Re E HW going ghat counts. Stisquehanna V4 800-311-3182 ... Internet Banker Support The "Available Funds" shown may include sweep balances from your line of credit or savings accounts. Click on Susquehanna Bank: Account Info SUSC]uetlQ! m,* Doing what counts. View Account Information lore Savings 5120 Account In/ormaHon Page 1 of 1 Currant Account Informaton Savinas 5120 / VINCENT S TERMIN Cuatomr Naas VINCENT b TEMUN WONIOVE a 7MUN 5935 EPRINO TREE CRT ENOLA PA 17025 Current Balance 14,076.00 Available Balance 14,076.00 Colleoted Balance 14,0'I6.00 Date of Last poposit 5/24112 Aaamt of Last Dal.eit 14, 000.00 Data of SYt statement 4/01/12 Seat statement aalanw 75.99 Interest Rata 0.1000001 Currant Petiod Iatareat 0.24 Sast Interest Paid 0.01 Data feat Intoro t Paid 4/30/12 Interest Paid Taar to Date 0.03 Inbarest Paid Last Yeat 0.49 Mallow FDIC C""0111 M O 1999.2012 O.WMt ftlk r pro0ud reawd br lack HaM a A..O.tM I- LFNO BIR Terms k Corldalorm gy31i y SgFjpt Susnuehanna Bahr Horne Pam https://cm.netteller.com/login2008Niews/Retail/Accountlnfo.aspx 5/31/2012 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: VINCENT S. TERMIN, NO. 2012-2135 Civil a Minor PETITION FOR COURT APPROVAL OF MINOR'S SETTLEMENT CERTIFICATE OF SERVICE AND NOW, this 31" day of May, 2012, I, Judith M. Becker, paralegal for Erick V. Violago, Esquire, a member of the firm of Griffith, Strickler, Lerman, Solymos & Calkins, hereby certify that I have this date served a copy of the Affidavit of Deposit of Minor Funds, by First-Class Mail, postage prepaid, addressed as follows: Mickey and Monique Termin 5835 Spring Tree Court Enola, PA 17025-1183 GRIFFITH, STRICKLER, LERMAN, SOLYMOS & CALKINS BY: Jud' h M. Becker, Paralegal for ERI K V. VIOLAGO, ESQUIRE Attorney I.D. 202344 Attorney for Plaintiff 110 S. Northern Way York, PA 17402 (717) 757-7602