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Home My WebLink About05-6295 Metzger, Wickersham, Knauss & Erb, P.c. By: Clark DeVere, Esquire Attorney LD. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 cdv0lmwke.com Attorneys for Plaintiffs IN RE: KARAH SCHREINER IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 6!; -I..).'IS (!/U;L"--r-~ PETITION FOR APPROVAL OF MINOR SETTLEMENT AND NOW, comes the Petitioners, Sam and Sandra Schreiner, as parents and natural guardians of minor Karah Schreiner, and petitions this Court for approval of a settlement of a minor's case in accordance with Pa.R.C.P. No. 2039 and in support of the Petition avers as follows: 1. Petitioners, Sam and Sandra Schreiner, husband and wife, are adult individuals residing at 12 Mall Road, Etters, York County, Pennsylvania, 17319. 2. Petitioners are the parents and natural guardians of minor Karah Schreiner, who resides with them, and who is 2 years old, having been born on May 16, 2003. #317707 3. Minor Karah Schreiner has selected Petitioners, as her parents and natural guardians, to represent her interests in this Petition. 4. At all relevant times hereto, Goodville Mutual Insurance was the business premises insurer for Raceway Stores at 202 Camp Hill Mall, Camp Hill, Cumberland County, Pennsylvania, 17011 and a seasonal store, Sport Spree at the East Mall, Harrisburg, Dauphin County, Pennsylvania, 17101. 5. On December 20,2004, Karah and her grandfather, Eugene Hockenberry, were shopping at the aforesaid business address of Sport Spree. 6. Karah was walking by the cash register holding her grandfather's hand when he heard a scream and a "pop." A metal adjustable shelf support with a hook on the end protruded out into the customer walkway. The hook caught in Karah's left eye, which popped as she yanked her head back. 7. As a result of this incident, Petitioner made a claim to Goodville, who insured the stores. 8. As a result ofthe incident, Karah was taken to Hershey Medical Center on December 20, 2004, where the physician reported that Karah sustained a corneal abrasion, a laceration to the superior palpebrae, and an external laceration. 9. At the hospital, Karah received wound care, was sedated in order to examine her eye more thoroughly, was prescribed an antibiotic eye drop, was instructed about increased risk of infection, and instructed to return in four days for a recheck. A true a correct copy of the hospital records are attached hereto as Exhibit "A" and incorporated herein by reference. - 2 - #317707 10. On December 24, 2004, Karah was seen at the Hershey Medical Center eye clinic as instructed for her wound, which was healing with no sign of infection. She was to discontinue the drops. Karah was to follow up as needed. 11. Karah has not received any further medical treatment. On March 23, 2005, this office conferred with Brian Johnson, MD of Hershey Medical Center, by telephone. Dr. Johnson stated that there was no visual field loss, no permanent injuries and future treatment was as needed. A true and correct copy of the hospital records are attached hereto as Exhibit "A" and incorporated herein by reference. 12. Karah's medical expenses for the treatment set forth above total $1,376.00. The Department of Public Welfare has paid $516.73. A lien has been asserted and negotiated down to $372.54, which amount will be paid back in satisfaction ofthe lien. A copy of the letter dated October 3, 2005 from the Department of Public Welfare accepting the reduced sum is attached hereto as Exhibit "BOO and incorporated herein by reference. 13. On behalf of its insured, Raceway Stores, Goodville Mutual has agreed to pay $5,000.00 to Karah and Petitioners to resolve the liability claim against Raceway Stores and its owner as a result ofthis incident. 14. The Petitioners, after consultation with counsel, has determined that it is in the best interest ofKarah to accept Goodville's offer on behalf of its insured and seek Court approval ofthe settlement. 15. Counsel was retained by Petitioners to represent Karah on a contingent fee basis of25% of gross recovery. A true and correct copy of the Fee Agreement is attached hereto as Exhibit "COO and incorporated herein by reference. - 3 - #317707 16. Counsel's attorney fee at 25% is $1,250.00. In addition, counsel has also incurred the following expenses in pursuing this claim on behalf of Karah: Filing Fees Photocopies Postage Long Distance Calls Fax Medical Records Travel for Investigation Total $ $ $ $ $ $ $ 4.88 $ 145.25 55.50 15.98 16.67 6.05 7.00 39.17 17. Petitioners respectfully request that his Honorable Court approve the compromise settlement of this claim with Goodville Mutual and Raceway Stores in the gross sum of $5,000.00, out of which Petitioners will receive the sum of$3,232.21 on behalf of Karah, the Department of Public Welfare will receive the sum of$372.54, and counsel will receive the sum of$I,395.25 for attorney fees and costs. 18. Petitioners propose to place their daughter's settlement proceeds is a federally insured restricted savings account at a bank, credit union or savings and loan association organized or existing under laws of the Commonwealth of Pennsylvania in the name of their daughter. 19. Petitioners also have been requested to sign the Release attached hereto as Exhibit "D" and incorporated herein by reference, upon approval of the settlement, which would release the Raceway Stores and Goodville Mutual from any further claims by Karah or on his behalf as a result ofthe incident at issue. 20. Petitioners also desire to discontinue the action filed in this matter upon filing ofthe Proof of Deposit with the Court. 21. Goodville, on behalf of its insured, Raceway Store, concurs with the filing ofthis Petition and also seeks approval for the minor's settlement under the terms set forth above. -4- #317707 WHEREFORE, Petitioners respectfully request that this Honorable Court approve of the minor settlement and enter a Decree distributing the funds as follows: (1) To be paid to Sam Schreiner and Sandra Schreiner, who are appointed guardians ofKarah Schreiner for the purposes ofthis Petition only, the sum of$3,232.21 to be placed in an insured savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated, or otherwise alienated until Karah Schreiner reaches her majority on May 16, 2021, except upon prior Order ofthis Court"; (2) To be paid to Metzger, Wickersham, P.c., for counsel fees and expenses- the sum of$I,395.25; (3) To be paid to the Department of Public Welfare for medical expense lien, the sum of$372.54. It is further requested that an Order be entered granting Sam Schreiner and Sandra Schreiner, as parents and natural guardians ofKarah Schreiner, authorization to sign the Release attached to the Petition, and discontinue this action upon filing of the proof of deposit of the sum for the Minor as set forth above METZGER, WICKERSHAM, KNAUSS & ERB, P.c. By: C ;.-d~~./ Clark DeVere, Esquire Attorney LD. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, PA 17110-0300 (717) 238-8187 Attorneys for Petitioners Dated: /,}./;J. /oS- , , - 5 - #317707 VERIFICATION I, Sam Schreiner, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The langnage of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. // / /-': <....n..___..U / ___/::-'~~_m ~ --". Sam Schreiner - Dated: . /, //.~ /.r /('~ . - ./ _m:' C<..j 337438 VERIFICATION I, Sam Schreiner, as parent and natural guardian of Karah Schreiner, hereby certifY that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. L ./ / /""'.. ..------/ ,-- ----~._- , Sam Schreiner, as parent and natural guardian ofKarah Schreiner Dated: /./ ,L-/-<'-f':}< /(./ ---' ,_/~ 337438 VERIFICATION I, Sandra Schreiner, as parent and natural guardian of Karah Schreiner, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief. To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. , ~. / ~7 .-,- /"/ -----z;">~~ .5'~/(>N" -'- ~"' Sandia Schreiner, as parent and natural guardian ofKarah Schreiner Dated: ,/;;,. f~)' ~, 337438 VERIFICATION I, Sandra Schreiner, hereby certify that the following is correct: The facts set forth in the foregoing Petition for Approval of Minor Settlement are based upon information which I have furnished to counsel, as well as upon information which has been gathered by counsel and/or others acting on my behalf in this matter. The language of the Petition for Approval of Minor Settlement is that of counsel and not my own. I have read the Petition for Approval of Minor Settlement, and to the extent that it is based upon information which I have given to counsel, it is true and correct to the best of my knowledge, information, and belief To the extent that the content of the Petition for Approval of Minor Settlement is that of counsel, I have relied upon such counsel in making this Verification. I hereby acknowledge that the facts set forth in the aforesaid Petition for Approval of Minor Settlement are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. / .-r-h?k ~. /' ~ - ~ /~hr~'~_7 Sanara Schreiner Dated: mY)- ////)<:'" // ,/ -/ '-...../ ,...'''-...--' / ~.' / . 337438 VERIFICATION The undersigned hereby certifies that he is the attorney for Petitioners, Sam and Sandra Schreiner, as parents and natural guardians of minor Karah Schreiner, and that the facts in the foregoing Petition for Approval of Minor Settlement are true and correct to the best of his knowledge, information and belief, and that said matters relating to the Petition for Approval of Minor Settlement are as known to the undersigned as to the clients, Karah Schreiner, by Sam and Sandra Schreiner, her parents and natural guardians, said knowledge being based upon information contained in the attorney's file in this matter, and further states that false statements herein are made subject to the penalties of 18 Pa. C.S.A. 94904 relating to unsworn falsification to authorities. ~~"".~L Clark De V ere, Esquire Dated: I,,," /~/{j;;- I 337438 CERTIFICATE OF SERVICE I, Clark DeVere, Esquire, of the law firm of Metzger, Wickersham, Knauss & Erb, P.c., hereby certifY that I served a true and correct copy of the forgoing Petition for Approval of Minor Settlement with reference to the foregoing action by first class mail, prepaid postage, this ~ day of 7Jec ~ ,2005, on the following: Charles Kidhardt Claim Representative Goodville Mutual P.O. Box 489 New Holland, PA 17557 c-~-~. (] Clark DeVere, Esquire 337438 k}~:b;r A PE NNSTATE ~. The Milton S. Hershey .. Medical Center HPI: '-....:). 0 __~C\.~+- _.---.J;'ci.\. , ~, \~ _------:::-Gi e.':::,Q' 8'---0"- . Pain: Y N ROS: Constitutional Eyes: ENT, mouth' Cardiovascular RespiratOlY: GI GU Musculoskeletal: Skin: Neurological Psychiatric: Other: Phvsical Exam: Onset /10 t ~ Factors As noted, other systems negative Y N N Y Weakness N Y Fatigue N Y hotophobia N Y N Y Rhinorrhea N Y N Y Palpitations N Y N Y Orthopnea N y Constipation N y Vaginal DIC N Y N Y Leg swelling N Y N Y N Y Syncope Dysphasia N Y Depression N Y Hallucinations \ v. j' '.~ \", G._, , o , c.;>... <:'" -) ~ I Location Radiation Unobtainable - Y WI. Chan e N Y Fever N Y Blur vision N Y Diplopia N Y Sore throat N Y Epistaxis N Y Chest pain N Y Pleuritic N Y Cough N Y Sputum N Y Abd. Pain N Y Nausea N Y Hematuria N Y 0 suda N Y Arm ain N Yle ain NY Rash N Y lesion N Y Numbness N Y Tinglin N Y Suicidal N Y Anxiety N Y Quality Quantit N Chills E e Pain Ear Pain Exertion Dypnea Vomiting Fre uene Back ain Seizure Ingestion NAME: SCHREINER, KRRAH MO: MR: 86E54754 DaBI 05....16....2003 Lac: EMER OOS#: 9028662 MR818 BP VL ,,,'. Wheezing Diarrhea Ineontinenece o ~'~.Q c. ~ \\c\- 1..9~ Co I 1.. Pc'-. "'v-.'_ \J-...\.r......'II-evv..c......;-~ . CA.-- o See attached PROGRESS NOTE for additional information: MOM !..J?ifferentiall?_i~gnosis:: 3) 1) 4) ~ ~ Procedure Note: ....-..--- EKG: Ep_~QursE!':-' Follow up with Treatment: .~ ~_/ Response: Return to em rgency department if Reclal: Hemocult 6) 7) B) days. // ~~&::/ ---.....----..------..-"./ - ~fs- 2-'\ Q:::;' MO#46353 SEX: F UISIT DRTE: 12....2E5....2004 Physician Time PMH: Cll l , -"-,~" Meds: N Y Other: ~.borato Studl.s: Qj N Y N Y Neutrophil N Y Atypicals + C, N Y , I"-'~ N Y Mg Troponin I: Myoglobin. PT: PTT: INR: 1. Bili: Alk Phos: ALT: Amylase. Lipase: UIA: U-HCG (+ I (-) Drug Screen: Cultures: Blood 1 2 Urine Study #1: DResult: Study #2: o Result: Study #3: o Result: 3) Where: o Cobra fonn t-'tl\'I"~ IAI t !5l Milton S. Hershey Medical Center ., College of Medicine EMERGENCY DEPARTMENT PATIENT FLOW RECORD ~6~E; SCHREINER, KARAH MR: 8064?54 MD#46353 008: 65....16,121363 LOCI EMER 5E><: F 005#" 90286 62 VISIT ~ATE' 12/2"/2""~ -- I \ '" ( '(.l NURSE'S NOTES D,te: 1101(f' \Ii 1l\.L-WL h f'!J2!/\[) 0 I" ~ \\~ -~ -- .. ..~._" "-----. -- .- -- .. - ------- - .~._.- - - -~_.- .. - .. -.-. ----- --- -- ____"...-0__.__ ".- """,::.. ::<.< .:.' ..::.::. ... ...... KEY '.< TIME ORAL IV TIME URINE NGT EMESIS UTD = up 10 date NfA " Not applicable NAM = Non-rebreather mask FR " French LOC = Loss a/COnscIOusness Td = Tetanusdiphlheria CPR = Cardia-pulmonary resuscitation VIS = Vaccination In/ormation sheet BVM = Bag-valve-mask EXP = Expiration ALS = Advanced lilesupport INIT= Initial Ell = Endo-tracheallube @ =AI 0' SAT = Oxygen saturation IMMOB. " Immobilizer lA=Leftarm MIC = Motorcycle LL= Lelt leg BCP = Birth Control Pills RA= Right arm INIT= Initials RL= Right Leg EXT = EXTENDED IV = Intravenous o R = Operating Room F=Fiberglass w!= with P = Plaster sol. = Solution TOTAL TOTAL OC OK = Quality Control OK LIS = Low Intermittent Suction DISPOSITION: [] DISCHARGED @ -"' ACCOMPANIED BY [] AMBULATORY [] CARRIED [] WHEELCHAIR [] AMBULANCE [] LOGICARE INSTRUCTIONS GIVEN TO: [] PATIENT [] FAMILY [] PARENT [] OTHER [] VERBALIZED UNDERSTANDING [] IV DISCONTINUED [J HEMOSTASIS ACHIEVED '] DRESSING APPLIED [] CRUTCH/SPLINT TEACHING COMPLETED WITH RETURN DEMONSTRATION [] PRESCRIPTIONS GIVEN '] REPORT CALLED TO EXT, CARE FACILITY @ [] REPORT GIVEN TO [] ADMITTED TO @ C REPORT GIVEN TO "' @ [J TO O.R, @ [] TRANSFERRED TO @ [] AIR '] AMBULANCE [] BELONGINGS '] W/PATIENT [] SAFE '] NONE [] W/FAMILY [] BELONGINGS FORM COMPLETED NURSE SIGNATURE INIT. NURSE SIGNATURE INIT, NURSE SIGNATURE INIT. NURSE SIGNATURE INIT. fR PT. Flow Shllt EMERGENCY DEPARTMENT PATIENT FLOW RECORD White to MR Yellow to EMD t-'tl~I~~IAlt _._'_____ _ ~ Milton -So Hershey Medical Center . College of Medicine EMERGENCY DEPARTMENT Pi ; MEDICATION PAIN SCALE USED ADULT NON COM PED. NEONATAL TiME MD [ MEDICATION / DOSAGE I TIME SITE PAIN RN ORD. INIT. ROUTE GIVEN SCALE INIT. I- i,,'.,. ..1 ~ ~ ..II1U VVI RU 01. ;>'V ~ .~L n .", '. ~ .""""\ 1--" c/ ~ ~ ~ ~ ~ ~ ~ ~ ~ .. ~ dTO,5cc '~J ADUL T 11 PEDS ~ Lon EXP ..... ~ii![i[ PHV$ICIAN"Ol'lDERS TIME MD TIME RN ORD. INIT. LAB STUDIES DONE I NIT. ~: Ci o DIMER - f--- I-j PL T CT --, CBe -" "~--- ':J PT pn o DIFF , nABG [~, ACETONE --~~.- ._~ Na 1'1 K DCI i] COo [1 BUN ~ Creat ::l GLUCOSE n CA nMG i.1 PHOS n LFT'S ~ AMYLASE 0 LIPASE C TROPONIN n MYOGLOBIN o UHCG i~-:; UADIP -~ U/A c MICRO 0 Ur. C&S o URINE DRUG SCREEN o GC CULTURE n CHLAMYDIA o BLOOD CULTURE [i #1 [J #2 [J ETOH 0 T&C UNITS OT&8 0 GLUCOMETER n I STAT LOCATION: LENGTH: SEVERITY: o SUPERFICIAL o LAYERED o COMPLEX o SUTURED o STAPLED o STERISTRIP o DERMABOND o WOUNDCARE TIME DAD .MD INIT.__ LOCATION: 0 R o L ::J FRACTURE o SPRAIN [J CONTUSION o SPLINT F P DACE o KNEE IMMOB o SLING o C.COLLAR o CRUTCHES o STRAIN o DISLOCATION OCAST F P o ANKLE lMMOB o WRIST SUPPORT o SHOULDER IMMOB o CAST SHOE o HAS OWN DR SIGNATURE INIT. DR SIGNATURE INIT, MR 692 6/01 TIM' NAME: SCHREINER, MO' MR: 8004754 008; 05/16/2003 LOCI EMER 005": 9028662 KRRRH MD'\l:46353 SEX: F U15IT DATE: 12/20/2004 ,AT I NIT. ~~~R- I TIME LYING BP PULSE SITTING BP PULSE STANDING BP PULSE o SALINE LOCK TIME MD SOL. ORD. INIT. MD INIT. RATE TIME ORDERED GAUGE SITE TIME DONE RN INIT. :J MONITOR ~ 02SAT o EKG o RESTRAINTS [l FOLEY SIZE COLOR o NGT/OGT o LIS o GASTROCULT o HEMETEST o CXR o KUB o AAS [J PELVIS [] CERVICAL SPINE o CT SCAN o SESTAMIBI [] ULTRASOUND ,] DOPPLER n MRI o EXTREMITY: o ECHO MISC. ::J02 [:i PEAK FLOW o SECLUSION AMT CLARITY SIZE CONTENTS o QC OK o QC OK NU CONSULTATION REPORT SCHR[J~[R KARAH MR_ 80047)4 051 I~, 120e3 OOS~ 9028HZ FELLOW OR RESIDENT: Oocuinent Chief Complaint (Ce) and History of Present Illness (HPI). Perform and document Physical Exam (PE). Document Plan 01 Care and relevant diagnostic test results STUDENT OR ANCILLARY STAFF: Document Palient Identlficalion liD), Past Medical History (PMH), Family Hlslory (FH) SJcial History ISH), and Review Of Systems (ROS) [ H [ R Cc: ta Iff' - n mc", rL &It! oJ."tr'I.f- {JD ffl1. 1'2-"'- I'" fo s;U1' . 0LCJc.) ICVLye~e(.ci /tLC LtVLf-<. ~1 ({ ~-<---(...(. /""....-.<.d.,....k p~f'o...-b, J !k(l ~ fN../f)9v flU11~ Sw-e LC ( :. ()' . \ . c - 'cS:Z:f,.,,J: . I ,~_,,-fv......, ~/ Svr~ 0 tl""--- '- /'\ t.~ ,... ''''''.,l. "i-I-<.-). ,- .rD, , ',---", I" """'~t"- A..A ) \ vV\~ ~ PM H)<. - cp M(M5 rp A.l\-if~c-r- fu.-. Lh- pc~ r~ tp ~'V- ~(~ ? ~~ 1) Iz k'./ c..--f- <6 ('r 'ZY=Gn--- f...'/.... 1,-<- J--v".) W L , /1'. R o.....)UU.. /.... ,...<., l'- L...J'I- W~: Q-,~ C",,<;C.IOVj sed.c..f-,':"- acR."",.~.$ k.-.e.) ~ - L)<. 'V- VC (2 <;EP 1). l<.-he( ~'l-2A.A- {..~., , , \ ' fC- j../tJL ~I(. " vV""'\..- A<>'u..........1 - ~L\A,.) l,trV.s~,) c....--<-...f.. A-~....~ t'-v.R~,.{ l"'-<.otA-..f.~ ._""""~ 1..,( 'Pc l'i +.........: i rkt (!) L'te Q ($) ~ f'/1.-\. ,j-'Cv, ~ ,.:.. -<-tL e-e-....: ~ - I (L ~ 1.."........ "> 1;\,......'" t<<-- ('0-, ~~ . E-vd..l 1...,,- ........~"'-L,.+L -i\.o f.'>-L&-....<...+~ - ft.....'r-'? .J... [...,v. ed- f-..... Op l-t f",..R......e'l ~ JC Title ~ure c..,.A rr~..0 ph.~ - Name (print) tl..{u{.'( Date {01'r- Time MR 11 Rev. 1219B CONSULTATION REPORT "J PENN STATE !51 The MiI10n S. Hcxxhey .., Medil:al Center SCHREIN[R KARAH MR- 8 00:'4 05/lblt003 OOS- 028bb2 [HE R Consent for Moderate Sedation The purpose of "MODERATE (CONSCIOUS) SEDATION is to provide relief for the patient undergoing a procedure that may be frightening, uncomfortable. and painfLlj'<:;, reqUires Immobility, Without sedation it may not be possible to safely perform procedures or tests. 1. I hereby authorize ~('j 0. ,1- o:;;...,,-,~ (physician), andlor such other staff physicians or resident physicians they designate. to perfonn upon me (or the patient Identified) "MODERATE (CONSCIOUS) SEDATION". 2. My physician has discussed with me the items that are briefly summarized below: a. The nature of conscious sedation: Sedative medications will be aiven in doses to minimize awareness of the procedure and minimize discomfort durina the orocedure, Breathina and oxvaen saturation levels in the blood especlallv are monitored and oxvaen may be aiven to maintain normal blood axvaen levels. b. The risks of moderate sedation may include: Decreased breathina effort and decreased blood axvaen levels, Excitabilitv Instead of sedation may occur in few children, Less cammon is the risk af "stopped" breathina which may reauire mechanical ventilation assistance or vomitlna chokina or an alleraic reaction to the medications. c. The feasible altemative to moderate sedation is: No sedation or phvsical restraints. d. Without moderate sedation it mav be difficult or impossible to perform the procedure or test or I mav be at risk for iniurv, 3. I am aware that in addition to the risks specifically listed above there are other risks that are present with respect to conscious sedation such as cardiac arrest which may require corrective measures or result in death. 4. I understand that during the course of this procedure, unforeseen conditions may arise which could require the nature of tile procedure to be altered and I therefore authorize my physician or other physician designees to provide such medicai treatment as necessary and desirabie in the exercise of professional judgment. 5. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the results of the procedure. 6. I acknowledge that the infonnation I have received, as summarized on this form, is sufficient for me to consent and i authorize conscious sedation to be performed. I have had the opportunity to ask questions about my condition, the sedation, alternatives and risks, and all questions have been answered to my satisfaction. 7. I authorize the Milton S. Hershey Medical Center to permit other persons to observe the sedation procedure with the understanding t such observation is for the purpose of ~adV~~I~. (pa~4~~gnaturelDatelTime) It .2...\.1.-d (Physician or Nurse) provide~nfnation summarized and obtained the consent for conscious sedation. J ~ ~~_,j / I">-\"'-CI k'f (PhysiCian SignaturelDate) MR 836 8/01 Consent for Moderate Sedation PEN NSTATE ~ The Miiton S, Hershey . Medical Center SEDATION and ANALGESIA DOCUMENTATION RECORD MEDICATION RECORD paoe 2 of .2 I r Time Time Time Given RNJMD/DO Initials Medication / DosefRoute ,~.~I(fn-lrli\vt K:ln(inJ I' ~ hrM\"I'[Jpr! '..)\~ r7 .J , n.1. '7-, ;::l--l?\ r tv 11 ilr"IH'I ur!IH..e.. l.l III , 14~ I , ^ ,J.1.l,/ 'PV 1.Dl?CT > N10dlfied BIDMC"Sedatlon Scoring System 0: Patient awake/Baseline mental status 1: Mild sedation; occasionally sleepy, easy to arouse, speech clear, responds to verbal stimuli 2: Moderate sedation; frequently sleepy, speecll slurred 3: Deep sedation; somnolent, difficult to arouse, responds to stemal rub Modified Irom Bettl Israel OeaconessMedical Cenler. Guidelines for Sedalivesand Analgesic Un; Bostoft MA 1995; Use~wtthpennis.si!ln of"",, ill," '1~tf CHREI~[R URAH ,. 8cC4754 05/1012003 ^ " -, 'ilrfAL siGN's Q:; tninules during proceClrl'rii Sedation BP Heart Rate FR Score Rhythm OzSat Oz Flow l'UotV n '---/ Ih r-,If\~ 1'.t7V I I\V I)Utl 1\ - A I fr I{j)"d. b\2A II-A t}4 /Xx \~ ) J?i n 'd- rB--1 II" 0 I?, PI ~<iO I Co, /4='1. L:::Iln ~ 14")" 0 \\.r.. / ~<: ,.,...,. () Im!StJ IJr, ", II I t"lrlC. ~ ^ ^". I II \1./ '1-1 "rt::rr 7T (-1 I~ ::::tJ'l, p,~ <::AI r, 1< IN', ilA t::..Ilv I, I~ loo 2A~ 14 l(["ff'r (.lit c'@J l<f- IW ~)A 0/: , Iln I -- T~ "J ~'A T 17 \.::\ Iv ! J / / J I TIME PROGRESS NOTES I91W~*~~ ~c~@ Procedure End Time: d Baseline level of consciousness or a score of less than or equal to 1 on the BIDMe Scale Vital Signs within 15% of baseline Oxygen Saturation 92% or greater, or at baseline level Airway reflexes intact with patient airway Can communicate at baseline level Can sit up unaided, if age appropriate Mild or no nausea/no vomiting within 30 min. Bleeding controlled Self-reported pain intensity level D 0-10 RS 0.6 bservational pain intensity scale: 0-10 Pedlatnc UWCH IV. POST-PROCEDURE: DISCHARGE CRITERIA: INDICATE TIME OR N/A A_dJ4S \ B. C. D. E. F, G. H, I. J,) \J(, Time IV Discontinued: Time Patient DischargedfTransferred: Instructions/Report to: Patient Destination: ~IS ~~\~ RN Signatur . Init: -4l-- lnlt: -~ATEI2./2JJ jDJ RN Signature; MR #834 rev 12/02 SEDATION and ANALGESIA DOCUMENTATION RECORD page 2 of2 '-"".' 'Of' PENN STATE ~ The :Milton S. Hershey ., Medical Center SEDATION and ANALGESIA DOCUMENTATION RECORD 0 C Sit 9 C 28662 aae'1 of 2 I. PRE-PROCEDURE NURSING ASSESSMENT 0 Informed Consent Obtained ~n intended DiagnOsis:(Q _ I.L!::---------------------mm--- D ~~~:rate ~~~~~~;~;ake \ Welght~~--\tIl:(..&iI~- iq ~~een~tl~heckilst: ~~:;,~~~~S conta:s c..~~~ ------H-;,~~1_;;9-Ald---Y;~/~-- ';;;~~:c Monitor Level of Consclousness....j.. ___________________ BP Monitor ~~~:O~~~~~Ta:~: _ ---~~- - _ -"'- "'----"'-~_ - -_=---= ~:~;~:::t: IV Site: 't ~Suct!on Apparatus IV Solution ___ :-f"-=,- wagNalve Set History of Substance Abuse:. Yes J 0 ~nant: Yes / ~ ------ G~esuscltatlon Worksheet Airway at risk {acc~'tfr; :otf~lifVA ~e~/~ ~ f" "" I [0' Reversal/Emergency Drugs Nurse Signature:~~ Datel~et1_ Time:~___ SCHHIN[R KARAH MR. B004754 05/1b1200J E MER II. PRE-PROCEDURE HISTORY & PHYSICAL EXAM (Physicians may document on this form or on the pre-procedure note/form) Indication for Procedure: ________________________ Diagnostic Study Results: Lab, X-ray Other Review of Systems: f"l.t \. J , t"'J "'-1 Past Surgical History: cf ~ Past Medical History: Allergies: VL.,J Current Medications: (j TEMP PULSE RESP BP _,_ O,SAT MUST BE COMPLETED IMMEDIATELY PRIOR TO PROCEDURE BY PHYSICIAN: AIRWAY ASSESSMENT: NORMAL ABNORMAL CIRCULATORY: PULMONARY: ASA Classifi~ation (Required when deep sedation is intended.) I. A normal healthy patient II. A patient wit mild systemic disease Ill. A patient wi severe sys . iseas Physician signature IV. A patient wHh severe system1c disease that is a constant threat to life V. A moribund patient who is not expected to survive without the operation VI. A declared brain*dead patient whose organs are being removed for donor purposes Date: l"L\'"L<J\U"\ Time: '2...\. \'"\..t.I III. INWf-PROl'fRt.RE A~~E~MENTfNOTj (;;aSeline prnoeedure VS within 5 minutes of the procedure): TempO\P F5 pUlse..lr:1- Resp BP 0 /:D. O,Sat ~ QA- Baseline serf~reported pain intensity level Baseline observational pain\~~y scale: Procedure Start Time: f).. 0.10NRS_ 0"5FRS_ 0.6AdultFRS ~O-10 Pediatric UWCH MR # 834 rev 12/02 SEDATION and ANALGESIA DOCUMENTATION RECORD page 1 of 2 t: o :;:; III 't:l Ql en Ql - e Ql 't:l o ~ ... .E 't:l E Ql - Ul :5 E 't:l < .2:- = o E E c c o :8 .~ (.) 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C'I E ~ ro E'~ o~ ~- Q) c:i E e 0 ~ " c w E e u ,5 '" E N o .s '" E q '" o ~ " " ." " " " 0 ~- ~.$ e e " " ~ N ;:!! w 'c o Ol '" 'E ~ 'c W N '" E " u: ~ o ~ ~ ~ .; m m " ~ '" .; c Q " " :a , <L ~ . " w " ~ u . as ~. ~ o .; m m '" .o 'Y ~ ~ N b " ro ~ ~ . ~ ~ ~ a '6 rn OC " 'E ':' N C ~ Il.l (II ci" ~ ti l: Q.l .~ ~ E ~ ~ ~ ~ 3. ~ < ~~ 'Eui ~ ~""': 8~ ~ .8:;= ~(Oi ~ ~i8 sl? "E ....:e~ "'CO> III (01"3:01 ~; 3 ~~'@ ~:: E ~..t:f ~ ~ :S' C>>] c: 6l(.) 0 Ol; ~ nj.Q ~ ~ll'i~~z'~:g .9 u a> ON""J::. Gl ~_~c::...E..~ ... 8 C"iuid; ~ ~ is o .; ~ S: <;r! 6: ~'iJ -m"'l'OC\l"".....lII .!:!!..s: ~ E f'l <lIij1;: III Q."It E c:].....lj 1~~zu:fi;?; -m:gl!!E:g6~g' c t:! 11I >.::l1J;S;;: tIlGlu~=~~B ~~.e8i18~l!! ro:a~~~~l!!~ ri '" >- l: C'- B III 'Qj:gg-.@-:.l!l<'ll'i Q).2 ~ a. l!! -a,~ a. ~8"cid ~'~,s~ c., 0 e; <ll- III ('JCii8~'~Ci~~ g15.g,g~~~~ ~'E6Q)~TI~i -0 <II =:5i Ie' .-:= 0 Ql:r.l1IQI"'Ocncr. CIJ ~ 11 ~ l!!S:~ >. cij~;:~~u:~ a. :ii ; 6 0 QI c.. CI c %.. c:::E 1il.E.!: :2 c:: ~ ~ w f:E'Zl ;,; ~~o,g: o....;3:.~ Q) :2_;Cri~~'g:r.:i g -:=.:::t (I) l- o~.... 1ll:3 >- ...,U_' ~ ~.5" ~-c~g~a~~-g &:5~if&L~J5~~ The MiJtQ,n S Hershey Medical Center - Emergency Department 500 University Drive, Hershey, PA 17033 (717)531-8333 Patient: KARAH SCHREINER Medical Record Number: 8004754 Date: 12120/2004 Time: 22:01 Discharge Instructions IMPORTANT: We examined and treated KARAH today on an emergency basis only. This was not a substitute for or an effort to provide complete medical care. In most cases, you must let your doctor check KARAH again. Tell your doctor about any new or lasting problems that KARAH has. We cannot recognize and treat all injuries or illnesses in one Emergency Department visit. If KARAH has special tests, such as X-rays, we will review them within a day. We will call you if there are new suggestions. After you leave, follow the instructions below. KARAH was treated today by Dan French, MD. THIS INFORMATION IS ABOUT KARAH's FOLLOW UP CARE Call as soon as possible to make an appointment for KARAH in 4 DAYS at the OPHTHALMOLOGY CLINIC, You can reach the OPHTHALMOLOGY CLINIC al (717)531.6955, UNIVERSITY HOSPITAL P.O. 850. HERSHEY, PA, 17033. This is a central appointment desk, called Careline, andtheywill help you set up your appointment at this clinic. If you have any problems or concerns before the appointment, call the Emergency Department. Please bring KARAH back to the Emergency Departmentif his or her symptoms get worse or CALL 531-5690 FOR ANY OTHER CONCERNS OR RETURN TO THE ER.. THIS INFORMATION IS ABOUT KARAH'S DIAGNOSIS CORNEAL ABRASION (Scratched eye). KARAH has scratched the outside of the eyeball. The outside of the eyeball is called the cornea. A scratch on the cornea is very painful. It can be very serious If not treated right away. This scratch should heal in 1 to 2 days. Until the eye is completely healed, there is an increased chance for infection. Do the following: Have KAAAH rest more that usual. Increased activity will cause both eyes to rub under the lids. CALL TO MAKE AN APPOINTMENT WITH THE OOCTOR TO RECHECK KARAH'S EYE IN 1 to 2 DAYS. Keep the follow-up appointment with the doctor. Call your doctor If KARAH has: any eye or vision problems after taking the patch off. . any new or severe symptoms. Return to the Emergency Department immediately if KARAH has: severe eye pain. . fever. THIS INFORMATION IS ABOUT KARAH's MEDICINE POL YMYXINlBACITRACIN OPHTHALMIC (Polysporin). Give this medicine to KAAAH in the following dose: 1 drop in the left eye every 6 hours until gone. This is a mixture of antibiotic medicines. It treats and prevents infections in the eye. Side effects may include: irritation, burning or itching in the eye. AlIergywould showup as: worsening redness, pain or itching In or around the eye. Do the following: Store this medicine away from heat, moisture or direct light. If you miss a dose, apply the dose as soon as possible. If it is almost time for KAAAH's next dose, skip the dose. Do not double the doses. To use the eye drops or ointment: 1) Wash your hands and remove the cap. 2) Do not touch the tip of the tube to your fingers or KARAH's eye. 3) Pull KARAH's lower lid down to form a small pouch. 4) Hold the medicine bottle over KARAH's eye. Gentlysqueeze the bottle until the drops fall gently into the pouch. For ointment, squeeze out a line of ointment across the pouch. 5) KARAH should close the eye for 1 to 2 minutes to spread the medicine over the eye. Call your doctor if KARAH has: any sign of allergy. no improvement. any new or severe symptoms. CAR SEAT SAFETY Protect your children in the car. The safest place for any child 12 years old and under is in the back seat. Every child should be buckled in a child safety seat, a booster seat, or with a lap/shoulder belt, if it fits. Infants under 20 pounds and under 1 year of age: Infants should ride in rear-facing carseats until they are at least20 pounds AND at least one year of age. The car seat must be in the back seat and face the rear of the car. Infants riding in the car must never face the front. In a crash or sudden stop, the baby's neck can be hurt badly. Infants in car seats must never ride in the front seat with air bags. In a crash, the air bag can hit the car seat and hurt or kill the baby. Neverhold an infant in your lap when you are riding in the car. In acrash or sudden stop, your baby can be hurt badly or killed. Children over 20 pounds and over 1 year of age: Children over 20 pounds and at least 1 year old should ride in a car seat that faces the front of the car, van or truck. Keep the child in the forward facing car seat for as long as they comfortably fit in it. Older children over 40 pounds should ride in a booster seat until the car's lap and shoulder belts fit right. The lap belt must fit low and snug on their hips. The shoulder belt must not cross their face or neck. Never put the shoulder belt behind their back or under their arms. Remember: All children are safest in the back seat, in a car seat and seat belt. Always read the car seat instructions and the car owner's manual. Make sure the car seat is secure and snug by pulling the base to either side or toward the front of the car. You and KARAH are the most important factor In KARAH's recovery. Follow the above instructions carefully. Give KARAH the medicines exactly as prescribed. Most important, see a doctor again as discussed. If KARAH has problems that we did not discuss, call or visit your doctor right away. If you cannot reach your doctor, return to the Emergency Department. If you have questions, call us. SATISFACTION SURVEY: It's been a privilege for us 10 care for you. You may receive a survey in the mail. We hope you will be able to take a few moments to complete the survey. Portions Copyrighted 1987~2004, LOGICARE Corporation Page 1 of 2 The Milton S Hershey Medical Center . Emergency Department 500 University Drive, Hershey, PA 17033 (717)531-8333 Patient: KARAH SCHREINER Medical Record Number: 8004754 Date: 12/20/2004 Time: 22:01 It helps us to improve service and reward staff. We like to post the surveys for all the staff to see. CHECK OUT: PLEASE FOLLOW THE BLUE PAW PRINTS TO THE CHECK OUT AREA, THE MEDICAL OFFICE ASSOCIATES Will NEED TO VERIFY INSURANCE INFORMATION WITH YOU PRIOR TO YOU lEAVING THE DEPARTMENT "I have received this information and my questions have been answered. I have discussed any challenges I see with this plan with the nurse or PhYSiCia~ . / ~' /P#j:::Y/x:. . ./f,:~;;:;,:C/, Responsible Person for KARAH 'SCHREINER Responsible Person for KARAH SCHREINER has received this information and tells me that all questions have been answered. ~ure Portions Copyrighted 1987-2004, LOGtCARE Corporation Page 2 of 2 I-'tNN:'> IAI t = Milton S. H( ley Medical Center ~ College of Medicine '{)0C ~s~ OPHTHALMOLOGY PATIENT HISTORY RECORD j-!fO/2?A. L5:l.dll7t'l/ A PATIENT'S NAME ~REFERRE6 BY-----~ ----- ------,n:lR:iMARY CARE PHYSICIAN /._------ ~ SEX A. BIRTH DATE Please answer the f9110wing questions about your medical status and history: 1_ Have you ever b_eien treated for any medical conditions (e,g., diabetes. high blood pressure, arthritis, etc.) Yes::J No G If YES, please explain:_____________ ___ 5- /17 /~) 3______~_ / ,~- :2- '--'I..-AG'E--- 2. Have y~h-~dan/eye disease (e.g., glaUco~~. Yes C No 0' If YES, please explain:. cataract, wandering or "lazy" eye, retinal detachment)? 3. Have you ever h~6 ~~~ surgery: Yes D No B If YES, please provide date and reason 4. Have you ever beren hospitalized Yes D No eg/ If YES, please provide date and reason 5. Do you take any;nedications? Yes D No g If YES, please list: Do you take any lye medications? Yes 0 No I:i If YES, piease list: 6, Do you have any drug or food allergies? ,. . '..'/ /;/ Yes 0 No D If YES, please liSt:~2'z(CL///m! Review of Systems Do you currently have any of the following problems: Yes ~ YES, please explain: rr ~ [;1) c:;r / rb/ [0" []./ Chronic fever, unexpected weight loss/gain, fatigue. 0 Ear/nose/throat problems (e,g.. hearing loss, sinus problems, sore throat) 0 Heart problems (e.g., chest pain, irregular heart beatL __ 0 Respiratory problems (e,g., shortness of breath, wheezing, coughing). ..._.-.. D Gastrointestinal problems (e.g., heartburn, abdominal pain, diarrhea, vomitingl- D Urinary problems (e.g" pain or discomfort, blood in urine),.. __ _ 0 Skin problems (e.g, rashes, excessive dryness).. D Musculoskeletal problems (e.g., muscle aches, joint pain, swollen joints) _ D Neurologic problems (e.g.. numbness. weakness, headaches, paralysis). 0 Psychiatric problems (e.g" depression, anxielYl_ _ 0 Family and Social History Do any medical or J3Y8 diseases run in your family (e.g., diabetes, high blood pressure, cancer, glaucoma, macular degeneration) Yes 0 No Q/'If YES, please explain: Do you smoke? Yes 0 No ~es, how much? I I drink alcohol? Yes 0 No ~f yes, how much? I If employed, how many hours per week do you work? I ~ J ... Comments ... M.D. Signature ... Date MR 861 (9/02) OPHTHALMOLOGY PATIENT HISTORY RECORD While copy - Chart Yellow Copy. Clinic r ) 'C..( PENN STATE NAME: SCHRElt\ER, KARAH - MO: M~INLARI ALl MD#: 85005 .. Milton S. Hershey Medical Center MR#: 80C4754 DOB: 05/16/2003 SEX: F . College of Medicine INS: MEDPLUS THREE RIVE STMJDARD lOC: OPH1 008#: 5113968 VIS:T DATE: 12/24/2004 OPHTHALMOLOGY EXAM FORM 8; 01 rW,i\ !.J New Requested by I.J Follow-up from 1212-1<'1 Page 1 of 2 HISTORY ALLERGIES: CC/HPI: C'C'? /'l-b'.1 fit( ~/q 5/t.Y"). E~ puJ /'? .,.// to( /AIo i'vILU A.',<~____ - /""IO-1rl, <;' Jt"1R ~----'" ~ Lq . Medication List p+ "lo ,,,- .? ~.i..( ct t' I" ..,-, k> o - U I~ Ocular: REVIEW OF SYSTEMS (ROS) y N Y N Y N Y N 1t('1 f'n;'" u ':J CONSTITUTIONAL ::J CJ RESPIRATORY U :.J MUSCULOSKELETAL IJ :.J ALLERGICI GlP .J .J EYES :J =.J GASTROINTESTINAL '.J U NEUROLOGICAL IMMUNOLOGIC .J .J EARS, NOSE, MOUTH, THROAT U :.J GENITOURINARY :J '.J PSYCHIATRIC U LJ ENDOCRINE ::J o CARDIOVASCULAR 0 o INTEGUMENTARY [J :.J HEMATOLOGIC/LYMPH IJ U ALL OTH ERS IIYes describe ~_.. ~ t.?(~ (''^''~ ---.--- .-.-.-- MEDICAL HISTORY: ~ ~-_.. ....-. Systemic:_______ -.-.--.-. FAMILY HISTORY: - 7 - - .--- -..----.-- --~--- .--t( History (ROS/PMFH) Reviewed Dated LJ no change LJ changes noted above. Initials EXAMINATION General Medical Status: ::J Oriented to time, place, person ::J Affect appropriate . . Visual Acuity ("l t-ht Left Distance sc /r ("l' P- I Distance cc LJ Rx Given -- Near Wearing Add Manifest / / Add Cycloplegic . Pupils: R _mm mm ~PO . Color . Pachymetry: . Keratometry: - - L - mm - mm - - PO Dark Light Reaction L R . Intraocular Pressure: T< . Visual Field: LJ Humphrey * o Applanation (Confrontation) LJ Goldmann * o Tonopen ;t' :J full t n t :J Tangent * *See additional form . Motility/Alignment [:~,w;~ I ~rSions full . other orthotropic in primary ~_.___.,_.__-.--.-----J Abbreviations: Technician APO = afferent pupillary defect cc = with correction sc = without correction OPHTHALMOLOGY EXAM FORM White Copy. Medical Records MR 905 Rev. 1/04 Page 1 of 2 Yellow Copy - Department ************************************************************************ Header Page ************************************************************************ Patient Name: Date of Birth: SCHREINER, KARAH 5/16/2003 12:00:00 AM Medical Record Number: 8004754 Financial Number: 9028662 Admission Date: 12/20/2004 8,19:00 PM Discharge Date: 12/21/2004 11:59:59 PM Patient Type: Emergency Facility: HMC Patient Location: HMC EMER Destination: Hershey Medical Center Reason: Legal ************************************************************************ Requester: Hershey Medical Center Date and Time Printed: 1/17/2005 9:28:22 AM Printed By: Shiner, Crystal L Device: HISU230201 PENNSTATE !5l Milton S. Hershey Medical Center . College of Medicine Penn State Milton S. Hershey Medical Center Penn State College of Medicine Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033~0850 Tet (717) 53 I .8055 Patient Name: Patient Sex: Patient Location: Visit Type: SCHREINER, KARAH Female EMER" Emergency PSUHMC MRN: Date of Birth: Visit Number: 8004754 51! 6/2003 9028662 Emergency D Department ocument Not e I I Final Document Electronically Signed by: French, Daniel K 12/21/20045: 15:58 PM ED SUMMARY Name: SCHREINER, KARAH HMC Number: 8004754 DOB: 05/16/2003 Date of Service: 12/20/2004 CHIEF COMPLAINT: Injury to the left eye. HPI: Patient is a 19-month-old female who is brought to the Emergency Department tonight by her parents with an injury to her left eye. According to the family, the patient was in a store earlier tonight when she tripped and fell into a rack which was supported by some protruding pieces of metal. The patient immediately grabbed her left eye and her father observed blood coming from the eye. There was no loss of consciousness. When EMS arrived at the scene, there was blood observed coming from the left eye: the eye was significantly swollen and it was not clear whether the blood was coming from a laceration to the lid or whether it was coming from inside the orbit itself. Patient's eye was wrapped in sterile gauze and she was brought to the Emergency Department. In the Emergency Department, the child appears to be quite uncomfortable, She has a bandage to her left eye. There are no other evident injuries. According to the family, there has been no change in her baseline behavior other than for her crying from the pain. She has not had any vomiting. PAST MEDiCAL HISTORY: Negative. Immunizations are current. MEDICINES: None, ALLERGIES: AMOXICILLlN. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives with natural family, REVIEW OF SYSTEMS: Positive for pain and bleeding from the left eye. Other symptoms were reviewed and were negative. Date Printed: 1/17/2005 Time Printed: 9:28 AM PENN STATE !5l Milton S. Hershey Medical Center . College of Medicine Patient Name: SCHREINER, KARAH PSUHMC MRN: 8004754 Emergency Department Document Not e I Final Document Electronically Signed by: French, Daniel K 12/21/20045:15:58 PM PHYSICAL EXAM: Vital signs: Afebrile. Heart rate 154, respiration rate 28, 02 sat 99% on room air. General: Well- developed, well-nourished female toddler. She has a wrap applied to her left eye. She seems moderately uncomfortable and somewhat agitated by the bandage. Otherwise, she appears to be in no acute distress. HEENT: With the help of nursing staff, the bandage was taken down, The right eye is normal. The left eye has an approximately 5 mm, superficial laceration to the superior palpebrae near the medial canthus; there is no blood coming from this wound. The superior palpebra is very swollen. Trying to open the eye with gentle pressure causes significant anxiety and/or pain to the child and I was unable to get a good glimpse of the pupils and the sclerae; however, there did not appear to be any obvious injury. The rest of the HEENT exam was normal. There are no other signs of trauma to the head. Ear canals are normal bilaterally, and there is no blood noted in the nose or in the mouth. Neck: Supple, nontender. lungs: Clear to auscultation bilaterally, Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops. Abdomen: Soft and nondistended. There does not appear to be any focal tenderness. Extremities: The child moves all extremities. There is no focai tenderness, and no lesions are noted. DIFFERENTIAL DIAGNOSIS: 1, Eyelid laceration, 2. Corneal abrasion. 3, Orbital injury. EMERGENCY DEPARTMENT COURSE: It was very difficult to obtain a good examination on the child's eye because of her agitated state and the lid edema. It was obvious that the child is going to need to be seen by Ophthalmology; accordingly. we will defer conscious sedation until Ophthalmology is present and we can do this procedure one time. The child's eye was re-bandaged with sterile dressings. She was left in the care of the mother. at which point the child calmed down, Ophthalmology was consulted to examine the child, Again, the child was very agitated and during their initial examination the decision was made for conscious sedation. I reviewed this procedure with the parents, and the mother signed informed consent after the risks and benefit of the procedure were described; please see the Informed Consent sheet in the chart, IV access had been obtained by the nursing staff. The child was given 10 mcg of Fentanyl and 0,5 mg of Versed, The child remained awake but was obviously sedated. Ophthalmoiogy was able to get a good internal and external exam of the eye: in addition to the small external laceration, the child has a laceration on the interior surface of the superior palpebrae and also has a corneal abrasion. No other injuries were noted. Please refer to their note. Patient was on monitor throughout the entire procedure and her vital signs remained stable, She tolerated the procedure well. I managed the entire conscious sedation. The child was observed for 30-60 minutes afterwards and remained stable. The child's injuries were discussed with the Ophthalmology Attending on call and also with Plastic Surgery who is covering facial trauma, It was decided that no wound closure would be attempted on the inside of the superior palpebrae. The child will be given Polytrim drops for her corneal abrasion, and she will foilow up with Ophthalmology. ASSESSMENT/PLAN: 1. Corneal abrasion. 2. lacerations to superior palpebrae, Date Printed: 1/17/2005 Time Printed: 9:28 AM PENN STATE !$I Milton S. Hershey Medical Center ., College of Medicine Patient Name: SCHREINER, KARAH PSUHMC MRN: 8004754 Emergency Department Document Not e I Final Document Electronically Signed by: French, Daniel K 12/21/20045:15:58 PM Patient's immunization status is current. Accordingly, no tetanus is required. Patient will follow up with Ophthalmology, Return to the Emergency Department for any worsening symptoms. #682405 Review/Sign: Daniel K French, MD DKF /SAT DD: 12/20/04 DT: 12/21/04 04:16 Date Printed: 1//7/2005 Time Printed: 9:28 AM PEI'-iI'iSiATE ~ Milton S. Hershey Medica] Lemer . College of Medic:me AUTHDRi::ATIDN cOR 'OM'ORG'ONCY TR'OATM'ONT AND R=L=AS= Dc INPORMATION !tlE unaers:;Jr1ed has been Informed of tne emergen::::y treatment conSloereu ne::essary' fm the patlsn, whDse name appear:; Of, the reverse hereof lattacheo' sne8!S ana sramped belol/J 0, soove') anc~ 1nat me ueaTmenT. anc proceoures wil; be :::eriormed OJ' onYSIClans, me;l108fS of tns TlOUSS sraff and ernoloyees aT tne hOS01131. Autn:::Jrl=atlon i:':' nereoj grantee] TN SL.:ch treatment anci procedures The undersigned has read tns above authorization and understands tne same and certifies trIal no guaramee of assurance has Deen maae as tD the results that may! be obtained. I hereby assign anc authorize payment directly to the Penn State Milton S. Hershey Medical Center. I authorize any hoider of medical or other information about me to release 10 my insurance carrier and its agents any information needed to de18rmine these benefits or benefjts for related services I acknowledge that the Penn State Milton S. Hershey Medical Center Privacy Notice has been provided to me. INSTRUCTIDNS: Please read all of tne above. An aU1hor\zation for emergency treatmem must be signed before treatment can be given. Authorization must be signed by the palient, 0: by an authonzed person in the case Df a minDr Dr when the pallent is physicaky Df mentally incompetent. (1. )J( )! ()q AM PM "ONCO! 4~ DATE: TIME: or (authOrized person) Relationship to Patient: ~ Witness: .~!~ fi/ elL- L) r' /1 For Non-emergency use of the emergency room only: Do you have access to a primary care physician or an outpatient cEnic for non-emergency care at this time: Yes_ No_ o Privacy Notice Given-Patient unable to sign o Privacy Notice Given-Patient declined to sign lv',?. 3/04 AUTHORIZATION FOR EMERGENCY TREATMENT AND RELEASE Or INrORMATION THE MILTON S HERSHEY MEDICAL CENTER PO BOX 853 HERSHEY, PA 17033 MEDICAL RECORD COPY MR328 (REV 9/00) +----------++-----------++----------++-------++--------++----++---++---++-+ I MR# IIOOS # II DATE II TIME II ROOM/BED II LOC II SVC II SRC II A I 08004754 9028662 12/20/04 08:19 P - EMER ECU 7 +----------++-----------++----------++-------++--------++----++---++---++-+ +-------------------------++---++----------++---++--++----++---++---++----+ I PATIENT NAME IISEXIIBIRTHDATE IIAGEIIMSIIMRSAIIVREIIADVIIREL I SCHREINER KARAH F 05/16/2003 1 S +-------------------------++---++----------++---++--++----++---++---++----+ +--------------------------------++--------------------++---++------------+ PATIENT ADDRESS CITY ST ZIP CODE 12 MALL RD ETTERS PA 17319 +--------------------------------++--------------------++---++---.---------+ +------------++---------------------------++~-----------~-~++--~~~~--~~---+ I PT PHONE II PT EMPLOYER II EMPLOYER PHONE II ~~~E I +----~-------++-----------------------~~--++---------~-~~~~++--~~-----~---+ +----------------~~--------++~------------++-------------++----------------+ I CONTACT II PHONE II WORK PHONE II COUNTY I HOCKENBERY LINDA 67 +-------------~------------++---------~---++-------------++------------~---+ +--------------------~-----------------------------------------------------+ INSURANCE INFORMATION NAME POLICY # GROUP NUMBER BELP P:AY f'l' e ~\t:y., +-------------------------------------------.-----------------------------+ +--------------------------------------------------------~-----_._---------+ REGISTRAR IXC +-------------------------------------------------------------------------+ +-------------------------------------------------------------------------+ I COMMENTS [ +-------------------------------------------------------------------------+ +------------------------------------++-----------------------------------+ IATTENDING PHYS 1 [[ATTENDING PHYS 2 I 46353 FRENCH DANIEL K 0 +------------------------------------++-----------------------------------+ +------------------------------------++-----------------------------------+ FAMILY PHYSICIAN REFERRING PHYSICIAN SELF REFERRED NO REFERRING/FAMILY PHYSICIAN FAX: FAX: +------------------------------------++-----------------------------------+ . . Lids and Adnexa: [J Neg Slit Lamp Examination: @) R nl abnl du J'.J :.YO .;Yo ,;;{ ::J d::J Cornea [J Pas Conjunctiva Cornea Tear Film Ant. Chamber Iris Lens Lens 00 L nl abnl l.V'u 5::J Ga'u 6.1 :t::J ,j::J R nl abnl U U 1.=..1 U o 0 . Fundus Examination: L nl abnl =:J CJ U '::J U [] Vitreous Optic Nerve Post Segment Impression: MEDICAL DECISION MAKING 'Ylf Cv1~ L.. e.'1P ~~~ Plan: p(e ft,-t? I ' I ''1 T'....... ~I Z-1 f ,e..,.} PHYSICIAN RTC: NEXT TIME: o Dilated Exam 0 VF D other MR 905 Rev. 1/04 Page 2 of 2 c- NAME: SCHREINER] KARAh MD: AMINlARI ALl MR#: 6004754 DOB: 05/16/2003 INS: MEDPlUS THREE RIVE ~ lOC: OPH1 & DOS': 5113968 MD#: 85005 SEX: F 81 ANDARD VISIT DATE: 12/24/2004 . Gonioscopy: @@ Lens Cornea uo r.------ -----.--- , LJ Extended Ophthalmoscopy see additional form L-____ Optic Nerve Head: o () RESIDENT PARTICIPATION 0 YES TEACHING PHYSICIAN DOCUMENTATION/SUMMARY History 5 I {/ ({,WvU2A/( tVh-a1 '7/v--... Exam t ----+- ' (It'YW/,L. ~:;1r;r ~ ,(rJAL)-, MDM Date I'1./21/or On this day I saw, exa I of the selVlces provld D Refraction 0 Gonio PHYSICIAN (j ate- o Dictated 0 Consult requested: o Patient Instructions Given Initials OPHTHALMOLOGY EXAM FORM White Copy - Medical Records Yellow Copy. Department 'b y t3 ty.h' ,I OCT. 3,2005 II: 14AM m i: 92 P. ^ L . COMMoNWEAl. TH OF PcNNSYI.VANrA D~PAATMENT OF PUBlIC WELFARE BUReAu OF FINANCIAL OPERATIONS DIVISION OF THIRD PARTY llABll.1TY CAsUALTY UNIT p,C.BOX S4S6 HARRrSBUM. PA 17105-6466 October 3, 2005 METZGER WICKERSHAM LYNETTE M SHOWERS CLIENT ADMINISTRATOR 3211 N FRONT ST PO BOX 5300 HARRISBURG PA 17110-0300 Re: KARAH SCHREINER (minor) CIS #, 050162350 . Iilcident Dat"e;:....!2(2'O/~(f04 -"-.. Dear Ms. Showers; The Department of Public Welfare maintains a lien in the amount of $516.73 for the above-referenced incident. The Department haa agreed to reduce its lien by 25% plus a prorata share of expenses and accept the net payment of $372.54 to satisfy the total lien amount. Cbecks should be made payable to the Department of Public Welfare and sent to my attention at the above address. We requeat tnat with &11 t~ansmitta1 of funds, you provide the Depa~tment with a copy of the final distribution sneet. In the event you have already brought or will bring any action resulting in a further recovery, we reserve the right to seek recovery of any additional unpaid portion of our medical/cash lien. This settlement in no way affects our future rights. Thank you for your Cooperation in this matter. If you have any further questions, please contact me. "=;:L , 0;.1 Elaine Wiest TPL program Investigator 717-772-6246 717-772-6553 FAx E'7'h: 11, t ~ CONTINGENT FEE AGREEMENT I, 5ovv!rr.> C,chre(flff individually and as parent(s) and natural guardian(s) of /L tV "- J., ,S r ~ U I/"r , retain and authorize the law firm of Metzger, Wickersham, Knauss & Erb, P.C., to do whatever they deem necessary or desirable in order to represent my dou,,", Iv in all claims for compensation and reimbursement for personal injuries, wage v loss, and economic and other damages resulting from an t::l ref d.,,, ~ that occurred on /.:1/::J(J/tJ'f I I 1. Attornev's Fees: The fee of the attorneys shall be contingent as follows: (a) Twenty-five percent (25%) of gross recovery; (b) SHOULD THERE BE NO RECOVERY BY SUIT OR SETTLEMENT, SAID ATTORNEYS DO NOT HAVE ANY CLAIM AGAINST US OF ANY KIND FOR LEGAL SERVICES RENDERED. 2. Expenses of Litigation: Actual expenses incurred on the business of the client shall be borne by the client and my attorney shall be reimbursed out of the balance, after deduction of attorneys fees, of any recovery for all legal expenses incurred in the prosecution of this claim which have not already been paid by me. I do hereby agree to pay all expenses incurred by our attorney in the preparation and presentation of this case and do understand that these expenses include, but may not be limited to, costs of medical reports and records, stenographic expenses connected with depositions, expert witness fees, photocopying charges, and mileage charges connected with the rendering of legal services. I understand that I am responsible for payment of these expenses regardless of the eventual outcome of the case and further understand that if our attorney deems it necessary, I may be asked to advance these costs prior to the incurring of any such expenses or the scheduling of any deposition. 288656-1 3. I hereby further agree that our attorney may charge us reasonable additional compensation if it is necessary to try the case more than once, if the case is appealed, or if proceedings in other courts are necessary because of the change of circumstance of a party or for other reasons. 4. I hereby further agree that our attorney is hereby authorized to bring suit or to settle and compromise the claim, to execute all documents pertaining thereto, and to do all lawful acts requisite for effecting the claim on our behalf. 5. I further authorize our attorney to payout of any proceeds of settlement or trial any unpaid medical bills for treatments or services made necessary by the injuries sustained in this accident and any workers' compensation liens. 6. I agree that our attorney accepts this employment on the condition that he will investigate this claim, and if it appears to be a recoverable claim, he will proceed to handle the claim; but if, after investigation, the claim does not appear to be recoverable, said attorney shall then have the right to rescind this Agreement. 7. I hereby further agree that if I decide to terminate this authority before any settlement is offered or any award is obtained the firm shall be entitled to reasonable compensation for all work done on the case up to that point. We agree that reasonable compensation for Clark DeVere, Esquire, or any other attorney involved in the handling of this case, shall be Two Hundred Dollars ($200.00) per hour, or such higher rate as shall constitute his standard billing rate at the time that the work is performed or the agreed upon percentage fee of one-third of any ultimate recovery, whichever is greater. 8. I agree that our attorney may withdraw from this case at any time after reasonable notice to us, and I agree to keep him advised of our whereabouts at all times and to cooperate at all times in the preparation and trial of this case, to appear upon reasonable notice for depositions and Court appearances, and to comply with all reasonable requests made of us in connection with the preparation and presentation of this case. Document #: 182430.1 - 2 - 9. I also understand that if the investigation reveals that a parent is contributorily negligent in causing the accident the attorney's representation will solely be limited to representing the injured minor and there will be no representation of the parent. I also waive any conflict of interest that may arise by my meeting with the attorney to discuss the case. 10. I understand and agree that in the event that my account is turned over for collection because of unpaid fees and/or costs/expenses, I will be responsible for payment of the costs of suit as well as reasonable attorney fees incurred in the collection of the monies owed to Metzger, Wickersham, Knauss & Erb, P.C. IN WITNESS WHEREOF, I have signed below on this cl). day of /Jet::, , 2004. ~k ~LWU~ CLIENT: METZGER, WICKERSHAM, KNAUSS & ERB, P.C. <T'7~ .-:;;> ATTORNEY: Clark DeVere, Esquire Document #: /82430. J - 3 - It 0 i ",h' /1- PARENTS-GUARDIAN RELEASE AND INDEMNITY AGREEMENT FOR AND IN CONSIDERATION ofthe payment to me/us of the sum of Five Thousand and _______m__ 00/100 Dollars ($ 5,000.00), the receipt of which is hereby acknowledged, I/we, the undersigned, father and mother and/or guardian of Kara Schreiner a minor, do forever release, acquit, discharge and covenant to hold harmless Ronald Forbes dba Raceway by Sport Spree, his heirs, successors and assigns of and from any and all actions, causes of action, claims, demands, damages, costs, loss of services, expenses and compensation, on account of, or in any way growing out of, any and all known and unknown personal injuries and property damage which we may now or hereafter have as the parents and/or guardians of said minor, and also all claims or rights of action for damages which the said minor has or may hereafter have, either before or after he/she has reached his/her majority, resulting or the result from a certain accident which occurred on or about the 20th day of December, 2004, at or near the Harrisburg East Mall. !/we further promise to bind myself/ourselves jointly and severally, my/our heirs, administrators and executors to repay to the said Ronald Forbes dba Raceway by Sport Spree, his heirs, successors and assigns any sum of money, except the sum above mentioned that he/she/they may hereafter be compelled to pay on behalf of said minor because of the said accident. It is further understood and agreed that this settlement is the compromise of a doubtful and disputed claim, and that this payment is not to be construed as an admission of liability on the part of Ronald Forbes dba Raceway by Sport Spree by whom liability is expressly denied. Vwe further state I/we have carefully read the foregoing release and know the contents thereof, and I/we sign the same as my/our own free act. Witness hand and seal this day of ,20 In presence of CAUTION: READ BEFORE SIGNING (SEAL) (SEAL) STATE OF COUNTY OF On this day of , 20 , before me appeared me personally known, and who acknowledged the execution of the foregoing instrument as and deed, for the consideration set forth therein. to free act My Commission Expires Public. Notary P r? ~ ~ t .~ ~ w ().~ _ (]v ~ $ r ~('~ ~ , 't: /y ~ '11" , , DEe 0 8 2005 J p~1 Metzger, Wickersham, Knauss & Erb, P.C. By: Clark DeVere, Esquire Attorney LD. No. 68768 P.O. Box 5300 3211 North Front Street Harrisburg, P A 17110-0300 (717) 238-8187 cdv(ciJ,mwke.com Attorneys for Plaintiffs IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA IN RE: KARAH SCHREINER NO. oS: -~~'iS C;o:L ~l DECREE AND NOW, this \;t\~ dayof \)"L"""1~("r, 2005, upon consideration of the Petition for Approval of Minor Plaintiff Compromise Settlement, it is hereby ORDERED and DECREED that the settlement for the gross sum of Five Thousand Dollars ($5,000.00) is APPROVED. Counsel fees and expenses are found to be fair and reasonable and also approved as set forth below. The distribution is directed as follows: (1) To be paid to Sam and Sandra Schreiner, parents and natural guardians ofKarah Schreiner, the sum of $3,232.21, to be placed in a fi;derally insured and restricted savings account or certificate of deposit, to be marked "not to be withdrawn, assigned, negotiated or otherwise alienated until Karah Schreiner reaches her majority on May 16,2021, except upon prior Order of the Court"; (2) To be paid to Department of Public Welfare for satisfaction of the medical lien the sum of$372.54; and (3) To be paid to Metzger Wickersham, P.c. for counsel fees and expenses - the sum of$I,395.25; and (4) Sam and Sandra Schreiner, as parents and natural guardians of Karah Schreiner, are authorized to sign the Release attached to the Petition and discontinue this 337438-1 ". .1 /,' .~ . .I:~' '":. --~----'"---->'-~- 1 . "" , . , action upon filing of the proof of deposit of the sum for the Minor as set forth above. BY THE COURT: /I ~ j(ull- J. cc: Clark DeVere, Esquire - counsel for Petitioners ~arles Kidhardt, Claims Representative, Goodville Mutual Insurance v01e..tL,3eR WiC-Xer.5hCLIYl ~ 337438.1