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Home My WebLink About02-11-05IN RE: PETITION FOR COURT APPROVAL TO SETTLE THE CLAIMS OF KIERSTIN BARCAVAGE, A MINOR, BY HER PARENTS AND NATURAL GUARDIANS, STEPHEN J. BARCAVAGE AND PENNY BARCAVAGE IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. ~.I-(1rj' -C51~1.3 ORPHANS' COURT DIVISION PETITION TO OBTAIN COURT APPROVAL TO SETTLE THE CLAIMS OF A MINOR AND NOW, come the Petitioners, Kierstin Barcavage, a minor, by Stephen J. Barcavage and Penny Barcavage, her parents and natural guardians, and file the within Petition to Obtain. Court Approval to Settle the Claims of a Minor; and in support thereof aver as follows: 1. Petitioner Kierstin Barcavage is a minor who resides with her mother-and natural guardian at 194 Fairview Street, Carlisle, Cumberland County, Pennsylvania. Kierstin was born on December 8, 1992, and is 12 years of age. 2. Petitioner Stephen J. Barcavage is the father and natural guardian of minor Petitioner Kierstin Barcavage, and resides at 37 Logans Run, Enola, Cumberland County, Pennsylvania. 3. On or about December 7, 2001, Kierstin was aback-seat passenger in a vehicle being operated by her father, Stephen J. Barcavage, westbound on Wertzville Road at the intersection of Valley Road in Hampden Township, Cumberland County Pennsylvania. 4. Mr. Barcavage's vehicle struck a vehicle being operated in front of him by Shawn Bucher, of West Fairview, Cumberland County, Pennsylvania. 2 Kierstin suffered a facial abrasion and right wrist injury and was treated at Holy Spirit Hospital. 6. Kierstin was diagnosed with right wrist fractures of the diaphysis of the radial and ulna, which were treated by casting. No surgical intervention was required. Copies of minor Petitioner's medical records detailing the treatment of her injuries are attached hereto as Exhibit "A". 7. Kierstin had a normal course of recovery for an injury of this type and is able to participate in normal physical activities for her age group. A copy of minor Petitioner's most recent x-ray and physician reports detailing her recovery from the right wrist injury are attached hereto as Exhibit "B". On the date of the incident Stephen J. Barcavage maintained an automobile insurance policy through United States Automobile Association ("USAA") policy number 00754217107109. 9. To date, all medical bills of Petitioner Kierstin Barcavage have been paid by USAA. 10. In an effort to settle this case, the Petitioners have agreed that the sum of Twelve Thousand Dollars ($12,000.00) will be paid by USAA to Kierstin Barcavage, a minor, in exchange for a release of all claims. Insofar as execution of the Release requires the Court's permission, attached as Exhibit "C" is an unsigned copy of the Release that has been proposed. 3 11. The $12,000.00 is to be paid to purchase a guaranteed annuity from USAA Life Insurance Company, with an address of ADU Life, 9800 Fredericksburg Road, San Antonio, Texas 78288, through an individually designed settlement designed by Ringler Associates, Three Gateway Center, 16 North, Pittsburgh, Pennsylvania, 15222. Distributions from the annuity will be made to Kierstin in four equal annual payments of $3,935.00 beginning at age 18. All payments will have been made before Kierstin turns 22 years of age. The total yield from the annuity is $15,740.00. 12. The Petitioners believe that the settlement enumerated in the Petition is fair and equitable and in the best interest of the minor Petitioner, Kierstin Barcavage. 13. USAA has offered to pay the sum set out in this Petition toward an amicable resolution of the claims and in exchange for Court approval and a properly executed release of claims. 14. USAA shall also pay costs and legal fees incurred with respect to the instant Petition for Court approval. 15. Petitioner Penny Barcavage, as custodial parent, is aware of the proposed settlement and concurs with the terms thereof. WHEREFORE, Petitioners respectfully request this Honorable Court to enter an Order approving the foregoing compromise settlement, directing the distribution of proceeds thereof as set forth above, authorizing Petitioners, upon payment of the aforesaid sums, to execute a full and final release on behalf of minor Petitioner. 4 Respectfully submitted: CALDWELL & KEARNS Dated: ~~ By. ~_.. oodburn, Esquire A ey LD. #81786 3631 North Front Street Harrisburg, PA 17110 (717)232-7661 Attorney for Petitioners VERIFICATION I verify that the averments in this document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904, relating to unsworn falsification to authorities. Date: ;~ ~ //~i By: teph J cav e, a ent and natural gua n of Kierstin Barcavage, minor CERTIFICATE OF SERVICE AND NOW, this ~~ day of '' _,~,~~J ~~ , 2005, I hereby certify that I have served a copy of the within document on the following by depositing a true and correct copy of the same in the U.S. Mails at Harrisburg, Pennsylvania, postage prepaid, addressed to: Stephen J. Barcavage 37 Logans Run Enola, PA 17025 Penny Barcavage 194 Fairview Street Carlisle, PA 17013 By: 04-5/81316 7 i )er'r lie .~':lilii' Hanipilen T1rp [:iAL~ ncidrni Location vL~rR~rzy n-I-r E v;vI 1 1 ~~ R(>,1u Patient ~iamc 4~ KII_RSIIN !3~AI(C:AV'AGI~- (,,," Street address F"'~ I`>~7F:AIiZVIL\VS"T1ZEf'l~ 'f, ~' ('itv StaleI_ip ~ CARLISLE PA I?ul3 -~ + aLS Unit 1lrmbership No h+~+ Private Physician Chief Complaint: Al3RAJION UNllF. Current i~irds: CLARfI ~\N ~Ilerg;irs (melk): NKA P\IHc: n ~~n netts ~ cuPU n ^ot' r Unit jVu• ' PCR V o. County Incid. Yo. Date Irnhnl t)It)ISUS ISi1~l2 I ~!I I ~ ~ 2 Jrl \ICD Receiving; Faciliti' I `) l ii I h)Iv SI)irit Hus~?iCtl Ph unc.Vn. arc Date of Birth Social Srr. Vii Sec ~J . )y!)_I?_t)S9i Lcmalr O Crr)c A;t 1 13rua11du~, t ;e~~r ~~ ENII I I;Yb33 Tinter Di~palch i 7 ~'~ :A~2 Siahlnccl.rr. Icnnifcr LitiIL U7d-il I fnroute ) .IY M V~J :\ it t t17JS O \~~ anive5cene D i);:iy epart Scene i)gJ)>; Out On-Berne Dent in Arrive facility U){ 13 S?s . R~{I 3S> 339 :bailable UR5) In Quarters U'>U.Y ~lydical G>nnnand Physician \ICC IN I':\IN Rltill i lL'KISI Narrative DID W'1 fH AN913 75 & FIRE CO 30 PUR AN (V1VA A L bVFR1~ZVILL 1 Fc VALLL-Y ROr1D ti1VA IN i~IIE titIDDLF 01 'I HE 1N1~C-IZSFCf10N VE! I K;A~7 !NTO THE. 13:1C!< OP ANOI HL-IZ V Fflll ISUS I AININ((_ IF\1~ENSIYI PK(I)IN"! F:ND DARIAGF \1'ITII (3UTI{ AIR [3Al,S DEPLOYED P( IS AN 3 1" O. FE~~IAI L l I1:\ I LVAS.SLiI Lti'(; IN [SACK SI',AT KEJ I KAINI_D ~+ [3L{HIND PASSENGER SFA1 PT SUSTAINED AN ABRASION UNDER H[R CHIN & PAIN TO RIG HT WRIST ARP:\ p {' ('0,111'l_AINS (.)1= P:11N IN LYRIST ARC-A bVHL-N SIiL= GRASPS R1Y HnND \VFI 1I P;\IN ALSO IN PIER p;1Li\1 r\RGA A,S WL=L1. NO ULFORtillTY OR DISCOLORATION NOTFU ALSO NOTED W'AS SOM[: RF,DNI~SS ABOU~f 1-11[ SCALP ON RIGHT SIDC PI W DOES NO L RF.hIEM13FR STRIKING IIEK I IGAD L3U (1111NKS SIIF S I RUCK I ILR ('HIN ON BACK OF FRONT SFA1 I'"I llFNILS LOSING CONSCIOUSNESS PIfYSICAI_ EXA!L1 SIUN COLOR NORMAL. AL'ARi11 AND DRY NEG TRAC[IFA DEVIA~IION PUPILS ErR LANG SOUNDS C!_FAR I31-LA 1~[RALLY" EQIiAL C3RE,1TH S0l1Nl:)S AI3D SOFT NON "FENllER LOWER FXTRLMITII~S LINREfv1ARKAE3LG Pl nLLRT AND OR1F,N~1 L D t a PT LV.1S GI VEN AN ICE PACK FOR HFR WRIS~F P~1- LVAS IIZANSI'OR~[1:D IN Tlll'. CAPI~AINS (I IrUIZ ALONG WI1 it rA ll!I)Dl' LiLrVt IRANSPORlTD10 IIOLI' SI'IKI f IIOSI'LI AL ARRIV[ D ~,~~ HOSP (r- 0813 HOURS RL-LLASEDI~O ER Sl:'1PF IN ROO~1 ~ ALONG LVfl~l1 H13R FATHER Cupyright.2Ui)U!L•led-Media, All Rights Reserved Pages I of I i .~ OED ~ $ 20~ S. } f- ! fa L ~ ? ^'`~ ~ ~~ t r.. y • L , ~ 1 .t-r-f `CL I ~i r i l - ... ~t - - 1 G -- - - - _ -_ ., sir.,- ~;;~~ ,~ ;i- - _ ;. - _ ... - - ~.,~ :_ _ ~ r r; , I E iii T T ,i,F' c . `t t - _ r.. ~ . __ _ ~ C ~ _ i l . i L i~TI(i;a 11:1rt ~'1 c-~ri= p"; - _-~-~_ 7 ,7!/ ~;=LJTET~. r~ i-r'"-~-'~ itt`i. ' -~- r,,~lEL' .-ri-- rr'il.=mar-. :~ .. cam;-^-;_ti`irs~_~ _TEr~t~~'. F'T I-c! ~:~ ~ 1^ `~ '- - ~ . i._ L, ,~: i j .1 rr-_'I ? r ~ '~ r'1 ('C . ~~ C =. it . 1 ter'. 1 •j^`'I ^,If ~ ?'.. t >-t+~i'~F '1-- Yri t .' _ ".1 .~. -'i ~i ~- - ! t-t._.11r ~I~~.t.~L I i~ir i._.'?''~~f r; ";- -1 r^rL; _ ~ ~ ! I -' i-'-' 1 i i_~i,.,r.i_C i. .. - ^T,"i-.:t'*-i ~ Fr:~ .rF'T~F'.ri^ -.r _ _ _ -'!`ice t= -~ ir, .. - ~- _ _ - ii '~ /l _ t ' _ L-'' . t ~ ~~ ~~ Y ~ ttiC' ~- . C l) / f ~~ CL ~ i `-lf 1 _. ~v i i ~ n i~t E . '- Y; t=~: ~: ~s +/ r=t =: E' , t< i E R ~" T I i 1 L.~ CL~. ~~ lam' ` T _ -~Et='E~ 8's •JIf1'_t'= [C"T lt~r ~i ~ -- ~~ I 1^' ~~ '- f"~~;:: •~.'~^i'c'. ~t-~ ~~ '\~ ~~ ~~`s' \_-' Date: 1 ~- Patient Name: Vital Signs Tem~~ Uo/r Pulse !o Resp 6~`P %` 5 ~ Sat Wt- k9 Est. /scale Pain Assess Lccation: .. ncnany. /10 ^ ~'/ong/Baker Dura±ion and frequency: - Character: ^ Sharp n Dull ^ Ache ^ Pressure ^ Burning ^ non- radiating ^ radiating ~a~~oi ~citcVCJ ~! FMD: ~- 1 P~ 5~,,.J Level of _C9 nsciousness ~t Alert O Verbal ^ Pain ^ Unresponsive - - . • L' ~ A - , e 1. ~. .. _ ~ t-. ~~ Q rCC~ r/~c - - r;. ~g9e'L-Sex: Ventilation Circulation ^ Clear ^ Pulses (site) ^ Obstructed ^ Present- 0 absent ^ Labored ^ Regular ^ irregular ^ ~ Non-labored O Strong ^ weak ' ^ Apnea Comment: ^ Intubated PRE-HOSPITAL Onset of sx/Time of I. B/P z Chief Complain#: Pulse ~ p~,,,,,,~, Rgtated Assessment Log in time: l ~ Triage Time: ~ -~ Time to exam room: ~;~ Zt~ Mode of arrival: ALLERGIES/reaction ^ BLS ^ NKDA ~es 7 Ambulatory ~(~~ . ^ Carried ^ Other: Latex alter 9Y~ ^ yes ---_____ ^ no ury: Tx prior to Arrival: t ~ , .Oxygen / ~ ~ _ ~ ~ ~;.~_ r' ~. ~ -4- G ~ >~ ~ ~u t %sat ~-. ~ r IV Therapy ~ ~ ~t `^ ~`-- __ ~ :~ ~ .~ Dextrostick /J~ " ~ ~~ ~-- Meds given _ ~ , ,~ - In route • ~ , Splint ^ c collar ^ C!D' ^ back-board O other: EMS signature: Time Triage Reassessment tnitial '~ Condition same Q Condition changed, see notes O Condition -same O Condition changed, see notes Condition same O Condition changed, see notes Ptv1H:__ pain? Medications: ^ See attached list . Dose ~~ ~~,' -~,",J Triage Disposition: ' ^ _`. Last tetanus LMP: ~ n/a Childhood immunization O UTD D not UTD Dose Screening O Exposure to measles, chickenpox, or TB in past month? Advanced directives: O no ^ yes attached O no ^ yes ^ Speaks no English Language Translation by:~_ AdulUChild abuse: Do you feel safe? ^ Unusual/suspicious marks (i.e. burns, welts, bruises, lacerations, punctures) ^ Potential Sexual Abuse D Potential Domestic Violence D Blind O HOH ^ Other: ^ No identifred Needs Dose ~ ~ 1 ,, ER Completed @ ~ by:_ .+, ~ y Jr._..-_-,~' ~ _ RN ./ .. Data Obtained b - J Triaged to Radiolo 9Y @ ^ N!A for ~ MA Interventions completed at Triage: Triage Notes: deformity: ^ no ^ yes Intervention ^ ice pack Time Initial distal pulses: ^ present ^ absent ^ sain spint ~!~ edema: ^ no ^ yes area ^ elevation t , ecchymosis: ki l ^ no , ^ yes area ^ c-collar ~ : - ~ ! tif~ l ~ s n co or: ki ^ WNL ^ cyanotic ^ mottled ^ medication ~: _ (seE~ d[.'arder shut) I,'` ~ ~ " s n temp: ^ warm ^ cool _ ^ other~% ~ . ~ ',. ~ 1 li i /~ ~ ~_~,"''(' ~' Holy Spirit Hospital Cam Hill PA 1 ~ ~ L i -%~ i ~ 1 '~ ' ' : ~ ' p , 7011 _ l ~ ~ , ~ -~~ _ /`~ ( t j yr r (~T John R• Dietz ECU :Nursing Assessment - t ? 4 ~' >< I -~ y f ~'af S Y ; 201-E C&Ot '" _._ ._ ~.., ~, ; - ~, ,~ fRI ~~ ~~t (' -i ~ ~ t cu 9 Rev.LLW t3iL11NG ! J .f I7~Z 3 -' t-:.i.';r'' .'-2t/1~ R-,q 07.37 V ' ` ~ ^ ~n - t.7-r .409 ,'1i_. ~_:~-` ~~ ~ ' ~ '~ ~~ ,. Initial Lab & X-Ray Orders Labs - , _ ,~' ( ] Ace[a ~inopnen ( J DOHS [ ] Thrombolytic Labs Cardiac - ~,<, ,T onr~tor• ~~ [ ]Acetone (SAGE) [ ] ESR [ ]Tox Screen [ =) EKG [ j Alcohol (ALGO) [ j Glucose' _ ( )Urine Tox Screen ' ~-- [ ] 02 UMi f J Amylase/Lipase [ J HCGS , - ~ = ! i ': - t f [ l T.,HR n. , -' ~.. _ [ ] APTT [ ]HIV [ i Type8Cross _ # of units [ J 02 Saturation ; ~' [ Jt~eH' flespiraton' ( ) ABG's ( ]Peak Flows Befcre/After Resp.`Tz. - ( J Respiratory Tx. [ ]Bl d [ ) Ltver (BOR) Medications /IV's /Additional Ord oo Cultures ers Profile [ J Type 8 Screen ' ( J BMP ( J Lytes ( ] UA: [ )DIP [ ] DIAG ( ] CBCP [ J Phencbarb [ ] Urine C 8 S ( I CMP ( ] PTP [ ]Urine HCG [ ] CRPt ( ] Salicylate [ J 4VC Breath Alco Test [ ] Digoxin ( J Theo [ ] WC Drug Screen [ ] Dilantin [ J Other: Radiology , [ ] AbdlObstr Series ( ) KUB [ ]Ankle R L ( ~ US Spine ~ "t _.. !! [ ]Clavicle r ( ] Cerv. Spine R!. /Lat. [ ]Nasal ~y~~ ~ [ ]Chest Rtn. !Port / TPA [ , ]Orbit R t [ j Elbow P. L [ ]Pelvis [ J Facial [ ] Pyelogram IVP ' ( J Femur R L ( i Ribs R L [ j Finger R L [ ]Shoulder R L ] Fcct R L [ J Skull - ( J Forearm R L [ ] Stemi:m [ ]Hand R L [ ] T/Spine ( J Hip R L i) Tib /Fib R L [ J Humerus [ j Knee R L ( 1 TOe L R L [ Wnst R L ( j Other: - Jime/CRT/Int._ ~ f ) ~'j~l! aEASON: _._1 x ~ ~ i+- - 'r)•"~ '~ rr ! ~, Special Procedures- U(trasound: C T: (W=With contrast; WO-Without) ( ]Abdomen [ ] AbdomeNPelvis W WO [ ] VO Scan [ j Duplex Doppler [ j Brain/Head W WO [ ] Echo- [ J Gallbladder [ ]Chest W WO cardiogram [ ] Pelvic% [ ) Spiral chest for PE Transvaginal ( J Other: Time/CRT/Int. REASON:~ Specimens/Cultures ( J Beta Strep AG Rapid [ ] Stool C 8 S [ ] CervicaVGenital [ J Stool O & P [ ] Chlamydia [ J Stool C. Ddficile [ ] GC Culture [ ] Tric~omonas ( J Monospot (rapid) [ .j-Wound C 8 S _.j _J Sputum C & S [ ]Other: Billing Classification: ~H`fSiCIAN CHARGE FACILITY CHA RGE J Level I ( J Level I Accident ]Level II [ J Level II ( ]Medical ~ ' ' _ el III ( ]level III [ ] Case t -- J Level IV ) j~ ( ]Extended Hrs: ] Level V [ ] level V ~- ! Dictated: Nalf [ j Completed .L - [. ``] CRITICAL CARE: hrs. Diagnostic Impression: ~~ ~I ~ ~ ~~ ~ ~~ ~ ~~] C no sultinglAdm _~~! Date: i i Time: 'r~~ ~- ~~t" r M D/DO/CRNP Holy Spirit Hospital 4 CampHiII PA i _, ~ ~ ~i -. ` s ~~ ~ ` ~ -~i -` ~`-~1 3 R X701 , , t ~ , 21 E John R. Dietz Emergency Center Physician Order Sheet' 1 ~= ~ F a (`~ ~! E~ S ~ E R i j: 2os-ECU REv. ,aco wtn,tu _, L ' ~l~l_I`~E i 2 / ~ `' ,r [ `? ~ ~ PA 170I3 -- ~~ '_ ~ C - 0 ~ ~ 7 Initials: Signature: - _ RN/MA Initials: Signature: - ~~ _ ~ - • - RN/MA Appearance: her, fal: Color: Temp: Speech,: Mental Status: Dcoriscious Ouncoo erati Respiratory: O Gastrointestinal ~ ]N/A Trauma ONIA ~~'+"dL O'aVNL warm" ] normal p ve ^lethargic ^combative s mmetrical Y and unlabored Dentes pain /symptoms ODuration! intensit Location ' t"'-'I 0Pa'? ']cool ^cbese Oflushed Ohot Oloud Oslurred Dcanfused Oanxicus i O O Dlabored Oretractions y 0nausea 0diarrhea ^abrasion ']laceration: Oemaciated Ocyanotic ]dry Otafkative r ented to: h sterical y Ope~son Response to Stimuli Oclear Dstridor Qvomdir.g Ocon=tipaicr. ^H Jecchymcsis: Ojaundiced ]diaphoretic0mumbling Oplace Oa ro riate PP P Jwheezing L / R ematemesis Last Bti1 Odeformih~ Gait Omott!ed Drash ObabY Otime Odelayed 0rales,'rhonchi L ! R 0cou h Bowel Sounds `]hurns: ~NiA ]normal rJabnormal __ g 0preductive ']Abdomen ]contusion: 0restraint/seclusion-Flow sheet _ 002 L via tender ]bleedirg Neuro ]NrA Sat Odistended Ofirm 0soft ~,,_ ._ Qheadache DPERL R ~L GU / GY N Orvia, Cardiovascular Dcnest ain r P ~ldenies Ostitf neck Size Oneck pain Pinpoint 00 Glasgow Score: Odenies sis Ourethral OMonitor;rhythm: area:___ Severity (?p Otacial droop Dilated D ] Onumb F Ofrequency discharge Ourqency Ovaginat dis charge Opacer Oedema _ Oconstant Osharp D!ntermdtent J ness ixed O O Ovveakness: Sluggish 00 ODysuria Ovaginal ble OH i t eding dull ]burnin g Oheavy non-reactive0'0 ema ur a Ofoley Oretention OJVD DS06 Opleuntic GLASGOW COMA SCALE present OOth ~ Ocapillary refill Dnausea EYES MOTOR RESPONSE VERBAL er. LMP DN/A 0rapid Odelayed Dnon-radiating 4 Spontaneous 6 Obeys 5 Oriented EENT 08enies s!s ON/A Ocalf !endemess R ! L ^radiating 3 To verbal command 5 Localizes pain 4 Disoriented E es c To pain 4Flexion-withdrawal 3 Inappropriate words ? No Response 3 Abnormal Flexion 2 Incomorehensive sounds y Ears Oblurred vision L / R ^Paln L Ode bl i Nose Throar / R Occngesfien Oscrs Acuity: L / 2 Abnormal Extension ? No Response u e v sion L / R Ddischar OPhclophcbia L ! R OOther: ge Odrainage Odroclin OE i _ _ g R /_ 1 No Response p staxis L / R Od• s ha / P sia Dwith lenses NURSING ASSESSMENT Signature: Initi l Completed bY:~ . ~ RN Time: ~ - a Si nature -- g Initial Protocol Initiated - ~ %-EKG done Labs lore "-rav done DCa!! bell-- ~within reach OSiderails up x2 OCompanion with patient JER procedure explained I - !V Therapy jconClllon cedes. 0=no inflammation/complica[iCn 1=eCema c=erythema 3=ecchymocis - 4=pain 5=harCness o=warmN 7=leaking) Date/ Tme Am[ Solunon Size Srte Rate Attempts Cond. Imhal t Tl,n,e I Notes - _ , ~ _ -- n >-, ,, '+`~S f'~ 7O -Qr~~t - ~ _-.l-A ~l.(~.i. "3 cam. 1~ -+~c,_ 'L,!,' :.-"~~ ~i: t 1 ~ ;!' ~~ ~,' 4701 21 E _ t ~, : , ~oly irit.F~ p~~ I `.: y -.Camp r1=~111 I~A'17011 ~ -' " - ~ ! ~ I John R. Dietz ECU Nursing Assessment! Notes 205-Ecu 06tC1 9'"Rev. LLW , - - Medications Time Druq Time ~ Motes x" - -- /.: Wit-' • ~ -- Route I j,te Initial Response __ 1~. Y ~ rl r~;:- -_ ,'r~r(t- % TRANSFER OR DISCHARGE i O discharged /accompanied by: wmbulatcry Owic ^ambulance to: Ohoma 0nursing home OAMA OOP. Dottier: Odischarge instructions given te: Dpatient ]family ^parent bother Overbalized understanding of d/c instructions OReport called @ to Oold records sent to floor Oclothing sheet done Otransferred to ^consent signed Condition: OSatisfactery OCritical ^Deceased to morgue ^Improved; pain scale /10 t -: - RtV Signatufe~-'~ l . ,' @ 1~:: (%x'~ .'f-iy •(. ' I t fir 1.=~ ~iv: ~~ ~ .~ r f - ` ~ r' ~ ~ L r J >, "T • ~ , '' E121 C~ ~" ~ 17025, i `'~`' i5 3-7491 `~ ' - ~ - 1 977 E" ;, - ,J~~r <<.~i ADM. DATE: 12/07/2001 CHIEF COMPLAINT: Motor vehicle accident. HISTORY OF PRESENT ILLNESS: This 8 year oid female was the restrained back seat passenger in an automobile accident in which her father's vehicle struck another vehicle causing her to be thrown forward and striking her chin and wrist against the back of the front seat. There was no loss of consciousness. The patient complains only of left sided jaw pain and right wrist discomfort_ PAST MEDICAL HISTORY: Negative. MEDICATIONS: Claritin. ALLERGIES: Unknown. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: Non-contributory. REVIEW OF SYSTEMS: Non-contributory. PHYSICAL EXAMINATION: This is a well developed, well nourished, 8 year old girl in no acute distress. Vital Signs reviewed on nurse's notes, within normal limits except for a pulse of 103. HEAD: Normocephaiic. Atraumatic. There is swelling, abrasion, and tenderness of the left side of the ja~,v. There was no deformity. EYES: Conjunctiva without discharge or injection. Lids without lesions. PERRL. ENT: Ears: Tympanic membranes without perforation, injecticn, cr bulging. ~rlouth: Lips, teeth, and gums normal. Throat: Oropharynx without lesions or exudate. Airway patent. Nose: Nasal mucosa normal. Sinuses: No sinus tenderness. NECK: Supple, symmetrical, non-tender, no (ymphadenopathy. Trachea midline. Thyroid non- palpable. LUNGS: Normal respiratory effort. Breath sounds equal. No rates, rhonchi, or wheezes. CARDIAC: Regular rate and rhythm without murmurs, ectopy, rubs, or gallops. No pedal edema. HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 EMERGENCY ROOILI REPORT Page 1 of 2 NAME: Barcavage, Kierstin N1R#: 470121 ROOM: ER1 DR.: PHILLIP N1AGUIRE, MD ORIGINAL NAME: Barcavage, Kit.,,tin MR#: 470121 GIIABDOMEN: Soft, non-tender, normal bowel sounds, r.o masses. No hepatcsplenomegaly. SKIN: Normal color and turgor. No rashes or lesions. EXTREMITIES: There is swelling and tenderness about the right wrist with full active range of motion. Right hand is neurovascularly intact. NEUROLOGICAL: Alert and oriented to person, place, and time. Cranial nerves intact. Sensory and motor function normal. Reflexes symmetrical. PSYCHIATRIC: Oriented to person, place, and time. Mood and affect appropriate. DIAGNOSTIC RESULTS: X-ray of the right wrist show fractures of the diaphysis of the radial and ulna. The mandible x- rays were negative. PROGRESS NOTES AND MEDICAL DECISION MAKING: Shortly after examination, an ice pack was placed on the patient's wrist. On receipt of the patient's x-ray results, a phone call was placed to Frank Horner, PA-C who will see the patient in the Emergency Department. CLINICAL IMPRESSION: 1. Motor vehicle accident. 2. Fracture of right wrist. PM/pm DOC #: 197580 D: 12/07/2001 T: 12/07/2001 9:10 P 145044 cc: HOLY SPiR1T HOSPITAL Camp Hill, PA 17011 ti EILIERGENCY ROOM REPORT PHILLiP MAGUIRE, MD Page 2 of 2 NAEVIE: Barcavage, Kierstin MR#: 470121 ROOM: ER1 DR.: PHILLIP P.~AGUIRE, MD ORIGINAL Ho)y Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT: BARCAVAGE, KIERSTIN MRn: 470121 SOC SEC: 999-12-0892 ORD DR: PHILIP MAGUIRE M.D. PT TYPE: E DOB: 12/08!1992 LOCATION: ER1- DICTATION DATE: Dec 7 2001 9:50A TRANSCRIPTION DATE: Dec 8 2001 2:42P ADM DATE: 12!07/2001 ARRIVAL DATE; 12/07/2001 NOSP SERVICE: ER1 ***Finat Report*** EXAMINATION: MANDIBLE {2V}, PANOREX {1V} 701'10 -12/0712001 COMMENTS: INDICATION: Motor vehicle accident. There is soft tissue swelling around the mandible. There is no convincing evidence of fracture of the mandible. The panorex view shows no dislocation at the temporomandibular joints or fracture of the condylar necks. CONCLUSION: Mandible probably negative for fracture. DICTATED BY: HOWARD BRONFMAN M.D. / SEH DATE OF EXAM: 12/0712001 SIGNED BY: HOWARD BRONFMAN M.D. DATEITIME: Dec 10 2001 9:30A Holy Spirit Hospitai Department of Radiology and Diagnostic Imaging Camp Hill, Pennsylvania 17011 (717) 7ti3-2600 PATIENT: BARCAVAGE, KIERSTIN I~tR#: 470121 SOC SEC: 999-12-0892 ORD DR: PHILIP MAGUIRE M.D. PT TYPE: E DOB: 12/08/1992 LOCATION; ER1- DICTATION DATE: Dec 7 2001 9:50A TRANSCRIPTION DATE: Dec 8 2001 2:38P ADM DATE: 12/07/2001 ARR)VAL DATE: 12!07/2001 HOSP SERVICE: ER1 **"`Fina! Report'"'* EXAMINATION: RIGHT WRIST (2V) 73110 -12107/2001 COMMENTS: INDICATION: Trauma. There are distal diaphyseal fractures of the radius and ulna. These occur about 2.5cm proximal to the growth plate. The fractures run transversely. As seen on the lateral view there is some impaction and infolding of the cortical bone anteriorly at both fracture sites. There is a questionable metaphyseal fracture from the lateral corner of the distal radius consistent with a Salter (Il} and a very questionable linear fracture on the medial side of the distal radius which extends into the growth plate. There is no widening of the radial physis or displacement to the radial epiphysis. The ulnar epiphysis is in normal positron. The carpal bones are anatomic. CONCLUSION:,-Fractured distal radius and ulnar diaphyses with questionable nondeforming Salter (li} fracture distal radial rnetaphysis. DICTATED BY: HOWARD BRONFMAN M.D. / SEH DATE OF EXAM: 12/07/2001 SIGNED BY. HOWARD BRONFMAN M. D. DATEITIME: Dec 10 2001 9:30A Im~ninn Cn»iiroc C_n»ct~lf~fin» Page __ i OFFICE RECORD ALLAN J. MIRA, M.D. Name BARCAVAGS, KIERSTIN L_ DOB: 12/8/92 I3/O1 OFFICE ZIISIT: This is a 9-year-old female who was injured in a motor vehicle accident on December 7th. She was seen at Holy Spirit Hospital, x-rays were taken at that institution and apparently a P.A. in the emergency room applied a short arm cast on her right upper extremity. She was a passenger in the car in the back seat with the seatbelt on where she stopped her momentum with her hands against the back of the front seat injuring her right wrist. She denied any other injuries. Her x-rays from Holy Spirit were reviewed and a new set was taken to make sure that she was in satisfactory position after the cast and after a week. These look satisfactory as well with a minimally angulated impacted-type fracture of the distal radius and ulna. Neurovascular status was intact. The cast was in good shape. Elbow range of motion is good as were the fingers. She was given cast instructions and instructions about activities. I told her that she needed to have the cast on approximately another 2 weeks for a total of 3. We will see her at that time for cast off and x-ray and further instructions, sooner if needed. AJM/kas ~ U Ltlr I J e tIC~.PeL'.~Lr ~l1! / L9`_+-tiiL ~~ ~ CARLISLE REGIONAL MEaICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT N,4ME: BARCAVAGE KIERSTIN L X-RAYS: 70J019 EXAM DATE: 12/13/2001 ORDERING: ALLAN J MIRA,MO SUR ATTENDING: CONSULTING HOLLY C. H. HOFFMAN,MD PE HISTORY: MAB FX CHECK R WRIST XR~~ 27829 MAB FX CHECK R WRIST XR~~ 27829 RIGHT WRIST - TWO VIEWS ~73/DO INDICATION: Follow up. lC' 14~ U1 11:44 F'. III /Ij: MED REC ~~: 7000'I9 ACCOUNT ~`: 7105%3S O.O.B.: 12/08/1992 ROOM: OP The antecedent study is not currently available far comparison. Fractures have been casted. Epiphyses and growth plates are normal. REVIEWED AND SIGNED ~OFFRE P LEWIS MED INTERPRETING PHYSICIAN DATE DICTATED: 12/14/2001 DATE TRANSCRIBED: 12/14/2001 TRANSCRIPTIONIST: JN 8025482 AUDIT PAGE 1 OF 1 12-14-01 12:33 RECEIVED FROM:C717) 249-1212 P-02 Page i ,.-~ OFFICER CORD ALLAN J. M 3A, M.D. Name BARCA~7AGE, KIERSTIN L. DOB: 12/8/92 - . 13/01 OFFICE VISIT: This is a 9-year-old femalF who was injured in a motor vehicle accident on December 7th. :she was seen a Holy Spirit Hospital, x-rays were taken at that institution a;~d apparently ~ P.A. in the emergency room applied a short arm cast on her ri:fht upper ext. amity. She was a passenger in the car in the back seat with Ll;e seatbelt on where she stopped her momentum with her hands against the back cf the front ~~at injuring her right wrist_ She denied any other injuries. Her x-rays f:gym Holy Spirit were reviewed and a new set was taken to make sure that she was in satisfactory position after the cast and after a week. These look satisfactory as well with a minimally angulated impacted-type fracture of the di tal radius and ulna. Neurovascular status was intact. The cast was in good s:ape. Elbow range of motion is good as were the fingers. She was given cast nstructions and instructions about activities. I told her that she needed to have the cast on approximately another 2 weeks for a total of 3. We wi=i see her at that time for cast off and x-r~iy and further instructions, sooner i.f needed. AJM/kas /0-' OFFICE VISIT: This patient is seen now ~t 3~ weeks since injury. Her cast is of~. X-ray shows good periosteal c.llus and good alignment. She has minima;. tenderness, 50$ range of motion ~t the present time. She was given the written instructions about activitie no gym for the rest of the month yet. i will see her late this month and >tart doing some push-ups on January 21st. [ will see her sooner if needed. 77M/kas 02 OFFICE VISIT: This patient is seen in fc;low-up now 8 weeks since injury. She has ,_i>solutely full range of motion, s1-3ht fullness in the fracture area, no tend~~ness. She can do a push-up we 1. She was discharged with the written :.nstructions to return prn. I tole her the thickness should subside in about a year. AJM/kas CARLISLE REGIONAL vIEDICAL CENTER RADIOLOGICAL INT,RPRETATION PATIENT NAME: BARCAVAGE KIERSTEN X-RAY#: 700019 EXAM DATE: 1/02/2002 ORDERING: ALLAN J MIRA,MD SUR ATTENDING: CONSULTING: HOLLY C. H. HOFFMAN,MD PE HISTORY: MAB FRACTURE R WRIST MAB #27829 RT WRIST RIGHT WRIST - 2 VIEWS HISTORY: Fracture follow-up. MED REC ## : 700019 ACCOUNT ##: 7111497 D.O.B.: 12/08/1992 ROOM: Op v Since 13 December 2001, the cast ias been removed. There is increasing sclerosis and callus a= the fracture site indicating healing. On the lateral view, there is slight lucency in some of the volar callus which would raise the possibility of motion. IMPRESSION: Healing fractures. However, them may be some motion at the radial fracture site as there is -come lucency through the callus. REVIEWED AND SIGNED DAVID ROYAL,MD INTERPRE`T'ING PHYSICIAN DAT:; DICTATED: 1/03; 2002 DATi' TRANSCRIBED: 1/03;''2002 DATI'. SIGNED: 1/03,'2002 TRAT:~CRI~TIONIS`I': CPS 858~~698 ORDERIIG PAGE 1 OF 1 ~IAB WRIST :~P & LATERAL _/ ~. CARLISLE REGIONAL ~ EDICAL CENTER RADIOLOGICAL INTE'PRETATION PATIENT NAME: BARCAVAGE KIERSTIN L X-RAY#: 700019 EXAM DATE: 12/13/2001 ORDERING: ALLAN J MIRA,MD SUR ATTENDING: CONSULTING: HOLLY C. H. HOFFMAN,MD 'E HISTORY: MAB FX CHECK R WRIST XR# 278:9 MED REC #: 700019 ACCOUNT ## : 710 5 7 3 3 D.O.B.: 12/08/1992 ROOM: Op MAB FX CHECK R WRIST XR# 278:9 RIGHT WRIST - TWO VIEWS INDICATION: Follow up. The antecedent study is not curren.ly availaUle for comparison. Fractures have been casted. Epipr~ses and ~r~owtl: plates are normal. REVIEWE?~~ AND SIGNED JOFFRE 1? LEWIS MED INTERPkEI'ING PHYSICIAN DATE DICTI~.TED: 12/14/2001 DATE TRAN:.'CRIBED: 12/14/2001 DATE SIGPi'~D: 12/14/2001 TRANSCRII 'Z'IONIST: JN 8625482 ORDERING PAGE 1 OF 7. ~ WRiJT AP & LATi_ ~:1L ai.r.~v J. ~ .A, P c. Medical Arts B gilding Suite 20 220 Wilson ; `reet Carlisle, PA : X013 ORTHOPEDIC SURGERY Allan J. Mira, M.D. PATIENT INFORMA" ON SHEET ~! ~ ~T ~i PATIENT: t},~i~'/,~~ ... ~l~•'f~'G/-:/~1=. DATE: ~ 1 t ~~~ r , /, DIAGNOSIS: ~~a ~-~ ,, , . , ; Ir.::TRUCTIONS FROM DR. MIRA: 1° i ~ , Phone 249-7400 Patient's Signature MIRA ORTH~ PEDICS Medical Arts l iilding Suite 2C' ' 220 Wilson . treet Carlisle, PA 7013 UATHOPEDIC SI~~ZGERY Allan J. Mira, M.G. PATIENT INFORMA' ION SHEET PATIENT: ~,~~ ~ ',~LJ'L ~~ '~ ~~~„!" `'` J DATE: ~~~(/~ "~ DIAGNOSIS: J INSTRUCTIONS FROM DR. MIRA: ~ ~ i /) - -~ - 1 ' r ~ 1 ,~ , . ~ ~ j_,_,.~ I; Phone 249-7400 ~f .~ v Patient's Signature MIRA ORT~I('PLDICS Medical Arts`` iilding Suite Zf ~ - 220 Wilson trees Carlisle, PA 7013 GRTHOPEDtC SURGERY At1an J. Mira, M. D. Phone 249-7400 PATIENT INFORML ION SHEET PATIENT: ~~ ~'~~'~ ~~..CQdID~,~ DATE: >~~~~I3~(~~ DIAGNOSIS: It•iSTRUCTIC.:~; FROM DR. MIRA: ',~ ,,, y ,~ ~, _~ ~ , `~ ~ Patient's Signature RELEASE AND SETTLEMENT AGREEMENT' I. RELEASE AND SETTLEMENT A. THE UNDERSIGNED, Kierstin Barcavage, a minor, by and through Stephen Barcavage and Penny Barcavage, parents and natural guardians of Kierstin Barcavage, and Stephen Barcavage and Penny Barcavage, individually, ("CLAIMANTS") on this -61 day of (J , 2004, for and in consideration of the sum of $12,000.00, paid by nited Services Automobile Association-Casualty Insurance Company (USAA-CIC) ("INSURER"), to fund the periodic payments as provided for in Section 104, Subsection (a) (2) of the Internal Revenue Code of 1986, as amended, specified in Section II, paragraph F of this AGREEMENT, which INSURER contracts and agrees to payor cause to be paid to the persons or entities named in Section II, paragraph G, the receipt and legal sufficiency of all of which are expressly acknowledged, does hereby forever RELEASE, ACQUIT AND DISCHARGE Stephen Barcavage ("RESPONDENT"), INSURER and their servants, agents, officers, attorneys, claim adjusters, successors, heirs, assigns and all other persons, firms or corporations, from any and all claims, actions, causes of action, damages, liens of every kind and character, and/or other obligations of every kind and character, including all expenses incurred or to be incurred, on account or arising out of or in any way related to any and all injuries or damages to me, as a result of all occurrences involving CLAIMANTS and RESPONDENT on or about the 71h day of December, 2001, at or near Enola, in the Commonwealth of Pennsylvania. B. THIS RELEASE IS INTENDED TO AND DOES COVER ALL CLAIMS FOR INJURIES AND/OR DAMAGES, WHETHER OR NOT KNOWN TO THE PARTIES AT THE TIME THIS SETTLEMENT AGREEMENT IS EXECUTED, WHICH HAVE RESULTED, MAY HEREAFTER RESULT FROM, MAY HAVE BEEN, OR MAY BE CLAIMED TO HAVE BEEN CAUSED BY OR RESULTED FROM THE DESCRIBED OCCURRENCES. C. As additional consideration fOT the described payments, CLAIMANTS, for themselves/their heirs, executors or administrators, and assigns, agreels] to and doles] indemnify and hold harmless RESPONDENT, INSURER and all others released by this AGREEMENT from any and all claims, demands and causes of action or any nature or character which have been made, or which may in the future be made by any person, firm or corporation claiming by, through or under them, including, but not limited to, all hospital, medical or other expenses or liens which are or could be asserted. n. PERIODIC PAYMENTS A. Notwithstanding any other provision of this AGREEMENT, INSURER is and will remam contractually responsible for all periodic payments under this AGREEMENT. B. RESPONDENT and INSURER agree that CLAIMANTS (to whom, or upon whose behalf, the periodic payments contracted for in the AGREEMENT are to be made) made claim against RESPONDENT for damages arising from or involving physical injuries or physical sickness. Those claims, among others, are being released and settled by this AGREEMENT. C. The Parties further agree that all periodic payments specified in Section II, paragraph F, of this AGREEMENT are being funded by the purchase of a "Qualified Funding Asset," as defined in Section 130(d) of the Internal Revenue Code of 1986, from USAA Life Insurance Company, which will provide for payment of the periodic payments, INSURER will be the sole owner of the "Qualified Funding Asset." INSURER guarantees that the periodic payments will be made as specified in the PERIODIC PAYMENT SCHEDULE. D. CLAIMANTS agree: (I) that INSURER is not required to set aside specific assets to secure the periodic payments; (2) that the periodic payments cannot be accelerated, deferred, increased or decreased by CLAIMANTS; and (3) that the periodic payment(s) shall not be, and cannot be, subjected in any manner to sale, transfer, assignment, pledge, mortgage, encumbrance, lien, collateral, or any similar transaction. Any attempted sale, transfer, assignment, pledge, mortgage, encumbrance, lien, collateral, or similar transaction is void. E. CLAIMANTS shall have no legal, equitable, vested, or contingent interest in the "Qualified Funding Asset" and their rights against INSURER, the company from whom the "Qualified Funding Asset" is purchased, or against the "Qualified Funding Asset" will be solely those of a general creditor. F. PERIODIC PAYMENT SCHEDULE: $3,935.00 annually, for only 4 years, guaranteed, beginning on December 8, 2011 G. THE PERIODIC P A YMENT(S) WILL BE MADE PAYABLE TO: Kierstin Barcavage H. Any periodic payments to be made after the death of CLAIMANT, Kierstin Barcavage, under this SETTLEMENT AGREEMENT will be made to the Estate of Kierstin Barcavage, as designated at the time of settlement (or in writing from time to time thereafter by the guardian of said CLAIMANT with Court Approval) by said CLAIMANT, upon attaining the age of majority, and delivered to INSURER. If no person or entity is designated by said CLAIMANT, or if the person or entity designated is not living at the time of said CLAIMANT'S death, the payment will be made to the Estate of said CLAIMANT. I. All sums set forth herein constitute damages on account of personal physical injuries or physical sickness, within the meaning of Section 104 (a)(2) of the Internal Revenue Code of 1986, as amended. 2 Ill. GENERAL PROVISIONS A. It is expressly understood and agreed that this settlement is a compromise of a disputed claim, that the payments provided for may not be construed as an admission of liability by RESPONDENT or INSURER, and that RESPONDENT and INSURER expressly deny any liability to CLAlMANTS. B. CLAlMANTS covenant that no representations or promises other than those expressed in this SETTLEMENT AGREEMENT have been made to them in regard to this settlement, that they have carefully read and fully understand this SETTLEMENT AGREEMENT, and that they understand that upon execution of this SETTLEMENT AGREEMENT, all rights, claims or demands CLAlMANTS may have against RESPONDENT and INSURER, except the contract to make periodic payments included in this SETTLEMENT AGREEMENT, are completely extinguished. C. SETTLEMENT AGREEMENT is to be construed and interpreted under the laws of the Commonwealth of Pennsylvania. Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. EXECUTED BY ALL PARTIES as of the date first stated above. CLAIMANT: Kierstin Barcavage, a minor CLAIMANT: Kierstin Barcavage, a minor " Xi Penny Barcavage, individually, and as parent and natural guardian of Kierstin Barcavage, a minor St en'Bareava, indiv y, and as parent and natural guardian of Kierstin Barcavage, a minor WITNESS: '. l '-7 II V "l"":- '\. C L ! WITNESS: ..0 )c INSURER: United Services Automobile Association - Casualty Insurance Company (USAA-CIC) Name Title EXECUTED at , this day of ,2004. 3 IN RE: PETITION FOR COURT APPROVAL TO SETTLE THE CLAIMS OF KIERSTIN BARCA V AGE, A MINOR, BY HER PARENTS AND NATURAL GUARDIANS, STEPHEN 1. BARCAVAGEANDPENNY BARCAVAGE IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA NO. ::LJ-05-(J/Lf3 ORPHANS' COURT DIVISION PETITION TO OBTAIN COURT APPROVAL TO SETTLE THE CLAIMS OF A MINOR AND NOW, come the Petitioners, Kierstin Barcavage, a minor, by Stephen J. Barcavage and Penny Barcavage, her parents and natura] guardians, and file the within Petition to Obtain Court Approva] to Settle the Claims of a Minor; and in support thereof aver as follows: ]. Petitioner Kierstin Barcavage is a minor who resides with her mothefand natura] guardian at ]94 Fairview Street, Carlisle, Cumberland County, Pennsylvania, Kierstin was born on December 8, ]992, and is ]2 years of age, (,..) \..0 2. Petitioner Stephen J, Barcavage is the father and natural guardian of minor Petitioner Kierstin Barcavage, and resides at 37 Logans Run, Eno]a, Cumberland County, Pennsylvania. 3. On or about December 7, 200], Kierstin was a back-seat passenger in a vehicle being operated by her father, Stephen J. Barcavage, westbound on Wertzville Road at the intersection of Valley Road in Hampden Township, Cumberland County Pennsylvania. 4. Mr. Barcavage's vehicle struck a vehicle being operated in front of him by Shawn Bucher, of West Fairview, Cumberland County, Pennsylvania. 2 5. Kierstin suffered a facial abrasion and right wrist injury and was treated at Holy Spirit Hospital. 6. Kierstin was diagnosed with right wrist fractures of the diaphysis ofthe radial and ulna, which were treated by casting. No surgical intervention was required. Copies of minor Petitioner's medical records detailing the treatment of her injuries are attached hereto as Exhibit "A". 7. Kierstin had a normal course of recovery for an injury ofthis type and is able to participate in normal physical activities for her age group. A copy of minor Petitioner's most recent x-ray and physician reports detailing her recovery from the right wrist injury are attached hereto as Exhibit "B". 8. On the date of the incident Stephen J. Barcavage maintained an automobile insurance policy through United States Automobile Association ("USAA"), policy number 007542171C7109. 9. To date, all medical bills of Petitioner Kierstin Barcavage have been paid by USAA. 10. In an effort to settle this case, the Petitioners have agreed that the sum of Twelve Thousand Dollars ($12,000.00) will be paid by USAA to Kierstin Barcavage, a minor, in exchange for a release of all claims. Insofar as execution of the Release requires the Court's permission, attached as Exhibit "c" is an unsigned copy ofthe Release that has been proposed. 3 II. The $12,000.00 is to be paid to purchase a guaranteed annuity from USAA Life Insurance Company, with an address of ADU Life, 9800 Fredericksburg Road, San Antonio, Texas 78288, through an individually designed settlement designed by Ringler Associates, Three Gateway Center, 16 North, Pittsburgh, Pennsylvania, 15222. Distributions from the annuity will be made to Kierstin in four equal annual payments of $3,935.00 beginning at age 18. All payments will have been made before Kierstin turns 22 years of age. The total yield from the annuity is $15,740.00. 12. The Petitioners believe that the settlement enumerated in the Petition is fair and equitable and in the best interest of the minor Petitioner, Kierstin Barcavage. 13. USAA has offered to pay the sum set out in this Petition toward an amicable resolution of the claims and in exchange for Court approval and a properly executed release of claims. 14. USAA shall also pay costs and legal fees incurred with respect to the instant Petition for Court approval. 15. Petitioner Penny Barcavage, as custodial parent, is aware of the proposed settlement and concurs with the terms thereof. WHEREFORE, Petitioners respectfully request this Honorable Court to enter an Order approving the foregoing compromise settlement, directing the distribution of proceeds thereof as set forth above, authorizing Petitioners, upon payment of the aforesaid sums, to execute a full and final release on behalf of minor Petitioner. 4 Dated: ~h /u'l Respectfully submitted: CALDWELL & KEARNS By: ~~ oodburn, Esquire A ey J.D. #81786 3631 North Front Street Harrisburg, PA 17110 (717) 232-7661 Attorney for Petitioners 5 VERIFICATION I verify that the averments in this document are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. c.s. 94904, relating to unsworn falsification to authorities. Date: ;) 17 l{j~ . By: CERTIFICATE OF SERVICE ,;'1t':~'1t ti/V--1 \~ I that I have served a copy ofthe within document on the following by depositing a true AND NOW, this 'l ~ dayof , 2005, I hereby certify and correct copy of the same in the U.S. Mails at Harrisburg, Pennsylvania, postage prepaid, addressed to: Stephen J. Barcavage 37 Logans Run Enola, P A 17025 Penny Barcavage 194 Fairview Street Carlisle, P A 17013 04-55/81316 By /\\;~~~:~ ( \ , I ........".., / x .) 7 Penr iylvania EIVIS Ref. rt Sl'r~in' ."\I:'U1W I.'lIi! :"/0. I'Ll{ :\'0. (Coullty Infill. :\11. ID:llt' II~lIl1pdCJl Twp r_1\lS 21 !)ll~n l UtIlI ~()5 \sun2 \2'\Iii2011l Incidt'llll.oc3tillll ,\IeD - Hl'(t'i\'ing Fal"llilY \\.TI{"]l\'IUT & vAtU:Y [U),\l) 2\<)$\ I !III", Sp\ll\ \ \$';])\\:'1\ J->:l1it'lll '-<:lllH' I'h'JIIl' :"'0. '\:":l' I Datt ,')1 Birth Sorbl St'o:. ;"'0. 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BARCAVAGE ~STEF~iEN -:)' ~C''3A!'~ FL't-t PT FEL TO GUAR: 0 E;S ~: =-E2=::.: ,C--"EF: ...r- >. _, ~. .- ~-_lI'~)L ;--; !F~_/1702S FH ~17 72:=>-7481 C>]i-1TAC.T H:;;iE':: , --." rn I i-l=;U~;!j-I:=-E I i',)FDPriA T I [.ri :'L.?in I !.;:3UF"::';'/CE co '_.'j::':;. ;=G:_ I J:: SUE:SCR i EE.r:;; .-,.-, :-',;:..L Fe \lFY ,-. ",'-,r', ,--Hr'~J F'r.:EC-EPT /~:UTi-i ~ ;,'":--....,,~:!::' ~ F;;E CERT FnDN~ # ;.~1 Aura rrj;L:~~;4UCE 1/0 EARCAl/AGE ~STE~fi~:'J ;~}) ~S~;~~;~:~i;.iE -E~RCAVAGE .STEPHEN [, I ~ .~ Ytc;t...20c:4'::: 194 .; n;',-::.7::: t:;-J (j;-) - - _. .. . - - - o ~;"I NANE: ::,ERE!:' S,: :/ , C-t" QiJ,J /I u t --r1 ,kal<;tv( "& V ().~ :}./A I I ~\f~ iJ u)lv)21L r!rV[ IS th()l-fh,~rci rJiaJ tu1 Cl f)l4 ~ ~0cL.cVU: 8AF~C;iVAGE ,KIERSTIN I.f PT#: 179:37702 HRj':: 47,)121 .J i tl~_\E: Eel TED 2"1': -..\c<_\ ~,,'~~TE: 1)-'\ 0' EUD Or DOCUHE;;T --"-~"'.2>~--'- ~"'-\~I'~-"- PEl) 1::<../;--;:.. AGl"::,FES'3: iSL:F~ ~ ADC'PES:::: L=;~,_IF~ ~ r;[:,DF[ :=;::::: :::i;T3: Fl"tc'--Cf;F.i- z..2LE /-,,\\ I ': ''\ 'c \_ h,' (J ,---,/ _ __I' \-..1.. . :.- -' ~,'~..~~:- ~. '..!...;. ':' 't-- .' ca.rcc< Vd,ciz-Age:? Sex E Ventilation Circulation' ,0/ Clear '0 Pulses (site) '0 Obstructed '0 Present- '0 absent '0 Labored '0 Regular '0 irregular '0 / Non-labored '0 Strong '0 weak /0 Apnea Comment: '0 Intubated Date: I L - to I FMD: I' lL i f'( Sf ,;-J Patient Name: Vital Signs T emPj1dL Voir Pulse lu-z, Resp~ B/P~ % Sat WL kg Est. scale Pain Assess Location:_ Intensity: 110 '0 A,dult (1-10) '0 Wong/Baker Duration and frequency: _ Character: 'D Sharp 'D Dull '0 Ache o Pressure o Burning [) non- radiating o radiating What relieves pain? Level of C9nseiousness [( Alert '0 Verbal o Pain Cl Unresponsive PRE-HOSPITAL BIP '- Pulse Rh hm Resp Oxygen / %sat IV Therapy Dextrostick Meds given In route Splint: '0 c collar '0 CIO" '0 back-board '0 other: EMS signature:- r' (I' (',..J Medications: 0 See attached list Log in time: t] ~ ~O Triage Time: ()/i? n Time to exam room:rjX Z-O Mode of arrival: ALLERGIES/reaction '0 BLS '0 NKOA 'O~tS / )<J Ambulatory ~ '0 Carried CJ Other:_ Latex allergy: '0 yes '0 no 1 -:t Onset of sxfTime of Injury: Tx prior to Arrival: Chief Complaint: I, j Rated Assessment \ 'l "5~~ b~ c k =~ -+ c, In "" ,-. . C~' ,~ J k: /''2:J ,---,,--,t (--::,-'~e '.lr",.... ~ 't::c:)<-. , w":- ~ !Q::LVC-- I-'-'c t- f'~ Screening o Exposure to measles, chickenpox, or T8 in past month? Advanced directives: '0 no 0 yes attached '0 no '0 yes '0 Speaks no English Language Translation by: I"{ '. .,il Adult/Child abuse: Do you feel safe? ,\ Time Triage Reassessment Initial _Q Condition same 0 Condilion changed, see notes o Condition same C) Condition changed, see notes~ _D Co~dilion $F,lme 0 Condilion changed, see notes~ PMH o Unusual/suspicious marks (i.e. burns. welts, bruises, lacerations, punctures) o Potential Sexual Abuse o Potential Domestic Violence On/a '0 Blind '0 HOH '0 Other: Last letanus LMP: Childhood immunization 0 UTD 0 nol UTO Dose Dose o No Identified Needs Dose Complet~d . ,l, / :r~~\J ; '- -k)\'~-/:'l,:- ./;/. ~; ", ' - . "'! MA "-'~-~'.' Triage Disp()sition: o Tnaged to Radiology @ for deformity: distal pulses: edema: ecchymosis: skin color: skin temp: RN , ~ . ; '0 N/A Interventions completed at Triage: Triage Notes: Intervention Time Initial '0 ice pack _ " I; '0 sain spint, J " 6' g~~~~~~~n ? .,' IstOll. " ,V , '0 medd,'Loh{. (,:e~ q~Jorde<she~t) ) , f, ~ iL- JJl'[(j '0 other,.., .f ,_ ,', c- () oI"" ,; / I' J L ( "I II / c/"~ \- I., {/'-'" i-I t' _ .,1 /'-~L..... ;\ a. i ~ 1 &+qL~ -, - n (,', I.) I ~; "c',- _' " I i ~ 2 "i'!;?' 4 7 I) I Z 1 [ i')(CU!-{t/,. CAV.GC' .KIPST1N v 114 F)I;;,VI~'" ST ERI","',",-, C ,- l ! -If I' ~\,~, r t ,;: C 0 ;h, ~ '9" \, \ '"' 1'1 170 13 ;,"'i~,f'7Ji: - ., d'" ." Z,',- 240-0737" ~J~t:. BlUING '1 ~ 'lc 17- nq Q , r n . ~ _ u _'.c~.;...:~~,.~ '0 no '0 yes o present '0 absent o no 0 yes area o no 0 yes area '0 WN'L 0 cyanotic '0 mottled o warm 0 cool 2C1.Ew C6l01 rji' Rev. llW Holy Spirit Hospital Camp Hill, PA 17011 John R Dietz ECU Nursing Assessment Initial Lab & X-Ray Orders: labs [ ] Acetaminophen I l Aceton~~tSACE} [ J Alcohol (AlCO) I ]AmyI8se/Upase I JAPTI [ J~BH' { ] Blood Cultures [ J BM~ I [CBCP 1 jCMP I [CAP1 I ] Digo;.:in ( ] Oilanlin Radioloqy [ I AbdlObstr Series ( jAnk!e R L [ ] Clavicle R L [ I Cery, Spine Rt flat. [ I Cllest Rtn. J Port I TPA ] Elbow R L J Facial J Femur R l ]Finger_A L ] Foot A l J Forea~m R L ] Hand R l I Hip R L ) Humerus R l I Knee R L I Other" " " .I \,\ , I J DOAS [, ] ESA l tG!ucoss" I J HCGS' I I HIV ( J Liver profile llytes I Phenobarb J PTP J Salicylate I Thea ~EASON h ~ I' I 1'b U-- ~ J Thrombolytic Labs J T ox Screen [ ) Urine Tox Screen -,TSHR IJ, -\ /;.':- ~~. I Type&Cross _ # of units (BOR) I Type & Screen J UA, I ) DIP I ) DIAG J Urine C & s I Urine HCG ] We Breath Alec Test ] We Drug Screen I Other: I IKUB .! 1l!SSpine;'O ;". ( rtJ Ma,dlble i.Jl.J".p<:,JL(>" .' I . I ~asal '". t;>l"~'t" I 'J Orbit A.l \. [ ] Pelvis f ] Pyelogram IVP [ I Ribs -R I ] Shoylder A [ ] Skull L L 1 Sternum ] T/Spine []Tib/Fib R L I voe_~ L [..I]Wrisl R !l Jirne/C~T!ln!. _ L ';l"~~d q ~(;' , I' '.'~ , -,1./ -. ",.. .'JQ . . Cardiac '. - " . . r',;'" ,~'f.~ ~JIt'lOMor Respiratory I J ABG's ~ . f ] Peak Flows Before/After Ae;p.irx.- [ J Respiratory lx. I 'J EKG f "J02_UMin [ J 02 Saturation ,- '--- -..I Medications I IV's I Additional Orders Dale/Time OtueiTime/lnl IV: NSSI DSWI LRI DS/.4SNSI DS.9NS WO/KVO/infuse at mlslhr [ ] Obtain old records [ ] Td [ ] Protocol initiated for: ~.;, . " , ~.1,~ , , ( , , 0;: - , . , . -~. '.~ /'~> " . - ; - , " .' . '. \. .' .. . . '-j(IL" - f , c' / , , /- .lC_ i...v'- .., . Special Procedures: Ultrasound: CT: (W=With contrast; WO=Without) [ 1 Abdomen l r Abdomen/Pelvis W WQ { I VQ Scan [ I Duplex Doppler [ I BrainlHead W WQ [ ] Echo- ( I Gallbladder (1 Chest W WO cardiogram 1 Pelvic! I Spiral chest for PE Tr<3;1Svaginal I Other: :::I,EASO~i:- Time/CRl/lnt. Initials: Signature: RN/MA Specimens/Cultures [ I Bela Slrep AG Rapid { I CervicaVGenila\ [ ] Chlamydia ( 1 GC CU!\\Jfe { ] Monospo! (rapid) _l JSpu\umC&S J Stoole & S lS\ooIO&P J Stool C. Ditficile j T Ilchomonas .- .tWound C & s lOther: Billing Classification: ::>HYSIC1AN CHARGE FACILITY CHARGE I Level I ~ 1 Level I . ] Level II { J level II ~I [ 1 Level III I Level IV ~V I Level V { 1 level V Initials: Signature: ~.~:-:-._- ,,;...-:. .:_-... -c.' RNlMA Dictated: Half [ ] Completed f.LJ CRITICAL CARE: _ hrs. IiVi \\ A:' 1=)<... @) 1rJ-t I~l Diagnostic Impression: / ' 6!JgI~~m)Y:f9 Phr6 ',/fi,.,:,"' /) ,;/:;"i.,&(: y lease 1 :-'--- Signatu~e:h I {/(~- ,~'---'::, MD/DO/CRNP J Extended Hrs.- ,. Date: . . (I':11/-'1 ' ~ i j ;J~~e: ;~..C/' (;.\7 ! '. j! _, IL{;'- t- j" '- -. (( 'j'! , , . l-; ':--;',"- ~fJ y-zt ..., Holy..Spiril Hospital ?f Camp Hill, PA I ~ John R Dietz Emergency Ceder ~ Physician Order SheetL, 206.ECU REV. 10100 Wt~k:: '1"1 c". -n n::> M R 470121 E :: ~ 1,',( H ~Gf ",KI ERST I!I ,.fl: , 1::. r.\ I .~ , I E \4 S T E R I .,:~,.\ c \ 0 II $lE '~ P A 17013 ....i!t1 ! 21 02 n H 2 ? ~O-0737;;,.;':f~~"'- '\'1- \ 2-(\~'H En GROUP, '~~f,,~S'1i .t ;...:. It! /_._1 ( ! Appearance: Gene;af. Color: Temp: Soeech: :l'NNL aWNL ::::Lr.arrn- Onormal Clrrail Opal.;- CleGol Oloud uobese Oflushed 0 hot Oslurred Oernaciated ::kyanotic :Jdry Otalkati'le o jaundicedJ diaphoretic 0 mu mbling Gait. OmOlt!ed Orash Obaby gj'iiA ::Jnormal Clabnormal Mental Status: ':lcoliscious Ouncooperative Diethargic Ocombative Oconfused Oanx:cus Oriented to Ohysterical Opers~n Response 10 Stimuli Opl~ce Oappropriale Otime Odelayed DrestrainVseclusion.flow sheet Neuro ClN/A ~j_ '_ Dheadache OPERl R L Osliff neck Size __ ':Jneck pain Pinpoi~f O'::J :Jfac:al droop Dilated 0 :l ::l'1l.:mbness. Fixed O:J Oweakness Sluggish 0 :J non-reactive.:J 0 GLASGOW COMA SCALE EYES MOTOR RESPONSE 4 Sj::ontaneous 6 Obeys 3 To verbal command 5 localizes pain 2 To pain 4 Flexion-witr,drawal 1 No Response 3 Abnormal Flexion 2 Abnormal Extension 1 No Response GU I GYN Gla:3gow Score: Odenies sis Orrequency Ourgency ODysuria ClHematuria Oretention ClOther: VERBAL 5 Oriented 4 Disoriented 3 Inappropriate words 2 In comprehensive sounds 1 No Response EENT Eyes Oblurred vision L! R Odouble vision L I R o Photophobia L I R NURSING ASSESSMENT, Completedby~. .--' ../ RN Time: ", , ;: Pi"Clccoi IniliattSQ.. /-EKG done Labs done X-ray dene Clean bell-- within reach"CJSiderails up x2 ClCompanion witli patient .:JER procedure explained IV Therapy iCOrlc,tiOrl cedes. O~no irlflammatK,nlcomplication 1"ecema 2~erytr.ema 3~ecchymOSl5 4=palrl 5=harcne,>s 5-w<irmlh l~leaklng) Date! TJme Amt SOil/liOn. Size Site Rate Attempts CQrld. Imllal . Time Notes . . .co ; ,~- :::":,2 (1 -...., -';..1 ...1,__.. ,., 0.,,5 h- :1- f' "~'I ;_--"~-;J,,/\ Iri.() 11:\11 I:.... I.~ !.).) ,~ 70 ':"cf/.,:',jt'-,) .r l",~~l .x. _.!'c_ 1.;~' [L/-(:,' /~f I'r~-~' /J1i~lh. J() (t_ (lli\~-jj(D:-;..---t;/:;~---~)"':?'-!>L"i\.r"7~'-.r0.'U \',:.t$., I!,)l u<'l '."-,.( ,,' "rP ;L " . (),: ' :) l c;::...:>;: <l' C . " <, 7 ~'(,. ji, .... - 1 -.' i I (: .."J '; '; 4 7 0 I 2 I C.\1\:[ ~1t~STI' '\! '1 I lOj ,>. [ '''''''''I~!\I ..'_ . # '" oJ - , , <"I..... ') ') J.'"" _ _~ 7 'l""J '. ,c ' ,{joly:sniritJ-lA'iPi\91 _ C ; \ _ 1 '~a";d;fW"1 PA'11011 i~) ~... I - 1 John R. Dietz ECU Nursing AssessmenU Noles 2C5-E<:u06/Cl SltoRev_lLW L €: ,._."..'....0 Respiratory: _Osymmetrical and unlabored o labored Oretractions o clear 0 stridor Qwheezing l ! R Orales/rhonchi L 'R Ocough Oproductive_ 002_L via_ % Sat ONJA Ourethral discharge O'/aginal discharge Ovaginal bleeding Oroley present_It lMP ON/A DN/A Ears DPain L/R Odischarge GOther Jaenies s/s Signature: ~-.~ Medica!ions Time Drug I~_\i.( _ .,- ..... f Ji.: .' '/' " ;(. 'c~\:: r { , > Gastrointestinal ONIA .~Oenll>s pain Isymptoms GOuration! intensity_ Dnausea Odiar~hea Ovomiting Oconstipaticn OHematemesis last 8M Bowel Sounds ::::)Abdomen tend,;-r Odistended ::Jrrrm ::Jsoft Cardiovascular o Monitorlrhythm Opacer Q edema ':JjVD Ocapillarj refill o rapid 0 delayed :Jcalf terderness R I L Nose Ocongestion Odrainage DEpistaxis L! R Trauma ONfA Location Oabrasion 'Jlaceration: Oecchymcsis. Qceformity. o burns: ,:Jcontusion Obleeding C1Chest pain OEJenies area Severity _/10 Oconstant Osharp ::J;nlermittenl ::Jdull :Jburning ::Jheavy ::JSOB Opleuritic Clnausea Onon-radiating Oradiating Throat Osore Acuity. Odrooiing Odysphasia L_f_ R ( o wiihienses Initial Signature .', c;. ,(\ - i TRANSFER OR DISCHARGE o discharged laccompanied by: Oamburalory Owic Oambulance to: Ohome Clnursing home OAMA OQR Dother: Odischarge instructions given to: Opatient Dfamily Dparent Dother: Dverbalized understanding of die instructions OReport called @ to Oold records sent to floor Otransferred to Condition: OSatisfactory DCrilica! ODeceased to morgue o Improved; pain scaJe_/10 RN Sigflalure.:-"--...7c0/./ . ",@.ui.Lt c . / r;~ '/::-Y10 r 1'"-:. \' (.\ J '1-C-t C C . 'I I;' .-: Y .... - "...,. . '.> .. -' - . I f".~t..'~-!f~..v: .~1"'-1\.r.'1'-l - \..'" A V 1 "r,:c ~ ~ :.~:~jb 7j).I~77 1!. ~ E Route . . .'.:.- Time Noles r I ~-HB I [ -.' "'- :. v j~ . U i i; a Initial S.te Initial Response ./-:-, . Oclothing sheet done Oconsent signed [ R J 17025 , J , " ADM. DATE: 12/07/2001 CHIEF COMPLAINT: Motor vehicle accident. HISTORY OF PRESENT IllNESS: This 8 year old female was the restrained back seat passenger in an automobile accident in which her father's vehicle struck another vehicle causing her to be thrown forward and striking her chin and wrist against the back of the front seat. There was no loss of consciousness. The patient complains only of left sided jaw pain and right wrist discomfort. PAST MEDICAL HISTORY: Negative. MEDICATIONS: Claritin. ALLERGIES: Unknown. FAMilY HISTORY: Non-contributory. SOCIAL HISTORY: Non-contributory. REVIEW OF SYSTEMS: Non-contributory. PHYSICAL EXAMINATION: This is a well developed, well nourished, 8 year old girl in no acute distress. Vital Signs reviewed on nurse's notes, within normal limits except for a pulse of 103. HEAD: Normocephalic. Atraumatic. There is swelling, abrasion, and tenderness of the left side of the jaw. There was no d~formity. EYES: Conjunctiva without discharge or injection. Lids without lesions. PERRL. ENT: Ears: Tympanic membranes without perforation, injection, or bulging. Mouth: Lips, teeth, and gums normal. Throat: Oropharynx without lesions or exudate. Airway patent. Nose: Nasal mucosa normal. Sinuses: No sinus tenderness. NECK: Supple, symmetrical, non-tender, no lymphadenopathy. Trachea midline. Thyroid non- palpable. LUNGS: Normal respiratory effort. Breath sounds equal. No rales, rhonchi, or wheezes. CARDIAC: Regular rate and rhythm without murmurs, ectopy, rubs, or gallops No pedal edema. Page 1 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 " NAME: Barcavage, Kierstin MR#: 470121 ROOM ER1 DR.: PHILLIP MAGUIRE, MD ORIGINAL EMERGENCY ROOM REPORT NAME: MR#: Barcavage, Kit.'0tin 470121 GI/ABDOMEN: Soft, non-tender, normal bowel sounds, no masses. No hepatosplenomegaly. SKIN: Normal color and turgor. No rashes or lesions. EXTREMITIES: There is swelling and tenderness about the right wrist with full active range of motion. Right hand is neurovascularly intact. NEUROLOGICAL: Alert and oriented to person, place, and time. Cranial nerves intact. Sensory and motor function normal Reflexes symmetrical. PSYCHIATRIC: Oriented to person, place, and time. Mood and affect appropriate. DIAGNOSTIC RESULTS: X-ray of the right wrist show fractures of the diaphysis of the radial and ulna. The mandible x- rays were negative. PROGRESS NOTES AND MEDICAL DECISION MAKING: Shortly after examination, an ice pack was placed on the patient's wrist. On receipt of the patient's x-ray results, a phone call was placed to Frank Horner, PA-C who will see the patient in the Emergency Department. CLINICAL IMPRESSION 1. Motor vehicle accident. 2. Fracrure of right wrist. PHilLIP MAGUIRE, MD PM/pm DOC #: 197580 0: 12/07/2001 T: 1210712001 9:10 P 145044 cc: Page 2 of 2 HOLY SPIRIT HOSPITAL Camp Hill, PA 17011 ~ NAME: Barcavage, Kierstin MR#: 470121 ROOM: ER1 DR.: PHilLIP MAGUIRE, MD ORIGINAL EMERGENCY ROOM REPORT Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT: MR#: SOC SEe: ORD DR: PT TYPE: DOB: LOCATION: BARCAVAGE, KIERSTIN 470121 999-12-0892 PHILIP MAGUIRE M.D E 1210811992 ER1- DICTA nON DA TE: Dee 72001 9:50A TRANSCRIPTION DATE: Dee 82001 2:42P ADM OATE: 12/07/2001 ARRIVAL DATE: 12/0712001 HOSP SERVICE: ER1 '''final Report'" EXAMINATION: MANDIBLE (2V), PANOREX (1V) 70110 - 1210712001 COMMENTS: INDICATION: Molar vehicle accident. There is soft tissue swelling around the mandible. There is no convincing evidence of fracture of the mandible. The panorex view shows no dislocation at the temporomandibular joints or fracture of the condylar necks. CONCLUSION: Mandible probably negative for fracture [)ICTATED BY: HOWARD BRONFMAN M.D. I SEH DATE OF EXAM: 12/07/2001 SIGNED BY: HOWARD BRONFMAN MD. VA TEITIME: Dee 10 2001 9:30A 1.......__;_.... c..._.=_...._ ,......._.....1&.....=__ Holy Spirit Hospital Department of Radiology and Diagnostic Imaging Camp Hill, Pennsylvania 17011 (717) 763-2600 PATIENT: MR#: SOC SEe: ORD DR: PT TYPE: DOB: LOCATION: BARCAVAGE, KIERSTIN 470121 999-12-0892 PHILIP MAGUIRE M.D E 12/08/1992 ER1- DICTATION DATE: Dee 72001 9:50A TRANSCRIPTION DATE: Dec 82001 238P ADM DATE: 12/07/2001 ARRIVAL DATE: 12/07/2001 HOSP SERVICE: ER1 U*Final Report-.- EXAMINATION: RIGHT WRIST (2V) 73110 -12/07/2001 COMMENTS: INDICATION: Trauma. There are distal diaphyseal fractures of the radius and ulna. These occur about2.5cm proximal to the growth plate. The fractures run transversely. As seen on the lateral view there is some impaction and infolding of the cortical bone anteriorly at both fracture sites. There is a questionable metaphyseal fracture from the lateral corner of the distal radius consistent with a Salter (II) and a very questionable linear fracture on the medial side of the distal radius which extends into the growth plate. There is no widening of the radial physis or displacement to the radial epiphysis. The ulnar epiphysis is in normal position. The carpal bones are anatomic. CONCLUSION:, Fractured distal radius and ulnar diaphyses with questionable non deforming Salter (II) fracture distal radial metaphysis. DICTATED BY: HOWARD BRONFMAN MD.! SEH DATE OF EXAM: 1210712001 SIGNED BY: IJATEfTIME: HOWARD BRONFMAN M.D. Dee 102001 9:30A 1""'!:lInin" ~C"/i,.~c: ~^nelll+~t;^n Page 1 OFFICE RECORD ALLAN J. MIRA, M.D. Name BARCAVAGK, KIERSTIN L. DOB: 12/8/92 13/01 OFFICE VISIT: This is a 9-year-01d female who was injured in a motor vehicle accident on December 7th. She was seen at Holy Spirit Hospital, x-rays were taken at that institution and apparently a P~A. in the emergency room applied a short. arm cast on her right upper extremity. She was a passenger in the car in the back seat with the seatbelt on where she stopped her momentum with her hands against the back of the front seat injuring her right wrist. She denied any other injuries. Her x-rays from Holy Spirit were revie.,ved and a new set was taken to make sure that she was in satisfactory position after the cast and after a week. These look satisfactory as well with a minimally angulated impacted-type fracture of the distal radius and ulna. Neurovascular status was intact. The cast was in good shape~ Elbow range of motion is good as were the fingers~ She was given cast instructions and instructions about activities. I told her that she needed to have the cast on approximately another 2 weeks for a total of 3. We will see her at that time for cast off and x-ray and further instructions, sooner if needed. AJM/kas I: UIII. l,alll~lt' t\t:j.rIt'LL."U. l/lf! (.'+'::1-II.li lL/lL.f.'Ul l~;l.jq r'.UUIJ~ Y. / "I) c . CARLISLE REGIONAL MEDICAL CENTER RADIOLOGICAL INTERPRETATION PATIENT NAME: X-RAyno EXAM DATE: ORDERING: ATTENDING: CONSULTING HI STORY: MAB MAB BARCAVAGE KIERSTIN L 700019 12/13/2 00 1 ALLAN J MIRA.MD SUR HOLLY C. H. HOFFMAN,MD PE FX CHECK R WRIST XRU 27829 FX CHECK R WRIST XRU 27829 MED REC /I; ACCOUNT If; D. D. B. ; ROOM: 700019 7105733 12/08/1992 DP RIGHT WRIST - TWO VI EWS 73/00 INDICATION; Follow up. The antecedent ~tudy i~ not currently available for comparison. Fracture~ have been casted. Epiphyses and growth plate~ are normal. REVIEWED AND SIGNED JOFFRE P LEWIS MED INTERPRETING PHYSICIAN DATE DICTATED: DATE TRANSCRIBED; TRANSCRIPTIONIST: 8625482 12 -14 - Ell 12: 33 12/14/2001 12/14/2001 IN AUDIT PAGE 1 OF 1 RECEIVED FROM: <717> 249-1212 P. Ell Page 1 ...-........... OFFICE R CORD ALLAN J. M ,A. M.D. Name BARCAVAGK, KIERSTIN L. ooB: 12/8/92 13/01 OFFICE VISIT: This is a 9-year-old femalr who was injured in a motor vehicle accident on December 7th. She was seen a Holy Spirit Hospital, x-rays were taken at that institution ai-Id apparently i P.A. in the emergency room applied a short arm cast on her rJ IJht upper ext: ~rni ty. She was a passenger in the car in the back seat with the seatbelt on ,.,here she stopped her momentum with her hands against the back of the front ~ 2at injuring her right wrist. She denied any other injuries. Her x-rays f;)m Holy Spirit were reviewed and a new set was taken to make sure that she was in satisfactory position after the cast and after a week. These look sa .isfactory as well with a minimally angulated impacted-type fracture of the di tal radius and ulna. Neurovascular status was intact. The cast was in good s: :ipe _ Elbow range of motion is good as were the fingers. She was given cast nsiructions and instructions about activities. I told her that she needed to have t.he cast on approximately another 2 weeks for a total of 3. We wi: L see her at that time for cast off and x-relY and further instructions, sooner 1. f needed. AJM/kas ~/02 OFFICE VISIT: This patient is seen now It 3! weeks since injury. Her cast is off. X-ray shows good periosteal c .llus and good alignment. She has minima"~ tenderness, 50% range of motion It the present time. She was glven the wr lten instructions about activitie , no gym for the rest of the month yet. 1 will see her late this month and ,tart doing some push-ups on January 21st. (will see her sooner if needed. 1 JM/kas '02 OFFICE V, SIT: This patient is seen in ff ~low-up now 8 weeks since injury. She has ,c.!Jsolutely full range of motion, s1: jht fullness in the fracture area, no tendL.:...ness. She can do a push-up we 1. She was discharged with the written ,nstructions to return prn. I toll her the thickness should subside in about a year. AJM/kas CARLISLE REGIONAL vfEDICAL CENTER RADIOLOGICAL INT:RPRETATION PATIENT NAME: X-RAY#: EXAM DATE: ORDERING: ATTENDING: CONSULTING: HISTORY: MAB MAB BARCAVAGE KIERSTEN 700019 1/02/2002 ALLAN J MIRA,MD SUR HOLLY C. H. HOFFMAN,MD PE FRACTURE R WRIST #27829 RT WRIST MED REC #: ACCOUNT #: D.O.B. : ROOM: 700019 7111497 12/08/1992 OP (\ V RIGHT WRIST - 2 VIEWS HISTORY: Fracture follow-up. Since 13 December 2001, the cast 1as been removed. There is increasing sclerosis and callus a: the fracture site indicating healing. On the lateral view, th,re is slight lucency in some of the volar callus which would rlise the possibility of motion. IMPRESSION: Healing fractures. However, ther, may be some motion at the radial fracture site as there is :ome lucency through the callus. REVIEWED AND SIGNED DAVID ROYAL,MD INTERPRl::TING PHYSICIAN DA'I. DICTATED: DATE TRA.1'JSCRIBED: DATE SIGNED: TRAL3CRIPTIONIST: 8589698 'lAB WRIST .,P & LAlERAL 1/03/2002 1/03/2002 1/03!2002 CPS ORDERIHG PAGE 1 OF 1 ~- -/ CARLISLE REGIONAL 1\ EDICAL CENTER RADIOLOGICAL INTE,PRETATION PATIENT NAME: X-RAY#: EXAM DATE: ORDERING: ATTENDING: CONSULTING: HISTORY: MAE MAE BARCAVAGE KIERSTIN L 700019 12/13/2001 ALLAN J MIRA,MD SUR HOLLY C. H. HOFFMAN,MD 'E FX CHECK R WRIST XR# 278 :9 FX CHECK R WRIST XR# 278 ~ MED REC #: ACCOUNT #: D.O.B. : ROOM: 700019 7105733 12/08/1992 OP RIGliT WRIST - TWO VIEWS INDICATION: Follow up. The antecedent study is not currenly available for comparison. Fractures have been casted. Epipt'ses and growth plates are normal. REVIEWED AND SIGNED JOFFRE !' LEWIS MEC, INTERPRETING PHYSICIAN DATE DICTi,TED: DATE TRAN.:CRIBED: DATE SImi~D: TRANSCRIl'J'IONIST: 8625482 UlWIlli>1'AI'&LATi ,.\L 12/14/2001 12/14/2001 12/14/2001 IN ORDERING PAGE 1 OF 1 ORTHOPEDIC SURGERY Allan J. Mira, M.D. j I . f" , PATIENT: IljA/Jf7;~ O(;/CtI ij~ DATE: ,,< I / Ja J... DIAGNOSIS: ..,1J ,'. .,t? ""{ Z 'Il" f I /.. "A..; , U/~<L"", / Ir:,:TRUCTIONS FROM DR. MIRA: d /!,J (I l.U ALLAN J. Mr A, P. C. Medical Arts B liIding Suite 20. no \Vilson ~ reet Carlisle, PA : '013 PATIENT INFORMA- ON SHEET I,: , t I. f l:/7~,'!U).:/... /II;} JJ-i.~ tEd;J~ /1 (,1 f.7,M.r tI}lJ.. I~P' tUV . , /,; //).:(. r,,,., , .....-,. . ~. >.nA....A..v'J..; . t /i;j d; d. Patient's Signature ~" ~, Phone 249-7400 MIRA ORTHf PEDICS Medical Arts] IiI ding Suite 2e . 220 Wilson, treet C,r/isle, PA 7013 , , ORTHOPEDIC Sl:i1GERY Allan J. Mira, M,D Phone 249-7400 PATIENT INFORM.A' ION SHEET PATIENT: KJ.I':JiJ1-/ DATE: / ;0.,/ tJ :'( DIAGNOSIS: /.~/,' J) ,1 ("/ j' /-' ;\f ,!,.J" -,"v t.,{ I ?t ' '- ~'- '};l ;1 i /, ! 'll r J,.,j /{} U~7A)LIP- INSTRUCTIONS FROM DR. MIRA: , I I 'j /, (;,1,/ /i Ii /{d I P.I jJc),. L d,; /L)J uJ11L , /'J ,-7 3 II , (lil,jU/,,> Vft _J" I), If)!? I~~!... , 17) 11 In. I,' i / I ""~ '7/ J'!") '" '-//1/ ,;rtiJ 1." .", I ,,'?\ / ' (;c/U d fi.L'U d . 'J v Orl) //.11 ))(',,/'IL +]I'd/1 I'jJ4 t,' hli/ 4 . 1 Patient's Signature ORTHOPEDIC SURGERY Allan J. Mira, M.D. PATIENT: 1{jj/~ 8(l}./: ((.JIO?-U DATE: /'~1/3J6I DIAGNOSIS: " tit- f1 )jU. d f'/u c.""U.u.J- INSTRUCTIC'. FROM DR. MIRA: . .~ I 1/:-1 " '(, /1. I c' . . , , I)) 'i . ii:J. .,' ,) ,," J t ~. MIRA ORTI;H 'PE:DICS Medical Ant';ilding Suite zr , 220 Wilson treet Carlisle, PA 7013 PATIENT INFORMt ION SHEET I _-1 ; i 'f I ( Ii'! '" I..... Phone 249-7400 Patient's Signature