HomeMy WebLinkAbout13-5138 .
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JOHNSON, DUFFIE, STEWART&WEIDNER s 4;1S I`LVP l�'� Attorneys for Defendant
J
By: Matthew Ridley Erie Insurance
I.D. No. 204265
301 Market Street
P. O. Box 109
Lemoyne, PA 17043-0109
(717) 761-4540
mr @jdsw.com
IN RE: IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COU , LV IA
E DDIE C. LOCKE, a Minor
NO, )7PY
ltl� .
PETITION TO APPROVE MINOR'S SETTLEMENT
AND NOW, comes the Petitioner, Codeal Locke, as parent and natural guardian
of Eddie C. Locke, a minor, and Petitions this Honorable Court to approve settlement of
the personal injury claims of Eddie C. Locke against Eddie Mullen, Ill, and Erie
Insurance ("Erie") and in support thereof aver as follows:
1. This matter arises out of an accident of October 9, 2012, which occurred
when hot blacktop from a dump truck burned portions of the neck, shoulders and upper
chest of minor Eddie C. Locke while he was helping his uncle, Eddie Mullen, 111, patch a
driveway in Altoona, Pennsylvania.
2. Eddie Locke was born on April 28, 1996, and is the son of the Petitioner,
Codeal Locke, his natural parent and guardian.
3. The Lockes reside at 4045 George Busbee Parkway, Kennesaw, Georgia
30144.
4. Mr. Mullen resides at 90 Salem Church Road, Lot 524, Mechanicsburg,
Pennsylvania 17050, and so resided at the time of the accident.
5. Mr. Mullen has commercial automobile liability insurance coverage
applicable to this matter through Erie Insurance in the amount of $500,000.00 per
person. (See Mr. Mullen's declarations page attached as Exhibit A.)
6, Because Eddie Locke is a minor and is not represented by counsel, this
Petition has been drafted by counsel retained by Mr. Mullen's liability carrier.
7. Eddie Locke treated as an outpatient at Altoona Hospital for his burns on
October 9, 15 and 24, 2012. (See the records of Altoona Hospital attached as Exhibit
B.)
8. On October 9, 2012, he was described as having a 2 x 4 centimeter area
of 1st degree burn mixed with small ruptured blisters of 2nd degree burn on the back of
his neck; tiny ruptured blisters/spots of 3d degree burn at the back of both ears; a blister
of 2nd degree burn at the left inner upper arm; and primarily first degree burns at the
shoulder and lateral upper arms. (Exhibit B at p. 2.)
9. Eddie Locke has not treated for his burns since October 24, 2012, and has
fully recovered from injuries, although he does have some residual skin discoloration.
110. The parties have agreed to settle Eddie Locke's personal injury claim for
$15,000.
11. In consideration of the fact that Eddie Locke is 17 years of age and will
reach 18 years of age on April 28, 2014, Petitioner requests this Court authorize the
carrier to pay a lump sum of$15,000.00 via check, payable directly to Eddie Locke.
12. In the alternative, Petitioner proposes that $15,000.00 be paid in a lump
sum and deposited into a restricted minor's account for the benefit of Eddie Locke at
Wells Fargo Bank, 2778 Cobb Parkway NW, Kennesaw.
13. Codeal Locke, as parent and natural guardian of Eddie Locke, joins this
Petition and agrees that the proposed total settlement of $15,000,00 is in the best
interest of her son, Eddie Locke. (A signed Verification of the Petitioner is attached as
Exhibit C.)
14. If this Court so requires, the undersigned counsel shall cause to be filed
with the court a document of the court's choosing as proof that a total of$15,000.00 has
been deposited in a restricted account for the benefit of Eddie Locke.
15. If approved by this Court, the settlement will be memorialized by a general
release signed by the Petitioner. (A copy of the proposed release is attached as Exhibit
E.)
16. No suit has been filed in this matter, as settlement has been reached
without litigation.
17. No attorneys' fees or costs will be taken from the proposed settlement
funds.
WHEREFORE, Petitioner Codeal Locke, as parent and natural guardian of Eddie
C. Locke, a minor, respectfully requeststhis Honorable Court authorize the parties to
enter into this agreement and sign the Order disbursing funds as outlined above.
Respectfully submitted,
JOHNSON, DUFFIE, STEWART & WEIDNER
BY:
Matthew Ridley, Esquire
Attorney I.D. No. 204265
301 Market Street
P.O. Box 109
Lemoyne, PA 17043-0109
(717) 761-4540
mr@jdsw.com
Date: August 2013 Counsel for Petitioner
as Parent Natural Guardian of
Eddie C. Locke, a Minor
Date: August��, 2013
569805
EXHIBIT A
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CF3 ERIE INSURANCE EXCHANGE
PIONEER COMMERCIAL AUTO POLICY
NON-FLEET i
AMENDED DECLARATIONS 02 * * EFFECTIVE 03/20/12
ATTACH THIS TO YOUR POLICY.
REASON FOR AMENDMENT - AUTO 16 ADDED
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AA7777 CONSUMERS INS AGY INC. 03/10/12 TO 03/10/13 Q03 1030696 H7
' I
EDDIE MULLEN III AS LISTED BELOW
90 SALEM CHURCH RD
LOT 524
MECHANICSBURG PA 17050-5275
ADDED AUTO 16 05 ATM TRLR 1A9FB20255L429324
• YOUR COLLISION COVERAGE AND DEDUCTIBLE APPLY TO PRIVATE PASSENGER
• AUTOS YOU, A PARTNER OR EXECUTIVE OFFICER RENT FOR 45 DAYS OR LESS. * i
• THIS IS SUBJECT TO LIMITS, TERMS AND CONDITIONS IN THE POLICY.
*************************************************************************
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ITEM 4 . AUTOS COVERED
AUTO YR MAKE VIN ST TER SYM CM CL RATING CLASS
10 04 FORD F650 SUPE 3FRNF65224V615263 PA 4F V6 8
11 00 HIRED AUTO PRIMARY BASIS PA 4F j
12 00 NON-OWNED AUTO 1 - 25 EMPLS PA 4F
13 11 FORD PU 1FTFWIETXBFC62206 PA 4F U2 6
14 10 FORD MUSTANG 1ZVBP8AN2A5152781 PA 4F J I CPB
15 11 FORD TAURUS SEL 1FAHP2EW5BG100540 PA 4F I 50 46 CPB
16 05 ATM TRLR 1A9FB20255L429324 PA 4F D6 8
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ITEM 5 . INSURANCE IS PROVIDED WHERE A PREMIUM, OR INCL, IS SHOWN FOR THE
COVERAGE. COVERAGES, LIMITS AND ANNUAL PREMIUMS ARE AS FOLLOWS-
M EQUALS THOUSAND $ # 10 # 11 # 12 # 13 # 14 # 15
LIABILITY PROTECTION-
BOD INJ & PROP DAMAGE $500M/ACC 351 334 262 26
HIRED AUTOS LIABILITY-
BOD INJ & PROP DAMAGE $50OM/ACC 41
EMPLOYERS NON-OWNED AUTOS LIABILITY-
BOD INJ & PROP DAMAGE $500M/ACC 51
FIRST PARTY BENEFITS-
MEDICAL EXPENSE $25M 16 16 21 2
INCOME LOSS $1M/MONTH, $15M MAXIMUM 5 5 7
ACCIDENTAL DEATH $10M 4 4 4
FUNERAL BENEFIT $2. 5M 2 2 2
UNINSURED MOTORISTS COVERAGE-
BODILY INJURY $300M/ACC-UNSTACKED 21 21 17 1
UNDERINSURED MOTORISTS COVERAGE-
BODILY INJURY $300M/ACC-UNSTACKED 84 84 91 9
PHYSICAL DAMAGE COVERAGES-
COMPREHENSIVE - $500 DED 63 109 85 8
COLLISION - $500 DED 291 319 326 29 i
HIRED AUTOS PHYSICAL DAMAGE-
COMPREHENSIVE -- $500 DED 5
COLLISION - $500 DED 10
TOTAL ANNUAL PREMIUM FOR EACH AUTO 837 56 51 894 815 78
ADDITIONAL CHARGE DUE TO THIS CHANGE $ 47
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M EQUALS THOUSAND $ # 16
LIABILITY PROTECTION-
BOD INJ & PROP DAMAGE $500M/ACC 29
PHYSICAL DAMAGE COVERAGES-
COMPREHENSIVE - $100 DED 5
COLLISION - $250 DED 14
TOTAL ANNUAL PREMIUM FOR EACH AUTO 48
TOTAL ANNUAL POLICY PREMIUM $ 3,482
ITEM 6 . APPLICABLE POLICY, ENDORSEMENTS, EXCEPTIONS TO DECLARATIONS ITEMS
ALL AUTOS - CAP 04/96, ACPA01 03/09, UF2772* 11/11, UF019O* 06/11, i
UF2106* 04/08 .
AUTO 10 - ABAZ09 06111, AHPU01 11/11, ABPNOI 10/98.
AUTO 11 - ACPA 12/95.
AUTO 13 - ABAZ09 06111, AHPU01 11/11, ABPNOI 10/98 ..
AUTO 14 - ABAZ09 06111, AHPU01 11/11, ABPN01 10198.
AUTO 15 - ABAZ09 06111, AHPU01 11/11, ABPN01 10/98 .
Q03 1030696 CONTINUED ON NEXT PAGE
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ERIE INSURANCE EXCHANGE
PIONEER COMMERCIAL AUTO POLICY
NON-FLEET
AMENDED DECLARATIONS 02 * * EFFECTIVE 03/20/12
ATTACH THIS TO YOUR POLICY.
REASON FOR AMENDMENT - AUTO 16 ADDED
AA7777 CONSUMERS INS AGY INC. 03/10/12 TO 03/10/13 Q03 1030696 H7
EDDIE MULLEN III
90 SALEM CHURCH RD
I
LOT 524
MECHANICSBURG PA 17050-5275
WTI-THEFT DISCOUNT APPLIES-PASSIVE DISAB AUTO 14
PASSIVE RESTRAINT DISCOUNT APPLIES - MULTIPLE AIRBAGS AUTO 14
PASSIVE RESTRAINT DISCOUNT APPLIES - MULTIPLE AIRBAGS AUTO 15
ANTI-LOCK BRAKE DISCOUNT APPLIED AUTO 14
ANTI-LOCK BRAKE DISCOUNT APPLIED AUTO 15
EXPLANATION OF COMMERCIAL PASSENGER RATING CLASS j
AUTO 14 - COMMERCIAL - BUSINESS USE
AUTO 15 - COMMERCIAL - BUSINESS USE
MISCELLANEOUS INFORMATION I
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TRUCKS TRACTORS TRAILERS RADIUS OF OPERATIONS
50 MILES UNLESS OTHERWISE SPECIFIED i
VEHICLES - RADIUS OF OPERATIONS - 51-100 MILES
010 013
ITEM 7 . EACH AUTO WE INSURE WILL BE PRINCIPALLY GARAGED AT THE ADDRESS SHOWN
IN ITEM 1, UNLESS ANOTHER ADDRESS IS SHOWN BELOW.
ITEM 8 . EACH AUTO WE INSURE IS USED IN THE BUSINESS AS SHOWN BELOW.
ITEM 8 DRIVEWAY/SIDEWALK CONSTRUCTION
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ITEM 9 . UNLESS OTHERWISE INDICATED BELOW, THE NAMED INSURED IS THE SOLE
OWNER OF EACH AUTO WE INSURE.
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ADDITIONAL INSURED FOR AUTO 10 LIENHOLDER FOR AUTO 10
GDM LEASING INC GDM LEASING INC
WESTERN AVE WESTERN AVE
PO BOX 70 PO BOX 70
TEMPLE PA 19560-0070 TEMPLE PA 19560-0070
ADDITIONAL INSURED FOR AUTO 13 LIENHOLDER FOR AUTO 13
GDM LEASING INC GDM LEASING INC j
PO BOX 70 PO BOX 70
TEMPLE PA 19560-0070 TEMPLE PA 19560-0070 j
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ADDITIONAL INSURED FOR AUTO 14 LIENHOLDER FOR AUTO 14
GDM LEASING INC GDM LEASING INC
PO BOX 70 PO BOX 70
TEMPLE PA 19560-0070 TEMPLE PA 19560-0070 j
ADDITIONAL INSURED FOR AUTO 15 LIENHOLDER FOR AUTO 15
GDM LEASING INC GDM LEASING INC
PO BOX 70 PO BOX 70
4450 FIFTH STREET HIGHWAY 4450 FIFTH STREET HIGHWAY
TEMPLE PA 19560-0070 TEMPLE PA 19560-0070
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Q03 1030696
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EXHIBIT B
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Locke;Eddie C
ALTOONA REGIONAL DOB:4/28/1996 MI6
W01 72:6 Kg"*L'
PgERY MedRec:000000508512
A=um:000306972555
Patient Data
Complaint:Black top all over body walls—in/ah
Triage Time:Tue Oct 09,201217:21 ED Attending:Miller,Rebecca
Urgency:ESI 2 Primary RN:Boyek,Michael
Bed:1:D TEAMZ
Initial Vital Signs: 10/9/201218:55
BP: R:
P: T:
02 sat: Pain:7
DIAGNOSIS(eons ttm
FINAL-PRIMARY:2nd degree burn.
VITAL.SIGNS
VITAL SIGNS:Pain:7,Time::10/9/2012 18:55.o8:55 MM)
BP: 149169,Pulse:73,Resp: 18,02 sat:99%on.ra,Time: 10/9/201219:05,(i¢m mm)
Ti
Temp:97.9oral, me: 10/9/2012 19:08.am M'M')
Pain:5,Time: 10/9/2012 19:08.(1,9:09 Mrs
PAST MEDICAL WSTORY(wed occ io.=21s1s echo
MEDICAL HISTORY:No past medical history.
SURGICAL HISTORY. Patient has had no previous surgical history.
PSYCHMTRICHISTORY•No previous psychiatric history.
SOCIAL HISTORY.. "lives in geocgia"—in Altoona doing temporary work for uncle—
dropped ont of high school.
BPI BURN iw-d Oa 10..201215n4 RCMP
CHIEF COMPLAINT.•Patient presents for the evaluation of tad degree.
HISTORIAN,•History obtained.from patient.
77ME COURSE:Onset of symptoms reported as sudden,Just prior to
presentation.
QUALITY:Pain is burning.
CONTEXT.•Ruptured.
LOCATION:The%of total area burned is 5.
NOTE'S: 16 year old male—denies any past medical history—presents after accidently
pouting hot asphalt on himself.about 30 minutes prior to arrival.He was working of the pouring arm
of-the vehcile,swung it wrong and some poured on the back of his neck and upper arms.Pt says that
his coworkers immediately poured deisel on him to get it off.Denies syncope,headaches,sob,chest
tighthness.
ROS coved Oct 10.201215:14 RCM)
CONST7TU770NAL:No weakness.
CARDIOVASCULAR:No chest pain.
RESPIRATORY•No Cough,SOB.
GL•.No abdominal pain,nausea,vomiting.
Prepared:Wed Oct 24,2012 20:51 by KEK Page:I of 7
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Locke,Eddie C
DOB:4/29/1996 M16
ALTOONA REGIONAL Wtilk 72.6-Kg(est.).
PRIMARY �:000306972555
NEUROLOGIC:No headache,focal weakness.
ALL SYSTEMS NEGATIVE:All relevant systems reviewed and all negative except for the
above.
PHYSICAL EXAM(Wed oet 10.2012 15.18 RCM)
CONST7070NAL:Patient is afebrile,Vital signs reviewed,Patient has normal pulse,normal
blood pressure,normal respiratory rate.Welk appearing,Alert and oriented X 3,Patient
appears uncomfortable,Patient has mild pain distress.
HEAD.Atraumatic,back of neck has 2 x 4 cm area of 1 st degree burn mixed with some small
raptured blisters of 2nd degree burn.
EYES.-Eyes are normal to inspection,Pupils equal,round and reactive to light,Sclera are
normal,Conjunctiva are normal.
ENT.• back of both ears have tiny ruptured blisters?spots of 3rd degree bars as pt's pain
is not very sevem ear canals unaffected.
NECK.•Normal ROM.
RESPIRATORY CREST-Chest is nontender,Breath sounds normal,No respiratory distress.
CARDIOVASCULAR:.RRR
ABDOMEN:Abdomen is nontender.
UPPER EXTREMITY.• left inner upper arm has unruptared blister of second degree burn—
aboat 4% bsa.shoulder and lateral upper arms bilaterally have primarily first deree burns.
LOWER EXTREMITY.•Inspection normal.
NEVRO:.GCS is 15,No focal motor deficits.
SKIN:Skin exam.normal except as noted.
PSYCHIATRIC.•Oriented X 3.
DOCTOR NOTES
TEXT.- pt is'in from out of town—no doctor—no plan to go home for at least 6 weeks.i
instructed him to return here for follow up care.
there is at worst 4.5%bsa 2nd degree burns—pt given silvadene and care instructions—return
here is worse immediately and come back.for a recheck in 1 week if getting better.tetanus up to date.
no distres&pain controlled.(wed am lo.201215:19 RCM)
black top was removed by nursing with water in decon room prior to my exam.(wedoct
10.2012 15:20 RCM)
CURRENT MEDICATIONS
No recorded medications
MEDICATION ADMINISTRATION SUMMARY
Fpiji.Name JDose Ordered lRoute JSw= ITime
Percocet 5/325 51325 two to o JP0 10rder6d 213210/912012
Dilaudid 11 Mg 1XV lGivda 17:54 1019/1012
Detailed record available in Medication Service section.
Prepared:Wed Oct 24.2012 20:51 by IEK Page:2 of 7
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Locke,Eddie C
DOB:4/28/1996 M16
ALTOONA REGIONAL WtfHt»72.6 Kg(at.)
PRIMARY AAAcccttNurn° 97zss5
TRIAGE(17:21 AM)
TRIAGE NOTES. pt reports black top to upper body.pt direct-to Decon shower.
(11:21 AM)
P_A77ENT.-AGE: 16,GENDER male,DOB:Sun Apr 28, 1996,TIlVIE OF GREET:Tue Oct 09,
.2012 17:13,TETANUS:CURRENT,Current vaccinations:None,Ambulance Patients:N/A,KG
WEIGHT:72.6(est.),MEDICAL RECORD NUMBER 000000508512,ACCOUNTNUMBER
000306972555,PERSON ID:000306972555,Admitting:Out of area,.(17.21 Aowu
NAME:Locke,Eddie C,SSN:2599504'19.(18:16)
PHONE:(706)631-9021.am
ADMISSION.URGENCY:ESI 2,ADMISSION SOURCE:A.Private Residence,TRANSPORT:
A.Walk In,DEPT:Emergency,BED:WAFTING.(17:21 AOWI)
COMPLAINT.- Black top all over body walk—in/ah.wai Aowl)
ADDMONAL VftAL SIGN INFORMATION:Blood.pressure to the right,Pulse is regular_
n9:os nos)
SUICIDE ASSESSMENT,-Suicide risk,patient denies suicidal ideations.am mm)
MENTAL STATUS.Conscious,Oriented X3,GCS Eye Opening::4,GCS Verbal Response:5,
GCS Motor Response:6.(19:05 mlr»)
SPEECH.•Cohereat.agzmrys)
FALL RISK.•No risk for fall.o9:os m 1i)
SKIN:Temperature is warm.,Moisture is dry,Turgor is good.(19:as mm)
PAIN.-Triage assessment performed:(19:05WB)
KNOWN ALLERGIES
No recorded allergies
NURSING ASSESSMENT:SKIN
NOTES: Agree with triage note.
Patient has reddened area to anterior and posterior arms B/L with some blistering around wrists,
Patient has reddened and blistering area to back of neck.
Skin under hairline appears unaffected.
Approximate area affected 15-20%.(arses B/L and area to back of neck)
Patient reports_diesel fuel was used to wash off tar.ay 2)msrs)
CONSTITUTIONAL:Complex assessment perfoiined,Patient arrives ambulatory with steady
gait to treatment area,History obtained from patient,Patient is cooperative,alert and oriented x 3.
Patient appears in no acute distress,Patient's mucous membranes are moist and pink,Patient
arrives to treatment area ambulatory,Patient with steady gait oui m 1B)
SKIN.Pain described as burning,Pain is continuous,Bung.(18:31
mvs)
Prepared:wed Oct 24,201220:51 by KE K Page:3 of 7
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Locke,Eddie.C
ALT04NA REGIONAL 4/28/1996 M16
772. x
P�Y MedRec:000000508512
AcctNum.000306972555
MEDICATION SERVICE
Dilaudid: Order:.Dilaudid(Hydromorphone Hydrochloride)-Dose: 1 mg:IV
Ordered by:Rebecca Miller
Entered by:Rebecca Miller Tue Oct 09,2012 17:57
Documented as given by:Jennifer Hewitt Tue Oct 09,2012 17:54
Patient,Medication,Dose,Route and Time verified prior to administration.
Verbal order read back and verified,Amount given: lmg,IV SITE#1 IVP,initial medication,Slowly,
Connections checked prior to administration,Line traced prior to administration,Catheter
placement confirmed via flush prior to administration,IV site without signs or symptoms of infiltration
during medication administration,No swelling during administration,drainage during administration.
IV flushed after administration,Correct patient,time,route,dose and medication confirmed prior to
administration,Patient advised of actions and side-effects prior to administration,Allergies
confirmed and medications reviewed prior to administration,Patient in position of comfort,Side rails
up,Cart.in lowestposition.
Percocer.5 1325: Order.Percocet 5/325(Acetaminophen)-Dose:5/325-two to go:
PO
Ordered by:-Katrina Pipetti
Entered by:Katrina Pipetti Tue Oct 09,2012 21:32.
NURSING PROCEDURE: NURSE NOTES
TIME. Time: 1721,Dr.Blescia notified of pt arrival,Charge RN notified,pt to decon room.
(17.50 AM)
IV fluids infusing.(18:32 WD)
1900 LR infusion complete.(19:01 Mrs)
Patient reported reduction in pain.(19:o9 are)
10/9/121800 LR infusion initiated;on IV pump at 1000ml/hr initiated by J.Hewitt RN.(wed Oct
10.201215:13 MM)
VITAL SIGNS.•Pain:7,Time: 1850.(is:s5 MrB)
BP: 149,/69,Pulse:73,Resp: 18,02 sat:99%,ra,Time: 1838.(19:m mm)
Temp:91 9oral.(19:01 M18)
Pain:5.(19:09 Mrs)
NURSING PROCEDURE: CARDIAC MONITOR os.1 Mrs)
TIME.:Patient's identity verified by,patient stating name,patient stating birth date,Procedure
was performed at 1820,Patient placed on cardiac monitor,placed on continuous pulse Oximetry.
Strip posted on chart,Disposable BP cuff applied,After procedure,patient tolerating monitoring,
After procedure,alarms set and on.
NURSING PROCEDURE:DECONTAMINATION(1sa4a.xs)
TIME:Time of arrival 1721,Arrived by,private vehicle,Contaminant asphalt,Confirmed,
Contaminant was liquid,Contamination was dermal,Contaminate was in body cavities,0-5 other
people contaminated,In the ED clothing was removed,Head to toe soap and water,Body cavity
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Locke,Eddie C
DOB: 811996 M
ALTOONA REGIONAL Wt/H 72.6 Kg(estl}
PRIlIZARY MedRec:000000508512
Acc tNum:000306972555
irrigated,.After procedure;runoff collected in.a self contained drainage system,Decontamination
completed at.1750.
SAFETY.•Side rails up,Cart in lowest position.
NURSING PROCEDURE:DISCHARGE NOTE r_i:31 MXL3)
TIME:Patient discharged to,home,Patient,ambulates without assistance,Transported via
fnend/family driving,Accompanied by family member,Patient instructed not to drive home,Discharge
instructions given to,patient,Simpletmoderate discharge teaching performed,Name of
prescription(s)given:Toradol,Percocet,Prescription given and additional instructions on side
effects of same given,Above Persons)verbalized understanding of discharge instructions and.
NURSING PROCEDURE:IV
ME. Patient's identity verified by,patient stating name,patient stating birth date,hospital ID
Bracelet,Indications for procedure:medication administration,Procedure performed at 1750,IV
established, 18 gauge catheter inserted,into right wrist,#1 site,in I attempt,Saline lock established,
Amount 10ml,Labs drawn at time of placement,Labs labeled and sent to lab,After procedure,no
swelling noted at site,After procedure,no drainage noted at site,After procedure,no redness,
Sterile dressing applied,20 ensure dressing applied,Patient tolerated procedure well.(17:56
sKS)
Patient's identity verified by,patient stating name,hospital ID bracelet,at 2125,Discontinued due
to,patient being discharged,Care after removal,sterile dressing applied.(21:30 MM)
Procedure performed at late entry 1803,LR 1 Liter hung, 1st bag hung,IV bolus of 1000 ml
established,via pump tubing,on IV pump.cwwoa 10,201212=1EBB>
SAFETY.•Side rails up,Cart in lowest position,Call light within reach.mm sKB1
NURSING PROCEDURE:MEDICATION
MWICA770N•Patient's identity verified by,patient stating name,patient stating birth date,
Procedure was performed at 1855,DILAUDID, Img,given IVP,Repeat.same medication,IV site
without signs or symptoms of infiltration during medication administration,No swelling during
medication infusion,drainage during medication infusion.Per VO Dr.Miller.(16s5
MA)
Patient's identity verified by,patient stating name,hospital ID bracelet,SILVADENE,VO Dr
Miller.Silvadene applied to barns.(n-.471wa.3)
IMAGING
.ACUITY.• Image captured from scanner.(22:10 nxB)
DISCHARGE: Image captured from scanner.(22:11 nsB)
PROCEDURES AND TESTS. Image captured from scanner.(s2:uDrz)
ACUITY.• Page 002 added.Image captured from scanner.(2211 nxB)
Page 003 added.Image captured from scanner.(uc11 DxB)
Page 004 added Image captured from scanner:(2212 DKB)
Page 005 added.Image captured from scanner.(nag DKB)
DEMOGRAPHIC: Image captured from scanner.(x:12 M)
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Locke,Eddie C
ALTOONA REGIONAL DOg:4/28/1996]V116
Wt1Ht:72.6 Kg(est)
PRIMARY MedRec:000000508512
AcctNum:000306972555
MED TO GO: Image captured from scanner.(29c47 Cxo)
ACUITY- Image captured from scanner.(23:48 cxo)
Page 002 added Image captured from.scanner.(3:49cxo>
Page 003 added.Image captured from scanner.(m:48 cxo)
ORDERS
1 liter ns bolus by Miller,Rebecca-for Miller,Rebecca on Tue Oct 09,2012 17:57 Status:Done by
Beiswenget,Sarah Tue Oct 09,201218:03
DISPOSTPION
PATIENT• Disposition:A.Home,Condition:Stable.(2o:uRcw
TRANSFER IN:NO,Hold Patient:No,IV Wed @ discharge:YES,.Remove from F.R.(2131
ice)
ADhM
DIGITAL SIGNATURE: Miller,Rebecca.(Wed Oct 10.201215:19ACNO
Miller,Rebecca.coved oct 1o.201215:20 RCM)
INSTRUCTION rio:l6 Rcm)
DISCHARGE. BURNS.
SPECIAL: Keep your burns clean and redress them with more of the cream we gave you daily.
Since you do not have a doctor—if everything looks ok—come back to the ED in 1 week for a
re—examination.
If any of the burns are looping worse,please come back immediately.
PRESCRIPTION(20:16 RCM)
Percocer-51325: Tablet:.325 mg-5 mg:Oral:Quantity:*** l ***Unit:PILL Route:Oral
Schedule:Take As Needed Every 4-6 Hours Dispense: ***25***.
NOTES. No ref I ls
May substitute
Prescriber DEA:FM2427688
Prescriber NPI: 1184884595
Prescriber Medical License Number.MD441916.
Toradol: Tablet: 10 mg:Oral:Quantity:*** 1 ***Unit:PILL Route:Oral Schedule:every 6
boors Dispense:***20***.
NOTES. No refills
May substitute
Prescriber DEA:FM2427688
Prescriber NPI: 1184884595
Prescriber Medical License Number.MD441916.
Prepared:wed Oct 24,2 012 20:51 by KEK Page:6 of 7
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Locke,Eddie C
ALTOONA REGIONAL DOB:4/28/1996 M16
Wt/Ht'72.6 Kg(em)
PRIMARY MedRec:000000508512
AcctNum:000306972555
Key:
AOW1=Wagner,Ashley C%0--Oakes,Chelsea DKB=Brandt,Donna JLHS=Hewitt,Jennifer
KLP--hpett4 Katrina MJB=Boyek,Michad MXL3=Lander,Maria RCM=Mifler,Rehecca
SKB=Beiswenger,Sarah
Prepared:Wed Oct 2 4,2012 20:51 by KEK Page:7 of 7
�Altoona Regionai!!!!l�I�VIII VIII III �fil III11!1111 lIN!lII�III IlIII IIi�Illll end °�:';�8,196
f.-Health Sy�rn
MedRec:000000508512
lll�Ilill IIIO�I�IIIII� I Ills�I��I�Illll 1111111111 II Ill Ili) Attending:RC 6972555
M
Primary RN.WB
Bed:ED TEAM2
ALTOONA REGIONAL
MEDICATION RECONCHJATION
Your medication list is based on the information available to us at the time of your visit. It may not represent your
complete list or recent changes made.to your medications.It is important that you follow—up with your physician
with any medication questions or concerns you may have.
You were seen in.the Emergency Department on:Tue Oct 09,2012
MEDICATIONS GIVEN WHILE IN THE EMERGENCY DEPARTMENT
Dilaudid(Hydromorphone Hydrochloride)—Dose: 1 milligram(s):IV
PRESCRIPTIONS
ToradoI:Tablet: 10 mg:Oral
Dispense:20,Quantity: 1,Unit:PILL,Route:Oral,Schedule:every 6 hours
Percoce1-5/325:Tablet 325 mg-5 mg:Oral
Dispense:25,Quantity: 1,Unit:PILL,Route:Oral,Schedule:Take As Needed Every 4-6 Hours
Prepued:Wed Oct 24.2012 2051 by IEK 1 of I
Altoona Regional
EMERGENCY FLOW SHEET RECORD
Name:Locke,Eddie C Age:16Y MR:000000508512 Acct:000306972555
VITAL SIGNS MIB M B M B min
TIME 10/9/2012 19:08. 10/9/2012 19:08 ,10/9/2012 19:05 10/9/2012 18:55
BP 149/69
PULSE 73
RESP 18
TEMP 97.9oral
PAIN 5 7
02 SAT i 199%on ra
Name:Locke,Eddie C Age:16Y MR:000000508512 Acct:000306972555
Prepared:Wed Oct 24 20:51:20 2012 by KEK Page: 1
1111111111IIIIIhiIIIII[III{Illl�IIIIIIII�IIII�II�liflll�l(111111 I(II(III�IIIIII(I�II�(III��I�III���II!([<lfl�(ll[Iffllf(��f
Locke,.Eddie C
DOB:428/1996 M16
ALTOONA REGIONAL R Wt/HC 72.6 Kg(est.)
MEDICATION RECONCILIATION MedRec:000000508512
AcctNum:000306972555
Patient Data
Complaint Black top all over body walk—in/ah
Triage Time:Tue Oct 09,201217:21 ED Attending:Miller,Rebecca
Urgency:ESI 2 Primary RN:Boyek,Michael
Bed:ED TEAM2
Initial Vital Signs: 10/9/2012 18:55
BP: R:
P: T:
02 sat: Pain:7
MEDICATION ADMINISTRATION SUMMARY
I Druz Name Dose Ordered lRoute IStatw 17one
Percocet 51325 . _ 51325-two to. o jP0 10rdered 21:3210/9/2012
Dilaudid. 11 Ing JIV Given 117:54 10/9P-012
Detailed record available is Medication Service section.
PRESCRIPTION
Percocet-51325: Tablet:325 mg—5 mg:Oral:Quantity:*** 1 ***Unit:PILL Route:Oral
Schedule:Take As Needed Every 4-6 Hours Dispense:***25***.
NOTES: No refills
May substitute
Prescriber DEA:FM2427688
Prescriber NPL 1184894595
Prescriber Medical License Number.MD441916.
Toradol. Tablet.: 10 mg:Oral.:Quantity:*** I ***Unit:PILL Route:Oral Schedule:every 6
hours Dispense:***20***.
NOTES.- No refills
May substitute
Prescriber DEA:FM2427688
Prescriber NPI: 1194884595
Prescriber Medical License Number:MD441916.
CURRENT MEDICATIONS
No recorded medications
Key:
RCM=Miller,Rebecca
Prepared:Wed Oct 24.2012 2051 by KEK Pagge:1 of 1
0 ,
OH SystdM IIIIIIIIII(Ild�ll lll�I(lllllil0l lilllll�llllll(llllilllll(�Ilnl Age: 16YDOBEApr 28, 1996
Gender:M Wt.73.9 Kg
Medked:WOM0508512
IIllllil�Illlllllllll(IIIl III(Illlllilllilll(illlll(1(lilll((III(Illl Be` E 106999830
ALTOONA REGIONAL
DISCHARGE INSTRUCTIONS t_017 ! �-� ..`7.-7 t
---
Patients and Families
Thank.you'for choosing Altoona Regional for your emergency care. We hope to provide you excellent care and we
apologize for any delay. You may see many members of our team during your visit. We have many nurses,
physicians,technicians and secretaries.
Your emotional and spiritual need's are very important to us. We have clergy in house if you need anything.
Please just let us know.
If you have pain and it becomes worse,please talk with one of our team members.. Our goal is to make you
comfortable.'Our discharge instructions are tailored and specific to each of your needs.•
We are always open for suggestions on how we can provide excellent care to our patients.
If you had XRAYS:
The.interpretation of x—rays at the time of the-emergency visit may only be.a preliminary report. You will be
notified if there is a change in the interpretation when the x—rays are reviewed by the radiologist.
If you had CULTURES:
Cultures taken at the time of the emergency visit are not ready until one to several days afterwards. If culture
results are positive,you will be notified if change in the treatment is necessary.
FINAL DIAGNOSIS
Cellulitis—multiple sites[NOS]
FOLLOWUP CONTACT
FINDER,PHYSCIAN,General
Call between the hours of Sam
and S.pm
Phone: 1-800-258-4677
SPECIAL INSTRUCTIONS
Use the Keflex on schedule.
Use Tylenol as needed as directed for pain.
Return to the ER with new or worse problems,especially spreading redness of the skin,fever over 101F,or other
problems.
Use the Physician Finder number to locate a local family doctor for ongoing medical care.
MEDICAL INSTRUCTIONS
CELLULITIS—FOLLOW—UP UNSPECIFIED
You have been diagnosed with cellulitis.
This is a bacterial infection of the skin.Symptoms usually include redness,swelling,and warmth in the affected
area.Some people will have a fever with this infection.
Elevate the extremity above your heart level if possible.
Prepared:Wed Oct 24,2012 20:31 by DCB 1 oft
Copyright Picis,Inc.
Akaona Regional III I(I�VIII ilf�((i�IIIII IIla fll(I 1.111111111111 IN I Name:6 OB��8, 1996
Heath Gender.M Wt:73.9 Kg
MedRec:000000508512
I��Iilll IIIII IIIII Ills VIII 1!111 IIIII IIIII IIIII IIIII IIIII IIIQ IIIII Bed ED ECC 199s30
ALTOONA REGIONAL
DISCHARGE INSTRUCTIONS
Treatment of cellulitis includes antibiotics and elevation of the affected area.Sometimes the antibiotics need to
be given intravenously("IV")while other infections can be treated with oral(by mouth)medications.
The redness,swelling,warmth,and fever should start to improve after 2-3 days of treatment..You should return.
here or go to the nearest Emergency Department,or see your primary care doctor for a recheck as directed.
YOU SHOULD SEEK MEDICAL ATTENTION 1MMIV DIATELY,EITHER HERE OR AT THE NEAREST
EMERGENCY DEPARTMENT,IF ANY OF THE FOLLOWING OCCURS:
—Spreading redness even with treatment.You may wish to mark the area of infection with a pen to better watch
for improvement or spreading.
—'Increasing or continued fever after 2-3 days of antibiotics.
—Unusual or increasing pain at the site of the infection.
—Lightheadedness.-
-If feeling sicker at any time,or if.not improving as expected.
PRESCRIPTIONS
Keflex:Capsule:monohydrate 500 mg:Oral
Dispense:.21;Quantity: 1,Unit:tab(s),Route:Oral,Schedule:3 times a day
SEATBELTS: There is no doubt that seathelts save lives. Every day in the Emergency Department we see
people driving without seatbelts are more severely hurt. We always buckle up. Please do the same!
BILLING: You will receive a separate bill for the services provided by the hospital and the services provided by
your.physician.
Prepared:Wed Oct 24,2012 20:31 by DC8 2 o 2
Copyright Pids,.Inc.
IIInIII�IIIIINIIIIllllll�llllll(Iflllllllll(IIIINI�III��llllll 11181111l I(Illlllllflllll(I���IIIIiIUII(Illlllll�llllllliflff�f
Locke,Eddie C
ALTOONA REGIONAL Wt/t:771 Kgg6 MI6
PRIMARY MedRec:000000508512
AcctNum:000306983313
Patient Data
Complaint:Pain from prior burn walk—in/ah
Triage Time:Mon Oct 15,2012 20:04 ED Attending:Shepherd,Jessica
Urgency's ESI 4 Primary RN:Socie,Kathy
Bed:ED ECC
Initial Vital Signs: 10115/2012 20:02
BP:122l85 R:18
P:88 T:98.2
02 sat:98 on ra Pain:
ATTENDING(T.oa 1q.2014 mu iss)
HISTORY.•The documented history was done by the physician extender.
PHYSICAL EXAM:The documented physical exam was done by the physician extender.
CHIEF COMPLAINT.• agree w PAC assessment treatment plan and disposition.
DIAGNOSIS pogo m)
FINAL:.PRIMARY:Healing burns.
VITAL SIGNS(M.0.15.2012 20:04 MS)
VITAL SIGNS.BP: 122/85,Pulse:88,Resp: 18,Temp:98.2,02 sat:98 on ra,Time: 10115/2012
20:02.
PAST MEDICAL HISTORY c20:o9 sMx)
MEDICAL HISTORY_• No past medical history.
SURGICAL HISTORY. `Patient.has had no previous surgical history.
PSYCHIATRIC HISTORY. No previous psychiatric history.
SOCIAL •L HISTOR 'fives in georgia"—in altoona doing temporary work for uncle—
dropped out of high school.
BPI BLANK cao.ossmx)
CHIEF COMPLAINT: Pt here for recheck of his burns.Pt was burned with tar 1 wk ago and
has been.applying silvadene but is out of it.Pt reports still having occasional burning.Denies
redness/swelling/drainage.
HISTORIAN.-History obtained from patient.
TIME COURSE:Onset of symptoms reported as gradual.
SEVERITY Currently symptoms are mild.
ROS czo:ogam)
CONSTFIV77ONAL:Negative constitutional review of systems.
SKIN:Historian reports skin changes..
NEUROLOGIC.•Negative neurologic review of systems.
PHYSICAL EXAM mjosw
CONS77TU7IONAL:Patient is afebrile,Vital signs reviewed,Patient has normal pulse,normal
blood pressure,normal respiratory rate.Well appearing,Patient appears comfortable,Alert and
Prepared;Wed Oct 24.2012 20:51 by KEK Page:l of 4
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Locke,Eddie C
�t 3.19 MI6
ALTOONA REGIONAL w5Kg
PRIMARY MedRec:000000508512
AcctNum:000306983313
oriented X 3.
HEAD:Atraumatic,Normocephalic.
EYES:Eyes are.normal to inspection,Pupils equal,round and reactive to light,No discharge
from eyes,Extraocular muscles intact,Sclera are normal,Conjunctiva are normal.
UPPER EXTREMITY.-No edema,Normal range of motion.
AM. GCS is 15.
SKIN.• multiple scabbed lesions to the upper back/neck and bilateral upper arms.No
erythema,edema or drainage.
CURRENT MEDICATIONS mu Rss1
Toradol: .1 PILL Oral every 6 hours.x 10 mg—Oral—Q6H.
Acetaminophen—oxycodone: I PILL Oral Take As Needed Every 4-6 Hours.Entered brand:
Percocet-5/325 x 325 mg—5 mg—Oral—PRN 4-6 HR
TRIAGE(Mtin Oct 15.201220:04 RS5)
PATIENT:NAME:Locke,Eddie C,AGE: 16,GENDER:male,DOB:Sun Apr 28, 1996,TIME OF
GREET:Mon Oct 15,2012 19:53,RACE:White,TETANUS:CURRENT,TRANSFER IN:NO,Current
vaccinations:None,Ambulance Patients:N/A,SSN:259950479,Zip Code:30144,KG WEIGHT:73.5,
MEDICAL RECORD NUMBER:000000508512,ACCOUNT NUMBER:000306983313,PERSON ID:
000306983313,Admitting:None,.(rte Oct 1s.2012 20:04 Rs5)
PHONE:(706)631-9021.ao:ln
ADMISSION.-URGENCY:ESI 4,ADMISSION SOURCE:A.Private Residence,TRANSPORT:
A.Walk In,DEPT:Emergency,BED:WAITING.(Mon Oct 15.2012 20:04 RSS)
VITAL SIGNS:BP 122/85,Pulse 88,Resp 18,Temp 98.2,02 Sat 98,on ra,Time 10/15/2012 20:02.
(Mon Oct 15.2012 20:04 RS5)
COMPLAINT.• Pain from prior burn walk—in/ah.(Mon Oct 15.2012 20:04 RSS)
GREET(Mon oct 1s.=2 2o:o4 Rss)
TRIAGE 77ME(Mon Oct 15.2012 20:04 RSS)
ADDMONAL VITAL.SIGN INFORMATION:02 Sat is 100.(Mon Oct 15.2012 20.:04 RSS)
SUICIDE ASSESSMENT.-Suicide risk,patient denies suicidal ideation.(Mon oa 15.2012
20:04 RSS)
MENTAL STATUS:Conscious,Oriented X3,GCS Eye Opening:4,GCS Verbal Response:5,
GCS Motor Response:6,The GCS total is 15.(Mon oa 15.2012 20:04 RSS)
SPEECH.-Coherent.(Mon opt 1s.2012 2o:o4 Rs5)
FALL RISK No risk for fall.(2o:oa xss)
PAIN.-Triage assessment performed.(Mon Oct 15.2012 20:04 RS5)
NOTE'S.- pt states was burned last tuesday 10/9/12 with hot tar tonight still painful"out of
cream".(Mon Oct 15.W12 20:04 R85)
ESI.•ES level 3.(Mon om ls.eon 2o:o4 Rss)
ALLERGY(20:04 RS5)
No known drug allergies.
Prepared:Wed Oct 24,2012 20:51 by KEK Page:2 of 4
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Locke,Eddie C
DOB:M28/1996 M16
ALTOONA REGIONAL wt/Ht:73:5 Kg
PRIMARY MedRec:000000508512
AcctNum:000306983313
(KNOWN ALLERGIES
No]mown drug allergies
NURSING ASSESSMENT:SEIN h.,o:t2xssl
NOTES: patient presents with complaint pain s/p burn with hot tar last week.neck and right
arm with scabbed areas.
CONSTITUTIONAL:Patient.is cooperative,alert and oriented x 3.Patient appears in no acute
distress,Patient's skin is warm and dry,Patient arrives to treatment area ambulatory,Patient
with steady gait.
SKIN.No Drainage,multiple scabbed areas where patient was burned with hot tar last week,
On a scale 0-10 patient rates pain as 6.
BURN LOCATION:The%of total area burned is 0.
SAFETY:Side rails up,Can in lowest position,Friend at bedside.
.NURSING PROCEDURE:DISCHARGE NOTE(w:14K56)
TIME..Patient discharged at 2013,Patient discharged to,home,Patient,ambulates without
assistance,Transported via friend/family driving,Accompanied by friend,Discharge instructions
given to,patient,Simple/modemte discharge teaching performed,Teaching performed by ksocie,
Above Person(s)verbalized understanding of discharge instructions and.
IMAGING(an xisu
DISCHARGE.• Image captured from scanner.
ORDERS
DISPOSITION
PATIENT.• Disposition:A.Home,Condition:Stable.<waosmK)
Hold Patient:No,IV d/cd @ discharge:N/A,Remove from ER.(1-o:,a MQ
ADMIN
DIGITAL SIGNATURE: Koehle,Shawna.(w:�ssMX)
Shepherd;Jessica.rrw oa i6.wiz 00:35 rss)
INSTRUCTION aom sh .
SPECIAL: Keep the area cleaned with soap and water.Keep covered when working.Start to
apply regular antibiotic ointment to your burns.Continue the Toradol as needed for pain.
Return with any acute changes.
PRESCRIPTION
No recorded prescriptions
Prepared:•wed Oct 24,20I2 2051 by KEK Page:3 of 4
Locke,Eddie C
ALTOONA.REGIONAL DOB:4/28/1996 M16
Waft: 3.5 Kg
PItOURY MedRec7:Oo0 g 08512
AcctNum:000306983313
Key:
JSS=Shepherd,.Jessica KiS2=Skurnick4 Kathleen KS6-Socie,Kathy RSS=Srat Rita
SMK=Koehle,Shawna
i
Prepared:Wed Oct 24.2012 24:51 by M Page:4 of 4
AName:L DWO -A r 8,1996
'° Heal$1 Gender.M W t 73.5 Kg
ff �1i f MedRec:000000508512
��.7000306983313
Primary RN.KS6
Bed:ED ECC
ALTOONA REGIONAL
MEDICATION RECONCILIATION
Your medication list is based on the.information available to us at the time of your visit. It may not represent your
complete list or recent changes made to your medications.It is important that you follow—up with your physician
with any medication questions or concerns you may have.
You were seen in the Emergency Department on:Mon Oct 15,2012
KNOWN ALLERGIES
No known drug allergies
HOME MEDICATIONS
Acetaminophen—ozycodone
1 PILL Take As Needed Every 4-6 Hours.Comment:Entered brand:Percocet 51325 x 325 mg-5 mg--
Oral—PRN 4-6 HR
Toradol
1 PILL every 6 hours.Comment:x 10 mg--Oral—Q6H.
Prepared:Wed Oct 24.2412 20:51 by KEK}of 1
Altoona Regional
EMERGENCY FLOW SHEET RECORD
Name:Locke,Eddie C Age:16Y MR:000000508512 Acct:000306983313
VITAL SIGNS RS5
TIME 10115/2012 20:02
HP 122185
PULSE 88
RESP 18
TEMP 98:2
PAIN
02 SAT 98 on ra
Name:Locke,Eddie C Age:16Y MR:000000508512 Acct:000306983313
Prepared:Wed Oct 24 20:51:45 2012 by KEK Page:1
I IIII!1111 11111 Ii�l II(II 1411!IIIII��!Q��lII IIl14�lII Illii illl! i l�!sill)VIII!i lit IIIII II111 III a�i lI11i lilt!li l!I filll III[I IlI�
Locke,Eddie C
ALTOONA REGIONAL w�� 1996 M16
MEDICATION RECONCILIATION AcctNu:006000508331
AcctNtua:000306483313
Patient Data
Complaint:Pain from prior burn walk–in/ah
Triage T'mie:Mon Oct I5,2012 20:04 ED Attending:Shepherd,Jessica
Urgency:ESI 4 Primary RN:Socie, Kathy
Bed:ED ECC
Initial Vital Signs: 10/15/2012 20:02
BP:122/85 R:18
P:88 T:98.2
02 9at:98 on ra Pain:
PRESCRIPTION
No recorded prescriptions
CURRENT MEDICATIONS
Toradol: 1 PILL Oral every 6 hours.x 10 ma–Oral–Q6H.
Acetaminophen–oxycodone: 1 PILL Oral Take As Needed Every 4-6 Hours.Entered brand:
Percocet-5/325—x 325 mg-5 mg–Oral–PRN 4-6 HR-
Key:
RSS--Sral,Rita
Prepared:Wed Oct 24,2012 20:51 by KEK Page:1 of 1
STATEMENT
CNECK CREDrr CARD U504G FOR PAYMENT AND FILL OUT BELOW.
ALTOONA EMERGENCY PHYS 11 ® 0 v�
CARD NUMBER SEC.CODE AMOUNT
PO BOX 62282
BALTIMORE MD 21264-2282 NAME ON CARD(PLEASE PRINT) EXP.DATE
SIGNATURE
STATEMENT DATE I ACCOUNT N I PAY TM AMOUNT
10/28/12 1 ALT00306983313 $124.00
Questions?Call 800-666-2455 9:30am-Noon& 1:00-5:00pm EST Patient: EDDIE LOCKE AMOUNT PAID
9191907011220003069833130000124005 0 1017 11 x5 '7-717
MAKE CHECK PAYABLE&REMIT TO:
1'I�'Il��llll�llllll��lilllll�ll�ll�ll�ll��'��'���I�'I�III�III'll �I'�I'�I'�'1�I"Illl��llq��n�nl'�II'll�i'I�il�����'lli'�'I�I'I
CODEAL LOCKE ALTOONA EMERGENCY PHYS
4045 GEORGE BUSBEE PKWY NW PO BOX 62282
KENNESAW GA 30I44-4840 BALTIMORE MD 21264-2282
PLEASE CHECK BOX IF ABOVE ADDRESS IS INCORRECT AND INDICATE CHANGES ON BACK. ♦ DETACH HERE AND RETURN THIS TOP PORTION WITH YOUR PAYMENT
USING THE RETURN ENVELOPE ENCLOSED
IMPORTANT MESSAGE FROM YOUR PHYSICIAN
9J0 AM-NOON AND 1:00-5:00 PM EST
Date Prot. Description Charges Adjustments Medicare/ Insurance Patient You Pay
Medicaid Paid Paid Paid Usted Pa a
10/15/12 99283 ER EXAM-3 $124.00 $124.00
Service At ALTOONA REG HEALTH SY
Service By:S.MCDONALD,PA
OUR CALL VOLUME IS EXTREMELY HIGH ON MONDA Y
&TUESDAY.OUR AUTOMATED SYS -IS
AVAILABLE 24 HOURS PER DAY,7 JDAYS A WEEK.
Web payment and insurance filing options are available
at:www.mydocbill.com or 800-666-2455
USERNAME:ALT00306983313 $124.00 $0.00 $0.00 $0.00 $0.00 $124.00
PASSWORD:@LT633LK3
IMPORTANT:To assure proper credit,detach and return the statement above with your CHECK OR MONEY ORDER PAYABLE IN US CURRENCY
PLEASE REMIT BY'PAYMENT DUE BY'DATE TO AVOID FURTHER BILLING.
Direct Billing Questions To:800-666-2455 Statement Date:10/28/12
Directa Preguntas Facturaci6a a:800-666-2455 Account#:ALT00306983313
Questions?Call 800-666-2455 9:30am-Noon&1:00-5:00pm EST
**PAYMENT-D UE-UPON-RECEIPT** 63018-20121025-0003338-1-1
I Illl Il 111 II III Il 111 II 111 ll ll{II III II l�Il 111 II1�Il III IIII 11111 I IIII I IIII 11111 II III 11111 ll I�II IR it Ili II Ila��!fill!I!I!!it�I it III I III!
Locke,Eddie C
ALTOONA REGIONAL DwO�t�Kg6M16
PRY MedRec:000000508512
AcctNum:060306999830
Patient Data
Complaint:Recheck burns walls—in/ah
Triage Time:Wed Oct 24,2012.20:22 ED Attending•Kuo,Ia--Lynn
Urgency:ESI 4 Primary RN:Spicer,Kelly
Bed.ED ECC
Initial Vital Signs: 10/24/2012 20:20
BP:145/53 R:20
P:67 T:98.4 oral
02 sat:97 on ra Pain:
DIAGNOSIS(2o3o nce)
FINAL:PRIMARY:Cellulitis—multiple sites[NOS].
VITAL SIGNS cwea oz u.eon m';2,mm,
VITAL SIGNS:BP:145/53,Pulse:67,Resp:20,Temp:98.4 oral,02 sat:97 on ra,Time:
10/2412012 20:20.
PAST MEDICAL MSTORY(1o=0®)
MEDICAL HISTORY: No past medical history.
SURGICAL HISTORY: Patient has had:no previous surgical:history.
PSYCHIATRIC HISTORY.- No previous psychiatric history.
SOCIAL HISTORY.- "lives in georgia"—in altoona doing temporary work for uncle—
dropped.out of High school.
BPI.CELLULITIS cso•29 ncs,
CHIEF COMPLAINT..Patient presents for the evaluation of erythemaa,of the right,
chest, 1 cm in diameter,Skin intact.
HISTORIAN.•History obtained from patient
TIME COURSE.. Onset of symptoms reported as sudden.
LOCA770N.• right upper chest,left upper arm,left ear pinna.
ASSOCIATED WITH:Pain,Warmth.
MECHANISM,Possible source is burned 3 weeks ago,now with mild erythema surrounding
burn sites:
SEVERITY. Maximum severity is maid.
COMPLICATING FACTORS:Condition complicated by no known factors.
EXACERBATED BY.*Patient's condition exacerbated by nothing.
RELIEVED BY.•Patient's condition relieved by nothing.
NOTES: denies fever,proximal streaking.
ROS(2o3;aca)
CONSTTT'U77ONAL:Negative constitutional review of systems.
EYES.•Negative eye review of systems:
ENT. Negative ENT review of systems.
CARDIOVASCULAR:Negative cardiovascular review of systems.
RESPIRATORY. Negative respiratory review of systems.
Prepared:Wed Oct 24,2012 20:52 by KEK Page:1 of 5
IIIIlilll(1111l�III!!I(IIIIIIIIlII�Illliltl111111(111II�II(iillfiil lII�(IIIIIII�II�l�IIIVIII�l�iililllillVIIIIIIIIII�i�I�II�I
Locke,Eddie C
ALTOONA REGIONAL Wtt(H t 21Kg6 M16
PRIMARY MedRec:600000508512
AcctNum:000306999830
GI:Negative gastrointestinal review of systems.
MUSCULOSKELETAL Negative musculoskeletal review of systems.
SKIN:14 ktorian reports ceUulitis,skin changes.
NEUROLOGIC:.Negative neurologic review of systems.
PHYSICAL EXAM r..0-as Dca>
CONSTITUTIONAL-Patient is afebrile,Vital signs reviewed,Patient has normal pulse,normal
blood pressure,normal respiratory rate.WeII appearing,Patient appears comfortable,Alert and
oriented X 3.
HEAD.Atraumatic.,Normocephalic.
EYES.Eyes are no rmal to inspection,Pupils equal,round and reactive to light,No discharge
from eyes,Extraccular muscles intact,Sclera are normal,Conjunctiva are normal.
RESPIRATORY CHEST. Chest i's nontender,Breath sounds normal,No respiratory distress.
CARDIOVASCULAR.RRR,No murmurs,Normal S I S2,No rub,gallop.
UPPER EXTREMITY.-Inspection-normal,No cyanosis,clubbing,edema.Normal range of motion.
LOWER EXTREMITY.•Inspection normal,No cyanosis,clubbing,edema.Normal range of
motion,No calf tenderness.
NEVRO.GCS is 15,No focal motor deficits,focal sensory deficits,cerebellar deficits.Speech
normal,Gait normal,Memory normal.
SKIN.- mild erythema of the right upper chest wound,left pinny and left posterior upper arm.
there is no exudate,hemorrhage or edema.there is no tenderness to touch.
LYMPHATIC:No adenopathy in neck,adenopathy in axillae.
PSYCHIATRIC.Oriented X 3,Normal affect,insight,concentration.
CURRENT.MEDICATIONS cm:z;mnu)
None
MEDICATION ADMIIVISTRATION SUMMARY
IpmName Dose ordered iftoute IStatas Irme
Keflei 500MGP0 JPQ Givca 20:3410/24/2012
Detailed record available in Medication Service section.
TRIAGE(wed od24.2ot22omwra)
TRIAGE NOTES. Pt reports being burned with blacktop 2 wks ago.pt states that he now
thinks that he is has an infection at the site of his right upper chest.(wra oa u.2ou mm
M10)
PATIENT.-NAME:Locke,Eddie C,AGE: 16,GENDER:male,DOB:.Sun Apr 28, 1996,TIME OF
GREET:Wed Oct 24,2012 19:58,RACE:White,TETANUS:CURRENT,Current vaccinations:None,
Ambulance Patients:N/A,SSN:259950479,Zip Code:30144,KG WEIGHT.73.9,MEDICAL
RECORD NUMBER:000000508512,ACCOUNT NUMBER:000306999830,PERSON ID:
000306999830,Admitting:None local,.(ww m 24.2012 20:m MX2)
PHONE:.,(706)631-9021..rmsol
Prepared:Wed Oct 24.'2012 20:52 by KEK Page:2 of 5
I I l ll l� I II Ii 1�111 Ifl���i fl(�(II(I I(�I ll�l
II(IIIIIIIIIIIIIIIIIIIIIIIIIIiINlllllll�l(illlllillll�ll11111111111 IIl fll I lllfl Il �l[!
Locke,Eddie.C
ALTOONA REGIONAL w�t1i 9g M16
PRIMARY MedRec:000000508512
AcctNum:000306999830
ADMISSION.URGENCY:ESI 4,ADMISSION SOURCE:A.Private Residence,TRANSPORT:
A.Walk In,DEPT:Emergency,BED:WAITING.(ww Oct 24.2012 20:22 M-1)
VITAL SIGNS.BP 145/53,Pulse 67,Resp 20,Temp 98.4 oral,02 Sat 97,on ra,Time 10/24/2012
20:20.cww Oct 24.201220-M 1Jx21
COMPLAINT.• Recheck bums walk—in/ah.(wed oa 24.2012 2o:2z hux2)
ADDITIONAL VITAL SIGN INFORMATION:Blood pressure to the right,Pulse is regular,
Respiratory is unlabored,Temperature is oral.(2o.-23 m=)' '
DOMESTIC VIOLENCE:Domestic violence screening was not completed,No crisis
follow—up made.mm mm)
SUICIDE ASSESSMENT.Suicide risk,patient denies suicidal ideations.aom mm)
MENTAL STATUS.Conscious,GCS Eye Opening:4,GCS Verbal Response:5,GCS Motor
Response:6,The GCS total is 15,aom Mrx21
SPEECH.-Coherent.mm mn 1
FALL RISK.•No risk for fall.(2om mm)
SKIN.Temperature is normal,Moisture is normal,Turgor is good.(zom mw—,)
PAIN.Triage assessment performed r0Z MEL*
ESL•.ES level 4.(2o:23 mm--)
PREVIOUS VISIT ALLERGIES:No known drug allergies.nvao Oct 24.2012 20:22
KNOWN ALLERGIES
No known drug allergies
NURSING ASSESSMENT: SKIN(m37 xss2)
NOTES: Pt here to have burn to right upper chest rechecked,noted redness,and warmth
to site.
CONSTMMONAL:Complex assessment performed,Patient arrives ambulatory with steady
gait to treatment area,History obtained from patient,Patient appears comfortable,Patient is
cooperative,alert and oriented x 3.Patient appears in no acute distress,Patient's skin is warm and
dry,mucous membranes are moist and pink.
SKIN Skin warm and dry,right upper chest,Pain described as aching,Pain is
continuous,On a scale 0-10 patient rates pain as 4,Redness,to right upper chest.
MEDICATION SERVICE=29 ncs,
Keflex: Order:Keflex(Cephalexin(As Monohydrate))—Dose:500MGPO:PO
Ordered by:David Beck
Entered by:David Beck Wed Oct 24,2012 20:29,
Acknowledged by:Kelly SpicerWed Oct 24,2012 20:32
Documented as given by:Kelly Spicer Wed Oct 24,2012 20:34
Patient,Medication,Dose,Route and Time verified prior to administration.
Amount given:500mg,Site:Medication administered'P.O.,Correct patient,time,route,dose and
medication.confirmed prior to administration,.Patient advised of actions and side—effects prior to
administration,Allergies confirmed and medications reviewed prior to administration.
Prepared:wed Oct 24,2012 20:52 by KEK Page:3 of 5
I{Ililil�lullliltlll�Ill 11111111111{�illllllll{I�alliilllililll illlllll�IIIIIIII��IIIliIiIIII�11111!11111{iIIIII�IIiIIIl�i11111
Locke,Eddie C
ALTOONA REGIONAL DOB:4/28/1996 M16 Kg
PRIMARY MedRec:000000508512
AcctNum:000306999830
NURSING PROCEDURE:DISCHARGE NOTE(2o:4o rc=)
TIME:Patient discharged at 2039,Patient discharged to,home,Patient,ambulates without
assistance,Transported via friend/family driving,Accompanied by friend,Discharge instructions
.given to,patient,Complex discharge teaching performed,Teaching performed by Kspicer RN,Name
Of prescription(s)given:keflex,Prescription given and additional instructions on side effects of
same given,Above Person(s)verbalized understanding of discharge instructions and.
IMAGING aoso my)
CONSNET- Image captured from scanner.
ORDERS
DISPOSITION
PATIENT.• Disposition:A.Home,Condition:Stable.(2o--v Do)
TRANSFER IN:NO,Hold Patient:No,IV d/cd @ discharge:N/A,Remove from ER.(20:40
xss'.a
ADMIN
DIGITAL SIGNATURE.- Spicer,Kelly.(2o.4oxss2)
Beck,David,(20:42 DM)
INSTRUCTION ao:n DcB)
DISCHARGE: CELL-ULTTIS—FOLLOW—UP UNSPECIFIED.
FOLLOWUP: FINDER,PHYSCIAN,General,Call between the hours of 8am,and 5 pm,
1-800-258-4677.
SPECIAL: Use the Keflex on schedule.
Use Tylenol as needed as directed for pain.
Return to the ER with new or worse problems,especially spreading redness of the skin,fever
over 10117,or other problems.
Use the Physician Finder number to locate a local.family doctor for ongoing medical care.
PRESCRIPTION=3o Dm)
Keflex: Capsule:monohydrate 500 mg:Oral:Quantity: *** 1 ***Unit:tab(s)Route:Oral
Schedule:3 times a day Dispense: ***21 ***.
NOTES: No refills
May substitute
Prescriber DEA:MB 1258385
Prescriber NPI:
Prescriber Medical License Number.MA052119.
Prepared:Wed Ocr24,2022 20:52 by KEK Page:4 of 5
III Ilfll IIIII IIIII 1111!Ilfll ii�l ili11111�Ifll!hill II011lf l!1lill lllfl III!III IIlII Illll llil[IIIIi 1110IlI�IIIII 11101101�I�Illlf
Locke,Eddie C
ALTOONA REGIONAL DOB:4/28/1996 MI6
WUHt 73.9 Kg
PR BURY Medltec.000000sossl2
AcctNum:000306999830
Key:
DCB=Beck,'David JDY=Caton,Jennifer JLK=Kuo,Ja—Lynn .KSS2=Spicer,Kelly
MJK2=Kantosid,Matthew
Prepared:Wed Oct 24.2012 20:52 by KHK Page:5 of 5
Altoona Regional III I!U!llill IIIU V Jill V Age 16Y DOB:Eddie 9 K, 1996
�.-Health System g
MedRec:000000508512
IlllIII�I VIII IIIIIIIIII�I� 111111111 II��I Attending OJLK306999830
Primary RN.KSS2
Bed:ED ECC
ALTOONA REGIONAL
MEDICATION RECONCILIATION
Your medication list is based on the information available to us at the time of your visit. It may not represent your
complete list or recent changes made to your medications.It is important that you follow—up with your physician
with any medication questions or concerns you may have.
You were seen in the Emergency Department on:Wed Oct 24,2012
KNOWN ALLERGIES
No known drug allergies
MEDICATIONS GIVEN WHILE IN THE EMERGENCY DEPARTMENT
Keflex(Cephalexin(As Monohydrate))-Dose:500MGPO:PO
ROME MEDICATIONS
None
PRESCRIPTIONS
Keflex:Capsule:monohydrate 500 mg:Oral
Dispense:21,Quantity::.1,Unit:tab(s),Route:Oral,Schedule:3 times a day
Psepamd:Wed Oct 24,2012 20:52 by KEK t of 1
Altoona Regional
EMERGENCY FLOW SHEET RECORD
Name:Locke,Eddie C Age:16Y MR:000000508512 Acct:000306999830
VITAL SIGNS MJK2
TIME 10/24/2012 20:20
BP 145/53
PULSE 67
RESP 20
TEMP 98.4 oral
PAIN
02 SAT 97 on ra
Name:Locke,Eddie C Age:16Y MR:000000508512 Acct:000306999830
Prepared:Wed Oct 24 20:52:17 2012 by KEK Page:1
•- 1 I
IlIIIllllifilll�l��l((llli(l 1111{IIIIiI(IIIIIIIII�Illliffilllllll( Ifi�1110lIIIIIlI�I{1111111{�IDIIIII>tilllf�llllfl.11lilllllllllli
Locke,Eddie C
ALTOONA REGIONAL DOB:4/28/1996 M16
Wt/Ht:73.9 Kg
MEDICATION RECONCILIATION MedRec:000000508512
AcetNum:000306999830
Patient Data
Complaint:Recheck burns walk—in/ah
Triage Tune:Wed Oct 24,2012 20:22 F.D Attending:Kuo,Ja—Lynn
Urgency:ESI 4 Pranary RN:Spicer,Kelly
Bed:ED ECC
Initial Vital Signs: 10/24/2012 20:20
BP:145%53 R:20
P:67 T:98.4 oral
02 sat:-97 on fa Pain:
MEDICATION ADMINISTRATION SUMMARY
I Druz Name IDose.Onkred Route IStaw IT=e
Keflex 150Dmapo JPO lGivEd 20:34101242012
Detailed record available in Medication Service section.
PRESCRIPTION
Keflav Capsule monohydrate 500 mg:Oral:Quantity:*** 1 ***Unit:tab(s)Route:Oral
Schedule:3 times a day Dispense:***21 ***.
NOTES. No refills
May substitute
Prescriber DEA:UB1258385
Prescriber NPI:
Prescriber Medical License Number.MA052119.
CURRENT MEDICATIONS
None
Key:
DCB=Beck,David MJK2=Kantoski,Matthew
Prepared:Wed Oct 24,2012 20:52 by KEK Page:i of i
EXHIBIT C
Y, a
VERIFICATION / AFFIDAVIT
The undersigned statesthat the facts set forth in the foregoing PETITION FOR
APPROVAL OF MINOR SETTLEMENT are true and correct, and that the compromise
detailed in the Petition is in the best interest of my son, Eddie C. Locke. This
verification is made subject to the penalties of 18 Pa.C.S. § 4904, relating to unsworn
falsifications to authorities.
Codeal Locke, as Parent and
Natural Guardian of Eddie C. Locke, a Minor
Date: Augu$a1&— , 2013
CERTIFICATE OF SERVICE
I hereby certify that a copy of the foregoing Petition for Approval of Minor's
Settlement has been duly served upon the following, by depositing the same in the
United States Mail, postage prepaid, in Lemoyne, Pennsylvania, on August 30 , 2013:
Codeal Locke
4045 George Busbee Parkway NW
Apt. 8206
Kennesaw, GA 30144-4870
JOHNSON, DUFFIE, STEWART & WEIDNER
By: /' /
Matthew Ridley, Esquire
S
IN RE: IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
EDDIE C. LOCKE, a Minor
NO.
ORDER
AND NOW, this of 2013, upon consideration of the
Petition to Approve Minor's Settlement, it is hereby ORDERED that Petitioner is
authorized to enter into a settlement with the Respondents, Eddie Mullen, III and Erie
Insurance, in the gross amount of$15,000.00 on behalf of the Minor. Respondents shall
forward all settlement drafts or checks to Petitioner for proper distribution.
It is further ORDERED that the settlement proceeds are to be allocated to the
minor, Eddie C. Locke. Petitioners are hereby authorized and required to execute all
documentation necessary to deposit $15,000.00 in a Federally insured savings account
(as defined by Pa.R.C.P. 176) in a bank or like institution with the funds payable to
Eddie C. Locke upon his majority. The Certificate shall be titled and restricted as
follows:
Eddie C. Locke, a minor, not to be redeemed except for renewals and
entirety, not to be withdrawn, assigned, negotiated, or, otherwise,
alienated before the minor obtains majority, except upon prior Order of this
Court.
c ,
t t rn f-ri ..
- M CD��t
Petitioners shall file with the office of the Prothonotary within 30 days of the date
of this Order, a Certification that the funds awarded to the minor were deposited in
accordance with Pa. R.C.P. 2039(b)(2).
BY THE COURT:
J.
Distribution:
V Matthew Ridley, Esq., Johnson, Duffle, Stewart & Weidner, 301 Market Street, Lemoyne, PA 17043; Tel:
(717) 761-4540, E-mail: mr @jdsw.com y
co .
Pr /7Z
��t ,3
JOHNSON, DUFFIE, STEWART
By: Matthew Ridley
I.D. No. 204265
301 Market Street
P. O. Box 109
Lemoyne, PA 17043-0109
(717) 761-4540
mr@jdsw.com
2014 JUN 8 "hi 1
& WEIDNER.,,
�,U^r,E ERL.AND SGUNP(
PENNSYLVANIA
IN RE:
EDDIE C. LOCKE, a Minor
Attorneys for Defendant
Erie Insurance
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
NO. 13-5138 Civil
PRAECIPE TO FILE PROOF OF DEPOSIT
Pursuant to the Court's prior approval of the Minor's Settlement in the above -
case, kindly file of record, the proof of deposit attached hereto as Exhibit "A".
Date: June 17, 2014
633628
Respectfully submitted,
JOHNSON, DUFFIE, STEWART & WEIDNER
BY:
77
Matthew Ridley, Esquire
Attorney I.D. No. 204265
301 Market Street
P.O. Box 109
Lemoyne, PA 17043-0109
(717) 761-4540
mr@jdsw.com
Counsel for Petitioner
EXHI
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$15,000-00
$15,000-00
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Date Description
11/25/13 Savings Open/
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The information contained In this electronic message is confidential, proprietary and intended only for the use of the owner of the
email address listed as the recipient of this message. If you are not the Intended recipient, or the employee or agent responsible
for delivering this message to the intended recipient, you are hereby notified that any disclosure, dissemination, or distribution,
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6/17/2014
12 3a FM (17
CERTIFICATE OF SERVICE
I hereby certify that a copy of the foregoing Praecipe to File Proof of Deposit has
been duly served upon the following, by depositing the same in the United States Mail,
postage prepaid, in Lemoyne, Pennsylvania, on June 17, 2014:
Codeal Locke
4045 George Busbee Parkway NW
Apt. 8206
Kennesaw, GA 30144-4870
JOHNSON, DUFFIE, STEWART & WEIDNER
By• /'
Matthew Ridley, Esquire