Loading...
HomeMy WebLinkAbout14-4247THOMAS, THOMAS & HAFER, LLP Gordon A. Einhom, Esquire 1. D. 59006 geinhom@tthlaw. corn 305 North Front Street P.O. Box 999 Harrisburg, PA 17108 (717) 441-7054 geinhom@tthlaw.corn OF TFILED- HE P ROTI.fONOy A RY 2.014 JUL 22 [;iI:3 CUMBERLAND COUNTY PENNSYLVANIA Attorney for Petitioners Michael Sprow and Karin Sprow Forte IN RE: THOMAS SPROW, a Minor IN THE COURT OF COMMON PLEAS OF CUMBERLAND (,CnOUN ,P NO. {' _l -I ( �U L CIVIL ACTION - LAW PETITION FOR COURT APPROVAL OF MINOR'S COMPROMISE, SETTLEMENT AND DIRECT DISTRIBUTION AND NOW, come Petitioners Michael Sprow and Karin Sprow Forte, Parents and Natural Guardians of Thomas Sprow, and file this Petition to Approve Minor's Compromise and Settlement and avers the following in support thereof: 1. Petitioner Michael Sprow, is the father and natural guardian of the minor, Thomas Sprow ("Minor") and resides at 116 Millwood Drive, Harrisburg, PA 17110. 2. Petitioner Karin Sprow Forte resides with her minor son, Thomas Sprow, at 3407 Hawthorn Drive, Camp Hill, PA 17011. 3. The Minor was born on January 15, 2001 date of the accident described herein. 1 and was 12 years old on the 4. The Minor, Thomas Sprow, suffered personal injuries as the result of an accident that occurred on the premises of the Dick's Sporting Goods Store located at 5950 Carlisle Pike, Mechanicsburg, PA 17055 on September 20, 2013. 5. On the date of the incident, the Minor, Thomas Sprow, was on the premises of Dick's Sporting Goods and was test riding a bicycle in the Bike Department of the store and collided with the endcap of a shelving unit, sustaining a laceration to the upper palm of his right hand. 6. Minor, Thomas Sprow, was treated after the accident at Holy Spirit Hospital in Camp Hill, Pennsylvania where he received eight stitches to close the laceration to his hand. A true and correct copy of the Minor's Holy Spirit Hospital records related to the accident are attached hereto as Exhibit "A". 7. On the day following the incident, Minor, Thomas Sprow, was running a fever of 105 degrees, requiring a return trip to Holy Spirit Hospital and was prescribed pain medication and antibiotics for his pain and fever. 8. With the exception of a small scar on the palm of his right hand, all of the Minor's injuries have resolved. 9. The Minor's medical expenses for his injuries, with the exception of co- payments, have been paid by Petitioner Michael Sprow's insurance policy with Highmark Blue Shield. 10. Petitioner Michael Sprow, incurred co -payments totaling $117.50 which he has paid. 2 11. Dick's Sporting Goods has agreed to pay to Petitioners the sum of $3,400.00 in full and final settlement for Thomas Sprow's injuries arising from the above -referenced accident. 12. Undersigned counsel, Gordon A. Einhorn, Esquire and Thomas, Thomas & Hafer, LLP, have been retained by and compensated by Dick's Sporting Goods to represent the interests of Thomas Sprow in regard to this settlement. 13. Petitioners have not incurred any attorney's fees as a result of the accident and the filing of this Petition. 14. Petitioners, individually and as Parents and Natural Guardians of the Minor, Thomas Sprow, believe that this compromise settlement offer is fair and in the best interests of his son. 15. Petitioners understand that should this settlement be approved, neither the parents and/or natural guardians nor the Minor will be able to maintain or pursue any other or further liability claims against Dick's Sporting Goods, or any other persons, firms or corporations arising out of the accident which occurred on September 20, 2013. 16. Petitioners understand and approve of the General Release attached hereto as Exhibit "B", and the General Release will be signed upon approval of this settlement by this Court. WHEREFORE, Petitioners Michael Sprow and Karin Sprow Forte, respectfully request as follows: 1) That the Compromise Settlement Agreement be approved by this Honorable Court; 3 2) Upon this Court's approval of the settlement, Michael Sprow, Individually and as father and natural guardian of Thomas Sprow, be authorized to enter into the General Release, in the form attached to this Petition as Exhibit "B", on behalf of himself as Petitioner and the Minor, Thomas Sprow; and 3) That the sum of $3,400.00 be paid by Dick's Sporting Goods to Michael Sprow as the parent and natural guardian of Thomas Sprow. Date: 9//r// 1491772.1 Respectfully submitted, THOMAS, THOMAS & HAFER, LLP Go on A. Einhorn, Esquire ID No. 59006 Attorneys for Petitioners 4 VERIFICATION I, Michael Sprow, verify that the statements made in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. Micha Sprow VERIFICATION I, Karin Sprow Forte, verify that the statements made in the foregoing document are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. Karin Sprow Fort EXHIBIT A HOLY PIRff PATIENT FACESHEET — Health System Camp Hill, PA 17011 MEDICAL RECORD# 737931 SURGERY DATE SOCIAL SECURITY NO 999 01 1501 NURSE STA ROOM/BED ' ADMIT DATE / TIME 09/20/13 16:45 HOSP SRV ER1 PT TYPE E I CLINIC CODE ER1D PATIENT ACCT # 46210027 FIN CLASS F AGE 12 DATE OF BIRTH 01/15/2001 RACE 1 SEX M MS S CHURCH / R. PREF CATHOLIC AMBULANCE UNIDENTIFIED OR UNKNOWDEb ADM. REG DATE / TIME 09/20/13 23:22 CONFID N REG BY ERRED P A T1 I " NO T SPROW ,THOMAS RC 3407 HAWTHORNE DRIVE CAMP HILL, PA 17011 717 - 979-8840 PHOTO ID N GEO CODE LANGUAGE ENGLISH E A m Tp I L N V R -- UNEMPLOYED , - --c- 0 - OCCUPATION CHILD A --,r u A A1, A F No T 0 R SPROW ,MICHAEL MI 4812 FRANKLIN STREET HARRISBURG, PA 17111 717 - 979-8840 202 56 3591 RELATIONSHIP 0 GE Um A P R L A 0 NY T E 0R R ; r PA ATTORNEY GENERAL • i) HARRISBURG, PA 17120 p - CY1 \NJ, al 13 ' all\ 0 D‹ EC E N RT GA EC N T C y 1 SPROW ,MICHAEL 3407 HAWTHORNE DRIVE ' CAMP HILL, PA i ,,,,E -Liv-Li RELATIONSHIP F HOME PHONE 717 - 979-8840 WORK PHONE - EC Mo, N Ar GA EC N T C y 2 4 s 7 6,1)t , , 4 \ "V RELATIONSHIP' , 0) HOME PHONE WORK PHONE I N S u # R A1 N c E PLAN CODE Bli INS CO BLUE SHIELD POLICY # OPB104720106001 GROUP 0 02536400 AUTHORIZATION # ADDRESS PO BOX 890173 CAMP HILL PA 17089 PHONE/f VERIFIED • SUB NAME SPROW , MICHAEL MI Y REL TO PT G PRIORITY 1 I N S u # R A2 N C E ' PLAN CODE INS CO POLICY # GROUP # AUTHORIZATION # ADDRESS PHONE/f SUB. NAME: REL TO PT PRIORI 04 VER ( ' IE I N S u # R3,• A N c E PLAN CODE INS CO POLICY # GROUP/f AUTHORIZATION #R ADDRESS PHONE #VERIFIED SUB NAME MI R EL TO PT PRIORITY I N . s u A4 N c E . • PLAN CODE INS CO POLICY # GROUP/f AUTHORIZATION # ADDRESS PHONE/f SUB. NAME MI REL TO PT PRIORITY ER , ' ED ACCIDENT DESCRIPTION ITEST RIDING BIKE AT DICKS INJ ACC, DATE / TIME / IND. 09/20/13 16:00 0 PRIVACY NOTICE 092013 V03 ER LWS COMMENTS X ACCEPTED ALT PH NONE END DAROWISH ADMITTING DX. RT 5TH FINGER LAC ADMITTING DR. 509349 STROUP DUANE A ATTENDING DR. 509349 STROUP DUANE A REFERRING DR. 140111 ' ADMITTING COMPLAINT PINKY LAC BROUGHT BY: AMBULANCE SERVICE: • MEDICAL RECORD ER1 MR # 111 11111ti ii 737931 SPROW ,THOMAS R 111 PTACCT# t 1111 46210027 12 M 0/HO PIRIT PATIENT FACESHEET `"Health System Camp Hill, PA 17011 MEDICAL RECORD# 737931. SURGERY DATE SOCIAL SECURITY NO 999 01 1501 NURSE STA ROOM/BED ADMIT DATE / TIME 09/20/13 16:45 HOSP SRV ER1 PT TYPE E CLINIC CODE ER1D PATIENT ACCT # 46210027 -, FIN CLASS F AGE 12 DATE OF BIRTH 01/15/2001 RACE 1 SEX M MS S CHURCH / R. PREF CATHOLIC AMBULANCE UNIDENTIFIED OR UNKNOWB. ADM. REG DATE / TIME 09/20/13 23:22 CONFID N REG BY ERRSB PE A r 1 IF17011 ro SPROW ,THOMAS R 3407 HAWTHORNE DRIVE CAMP HILL, PA 717 — 979-8840 PHOTO ID N GEO CODE LANGUAGE ENGLISH P AM IP IL TE R UNEMPLOYED i !," 'p q ' �• `~ rE. ;C fi 00 ' GG�� / OCCUPATION CHILD �`; O I/q,tJJ ° G U R1 AN F oc R SPROW ,MICHAEL MI 4812 FRANKLIN STREET HARRISBURG, PA 17111 717 - 979-8840 202 56 3591 RELATIONSHIP 0 UM AP A'L D OR - R R PA ATTORNEY GENERAL HARRISBURG, PA 17120 � y 6 , r• - EC EN RT EA N r y 1 SPROW ,MICHAEL 3407 HAWTHORNE DRIVE CAMP HILL, PA 17011 RELATIONSHIP F HOME PHONE 717 — 979-8840 WORK PHONE - EC me EN RT Ec T C 2 { ,�N Or(� 4)1" i v 1 RELATIONSHIP HOME PHONE WORK PHONE - JjV✓ I N U# 1 NN C E PLAN CODE G11 INS CO BLUE SHIELD POLICY# 0PB104720106001 GROUP # 02536400 AUTHORIZATION # PO BOX 890173 CAMP HILL PA 17089 PHONE # VERIFIED SUB NAME SPROW , MICHAEL MI Y REL TO PT G PRIORITY 1 I S R # 2 N c E PLAN CODE INS COIIN POLICY# �l GROUP # AUTHORIZATION # ADDRESS PHONE # SUB. NAME: MI REL TO PT PRIORI V /� V VERT IED I S R # A3 N E PLAN CODE INS CO POLICY # GROUP # AUTHORIZATION # ADDRESS PHONE # VERIFIED SUB NAME MI REL TO PT PRIORITY I s . R # A4 N ._; E PLAN CODE INS CO POLICY # GROUP # AUTHORIZATION # ADDRESS PHONE # SUB. NAME MI REL TO PT PRIORITY f „ ' ER IED ACCIDENT DESCRIPTION TEST RIDING BIKE AT DICKS INJ ACC. DATE / TIME / IND. 09/20/13 16:00 0 PRIVACY NOTICE 092013 V03 ER INS DX ACCEPTED ALT PH NONE FMD DAROWISH ADMITTING DX. RT 5TH FINGER LAC ADMITTING DR. 509349 STROUP DUANE A ATTENDING DR, 509349 STROUP DUANE A REFERRING DR. 140111 ADMITTING COMPLAINT PINKY LAC BROUGHT BY: AMBULANCE SERVICE: Ri ER1 MEDICAL RECORD II MR # INETMINE'l 737931 SPROW ,THOMAS R off 46210027 12 M MRN:137931 I SPROW, THOMAS R j Holy Spirit Hospital Visit: 000046210027 Gender: Male I Location: Emergency Dept I• LAge:A2y.t16.70an72001)__ 0,2 Triage Note, ED revised 2012 [Authored: 20 -Sep -2013 17:20]- for Visit: 000046210027, Complete, Revised, Signed in Full, General Time to Room: To room xray then 23h at 17:26. Primary Triage: • Time of Triage • Reason for Visit • Language Spoken/Understood • Mode of Arrival • Means of Arrival • Accompanied by • Primary Care Physician Presenting Complaints: Chief Complaint Wounds and lacerations; Laceration, 17:20 The patient presents to the E.D. this P.M. w/ his mother. The patient is complaining of (R) hand pinky finger pain and laceration. The patient states that he was trying out a bicycle in a store, when he ran into a metal display device. English Private auto Ambulatory Parent(s)/guardian(s) Darowish and Associates Triage Level: 4. • Temp Fahrenheit • Temperature • Heart Rate • Systolic BP • Diastolic BP • BP Noninvasive Mean • Resp Rate • Sp02 (%) • Respiratory Measurements (Adult): • Weight Type/Method • Weight in lbs • Weight in kg • Height Type • Height in feet • Height in inches • Height in cm • BSA (m2) • BMI (kg/m2) Pain Assessment/Number Scale (0-10): • Presence of Pain • Pain • Pain Rating: Rest • Pain Rating: Activity 97.9 degrees F tympanic 91 126 mm Hg 75 mm Hg 92 mm Hg 20 99 room air Stated 140 lb 63.5 kg stated 5 feet 5 inch 165.1 cm 1.6 M2 23.2 complains of pain/discomfort Right: hand little finger 4 5 I Reque ted by: Musselman, Robert (HIS Tech), 07 -Apr -20 4 12:45 Page 1 of 2_i MRN: 737931 SPROW, THOMAS R Holy Spirit Hospital IVisit: 000046210027 Gender: Male Location: Emergency Dept kg!: 14_05-Jan-2001 • Comfort/Acceptable Pain Level 0 • Pain soreness Additional Question: • Do you currently have any No thoughts of hurting yourself or others? Triage Interventions: • Triage Interventions To X-ray Treatment Prior to Arrival: • Treatment prior to arriving No immunizations: • Immunization history Not current - pediatric Medical History: • Does the patient have any No medical problems? Surgical History: • Previous Surgeries? No Assessment & interventions: • Airway Patent • Breathing Normal • Circulation/Skin Pink; Warm; Dry • Mental Status (Adult) Alert; Oriented x 3; Cooperative • Mental Status (Peds) Attentive/quiet ED Advance Directive: • Advance Directive Not applicable (less than 18 yrs of age) Outpatient Medications: * Outpatient Medication Status not yet specified Triage: • Triage Disposition ER Electronic Signatures: Anderson, Joanna K (RN) (Signed 20 -Sep -2013 18:25) Authored: Treatment Prior to Arrival, Immunizations, Medical History, Surgical History, Assessment & Interventions, ED Advance Directive, Outpatient Medications, Triage Kendall, Hayley (ER Tech) (Signed 20 -Sep -2013 17:25) Authored: Time to Room, Outpatient Medications Maguire, Christopher (RN) (Signed 20 -Sep -2013 17:24) Authored: Primary Triage, Outpatient Medications Last Updated: 20 -Sep -2013 18:25 by Anderson, Joanna K (RN) LFiquested by: Musselman, Robert (HIS Tech),_07-Apr-2014 12:45 Page 2 of 2j SPROW, THOMAS R CLS Emergency Dept 13y M 15 -Jan -2001 ED, Group 737931/000046210027 20 -Sep -2013 17:51 XRY Hand 3 Views Right Report Received XRY Hand 3 Views Right ***Final Report*** EXAMINATION: HAND RT MIN 3V 73130 Sep 20 2013 COMMENTS: Exam: HAND RT Sep 20, 2013 05:29:00 PM Indication: Pain. Comparison: None. Findings: No acute fracture or dislocation identified. No radiopaque foreign body seen. CONCLUSION: No acute fracture identified. DICTATED BY: David Lynch, MD DATE/TIME: 09/20/2013 6:56 pm SIGNED BY: David Lynch, MD DATE/TIME: 09/20/2013 6:56 pm WORKSTATION: DLYNCH-DI Final Requested By: Musselman, Robert (HIS Tech) Printed from: Health Info Services 07 -Apr -2014 12:45 End of Report Page: 1 of 1 Initial Lab & X -Ray Orders: Labs ] Acetaminophen [ ) ESR ] Acetone (SALE) [ ] Glucose J Alcohol (ALCO) [ ] HCGS J Amylase/Lipase ( ] Quantitative ] APTT HCGS J BBH [ J HIV J Blood Cultures [ J Lithium ] BMP [ ] Liver profile J CBCP [ J Lytes I CMP ( J ProBNP CK, CKMB, TNT [ ) Phenobarb I Depakote ] Digoxin ] (Malin [ ) PTP [ ] Salicylate ( J Tegretol Radiology J Abd./Obstr. Series J Ankle R L Clavicle R L }Gem Spine --Routine (3 view) ) Cerv. Spine--AP/Lat ] Cerv. Spine --Portable Lat ] Chest --Routine or Portable ] Elbow R L ] Facial ] Femur R L ) Finger R L ] Foot R L J Forearm R L ] Hand R L ] Hip R L [ Humerus R L [ ] Other: REASON: ] Theophylline ] Thrombolytic Labs ] Toy Screen [ ] Urine Tox (DOAS) ]TSHR ] Type&Cross0 of units (BOR) ] Type & Screen UA: JDIP[ JDMAG. ( Urine C&S Urine HCG ] WC Breath Alco Test ] WC Drug Screen ] Other: ) Knee R L ] KUB J US Spine ] Mandible J Nasaf ( Orbit R L J Pelvis ] Pyelogram IVP ] Ribs R L J Shoulder R L ] Skull ) Sternum ] T/Spine ] Tib / Fib R L ] Toe __ R L ] Wrist R L Time/CRT/Int. Special Procedures: Ultrasound; CT: (W=With contrast; WO=W Abdomen Duplex Doppler Gallbladder Pelvis Transvaginal MRI Scan REASON: [ ] Abdomen/Pelvis W WO [ ] Brain/Head W WO [ ] Chest W WO [ ] Sprial chest for PE [ ] Other: out) [ J VQ Scan [ ) Echo- cardiogram Time/CRT/Int. Specimens/Cultures: [ ] Beta Strep AG Rapid [ J CervicaVGenital [ ] Chlamydia ( J GG Culture [ ] Monospot (rapid) ( )•Sputum C & S ( Stool C&S J Stool 0 & P ] Stool C. Difficile ] Trichomonas ( Wound C&S ] Other: Billing Classification: PHYSICIAN CHARGE FACILITY CHARGE [ ] Level I [ J Level I [ ] Level II [ ] Level II [ ] Level III [ J Level III [ J Level IV [ ] Level IV [ ] Level V [ ] Level V [ ) Accident [ J Medical [ ] Case t [ J Extended Hrs. Cardiac Respiratory [ ] Monitor [ ] ABG's [ ) EKG [ ) Peak Flows Before/After Resp. Tx. ( ] 02_ Umin. [ ] Respiratory Tx. [ J 02 Saturation edications / IV's /Additional Orders DOCTOR Order Time PHYSICIAN ORDERS NURSE Given lime IV: NSS/ D5W/ UV D5/ ,45NS/ D5.9NS WO/KVO/infuse at mis/hr [ J Obtain old records ( 3 Td [ 3 Protocol Initiated tor: 17 Sti I, �` I\+-, . t"2t , : c rte- `i rYv' Gry f �t rtt/ 4— leis, 'itrA/ 2O` / '`.. o0 (9ir rig) Elva read back Time: 1 () DIAGNOSTIC ISCHARGE !: J INPATIENT f J OBSERVATION J REGULAR [ ) TELEMETRY [ 3 CRITICAL CARE ADMITTING PHYSICIAN / GROUP: - IMPRESSION: Initials: Initials: Signature: CRITICAL Signature Date: Signature: !] Dictated MD/DO/CRNP 071/ 'Time: RN/MA RN/MA j [ Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center Physician Order Sheet 206 -ECU 5/11 REV. LLW fft-aAErr CfPV $PROW ,THOMAS R 12 M ER1 01/15/2001 ED GROUP 737931 737931 09/20/13 46210027 Please List All Current Medications: (Include all over-the-counter, vitamins, samples, herbs & other supplements). Please keep any medications with you and show them to the nurse. Name of Medication • Dosage, Route (by mouth, cream, etc.), Frequency Medication is Taken Time Medication Taken ast time you took this edication? D Patient has brought a legible, complete medication list that is copied and attached to this form. 4LLERGIES? YNo CI Yes, list all al orgies and reactions: 011"k-- 411ergic to Latex? No 0 Yes Source of Data: LI Patient Family U EMS 0 Bottles U List Patient's Pharmacy: Patient's Family Physician: alar(' Patient's Signature: Family Signature and Relationship if patient unable to sign: D teiTime: Patient unable to sign and family not available U Unable to clarify meication, dose, route or frequency at time of interview Practitioner Name Printed, Name Stamp, (MDIDO!PA/CRNPIRN): Practitioner Signature (MD/DO/PA/CRNP/RN): HOLY HOLY SPIRIT HOSPITAL Camp Hill, Pennsylvania 17011 Medication History Form Form MR 204 Rev. 10/07 FMC 10!07 White: Chart Yellow: ER Q1 Pink: Patient SPROW ,THOMAS R 12 M ER1 01/15/2001 ED GROUP 737931 737931 09/20/13 46210027 JOHN R. DIETZ EMERGENCY CENTER DISCHARGE INSTRUCTIONS/TRANSITION RECORD HOLY SPIRIT HOSPITAL (717) 972-4300 The examination and treatment you have received in the Emergency Center have been rendered on an emergency basis only, and are not intended to be a substitute for or en effort to provide. complete medical care. If you develop new problems or complications contact your physician or the Emergency Center. FOLLOW THE INSTRUCTIONS CHECKED BELOW: WOUND s�,t_jyiaTgi?Yifyyash over wound In 24 hours with soap and water or peroxides. ---r) Change dressing _____,times daily. Redress with Bacitracin/Neosporin and sterile dressing or leave it open if advised. (=) I<eep wound clean, dry ''(—)'covered ( ) uncovered SPRAINS, STRAINS, BRUISES, FRACTURES ( ) Elevate the injured part for_days to reduce swelling. ( ) Apply ice packs intermittently for_ days to reduce swelling. ( ) Ace wrap for support for., days. ( ) Wear splint ( ) At all times until follow-up. ( ) For activity as needed. ( ) Use sling for support. ( ) Use crutches: ( ) As needed, weight bearing as tolerated. ( )At all times. NO WEIGHT BEARING NECK/BACK ( ) Wear cervical collar for support for_days. ( ) Rest, avoid bending, lifting, strenuous activity for___.days. ( ) Apply moist heat for minutes times daily beginning in hours. ADDITIONAL INSTRUCTIONS ( ) Encourage fluid intake ( ) Clear liquid diet. Advance to regular diet as tolerated ( ) Off work/school from to ( ) Return to work on ( ) Light Duty until - Restrictions. ( ) No gym/sports until ( ) Follow instructions on Workmen's Compensation Form. ( ) Wear eye patch for hours. ( ) If nose bleed recurs, pinch nose firmly for 5 minutes continuously, return it bleeding not controlled. ( ) The interpretation of your X -Rays are preliminary reading. Your films will be reviewed by a radiologist. You or your Physician will be contacted if there is a change in the diagnosis. PROCEDURES ( ) None (' )•Laceration Repair ) l&D () Removal of Foreign Body ( ) Conscious Sedation ( ) Reduction of Dislocation ( ) Other MEDICATIONS ( ) Continue present medications except: ( ) Use Advil (Ibuprofen) or Tylenol as needed for pain, fever according to package instructions for age and weight, etc. )-Use the following medicines according to package instructions: 1: 3: ( ) The following medicines may cause drowsiness: DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING: The prescribed antibiotic/medication, may reduce the effectiveness of medication you are currently taking. Check package instructions or consult with Pharmacist. FOLLOW-UP This is our recommendation for follow-up. If your .___-ipst!rance.(HMO)-regiilre's a physician referral for specialty consultation. IT IS YOUR RESPONSIBILITY TO OBTAIN THE NECESSARY APPROVAL. { ) Follow-up with: ( ) Uri Center () Occ. Health/Company Doctor ( ')-Family Doctor or in t o days for: ( ) Follow-up ( ) Suture removal ( ) The following test was performed: ( ) CBC ( ) CMP ( ) EKG ( ) X-RAY ( ) CT ( ) Us ( ) OTHER IF YOU DO NOT HAVE A FAMILY PHYSICIAN CALL 763-2900 FOR PHYSICIAN REFERRAL. ( ) Call as soon as possible for appointment ( ) Pick up your X -Rays from the Radiology Department prior to your follow-up appointment. Call 763-2696 to have films ready. ) See your physician or specialist if not improved in days. {'.;)'Return to Emergency Center if you feel your condition is worsening, especially if i ( ) Your blood pressure was elevated. Check with your physician. r� �l Clinical I mpreesions: / (i /-- vii L I hereby acknowledge receipt of these instructions and Exit Care information. i understand that I have had emergency treatment only and that I may be released before all of my medical problems are known or treated. I will arrange for foilow,up-care-as71_have been instructed. It is my responsibility -to notify my=Psiniary Care Pl'ysician of this,visit. SiGNATURE: ./ - r'- .. � . — " � - __r.. ynlcia/rMD/DO/CRNP cr t: SIGNATURE: 1/ Patient or Ftesponstbte Person Date iOPATIENT/RESPONSIBLE/PERSON VERBALIZES UNDERSiTANDING SIGNATURE: t„ t /t!`. ; e) SIGNATURE: , r ,. " / Nurse RN'"-- Date HOLY SPIRIT HOSPITAL JOHN R. DIETZ EMERGENCY CENTER 503 NORTH 21ST STREET CAMP HILL, PA 17011-2288 (717) 972-4300 ( ) Salvatore Alfano, MD 025502E ( ) Ramesh Arora, MD 01672713 ( ) Nikolas J. Baran, DO 0S004697L ( ) Luke Chetlen, DO OS013145 ( ) Laura E. Crim, MD (i70368L () Kevin -Sean McGann, DO OS0109691( ) Susan DaCosta, CRNP SP007624B ( ) Rupen G. Modi, DO 0S014328 ( ) Pam Darden, CRNP SP006066B ( ) Lawrence H. Paul, MD 039524L ( ) Selena. DiPaolo, CRNP VP005264B ( )Terry Paul Rest, DO OS014492 ( Natalie Gillis, CRNP TP0060822B ( ) Jessica L. Riley, MD 442047 ( ) Michelle Hafe,,,CRNP7P005355B , . . ___.>� m_-.. __ >.m A.1A1/AA4 r n_.-.___sr_._'_._�_.._z'-niliinimn1,ciC90 ( I William Buckner, PAC MA052332 ( ) Matthew A. DiRodio, PAC MA000969L ( ) Jeffrey Horgan, PAC MA051306 ( ) Robert Pellegrino, PAC MA000693L () r' 1 C 1, l %B C_ CONSENT TO MEDICAL TREATMENT HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and employees, to the rendering of medical care, which may include routine diagnostic procedures and such medical treatment as my attending or consulting physician considers to be necessary. I also understand it is customary, absent emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or until I have had an 'opportunity to discuss them with a physician or other health care professional to my satisfaction. If I are a competent adult, I have the right to consent or refuse to consent. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital. I understand many of the physicians on the staff of Holy Spirit Hospital are not employees or .agents of the Hospital, but rather are independent contractors who have been granted the privilege of using these facilities for the care and treatment of their patients. Further, I realize this Hospital is a teaching Hospital and at the Hospital are health care personnel in training who, unless expressly requested otherwise, may participate or may be present during my care as part of their education. Still or motion pictures and closed circuit monitoring of patient care may also be used for educational purposes, unless I expressly request otherwise. I understand that in order to ensure a safe environment for patients, visitors and staff all property on the premises bf o pint Hospital is subject to reasonable search and/or seizure at any time without further notice. nitials RELEASE OF MEDICAL INFORMATION I authorize Holy Spirit Hospital to release to requesting health insurance carrier(s), their representatives and auditors, and any referring health care providers, such diagnostic and therapeutic information including and information relating to treatment for alcohol and substance abuse and/or treatment of psychiatric disorder; and/or confidential HIV related information, as may be necessary for them to determine benefit entitlement; to process payment claims for healthcare services provided during this hospitalization/treatment episode, for continuing care/treatment, and hospital operations. A photocopy or carbon copy of this authorization shall be considered as effective and valid as the original. The Undersigned also authorizes Medicare, when applicable, to release to another insurance carrier, upon their request, medical Information needed to make payment upon that claim. I understand and consent that the manufacturer of any implantable device inserted by my physician duri , pacers° of my surgery/procedure may be provided with my identification information, including social security number as mandated b -Law. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES Initials have received a copy of the Notice of PrivacY'Practices. The Notice describes how my health information may b used or disclosed. I understand that I should read it carefully.] am -aware that the Notice may be changed at any time. I may obtain a reviseclico the Notice by contacting this Organization's offices or on this'Organization's website at www.hsh.org. Initials INSURANCE ASSIGNMENT OF BENEFITS I authorize payment directlyt� Holy Spirit Hospital and my treating physicians of all benefits pays payanle under y,i s policies. I understand I am responsible to the Hospital and physicians for charges not covered by this assignm Initials STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AND PATIENT I request payment of Authorized Medicare benefits to me or on my behalf for any services furnished me by or in Holy Spirit Hospital including physician services. I authorize any holder of medical and other information about me, to release to Medicare and its agencies any information needed to determine these benefits for related services. Initials MEDICAL ASSISTANCE RECIPIENT • My signature certifies that I received a service or items from Holy Spirit Hospital and Dr. on the date listed below. I understand that payment for this service or item will be from Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal State Laws. I understand that certain tests and procedures may not be reimbUrsed by Federal and State funds and that I may be responsible for non covered charges. Also, I agree that if at the time of service, if I am not eligible for Medical Assistance, I will be responsible for balances owed to Holy Spirit Hospital. Initials I have read and understand each of the sections contained above. I understand that by signing this document, I am agreeing and providing the authoirization/consent contained in each of the above sections where my initials are located. I have had the opportunity to ask,questions regarding each of ti-eiiections and all such questions have been answered to my satisfaction. / Signature Relationship to Patient HOLY SPIRIT HOSPITAL CAMP HILL, PA. ONSENT FOR TREATMENT/RELEASE OF INFORMATION INSURANCE ASSIGNMENT Witness Time Date SPROW ,THOMAS R 12 M ER1 01/15/2001 ED GROUP 737931 737931 09/20/13 46210027 71 (4 09 Hand / Wrist Injury DATE7L!f1/3 TIME SEEN: r °' El on arrival ROOM:Z-3 rt _EMS A'r i rriva EMS treatments ordered Referred by. _ HISTORIAN: panel spoVt3e paramedics AGE j.Z bt rl'F HX / EXAM LiMITED 13 ' HP chiefcom•lai: inju "t•,_' ger thumb L and palm wris forearm elbow arm ex middle ri . sma ,.a kettf a . a • : where: .. today / yesterday home school neighbor's park work street J hi- e _ ti hdays ago severity .• pal j worse/persistent since mild oderat severe (1/10) .''• intermittent / lasting crush burn context: fall blo laceration human / animal bite modifying factors: _none pain on movement ROS CONST - recent illness / fever EYE - problems with vision ENT - nasal drainage MS - neck / back pain RESP - shortness of breath I cough GU - problems urinating LNMP preg post- menop ❑ all systems neg except as marked r GI - nausea / vomiting LYMPH - palpable nodes SKIN - rash NEURO - headache CVS - chest pain PSYCH - anxiety / depression • MS components also addressed in HPI PAST HX none R / L HANDED cardiac disease Afib CAD CHF MI hypertension diabetes Type I Type 2 hepatitis / HIV diet / oral / insulin prior injury _old records reviewed / summary: Tetanus lmm i in ED Meds- _non-! - s ito6e Allergies- __NKD see nu note SOCIAL IAL HX smoker ppd / past / quit_days / mos / yrs ago drugs alcohe cent / heavy / occasional) occupation living situation: alone n nursing home FAMILY HX Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center EMERGENCY PHYSICIAN RECORD Rev. 04 / 10 / 13 Page 1 of 2 Ci ❑ Nursing Assessment Reviewed 5i -mal 0 Abnormals Noted PHYSICAL EXAM General Appearance mild / no acute distress _alert PSYCH / egjen"t_fr.d x4 rr . ary intact (f) EXTREMIT HAND nml inspection non-tender _no evidence of FB oderat: / severe distress _disoriented to: person place time situation depressed mood / affect recent) remote memory impaired WRI c ml inspection non-tender _nml ROM* see diagram ess soft-tissue / bony ecchymosis limited ROM due to: pain / functional deficit _deformity _ nail injury complete /partial avulsion _see diagram_ _tenderness soft-tissue / bony tenderness in anatomical snuff box _wrist pain on axial thumb load swelling / ecchymosis limited ROM _deformity ��L R NE sation nml motor nml VASCULAR 1A�SULAR i vascular co promise TE DONS _tendon function normal Circle(ositives backslash rtkiq.ives, check Jnormi T=Tenderness S=Swelling E Ecchymosis 13 -Burn CcContusion L''Lacerafian A -Abrasion M. -puncture wound (0 •-without n, mild mod n,wderate sv=severe) digital nerve deficit decreased fine touch abnml 2 -point discrim. median nerve deficit sensory deficit- lat. 3 Vi fingers / tat palm motor deficit- pronation / thumb flexion index & middle finger flexion _ulnar nerve deficit sensory deficit- med. palm / med. 1 4 fingers motor deficit- thumb adduction / fingers adduct. _radial nerve deficit motor deficit- wrist drop / thumb extension pallor / cool skin / abnml cap refill pulse deficit radial ulnar tendon visualized / injury seen extensor flexor complete partial deficit in tendon function limited extension limited flexion SPROW ,THOMAS ERI ED GROUP 737931 09/ R 12 M 01/15/2001 737931 20/13 46210027 © 1996 - 2012 T-Systenz, Inc rItt HOLY PIRIT PATIENT FACESHEET 12, —Health System Camp 11W, PA 17011 . MEDICAL RECORD# 737931 SURGERY DATE SOCIAL SECURITY NO 999 01 1501 NURSE STA ROOM/BED ADMIT DATE / TIME 09/21/13 20:24 HOSP SRV ERI PT PIPE E CLINIC CODE ER1 PATIENT ACCT 8 46213112 IN CLASS F AGE 12 DATE OF BIRTH 01/15/2001 RACE 1 SEX M MS S CHURCH / R. PREF CATHOLIC AMBULANCE UNIDENTIFIED OR UNKNOWNEA ADM. REG DATE /TIME 09/21/13 20:48 CONFID ' N REG BY BASHO1 I N F 0 SPROW ,THOMAS R 3407 HAWTHORNE DRIVE CAMP HILL, PA 17011 717 - 979-8840 PHOTO ID N GEO CODE LANGUAGE ENGLISH p A Tp E NY T i-4- UNEMPLOYED . 0 -E R OCCUPATION CHILD 1 : I 14 'F I .0 IR SPROW ,MICHAEL MI 3407 HAWTHORNE DRIVE CAMP HILL, PA 17011 717 - 979-8840 RELATIONSHIP 0 GE UM AP Acli N 0 0 0 , Y E (0 0 R c It) N A C IT 1 SPROW ,MICHAEL 3407 HAWTHORNE DRIVE CAMP HILL, PA 17011 RELATIONSHIP F HOME PHONE 717 - 979-8840 WORK PHONE - E MO ET R GA C NT c Y SPROW , KAP.IN c 3407 HAWTHORNE DRIVE CAMP HILL, PA II 17011 C RELATIONSHIP M 2 HOME PHONE 717 - 979-8840 WORK PHONE - I : I ' PLAN CODE . B11 INS CO BLUE SHIELD POLICY # OPB104720106001 GROUP 8 02536400 AUTHORIZATION # ADDRESS p0 BOX 890173 CAMP HILL PA 17089 PHONE/I VERIFIED SUB NAME SPROW ,MICHAEL MI Y REL TO PT F PRIORITY 1 I N s u R A2 N C E PLAN CODE INS CO POLICY # GROUP # # AUTHORIZATION/I ADDRESS PHONE # VERIFIED SUB. NAME: MI REL TO PT PRIORITY i : ' PLAN CODE INS CO POLICY # GROUP/I AUTHORIZATION # ADDRESS PHONE # VERIFIED SUB NAME MI REL TO PT PRIORITY I N s u B It A4 N c ESUB. PLAN CODE . INS CO POLICY # GROUP/I AUTHORIZATION # ADDRESS PHONE/I VERIFIED NAME MI REL TO PT PRIORITY ACCIDENT )ESCRIPTION ACC. DATE / TIME / IND. PRIVACY NOTICE i 092113 03 ER RB - OMMENTS DX ELIC ALT PH NONE FED DAROWISH NO ID AT EEG DMITTING DX. ADMITTING DR. 180018 ED GROUP ATTENDING DR. 180018 ED GROUP REFERRING R111., , 140111 p kDMIITING COMPLAINT 'EVERFATHER ,,- -F--. BROUGHT BY: t- AMBULANCE SERVIC MEDICAL RECORD ER1 MR # o 737931 SPROW ,THOMAS R PT ACCT # NEIN 46213112 12 M MRN: 737931 SPROW, THOMAS R Holy Spirit Hospital 1 Gender: Ml t Location: Emergency Dept 1 Visit: 000046213112 1 A90: 12Y,11 Triage Note, ED revised 2012 [Authored: 21 -Sep -2013 20:25j- for Visit: 0000462 Complete, Revised, Signed in Full, General Time to Room: To room 12 at 20:41. Primary Triage: • Time of Triage • Reason for Visit • Language Spoken/Understood • Mode of Arrival • Means of Arrival • Accompanied by • Primary Care Physician Presenting Complaints: Chief Complaint Fever;. Triage Level: 3. • Temp Fahrenheit • Temperature • Heart Rate • Systolic BP • Diastolic BP • BP Noninvasive Mean • Resp Rate Sp02 (%) Respiratory Measurements (Adult): • Weight in lbs • Weight in kg • Height Type Pain Assessment/FACES: • Presence of Pain Additional Question: • Do you currently have any thoughts of hurting yourself or others? Triage Interventions: • Triage Interventions Treatment Prior to Arrival: LRequested by: Musselman, Robert (HIS Tech , 07 -Apr -2014 12:44 Page 1 of 2 1 112, 20:25 pt father states pt has fever 105.0 at home and was given ibuprofen at Bpm tonight. father states pt was seen yesterday for laceration to R hand and had sutures. pt denies pain, denies symptoms of infection at suture site. temp at triage=104.2 oral pt also do nausea. English Private auto Ambulatory Self; Parent(s)/guardian(s) Darowish and Associates it 104.2 degrees F oral 130 106 mm Hg 65 mm Hg 78 mm Hg 20 98 room air 140 lb 63.5 kg stated denies pain/discomfort No None MRN: 737931 .SPROW, THOMAS R I Holy Spirit Hospital Visit: 000046213112 Gender: Male I Location: Emergency Dept 1 ARP:...1..?Y. • Treatment prior to arriving Immunizations: • Immunization history Medical History: • Does the patient have any medical problems? Surgical History: • Previous Surgeries? Allergies: • No Known Allergies: Assessment & Interventions: • Airway • Breathing • Circulation/Skin • Mental Status (Adult) • Mental Status (Peds) ED Advance Directive: • Advance Directive Abuse Screening: • Patient states physically, emotionally, sexually hurt and/or threatened No No recent exposure No No Patent Normal Pink; Warm; Dry Alert; Oriented x 3; Cooperative Attentive/quiet; Not crying No No Outpatient Medications: * Outpatient Medication Status not yet specified Triage: • Triage Disposition ER Electronic Signatures: Lemire, Ina (RN) (Signed 21 -Sep -2013 20:42) Authored: Time to Room, Primary Triage, Treatment Prior to Arrival, Immunizations, • Medical History, Surgical History, Allergies, Assessment & Interventions, Outpatient Medications Timko, Sharon M (RN) (Signed 21 -Sep -2013 20:58) Authored: Primary Triage, Assessment & Interventions, ED Advance Directive, Abuse Screening, Outpatient Medications, Triage Last Updated: 21 -Sep -2013 20:58 by Timko, Sharon M (RN) [Requested by: Musseiman,Robert (HIS Tech), 07 -Apr -2014 12:44 Page 2 of 2 I MRN: 737931 SPROW, THOMAS R Holy Spirit Hospital Visit: 000046213112 Gender: Male ; Location: Emergency Dept Age: 12y (15 -Jan -2001) Medical Record Release [Authored: 07 -Apr -2014 12:44I- for Visit: 000046213112, Final, Entered, Signed in Full, General Allergies: • No Known Allergies: Active Lab Results: Chemistry: 21-Sep:2013 21:47 Comprehensive Metabolic Panel Result Value sodium, Serum -7-- Potassium,Serym_-_-1,1 Chloride,serum CO2, Serum Blood Urea Nite_wi, Serum Creatinine. F4r_1,9P --13T ra-nViEf 14 [5 - 18 Ma/DLI 0.8 1. [0.4 - 0.7 MG./DL.I Glucose, Random 122 65 - 140 Ma/DLI Calciumiferum 8.5 8.4 - 10.2 MGIDL.) Aspartate 20 J [0 - 40 U/L1 Confirmed • Transaminase, Serum Alanine Aminotransferase, Serum Alkaline Phosphatase, 12 1 [0 - 41 UIL] I Confirmed 317 r [- <300 U/L] I Confirmed I Protein, Total [6.0 - 8.0 G/DL] Serum ;... Albumin, Serum 4.2 [3.8 - 5.4 G/DL] ) . --, Bilirubin, Serum 0.4 [0.0- 1.0 MGIDL.11 Confirmed Total Hematologyi 21 -Se -2013 21:47 Complete Blood Count + Automated Diff Result .I. Value WBC7.3 -1- • ..00 492 r Abn -1 Range Text --I. [4.5 - 13.0 K/ULL, - 5.20 M/ULI [4 -1- [11.5- 15.5 GM/DL] ; I 1 --.1 iTd-a- ; _ Hemoglobin, Whole Blood 7.13.6 39.0 Hematocrit, Whole I Blood [35.0 - 45.0 %J [77.0 - 95.0 FLIT i MCV ; 79.3 MCH I 27.6 [25.0 - 33.0 UUG] ) MCHC I 34.9 [31.0 - 37.0 GM/DLI i RDW3 .2 2i7 . [11.6 - 13.8 %U 1i467400 K/UL] [9,1_,- Fe - -41] 1 I I Platelet Count_, MPV 1 9.5 5.5 Absolute Neutrophil Count, I Automated t _i_ Requested by: Musselman, Robert (HIS Tech), 07 -Apr -2014 12:44 Page 1 of 41 MRN: 737931 SPROW, THOMAS R Holy Spirit Hospital Visit: 000046213112 Gender: Male Location: Emergency Dept Age: 12y (15 -Jan -2001) Lymphocyfe % 4._ 72 . 4. 14617.674 ---- ----- ' ----1 --1 [4 - 8 %] 1 i [45 - 50 °A] i i - i 0.1 [0.0 - 0.9 %] Monocyte % 172- ttleutrophil % imm Gran % 75.6-1, • Eosinophil cic, , 0.1 4 1 a_ [1 - '6 a/0] Basophil % 0.4 [0 - 1.4 %] Lymph #yanual ______________ 0.6. • 4 [1.4 - 4.3] I Mono # Manual 1.3 [0.1 - 0.7] , 1-rnm 6ran # , [0.0 - 0.0] • Eosinophil # 0.0 1 [0.0 - 0.5] Itilanual Baso#1fianuai I - --------MT------------. [0.0 - 0.1] Microbiology: 21 -Sep -2013 21:45 Blood Culture. r Result I Value 1 i- 1 Source i1 E ..4 BloodCulture } • ,._.1 I no organisms I. I I isolated after 5 days 21 -Sep -2013 21:46 Blood Culture. I Result iValue Range j I Source Abn Range Text Blood Culture 1 Abn .1- I i _ i isolated after 5 days I .2:17S_e.p.-_26-13 e..46 -6 ultUre Screen, trep Group -A- .._..._. _. ___. - . • 1 Result I Value I Abn Range Text , -1 LSJ ource ; I _Throat 21 -Sep -2013 21:46 Group A Streptococcus Antigen Assay I- - - Result iI h.- Value I Abn Range I Text i Direct Antigendtp I I no group a A Strep. I beta -strep antigen 2, Throat Blood Text no organisms t Source _ Urine Studies: 21 -Sep -2013 21:47 Urinalysis, Reflex to Culture Result Color Tit'ine-Clarity Urine pH Specific Gravity Urine Ketones Urine Urine Bilirubin --L-e-UlTecytes -- Urine Glucose Urine Occult Blood ----- Total Urine Protein Value YELLOW CLEAR 676 1.023 I NEGATIVE —1 - NEGATIVE NEGATIVE -I Abn Range Text [AM,ST,YE] [CLEAR] 67.0]1_ 1 NORMAL i LARGE 1 1 1 NEGATIVE [NEGATIVE MG./DL.] Urine Nitrate NEGATIVE JI\IEGATIVE] I Requested by: Musselman, Robert tlIS 12 [1.002 - 1.030] [NEGATIVE [NEGATIVE]• ._ [NEGATIVE)._ [NORMAL NGJDLI ILI [NEGATIVE] SPROW, THOMAS R Hoiy Spirit Hospital 1 I Visit: 000046213112 Gender: Male ] Location: Emergency Dept Age: 12y_(15 -Jan -2001)_ L_ riiiiCequnti_Urine , I__ 41-50 1 - D 1 [0 5 #/HPF] 1 , I- I 1 WBC Count, Urine_ 0-2 _l_ _i_ [0 - 5 #/HPF] i i 1 Epithelial Cells 0-2 ' ! (0 - 5 It/HPF] 1 .._ i Bacteria ---- NEGATIVE [NEGATIVE] I i Immunology +SerCiiiii:----- 21 -Sep -2013 21:47 HeterophilAgglutiration, Serum Result Value J_ Abn nge • Heterophil I NEGATIVE I Agglutination, 1 , I_Serum i X -Ray: X-ray: 21 -Sep -2013 21:34, Chest Portable Chest Portable ***Final Report*** EXAMINATION: CHEST PORTABLE 71010 Sep 21 2013 COMMENTS: Exam: Portable chest radiograph History: Fever Comparison: None. Result: The cardiomediastinal silhouette is normal in size. The pulmonary vasculature is unremarkable. The lungs are clear without focal airspace opacity or pleural effusion. There is no pneumothorax. CONCLUSION: No acute cardiopulmonary abnormality. DICTATED BY: Christopher Bloomer, MD DATE/TIME: 09/21/2013 10:59pm SIGNED BY: Christopher Bloomer, MD DATE/TIME: 09/21/2013 10:59 pm WORKSTATION: BLOOMER -DI Request: Electronic Release of Information: • Purpose Electronic Signatures: Musselman, Robert (HIS Tech) (Signed 07 -Apr -2014 12:44) Authored: Abstract, Request All other requests MRN: 737931 SPROW, THOMAS R Holy Spirit Hospital Visit: 000046213112 Gender: Male Location: Emergency Dept Age: 1205 -Jan -2001) Last Updated: 07 -Apr -2014 12:44 by Musselman, Robert (HIS Tech) 1 [Requested by: Musselman, Robert (HIS Tech), 07 -Apr -2014 12:44 Page 4 of 4 Initial Lab & X -Ray Orders: Labs J Acetaminophen ] Acetone (SACE) ] Alcohol (ALCO) I Amylase/Lipase ] APTT ) BBH 3 Blood Cultures ]BMP 3 CBCP ]CMP 10c CKMB, TNT } Depakote ] Digoxin ] Dilatin 3 ESR Glucose )HUGS Quantitative HCGS ] HIV Lithium Liver profile ] Lytes J ProBNP } Phenobarb PTP Salicylate ] Tegretol Radiology ] Abd./Obstr. Series ] Ankle R L ] Clavicle R L ]Cerv. Spine --Routine (3 view) 3 Cerv. Spine--AP/Lat I Cerv. Spine --Portable Lat ] Chest --Routine or Portable ] Elbow R L ] Facial ] Femur R L ] Finger R L ) Foot R L 3 Forearm R L J Hand R L ] Hip R L } Humerus R L } Other: REASON: Theophylline ] Thrombolytic Labs Tox Screen [ ] Urine Toe (DOAS) 1.1 -SHR 3 Type&Cross _j o1 units (BOR) 3 Type & Screen ] UA: I ) DIP ( ] DIAG. I Urine C & S ) Urine HCG (WC Breath Alco Test WC Drug Screen ) Other: Knee R L ]KUB (US Spine } Mandible Nasal ] Orbit R L Pelvis 3 Pyelogram IVP I Ribs R L Shoulder R L (Skull ) Sternum 3 T/Spine ] Tib / Fib R L ) Toe __ R L ) Wrist R L Time/CRT/lnt. Special Procedures: Ultrasound: CT: (W=With contrast; WO=Without) [ ] Abdomen [ ) Abdomen/Pelvis W WO [ ) VO Scan [ ) Duplex Doppler [) Brain/Head W WO [ ] Echo- [ ) Gallbladder ( ) Chest W WO cardiogram [ J Pelvis ( ) Sprial chest for PE [ J Transvaginal ( 3 Other: [ i MRI Scan Time/CRT/Int. REASON: S ec' ens/Cultures:--- Beta ns/Cultures/Beta Strep AG Rapid 21 )[_i15tool C & S [ 3 Cervical/Genital f/ y Stool 0 & P [ ] Chlamydia [ 3 Stool C. Difficile [ ) GC Culture ( J Trichomonas ( 3 Monospot (rapid) [ ] Wound C & S ( ) Sputum C & S [ 3 Other: Billing Classification: PHYSICIAN CHARGE FACILITY CHARGE [ J Level i ( i Level I [ ) Level II 3 3 Level II [ 3 Level ill ( ) Level III [ I Level IV [ ) Level IV [ ] Level V 3 3 Level V Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center Physician Order Sheet [ ] Accident [ 3 Medical [ ] Case 1 [ ] Extended Hrs. Cardiac ( } Monitor [ ) EKG [ ] 02 Umin. [ ] 02 Saturation Respiratory [ ) ABG's [ J Peak Flows Before/After Resp. Tx. [ J Respiratory Tx. Medications / IV's / Additional Orders DOCTOT Order Time PHYSICIAN ORDERS NURSE Given Time IV: NSS/ 05W/ LW D5/ ,45NS/ D5.9NS WO/KVO/infuse at mis/hr [ ] Obtain old records [ I Td [ j Protocol initiated tor: ‘) L_ ,�- of ,�3 ', 1 — .c.) II 7 MLA". f , ," ' jr° \Q-J-J.k5t--e LIvP ,v" t J; L 3o R -LC -LC --L c /LGA.( --k- in, p ! '`fp* e.' .eP k_/� f s Othq �7 VL (/](1".S,—\1�7 \k/ Ova read back Time: —2.2; iSCHARGE f j INPATIENT f j OBSERVATION ( REGULAR O TELEMETRY [) CRITICAL CARE ADMITTING PHYSICIAN/ GROUP: DIAGNOSTIC IMPRESSION: - V 4 /u- -- P.1 L.d tiv - A Initials: Initials: CRITICAL CARE Signature: Date: Signature: Signature. hrs. A // RN/MA SPROW ,THOMAS ER1 ED GROUP 737931 09/21/1 f 1 Dictated MD/CS Time: �as-0 R 12 M 01/15/2001 737931 3 46213112 CRNP 4/Lily 4(03 ql? 110 Pm W-/fAtw C ( ) Apply ice packs intermittently !or_ days to reduce swelling. ( ) Ace wrap for support for__ days. ( ) Wear splint () At all limes until follow-up. ( ) For activity as needed. ( ) Use sling for support. ( ) Use crutches: ( ) As needed, weight hearing as tolerated, ( )At all times. NO WEIGHT BEARING: NECKBACK ( ) Wear cervical collar for support tor _days. ( /Rest, avoid bending, lifting, strenuous activity tor.days. ( ) Apply moisthealfor minutes times daily beginning in hours. ADDITIONAL INSTRUCTIONS ) Encourage fluid intake { ) Clear liquid diet. Advance to regula ( ) Off work/school from ( ) Return to work on ) Light Duty until' Restrictions ( ) No gym/sports until Follow instructions on Workmen's Compensation Form. ) Wear eye patch for hours. If nose bleed recurs, pinch nose firmly for 5 minutes continuously, return if bleeding not controlled. 1 The interpretation of your X -Rays are preliminary reading. Your films will be reviewed by a radiologist. You or your Physician will be contacted it there is a change,in.ihe diagnosis. at as tolerated. to PROCEDURES ( ) None ( ) Laceration Repair ( ) 18,D { ) Removal of Foreign Body ( ) Procedural Sedation ( ) Reduction of Dislocation ( ) Other } The following medicines may cause drowsiness: '/ DO NOT DRIVE OR OPERATE MACHINERY WHILE TAKING: -The prescribed antibiotic/medication, may reduce the effectiveness of medication you are currently taking. Check package instructions or consult with Pharmacist- . FOLLOW-UP This Is our recommendation for follow-up, if your insurance (HMO) requires a physician referral for specialty consullation, IT IS YOUR RESPONSIBILITY TO OBTAIN THE NECESSARY APPROVAL. S. )-Fallow-up with: ( Urgi Center ( )Doc. Heal}h/Corny oy Doctor {-4-Family Doctor or F-' +i-. 1—f2 -r-t., k in days for: -(--)'f=ollow-up t(,� ( ) Suture removal O The following test was performed: ( ) CRC () CMP ( ) EKG ( ) X-RAY ( ) CT (-) US () OTHER IF YOU DO NOT HAVE A FAMILY PHYSICIAN CALL 763-2900 FOR PHYSICIAN REFERRAL. ( ) Cali as soon as possible for appointment ( ) Pick up your X -Rays from the Radiology Department prior to your follow-up appointment. Call 763-2696 to have films ready. ( 'See your physician or specialist if not improved in days. ( ) Return to Emergency Center if you feel your condition is worsening, especially it ( ) Your blood pressure was elevated. Check with your physician. Clinical Impressions' 1- - .> it ;i i-.( • I hereby acknowledge receipt of these instructions and Exit Care infolmation. I understand that I have had emergency treatnieimt only and that I may be released before all of my medical problejns are known or treated. I will arrange for follow-up care as I have been instructed, It is my responsibility to notify my Primary Care Physiclanrof this visit, SIGNATURE: ..o � ': "..' J �._ . li ,• Phys)cieja:�tv)D/DO/CRNP ; SIGNATURE •r%r ;t'k- :11, Patfeet or Responsiele'j3erson , i /Date ( ) PATIENT/RESPONSIBI E' PERSON VERBALIZES UNDERSTANDING SIGNATURE: Nurse RN Date HOLY SPIRIT HOSPITAL JOAN R. DIETZ EMERGENCY CEN i'E 503 NORTH 2IST STREET CAMP HILL, PA 17011-2288 (717) 972-4300 ( ) Salvatore Alfano MD 025502E ( ) Kevin -Sean McGann DO OS0109691 ( ) Lorraine Bock CRNP TP003409B ( ) Matthew A. DiRodio PAC MA000969L ( I Ramesh Aroma MD 016727E ( ) Rupee G. Modi DO OS014328 ( ) Susan DaCosta CRNP SPOf17624B ( ) Duane Stroup PAC MA001653L ( Nikolas J. Baran DO OS004697L ( ) Laurence H. Pawl MD 039524L () Pam Darden CRNP SPO06066B ( ) Joey Wisner PAC MA002221 L O Luke Chetlen DO OS013145 (I Terry Paul Rat DO OS014492 (I Selena DiPaolo CRNP VP005264B ( 1 ( ) Larissa M.G. Clayton DO OS015268 ( ) Jessica L. Riley MD 442047 l ) Natalie Gillis , CRNP TP00608213 ( I Laura E. Crim MD 070368E ( ) Amy M. Taylor MD 420942 (1 Patricia K atzenmoyei. CRNP UP005363B (l ion Dubin DO 05006991 L () Jeremy J. Teppig DO OS014145. <: - ; ( ) Denuis.Macfiouoal l CRNP SP009092 ( ) Robert Ehlinger MD 027460E () Ranjana Sharma MD 0312651E1.6 -O 'ferciaa Willianis `. CRNPTPO06126B (I Anthony Guarrncino DO 090071551 O(' }_RaclmelYoungtsignd CRNPSP010606 ( ) Philip Maguire MD 0151163E DATE SIGNATURE M D /D O /NP DEA# REFILL TIMES EN ORDER FOR A BRAND NAME PRODUCT TO BE DISPENSED, THE PRESCRIBER MUST HAND WRITE "BRAND NECESSARY" OR "BRAND MEDICALLY NECESSARY" IN THE SPACE BELOW. 0LABEL DSUBSTITUTION PERMISSIBLE SPROW ,THOMAS R 12 M ER1 01/15/2001 ED GROUP 737931 737931 09/21/13 46213112 4 /2 - CONSENT TO MEDICAL TREATMENT 1 HEREBY CONSENT AND AUTHORIZE Holy Spirit Hospital, its agents, and employees, to the rendering of medical care, which may include routine diagnostic procedures and such medical treatment as my attending or. consulting physician considers to be necessary. I also understand -it is customary, absent emergency or extraordinary circumstances, that no substantial procedures will be performed upon me unless or until I have had an 'opportunity to discuss them with a physician or other health care professional to my satisfaction. If I am a competent adult, I have the right to consent or refuse to consent. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may involve risks of injury or even death and acknowledge that no guarantee has been made to me as to the results of any examination or treatment in this Hospital. k I understand many of the physicians on the staff of .Holy Spirit Hospital are not employees or agents of the Hospital, but rather are independent contractors who have been granted the privilege of using these facilities for the care and treatment of their patients. Further, I realize this Hospital is a teaching Hospital and at the Hospital are health care personnel in training who, unless expressly requested otherwise, may participate or may be present during my care as part of their education. Still or motion pictures and closed circuit monitoring of patient care may also be used for educational purposes, unless I expressly request otherwise. I understand that in order to ensure a safe environment for patients, visitors and staff all property on subject to reasonable search and/or seizure at any time without further notice. RELEASE OF MEDICAL INFORMATION I authorize Holy Spirit Hospital to release to requesting health insurance carrier(s), their representatives and auditors, and any referring health care providers, such diagnostic and therapeutic information including and information relating to treatment for alcohol and substance abuse and/or treatment of psychiatric disorders, and/or confidential HIV related information, as may be necessary for them to determine benefit entitlement; to process payment claim's for health' care services provided during this hospitalization/treatment episode, for continuing care/treatment, and hospital operations. A photocopy or carbon copy of this authorization shall be considered as effective and valid as the original. The undersigned also authorizes Medicare, when applicable, to release to another insurance carrier, upon their request, medical information needed to make payment upon that claim. I understand and consent that the manufacturer of •any implantable device inserted by my physician during • the course of my surgery/procedure may be provided with my identification information, including social security number, as f1d byFederal aw. e p Initjals raises ofHoly Spirit Hospital is 74(W ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 1 have received a copy of the Notice of Privacy 'Practices. The Notice describes how my health infomiat understand that I should read it carefully. I amawarethat the Notice may be changed at any time. I may obi contacting this Organization's offices or on this Organization's website at www.hsh.org. INSURANCE ASSIGNMENT OF BENEFITS •_ n may b' used or disclosed. I rf-Wrvised copy of the Notice by I authorize payment directly to Holy Spirit Hospital and my treating physicians of all benefits payable nde my psurance policies. I understrdl am responsible to the Hospital and physicians for all charges not covered by this assignment. nifa s STATEMENT TO PERMIT PAYMENT OF MEDICARE BENEFITS TO PROVIDERS, PHYSICIANS AND PATIENT I request payment of Authorized Medicare benefits to me or on my behalf for any services furnished me by or in Holy Spirit Hospital including physician services. I authorize any holder of medical and other information about me, to release to Medicare and its agencies any information needed to determine these benefits for related services, Initials MEDICAL ASSISTANCE RECIPIENT • My signature certifies that I received a service or items from Holy Spirit Hospital and Dr. on the date listed below. I understand that payment for this service or item will be from. Federal and State funds, and that any false claims, statements, or documents, or concealment of material may be prosecuted under applicable Federal State Laws. I understand that certain tests and procedures may not be reimbursed by Federal and State funds and that I may be responsible for non covered charges. Also, I agree that if at the time of service, if am not eligible for Medical Assistance, I will be responsible for balances owed to Holy Spirit Hospital. Initials I have read and understand each of the sections contained above. I understand that by signing this document, I am agreeing and providing the authorization/consent contained In each of the above sections where my initials are located. I have had the opportunity to ask qu tions regarding each of these sections and all such questions h ve been answered to my satisfaction. Signatur ( Relationship to Patient r HOLY SPIRIT HOSPITAL CAMP HELL, PA. CONSEIVT FOR TREATMENT/RELEASE OF INFORMATION INSURANCE ASSIGNMENT Witness Time Date lb? SPROW ,THOMAS R 12 M ER1 01/15/2001 ED GROUP 737931 737931 09/21/13 46213112 -2- 14 14 . Pediatric Illness . DATE: e ZI i 3 TIME SEEN: Z( -3;O Don arrival ROOM: EMS Arrival EMS treatments ordered Referred by: _ HISTORIAN: mother father ` patient paramedics AGE (7i1 / F(Z( hl!inri ¢HX/—EXAM LIMITED BY: HPI chief complaint: fever cough / congested fussy pulling ears rash ingestion not eating less active vomiting diarrhea onset 1 duration: _min / hrs / days ago constant sudden -onset intermittent episodes lasting -1A,1,f ":1 P --A/1 • worse /persistent since context: sick contacts home school other severity: fever to °F / °C oral rectal axillary TM not measured - subjective none noted associated symptoms: acting differently fussy crying more not sleeping less active inconsolable drinking / eating less not drinking last feeding/liquids decreased urination last urinated sleeping more I 0, (',,i CA - -, �N i /( L.pCLIL -c.c.a, • (Gtl31 pL l - (9 %9, 61_, 0'\-- . Similar symptoms previously Recently seen seen / treated by doctor / hospitalized vJ_ J Holy Spirit Hospital Camp Hill, PA John R. Dietz Emergency Center EMERGENCY PHYSICIAN RECORD Rev. 04 / 10 / 13 Page 1 of 2 ROS ENT pulling at ears R/L runny nose sores throat/ mouth EYES red eyes I discharge RESPIRATORY/GI cough trouble breathing vomiting / diarrhea abdominal distention blood in stools GU painful / swollen genital area problems urinating LNMP preg premenstrual '`ala systems neg except as marked cvS palpitations NEURO seizure MS extremity pain I swelling SKIN rash facial trunk extremities diffuse diaper rash LYMPH palpable nodes PSYCH anxiety/ depression • CONST components also addressed in HPI PAST HX _none Birth HX birth wt complications at birth premature birth wks diabetes Type I insulin asthma bronchitis I bronchiolitis cardiac problems congenital heart disease development delay old records reviewed / summary: 0.10 ear infection(s)_ febrile seizure pharyngitis pneumonia • seizure disorder sickle cell disease urinary tract infection(s) Surgeries / Procedures _none ,1_ll! -vC_. VP shunt Imm rnizations UTD / referred to PCP Medications _none see nurses note Allergies _NKDA aspirin ibuprofen acetaminophen see nurses note last dose SOCIAL HX smoker ppd / past! quit days ! mos / yrs ago drugs alcohol (recent/heavy/occasional) occupation living situation: alone at home in nursing home FAMILY HX _negative adopted _J ursing Assessment Reviewed ❑ VS Normal ❑ Abnormals Noted ��� PHYSICAL EXAM /n 7' 2 J /30 General Appearance mild / moderate I severe distress ,tfo acute distress ,_fussy / crying I cries on exam i irritable active/playful/smiles _lethargic / weak cry ttentiveness nml _grind eye contact aroused : I consolability _n feeding / suck _flat a er. fontanel _ poor consolability / poor intake suck__._.. ,__poor muscle tone closed / bulging / sunken anter. fontanel Circle/pbsitt es„ backslash aihgatives, check \Jormais SPROW ,THOMAS R 12 M ER1 01/15/2001 ED GROUP 737931 1S1 737931 09/21/13 46213112 10 (',.r: 1il7A O 1996 - 2012 T -System, Inc. PSYCH /6riented x4 food / affect nml ,--memory intact HEAD/EENT conjunct. & lids nml RERRL ,ears nml ase nml �pisarynx nml moist mucous membranes NECK _pple _lymphadenopathy* ....no masses RESPIRATORY _respiratory distress / prolonged expirations_ resp. distress _retractions / accessory muscle use bfeath sounds nml _decreased air movement _grunting ( infants ) _wheezes / rales / rhonchi / stridor CVS _murmur grade /6, sys / dies reg. rate & rhythm _peripheral pulses weak/thready Tieart sounds nml _slow cap refill sec ,-- strong periph pulses _tender no palpitations -ml capillary refill (GI) ABDOMEN _tenderness / guarding / rebound �_ on -tender _hepatomegaly / splenomegaly / mass bio distension abnml bowel sounds* -10 organomegaly __,..-rrml bowel sounds* {GU) EXAM _discharge / erythema / swelling / tenderness _nmt-vaginal exam bladder fullness / tenderness _circumcised (male) _testes undescended _uncircumcised (male) hernia chaperone (MS) EXTREMITIES _tenderne _non-tender ii-C._C-F/�Vl C��lti ✓l _nmi ROM* r + 11 SKIN cyanosis / diaphoresis / pallor / icterus Sao rash / lesions __poor skin turgor ` nro petechiae _diaper rash / skin rash Mimi color urticarial eczematous impetiginous warm, dry scarlatiniform manilla! erythematous _skin lesions NEURO _facial asymmetry ----Motor nml _sensory loss / weakness sensation nml LCN's nml (2-10) +euro at baseline LABS CBC Chemistries CRP ( UA normal except normal except RSV normal except WBC 3 Gluc Rotavirus A C- L11 Hgb i,3, (v BUN -►� Flu Screen— \A -IC 0-2-- Hct 'ZHct . ci , C) Creat a! Strep Screen Platelets Na Mono SpotL,,) Cultures sent segs K blood x bands CI urine L lymphs CO2 other _disoriented to person place time situation _depressed mood / affect recent / remote memory impaired _tenderness / swelling _scleral icterus / injected conjunctivae _EOM palsy / anisocoria / conjunctival exudate sunken eyes / photophobia _^TM erythema / dullness (R ! L ) _loss of TM landmarks (R / L ) TM obscured by wax (R I L ) rhinorrhea / purulent nasal drainage `pharyngeal erythema I tonsillar exudate ulcerations / vesicles _drooling! trismus! mass _dry mucous membranes meninglsmus / Brudzinski / Kemig's varlcelli form vesicular crusted Pulse Ox L OZ Ila: nmll hypoxic Time: Underline indicates organ system * equivalent or minimum required for organ system exam Pediatric Illness - 14 Rev. 04 / 10 / 13 Page 2 of 2 XRAYS CXR ❑Interp: by Me -Reviewed by me DDiscsd w/radiologist !hSnINAD __end- infiltrates _nml heart size _nm! lung inflation bilat Other PROCEDURES _ _ _ O Time outperformed_ , LP V _discussed risks, benefits, alternatives; parent/guardian consents, c' Time: fluid colorRBC WBC E: betadine prep glucose polys lymph N L3-4 L4 -5__ --__protein _________ monos_____ gm stn __-_- o PROGRESS ❑procedure(s) done by EDMD / midlevel Time .� % `?70 unchanged improved re-examined able to take food / fluid in emergency department _EGDT for sepsis considered 1 Asthma - brnnchadilntor tx/steno d(s) „Discussed with Dr �(� e will see patient in: ED / hospital / office Time nseled patent / family re r. ing, Additional history from: a /rad: results dle meed or a/b -up family caretaker paramedics Rx given _Smoking Cessation: discussed: plan /trigger/challenges/gave Rx time:_min CRIT CARE TIME (excluding separately billable procedures) 30-74 m_ in__75-104 min - -min CLINICAL IMPRESSION backs/ash differentials considered never Merlin itis Vomitin iarrhea Otitis`ed1a - R / L Dehydration Pharyngitis - Strep /Mono ♦ AstTir?ta-J 1;eactive Airway Disease Pneumonia (location) acute exacerb. status asthmaticus B / Bronchiolitis - RSV Cro Ga troeIilteritis / Enteritis Hyyoxemia In e'stion ntnza seasonal 1-1 t N I SepsisI-SIRS - severe Septic -hock Sin'bsitis Uppr-Respiratory Infection U ><b- elei ephritis Viral Syndrome DISPOSITION TIME- ' 2 ST) 0 admit 0 transfer ❑ observation POA charge 0 pending work-up 0 admitting MD notificatio CONDITION- 0 unchanged 0 Improved III Care transferred to Dr RESIDENT / PA / NP- s ransfer acceptance Time _ TI t/ (J./c/a ATTENDING NOTE: Please see resident/MUP note for details Resident/PA/NP's history reviewed. Patient Interviewed and examined by rue. HPI: My personal exam reveals - _1 agree with assessment and exception of ' At •nfirm di :no (es -bove. With MD/ O- R Template Complete ❑See Addendum (Dictated / Template if ♦ PQRS SPROW ,THOMAS R 12 M ER1 01/15/2001 ED GROUP 737931 737931 09/21/13 46213112 EXHIBIT B GENERAL RELEASE KNOW ALL MEN BY THESE PRESENTS, THAT FOR AND IN CONSIDERATION OF Three Thousand Four Hundred Dollars ($3,400.00), payable to Thomas Sprow, the receipt and sufficiency of which is hereby acknowledged, Thomas Sprow, Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, for themselves and each of his/her respective heirs, executors, administrators, assigns, and representatives, if any, do hereby release and forever discharge Dick's Sporting Goods, and all affiliated or related predecessors, successors, assigns, present and former parents and subsidiaries (whether or not wholly-owned and whether or not directly owned), former, present, and subsequent partners, shareholders, officers, directors, attorneys, agents, representatives, insurers, and employees and any and all other persons, firms, corporations, and entities, their heirs, executors, administrators, successors, assigns, and employees)(hereinafter collectively referred to as "Releasees"), and all other persons and firms, from any and all actions, claims for contribution and/or indemnification and/or subrogation, causes of action, demands, claims, damages, liens, judgments, suits, costs, fees, consequential damages, punitive damages, or any other thing whatsoever on account of all known and unknown losses, interest, attorney fees, costs, personal injuries, death, property damage, damages, debts, or loss of any nature which Thomas Sprow and Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, now have or may hereafter have, including all matters which were raised or which could have been raised in or in connection with, or anything whatever on account of, related to, or in any way growing out of, or incident to, be it directly or indirectly: the accident on or about September 20, 2013, involving Thomas Sprow at the Dick's Sporting Goods store located at 5950 Carlisle Pike, Mechanicsburg, Pa. 17055. Thomas Sprow and Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, and Releasees understand that this settlement is the compromise of disputed claims and represents a full accord and satisfaction of such claim or claims and that the payment is not to be construed as an admission of liability on the part of anyone, including Releasees, by whom liability is expressly denied. Thomas Sprow and Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, hereby acknowledge and assume all risk, chance, or hazard that the said injuries or damages may be greater or more extensive than is now known, anticipated, or expected. No promise or inducement which is not herein expressed has been made to Thomas Sprow and Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, in executing this Release. The undersigned do not rely upon any statement or representation made by any person, firm, or corporation, or other entity hereby released or any agent or any other person representing them or any of them concerning the nature, extent, or duration of said damages or losses or the legal liability therefor. 1 In consideration of the payment stated above, Thomas Sprow and Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, agree to hold Releasees harmless, and to defend and indemnify them against any suits, claims, actions, cross claims, judgments, liability, costs, demands and suits for damages, contribution, indemnity, subrogation, loss of service, attorney fees, expenses, or compensation which anyone or any entity may have on account of or in any way growing out of the damages and injuries which Thomas Sprow and Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, now have or may hereafter have, all matters which were raised or which could have been raised in or in connection with, or any other thing whatever on account of, related to, or in any way growing out of, or incident to, be it directly or indirectly, the accident on or about September 20, 2013, involving Thomas Sprow. Since freedom from costs of future litigation represents an important item of consideration bargained for in this agreement, it is agreed that damages recoverable for breach of this GENERAL RELEASE shall include reasonable attorney's fees and other costs incurred as a consequence of such breach. Thomas Sprow and Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, further declare that they have a full understanding of the terms of this settlement and GENERAL RELEASE, and that they had the benefit of legal counsel who has explained the terms of this instrument to them and its legal consequences, that the amount stated herein is the sole consideration of this GENERAL RELEASE, and they voluntarily accepts said sum and consideration for the purpose of making a full and final compromise, accord and satisfaction, adjustment, and settlement of all claims for injuries, losses, and damages resulting and relating to the aforementioned accident. This GENERAL RELEASE shall be construed and applied under the laws of the Commonwealth of Pennsylvania. This GENERAL RELEASE contains the entire agreement between the parties hereto and the terms of this GENERAL RELEASE are contractual and not a mere recital. It is further understood and agreed that there is no written or oral understanding or agreement directly or indirectly connected with the parties' settlement agreement and/or this GENERAL RELEASE that is not incorporated herein. The undersigned certifies that he is eighteen (18) years of age or older, is of sound mind, and FURTHER STATES, INDIVIDUALLY AND AS FATHER AND/OR GUARDIAN OF THOMAS SPROW, THAT HE HAS CAREFULLY READ THE FOREGOING GENERAL RELEASE OF ALL CLAIMS AND KNOWS THE CONTENTS THEREOF AND SIGNS THE SAME AS HIS OWN FREE ACT. 2 I, Michael Sprow, individually and as father and/or natural guardian of Thomas Sprow, have hereunto set my hand this day of , 2014 Signature of Michael Sprow Date 1515839.1 3 IN RE: IN THE COURT OF COMMON PLEAS THOMAS SPROW, a Minor OF CUMBERLAND COUNTY, PA NO. JLf /1) Ciiiit CIVIL ACTION — LAW ORDER AND NOW, this dayupon 2014, consideration of the Petition for Court Approval of Minor's Compromise, Settlement and Direct Distribution, said Petition is hereby GRANTED, and Michael Sprow, Individually and as Father and Natural Guardian of Thomas Sprow, is hereby authorized and directed to execute the General Release, attached to said Petition, and deliver the same to Dick's Sporting Goods, Inc., thereafter, the sum of Three Thousand Four Hundred ($3,400.00) Dollars shall be paid by Dick's Sporting Goods, Inc. to Michael Sprow as Father and Natural Guardian of Thomas.S row 141,4"44( 4..' . "34 tpeotoretIOT ft4VA, Moe- BY THECOIJ -T 401 ItAqv tS ?o1/ --r-a_r •, = moi -- r6z. mac, < _Ti COi3 1 t !_ / yam cnrr