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WAYNE A. QUACKENBUSH, I IN THE COURT OF COMMON PLEAS
Plainti!! I CUMBERLAND COUNTY, PENNSYLVANIA
I
v. I CIVIL ACTION - LAW
I qq, J3~.l. C IVI I Tt f (I"
GENEVIEVE V. HOCK, I NO.
Defendant I JURY TRIAL DEMANDED
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against
the claims set forth in the following pages, you must take action
within twenty (20) days after this complaint and Notice are served,
br entering a written appearance personally or by attorney and
f ling in writing with the Court your defenses or objections to the
claims set forth against you. You are warned that if you fail to
do so the case may proceed without you and a jUdgment may be
entered against you by the Court without further notice for any
money claimed in the COffiplaint or for any other claim or relief
requested by the Plaintiff. You may lose money or property or
other rights important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Court Administrator
Cumberland county Courthouse - 4th Floor
1 Courthouse square
Carlisle, PA 17013
(717) 240-6200
WAYNE A. QUACKENBUSH, I IN THE COURT OF COMMON PLEAS
Plaintiff I CUMBERLAND COUNTY, PENNSYLVANIA
I
v. I CIVIL ACTION - LAW
I 'I If 3 H>' ..L.
GENEVIEVE V. HOCK, I NO.
Defendant I JURY TRIAL DEMANDED
o 0 K P L i\ I N T
1. plaintiff Wayne A. Quackenbush is a citizen of the
Commonwealth of Pennsylvania and an adult individual who resides at
753 Siddonsburg Road, Lewisberry, York County, Pennsylvania.
2. Defendant Genevieve V. 1I0ck is an adult individual and
citizen of the Commonwealth of Pennsylvania who resides at 12
lIilltop Lane, Newville, Cumberland County, Pennsylvania.
3. The facts and occurrences hereinafter related took place
on or about August 16, 1993 at approximately 7:45 a.m on state
Route 11, West Pennsboro 'l'ownship, Cumberland County , Pennsylvania.
4. At that time and place, Plaintiff Wayne Quackenbush was
operating his motor vehicle, a 1982 Oldsmobile Cutlass Supreme, in
a west bound direction on state Route 11.
5. Route 11 in the area of the accident is a two-lane
highway which travels generally in an east-west diroction and has
a pOlted speed limit of 55 miles per hour.
Ii. At the accident site, lIilltop Lane is a side road which
intersects from the north with Route 11 and is controlled by a stop
sign.
7. At the intersecticn, no obetructions are present which
would prevent a motoriet traveling south on Hilltop Lane and
properly stopped at its interseotion with Route 11 from viewing
traffic approaching from the east or west on Route 11.
8. At that time and place, Plaintiff Wayne Quackenbush was
travelling within the lane of travel for west bound traffic on
state Route 11, approaching and in close proximity to Hilltop Lane.
9. At that time and place, Defendant Genevieve Hock was
operating a 1989 Ford Tempo in a south bound direction on Hilltop
Lane and was travelling in the lane of travel for south bound
traffio on Hilltop Lane.
10. At that time and place, the vehicle operated by
Defendant Genevieve Hock pulled out from a stop sign directly into
the path of Plaintiff Wayne Quackenbush's car.
11. As a result of Defendant Genevieve Hock pUlling directly
into Plaintiff Wayne Quackenbush's path, he was pressntsd with a
sudden emergency and was unable to stop before colliding with
Defendant's car.
12. The foregoing accident and all of the injuries and
damages set forth hereinafter sustained by Plaintiff Wayne
Quackenbush are the direct and proximate result of the negligent,
careless, wanton and reckless manner in which Defendant Hock
operated her motor vehicle as follows I
Failure to stop on Hilltop Lane at the point intersecting
Route 11 which would have had a view of approaching
traffio on Route 11;
Failure to keep alert and maintain a proper watch for the
presence of other motor vehicles on the highway;
Failure to stop and yield the right of way to traffio
approaching Route 11 so close as to constitute a hazard
in violation 75 Pa.C.B.A. SJJ2J;
Failure to yield the right-Of-way to Plaintiff'S vehicle;
PUlling across a lane of travel directly into the path of
Plaintiff Wayne Quackenbush;
(f) Failure to keep a proper watch for traffic on the
highway;
(a)
(b)
(c)
(d)
(e)
(g)
(h)
(i)
13.
Failure to drive her vehicle with due regard for the
highway and traffic conditions which were existing and of
which he was or should have been aware;
Failure to keep proper and adequate control over her
vehicle; and
Driving her vehicle upon the highway in a manner
endangering persons and property and in a reckless manner
with careless disregard to the rights and safety of
others and in violation of the Motor Vehicle Code of the
Commonwealth of Pennsylvania.
Plaintiff Wayne Quackenbush sustained painful and severe
injuries, which include, but are not limited to, acute cervical and
lumbar strain; ruptured or bulging disk; radiating pain in the
neck, back, and shoulder; sprain and contusion to the left side of
the chest; contusion to the right knee; and contusion to the
pelvis, as well as general shock and trauma to his body.
14. Dy reason of the aforesaid injuries sustained by
Plaintiff Wayne Quackenbush, he was forced to incur liability for
medical treatment, medlcation., ho.pitaillation., and .imilar
miscellaneous expenees in an effort to reetore himself to health,
and claim is made therefor.
15. Because of the nature of hie injuries, Plaintiff Wayne
Quackenbush has been adv1eed and, therefore, avers that he may be
forced to incur similar expenSDS in the future, and claim is made
therefor.
16. As a result of the aforementioned injuries, Plaintiff
Wayne Quackenbush has undergone and in the future will undergo
great physical and mental SUffering, great inconvenience in
carrying out his daily Ilctivities, loss of life's pleasures and
enjoyment, and claim is made therefor.
17. As a result of the aforesllid injuries, Plaintiff Wayne
Quackenbush hilS been and In the future will be Dubject to grellt
humiliation and embllrrllssment, Ilnd claim is made therefor.
lB. As a result of the aforementioned injuries, Plaintiff
Wayne Quackenbush hilS sustained work loss, lose of opportunity and
a permanent diminution of his earning power Ilnd capacity, and claim
is made therefor.
19. As a result of the aforesaid injuries, Plaintiff Wayne
Quackenbush has sustained uncompenutud work loss, and claim 11
made therefor.
20. Plaintiff Wayne Quackenbush continues to be pla9ued by
persistent pain and limitation and, therllforo, avon that hi.
7, After reasonable investigation, Defendant is without
knowledge or information sufficient to fonn a belief as to the
truth or falsity of the allegations contained in paragraph seven
(7) of Plaintiff's Complaint, "herefore, the same are denied,
B. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph eight
(B) of Plaint if f' s Complaint. Therefore, the same are denied,
9. After reasonable investigation, Defendant is without
knowledge or infOl~mat:ion sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph nine
(9) of Plaintiff's Complaint, Thel~efore, the same are denied.
10. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph ten
(10) of Plaintiff's Complaint. Therefore, the same are denied.
11. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a bel ief as to the
truth or falsity of the allegations contained in paragraph eleven
(11) of Plaintiff's Complaint. Therefore, the Bame are denied.
12. Paragraph twelve (12) of Plaintiff's Complaint sets
forth a conclusion of law to which no responsive pleading is
required. To tile extent facts are deemed to be alleged, they are
2
denied. With respect to subparagraphs (a) through (i) of
paragraph twelve (12) of Plaintiff's Complaint, Defendant denies
negligence in any of the following regardsl
(a) Failure to stop on Hilltop Lane at the point
intersecting Route 11 which would have had a view of
approaching traffic on Route 11;
(b) Failure to keep alert and maintain a proper watch for
the presence of other motor vehicles on the highway;
(c) Failure to stop and yield the right of way to traffic
approaching Route 11 so close as to constitute a hazard
in violation 75 Pa.C.S.A. ~3323;
(d) Failure to yield the right-of-way to Plaintiff's
vehicle;
(e) Pulling across a lane of travel directly into the path
of Plaintiff Wayne Quackenbush;
(f) Failure to keep a proper watch for traffic on the
highway;
(g) Failure to drive her vehicle with due regard for the
highway and traffic conditions which were existing and
of which he was or should have been aware;
(h) Failure to keep proper and adequate control over her
vehicle; and
:.
(i) Driving her vehicle upon the highway in a manner
endangering persons and property and in a reckless
manner with careless disregard to the rights and safety
of others and in violation of the Motor Vehicle Code of
the Conunonwealth of Pennsylvania.
13. After reasonable investigation, Defendant is without
knowledge or. information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph
thirteen (13) of Plaintiff's Complaint. Therefore, the same are
denied.
14. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph
fourteen (14) of Plaintiff's Complaint. Therefore, the same are
denied.
15. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph
fifteen (15) of Plaintiff's Complaint. Therefore, the same are
denied.
16. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph
sixteen (16) of Plalntiff's Complaint. Therefore, the same are
denied.
4
17. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph
seventeen (17) of Plaintiff's Complaint. Therefore, the same are
denied.
lB. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph
eighteen (lB) of Plaintiff's Complaint. Therefore, the Bame are
denied.
19. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph
nineteen (19) of Plaintiff's Complaint. Therefol"e, the Bame are
denied.
20. After reasonable investigation, Defendant is without
knowledge or information sufficient to form a belief as to the
truth or falsity of the allegations contained in paragraph twenty
(20) of Plaintiff's Complaint. Therefore, the same are denied.
WHEREFORE, the Defendant respectfully prays thiB Honorable
Court to dismiss Plaintiff's Complaint, and to enter judgment
against the Plaintiff and in favor of the Defendant.
5
NEW MATTIR
21. Paragraphs one (1) through twenty (20) are incorporated
herein by reference, and made a part hereof as if set forth in
full.
22. Plaintiff's claims are barred in whole or in part by
the provisions of the Pennsylvania Comparative Negligence Act.
23. Plaintiff's claims are bar~ed in whole or in part by
the provisions of the Pennsylvania No- Faul t Motor Vehicle
Insurance Act and/or the Pennsylvania Motor Vehicle Financial
Responsibility Law.
24. Plaintiff's Complaint fails to state a cause of action
upon which relief may be granted.
25. By his own actions, the Plaintiff did assume the risk
of any and all injuries and/or damages allegedly suffered.
26. If there is a legal responsibility for the damages set
forth in Plaint if f' s Complaint, the responsibil ity is that of
other individuals and/or entities over whom Defendant has no
control. Plaintiff's injuries and damages as alleged were not
proximately caused in any manner whatsoever by Defendant.
27. Plaintiff's claims are barred by the applicable Statute
of Limitations.
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v.
IN THE COURT OF COMMON PLEAS
CUMBERLAHDCOUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 94-33B2-CIVIL TERM
JURY TRIAL DEMANDED
WAYNE A. QUACKENBUSH,
Plaintiff
GENEVIEVE V. HOCK,
Defendant
PLAINTIFF'S RePLY TO DeFeNDANT'S New HATTBR
AND NOW/Plaintiff / Wayne Quackenbush / by and through his
attorneys/ Angino & Rovner, P.C./ hereby responds to Defendant's
New Matter as follows:
21. Pennsylvania Rule of civil Procedure 1030 provides that
a defendant may set forth as New Matter all averments of fact which
are not merely denials of the preceding pleadings. A review of
Defendant'. Answers to paragraphs 1 through 20 of the complaint
indicates that they are either admissions or denials, but no
averments of fact, and therefore, no responsive pleading is
required.
22. Denied. This averment is a conclusion of law to which no
responsive pleading is required. To the extent that a response may
be deemed proper, it is specifically denied that Plaintiff Wayne
Quackenbush was negligent in any manner upon the cause of action
stated in Plaintiff's Complaint, and therefore, it is denied that
the Pennsylvania Comparative Negligence Act is in any way
applioable to Plaintiff/s olaim.
23. Denied. This averment is a conclusion of law to which no
50926/DKR
reepon.ive pleadin; i8 required. To the extent that a re8pon8e may
be deemed proper, it i8 spscifically denied that the claims set
forth in Plaintiff's complaint are barred either in whole or in
part by the provisions of the Pennsylvania Motor Vehicle Financial
Responsibility Law. It is specifically denied that the
Pennsylvania No-Fault Motor Vehicle Insurance Act, which has been
repealed prior to the day of Plaintiff's accident, is in any way
applicable to Plaintiff'e claims.
24. Denied. This averment is a conclusion of law to which no
responsive pleading is required. To the extent that a response may
be deemed proper, it is specifically denied that Plaintiff Wayne
Quackenbush's Complaint fails to state a cause of action upon which
relief can be granted. To the contrary, it is averred that
Plaintiff'. complaint sets forth a cause of action for negligence
in the operation of a motor vehicle by the Defendant based upon
which Plaintiff is entitled to relief.
25. Denied. This averment is a conclusion of law to which no
responsive pleading is required. To the extent that a response may
be deemed proper, it is specifically denied that the doctrine of
a8lumption of the risk is in any way applicable to the facts set
forth in Plaintiff's Complaint, which avers the automobile accident
which occurred as a reeult of the Defendant's pulling from a stop
lign into the Plaintiff's path. It is specifically denied that
2
Plaintiff Wayne Quackenbueh in any way was aware of the Defendant's
negligent conduct prior to its occurrence or that he assumed the
risk of injuries which he received as a result of the Defendant's
negligent conduct, as set forth in Plaintiff's complaint.
26. Denied. This averment is a mixed conclusion of fact and
law to which no responsive pleading is required. To the extent
that a response may be deemed proper, it is specifically denied
that any other individuals or entities, other than the Defendant
identified in Plaintiff's Complaint, was the cause of or
responsible for Plaintiff's accident and resulting injuries. It is
further specifically denied that Plaintiff's injuries and damageR
were not proximately caused by the negligent conduct of the
Defendant, as set forth in Plaintiff's Complaint.
27. Denied. This averment is a conclusion of law to which no
responsive pleading is required. To the extent that a response may
be deemed proper, it is specifically denied that Plaintiff's claims
are in way barred by the applicable statute of limitations.
Plaintiff's cause of action arose on August 16, 1993, with
Plaintiff's being filed on June 21, 1994 and served on Defendant
Genevieve Hock on July 5, 1994, well within the two-yeer statute of
limitations provided for in 42 Pa.C.B.A. 55524.
3
, 4
WAYNE A. QUACKENBUSH, I IN THE COURT OF COMMON PLEAS
plaintiff I CUMBERLAND COUNTY, PENNSYLVANIA
I
v. I CIVIL ACTION - LAW
I
GENEVIEVE V. HOCK, I NO. 94-3382-CIVIL TERM
Defendant I JURY TRIAL DEMANDED
PLAINTIFF'S ARBITRATION MEMORANDUM
I. SUMMARY OF TIfE FACTS
This case arises out of an automobile accident, which occurred
on August 16, 1993, at approximately 7:45 a.m., on state Route 11,
West Pennsboro Township, Cumberland County, Pennsylvania. At that
time, Plaintiff Wayne Quackenbush was driving to his parents' house
in Leesburg, Pennsylvania. It was a bright, clear, dry day, and
Wayne was travelling in the lane of travel for westbound traffic on
state Route 11, approaching and in close proximity to Hilltop Lane.
At that time, Defendant Genevieve V. Hock pulled out from a stop
sign directly into the path of Plaintiff Wayne Quackenbush.
Plaintiff Wayne Quackenbush reacted, but was unable to stop before
colliding with Defendant Hock's vehicle.
The impact caused
Plaintiff Quackenbush's vehicle to spin and eventually come to rest
on an embankment on the berm of the road facing in a southbound
d i recti on.
fl~~, Police Diagram of the accident site attached
hereto aB Exhibit A. Liability of Defendant Genevieve Hock has
75740/MIJ>!
been admitted, and the sole issue tor the arbitrators is the nature
and extent ot damages sutfered by Plaintitf Wayne Quaokenbush.
Although Plaintiff Wayne Quackenbush was wearing his seatbelt,
he was violently lifted from the seat of his car and thrown
forward. He struck his forearms on the steering wheel, and his
knees went through the dash. His seatbelt yanked him back into the
seat, causing severe burns and bruises to his neck, chest, and
pelvis.
The accident was extremely violent, since Defendant Genevieve
Hock pulled immediately into the path of Plaintiff Wayne
Quackenbush I s vehicle. Extensive property damage resul tsd to
Plaintiff I scar, as depicted in photographs attached hereto as
Exhibit B.
Plaintiff W~yne Quackenbush suffered serious injuries as a
result of the automobile accident and required treatment for over
one year following the accident. Plaintiff Wayne Quackenbush also
suffered a period of disability shortly afte~ the accident, but he
fortunately has been able to return to full-time employment.
II. ~y OF MEDICAL TREATMENT AND INJURIES
As a result of the accident, Plaintiff Wayne QuackenbUSh, who
was 29 years old at the time, was violently lifted from the seat of
his car and thrown forward, his face inches from the windshield.
He struck his forearms on the steering wheel, and his knees went
through the dashboard. resulting in brui.... Hi. Ilatb.lt yank.d
him back into the seat, causing severe burns on his n.ck, ch.st and
pelvis. Wayne was driven to the Emergency Room at the Carlisle
Hospital by his parents, at which time he was examined and given
medication for the pain and released. It was not until
approximately two days later that he was unable to move and had
significant pain in his neck, back, left arm, and shoulder. Prior
to the accident, Plaintiff Wayne Quackenbush wn in excellent
health and was participating in the Army Reserves, having completed
a six year tour with the Army in November, 1992. As a result of
his increasing problems, Plaintiff Wayne Quackenbush sought
treatment with Dr. Keith Zeliger, D.O., who had previouSly treated
a member of his family.
Dr. Zeliger diagnosed Plaintiff Wayne Quacksnbush as having
suffered acute cervical and lumbar atrain, a contusion to the left
side of his chest, a contusion to the right knee and pelvis and was
given medication for the pain. Dr. Zeliger recommended physical
therapy, and Plaintiff Wayne Quackenbush began a course of
treatment which lasted slightly in excess of one year. A complete
Medical Treatment Summary of Plaintiff Wayne Quackenbullh is
attached hereto as Exhibit c. Plaintiff Wayne Quackenbush hn
taken the deposition of his treating physician, Dr. Keith Zeliger,
who has related Wayne Quackenbush's inuries to the acoid.nt to a
reasonable degree of medical certainty.
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9/29/93
10/6/93
10/26/93
6/20/84
6/24/84
6/0l/U
6/08/g4
6/22/84
6/24/84
7/11/U
Physical therapy
Ilarrisburg.
Neck and shoulders feeling a little better.
Motion improving. still severe headaches /
less frequent. continue phys ica I therapy.
Continue light duty. Will see in 3 weeks.
transferred
back
to
Dramatic improvement in back and neck.
Sorenese only with extension of neck
backwards. Discharge from physical therapy.
strength training exercises for neck,
shoulders / upper and lower extremities / lumbar
spine at the Central Penn Fitness Club for 6
months. Return to work - full duty. See in
December.
-
Patient called. Experiencing arm and shoulder
pain on left side for past 2 months. Dr.
~aneda prescribed Anaprox for pain.
Exam. Doing well until February. Pain in
neck radiating to left shoulder and down
lateral aspect of left arm. Occasional pain
in upper arm, across back of forearm into ring
and small flngers and index finger. Muscle
weakness of thumb and index finger. HRI of
the neck. RXI Tylenol w/codeine.
FOllow-up. HRI shows bulging discs at C4-5,
C5-6 and C6-7. No direct comprsseion on
Ipinal cord or nerve roots. Causing
inflammation from neck down his arms. Sent to
CAPMC for epidural injections for neck. See
in 5 days after first injection.
Epidural injection helped w/back pain. still
experiencing a lot of pain in back, neck and
arms. RXI pain medication.
Patient called. Having sleeping problems.
Follow-up. No relief from injections. New
phYlical thsrapy for neck. OXI bulging discs
at C4-5, C5-6 and C6-7 hot packs,
ultrasound, cervical traction and deep tissue
mu.aljl8. Strengtheni ng exel"cises. See in 2
Week., if no improvement refer to Dr.
Peppelman.
-
-
-
-
-
Call from patient requosted pain medication. 1
more week of physical therapy. still pain in
Ihouldera.
. .
.. ,.
DAMAGBS:
TIle Plaintiff was taken to the Carlisle Hospital where he was treated and released,
Please see Exhibit "A". As a result of the accident, the Plaintiff suslalned cervical and
lumbar stmin and headaches. He lrenled with Dr, Keith Zellger. Dr. Zellger recommended
physicallhempy and he continued lolrc.1t wilh Dr. Zeliger from Augusl 19, 1993 through
Oclober 6, 1993. At that time, he indicated Ihnl he felt much better. He was gelling
headaches less frequently nnd he hnd no olher complainls. He was then discharged by Dr,
Zetlger.
Seven months later, on Mny 24, 1994, the Plaintiff returned 10 see Dr. Zellger with
complaints of occasional pain In his lert shoulder. Once again, Dr. Zeliger recommended
physicallhempy and the Plainliff underwent physicalthempy from June 27, 1994 Ihrough
July 19, 1994. Please note thai during Dr, Zetiger's videolape deposition, he indicated Ihat
the Plaintiff had this exacerbation of his injuries due to Ihe fact that he was not exercising
regularly and he allowed his muscles 10 tighlen and get stiff. On AugusI 24, 1994, after
receiving two cervical epiduml steroid injections which did not provide him with any
significant relief, he went 10 see Dr, Peppehnan. Once again, Dr. Peppehnan recommended
physical thempy and following his thin! round of physicalthempy, the Plainliff appears to
have made II full recovery,
~:
AI the time of the IIccldent, Ihe Plainliff was employed as an assistant manager with
Burlington Coat Factory, Following Ihe accident, his job was given to someone else and he
2
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MUA EiACi( OF I~ECI', PAIIi r,ADI
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L CHEST MUSCLE PAIN (rkn~ Sl~T
BEl. T)
0006
0610
1116
1625
2640
4155
5665
CLASS 8
l8SERVAnON, EACH HR
111VATE EXAM CHARGE
:MERG VISIT
,MERG VISIT
MPLOYEE HEALn~ VISIT
26600
26606
26610
26616
26620
26626
26630
26036
26017
26010
20018
IGHT SOURCE FOR SPECULUM 20645
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oIJECTlON FEE
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i AST, SCOTCH SHORT ARM
AST, SCOTCH LONG ARM
:AST, SCOTCH SHOlll LEG
,AST, 5COTCIl LONG LEG
AST, CYLNDR LEG
80008
28009
28037
26031
28032
26033
28034
28030
CAST ROLL. SCOTCH
EKG MONITOR
EXTERNAL PACER
PACER PADS
GASTROIHEMO 5UDE
KIDDE TOURNIOUET
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NURSING DOCUMENTATioN -:- EM[R(lI:N~Y DEPARTMENT' ,I ~.:.' _' ;0,,'1' 'I
TRIAGE NOTE: Dale: ;.1 !'l..3-~' I
Tlltlgc Staluli Mode 01 Afflval ^ff1Ved~
o Pnorily I I] ALS lJ ULS LJ Pohce 0 friend ,,'
~1'norilY II ,r.r Ambulalory ~illent 0 SPOUI8 '
o Prlonly III 11 Whealct'a" 0 Sell 0 Olher
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Nursing Actlon/Commolll' __C~ Q.~&-,~l :".11
Childhood hllmUIII,.""". (lUTO 0 Never o1/_i~~
Tfsalmenl PIIOI 10 Arllval
~.1 earlisIe, l-I9sPital
\~"lr~\,I~t;tlee2 , .
'NAME~:)l t (jJLI~a1' b(.<4,,<-
ROOM. AGE ~ 'is WT _______
VITAL SIGNS TIME ()'1~ T --'''-t.---.
P -{_ R Up ~1~6__
ALLERGIES:
CURRENT MEDICATIONS:
TETANUS STATUS:
o Within 5 Yea"
o 5,10Yeaf6
o More than 10 Year.
o Never
mlAGE NURSE SIGNATURE
d;L
= TREATMENT IN PROGRESS ON ARRIVAL:
o CPR Down Time
o Airway - 0 Oral, 0 Nasal - e
o Airway, Endotracheal - Size
o Alrwey, Na.olracheal - Slza
o IV Solullon Site
= GENERAL APPEARANCE
PUL
egular
full
RE
DRUGS:
Olin
o Monitor - fIl'yll,m ___.._, nale
o Oll)'gen - O~k, 0 NC ,- I./Mm ___
o Spln8lImmobllllal;o,,;-- ,
o Ma.t ________",,_ ____
o Pre..ure Dle.Slng 11 011'0' ___
-----.:.--.
Size
(J Dusk Y
o Cy.notlc
o Nlllbed.
o Clrcumor.1
o L.cer.bon
o Edeml
Luna Bound.:
ONOtmal
o NIA
CO OR
o Inegular 0 Other Good
o Weak 0 Pale
o Shallow 0 Rapid 0 Audlllle filiIlt
o Deep 0 Slow Wheeze "0 Warm
o Labored 0 Slrldor 0 Relrachons 0 9"
Rrghl: 0 R,Io. 0 Wllflll Men',1 Alto".,.",:
o Rhonchi 0 Nlllnl ~n..,
len:
o Ralll 0 WIllen opnl"
o Rhonchi 0 Nlllnl 0 Blunll<l'llll
o Otlto,tv,
o Appl.henllVt
o n"I~I&IComballv.
r
o Flu.hed
o Jeundlced
o Cool 0 Ecchymo.IS,
o Clammy 0 nl.h,
Spooch
1'1 NOlm,1IC101I
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= INITIAL NURSING 23..NT VIEW:
REASON FOR VISIT: TRAUMA
PAST MEDICAL IiISTO Y:
TIME: U Ch
o MEDICAL 0 PSVCIiOSOCIAlJEMOllor.AL
LMP
, '
SUBJECTIVE: Ceuse ollnlu'y/H,story 01 Pre.enllilne . (Whellhe /lIlJI'nt le~, -;~~-~5- _=, ,'. r;!.j~_,~~
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OBJECTIVE: PhYSlcellnlorrnatron (WtlDlyo~"~;;;i;,;-;o ~ee,Aji;{~~;;:;""...., ''\J-(,;;,..4.' ~~:n~;" ~::~:AIrW'y
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L._.~~~-'-:_... ~ - - - :~ :VKO ::; ~:r~:~i~~nltor
PATIENT PROBLEM: NUllIng DI8QnO!iI' Iiunwmpt,anu h"mlllll"JllIr 1IFljlttlfllltllll (1 G.toly M..aw..
__ L!Ue.1eIJsIK,I\ lhuu"hll'tuttUI. AI' tr, (1 HlIIlfalnl1 loJ LIl~:ld8 flllcaullonl
_,~ORl'Ult Allllllh'JIlI III Hr'JltrlhblllUI If hilI' (] fittllwB Pllclutloni
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tOI!lllij, In.II'Hj~' "t'\I'~ h'''''ll.1 I J Camta,' M..,urOl
IlurtJ VOloJf!lt' AUlllllon, III tl'IlH..IIHtijll IJllh1l1 U Pain Ci)Ulftll
(iU (nil. nut hllflll.tKl f.4l1h'hl~ IllIl'illllH1 1J I'oinlun 101 CIlml0l1
llullO fillftll'lilrt All In 111/11'1 -
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OUTCOME/GOAl ElpOCled ['V nlScharuo
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.
WAYNE A. QUACKENBUSH, 1 IN TilE COURT OF COMMON PLEAS
1 CUMBERLAND, PENNSYLVANIA
PLAINTIFF 1
1
1 CIVIL ACTION - LAW
V 1 NO. 94-3382-CIVIL TERM
1
GENEVIEVE V. 1l0CK, 1
1
DEFENDANT 1 JURY TRIAL DEMANDED
DEPOSITION OFI KEITH L. ZELIGER, D.O.
TAKEN BYI
PLAINTIFF
BEFORE 1
MARIA N. O'DONNELL, RPR
NOTARY PUBLIC
DATE 1
JUNE 29, 1995, 1124 P.M.
PLACE 1
450 POWERS AVENUE
HARRISBURG, PENNSYLVANIA
APPEARANCES 1
ANGINO & ROVNER, P.C.
BYI MICHAEL E. KOSIK, ESQUIRE
FOR - PLAINTIFF
LAW OFFICES OF DONALD R. DORER
BYI JEFFREY BAXTER, ESQUIRE
FOR - DEFENDANT
~ 7I1brig~, 'Folh ir JVaWt :RtfK'rlin9 &rYiu, 8nc.
115 PINE STREn . IiARRISBURG, PA 17101
Ii""'burg 717,232-&644 r.. 717.232,8637 l.ncu'., 717,383.6101
'i
,
,
, ,
.,
. .
2
1 WITNESSES
2 NAME DIRECT CROSS
3 KEITH L. ZELIGER, D.O.
4 BYI MR. KOSIK 3 --
5 BYI MR. BAXTER -- 28
6
7
8
9
10
11
12 BXHIBIT8
13
14 ZBLIGER DBPOSITION EXHIBIT
15 1. CURRICULUM VITAE
16
17
18
19
20
21
22
23
24
25
PRODUCSD AND HARKBD
8
.
3
1 KEITH L. ZELIGER, D.O., called as a witness,
2 being duly sworn, testified as followsl
3 DIRECT EXAMINATION
4 BY MR. KOSIKI
5 Q Dr. Zeliger, could you state your full name for
6 the record.
7 A Keith Lawrence Zeliger.
8 Q And, doctor, do you practice in association with
9 any other doctors?
10 A I am in partnership with Robert Kaneda at East
11 Shore Orthopedic Associates.
12 Q If you could explain the type of medicine that
13 you practice and what is involved in that practice?
14 A I practice orthopedic surgery which is that
15 branch of medicine and surgery that deals with injuries to
16 the musculoskeletal system.
17 Q If you can, doctor, please briefly describe what
18 your medical educational background is?
19 A I attended medical school at the Philadelphia
20 College of Osteopathic Medicine from 1981 to 1985. After
21 which I served a one year rotating internship at Community
22 General Osteopathic Hospital in Harriaburg, PennsYlvania.
23 After which passing Pennsylvania state boards, I
24 received a license to practice medicine and surgery in the
25 State of Pennsylvania.
4
1 I then served a four year residency in orthopedic
2 surgery at community Osteopathic Hospital alBo with
3 fellowships during that time at Jackson Memorial Hospital in
4 Miami, Florida, which was a fellowship in orthopedic trauma
5 surgery.
6 I also spent three monthB with -- during that
7 time my residency with Dr. Lannie Johnston in Lancing,
8 Michigan doing arthroscopic surgery which I completed my
9 residsncy, served one year fellowship in sports medicine and
10 arthroscopic Burgery in Philadelphia, Pennsylvania with Dr.
11 Nicholas Dinubile and Dr. Vincent DiStefano in Graduate
12 Hospital and Delaware County Memorial Hospital, after which
13 I entsred into practice at Susquehanna Orthopedic Associates
14 here in Harrisburg, Pennsylvania.
15 And this last year Susquehanna Orthopedic
16 Associates was disbanded, and Dr. Kaneda and mysslf stsyed
17 hsre at this location reforming a new group called East
18 Shore Orthopedic Associates.
19 0 But essentially you have been at the lame
20 physical location?
21 A Five years.
22 0 Five years.
23 The fellowships that you dflloribed in addition \.0
24 your residency, what. h the {Ufference in qullHJ \.hlOlH)h
25 these variouB follnwllhipo?
5
1 A When you finish a residency, you have been
2 trained in general orthopedics and you are expected in four
3 years to try to learn all of that, during which time you
4 have the opportunities to spend whatever amount of time that
5 your residency allows and then post residency training for
6 whatever period of time, either six months or a year to try
7 and subspecialize within the area of orthopedics, and I
8 chose to subspecialize in the areas of orthopedic trauma,
9 sports medicine and arthroscopic surgery.
10 Q You mentioned licensing in Pennsylvania?
11 A Yes.
12 Q You are licensed to practice medicine here?
13 A Yes. I received my license in I believe 1986.
14 Q The license that you have from Pennsylvania, do
15 you have any certifications in that field?
16 A Yes, I am board certified.
17 Q If you can, explain what board certification in
18 the area of orthopedic surgery means?
19 A Doard certification in any field is a process by
20 which the people who specialize in that field are trying to
21 regulate the expertise or level of competency within that
22 field.
23 In orthopedics, in the osteopathic profession,
24 there is -- the process of board certification is a
25 three-part process. It's a written examination, an oral
G
1 examination and a practical examination.
2 The written examination is taken a year after you
3 graduate from your residency, or in case if you do a
4 fellowship usually the year following your fellowship.
5 Once you have accumulated at least 200 major
6 cases, or I -- correction there, after you -- once you have
7 completed the written part of the examination, then the
8 following year, you take the oral examination.
9 Once you have completed the oral examination, you
10 have accumulated at least 200 major cases and the American
11 Osteopathic Board of Orthopedic Surgery defines what those
12 major cases are, you are then allowed to apply for part
13 three. From the time that you apply, within one year the
14 Board of Orthopedic Surgery will find two or three examiners
15 to corne to the hospital or hospitals where you practics,
16 review your records, which they can pull all or some, that
17 is up to them and to the rules and regulations.
18 After they have reviewed through those records,
19 they watch you perform surgery, you are required to perform
20 at least three major cases.
21 And if you perform those cases to their
22 satisfaction, your records are all up to date, conaidnred to
23 be to their satisfaction and to the board's satisfaction,
24 and you have completed part one and part two succossfull y,
25 you are then deemed board certified.
7
1
So this is a process over and above the licensing
Q
2 requirements for the state?
3
4
5
6
7
o
9
10
11
12
13
14
15
16
17
10
19
20
21
22
23
24
25
A
Q
And it's essentially a review by peers of yours,
Yes.
other doctors who do what you do?
A Yes.
Q
Are the requirements more stringent than the
state licensing requirements?
A Yes. State licensing requirements is just a
written examination and an oral examination.
Q You talked about the fellowships. Since becoming
board certified, do you see patients that have traumatic
injuries such as those which we're going to discuss in Wayne
Quackenbush's case on a regular basis?
A Yes, we did see a lot in our practice, both my
partner and myself see a lot of patients from -- with trauma
from both motor vehicle and industrial accidents.
We do a lot of workmen's comp and a lot of auto
in our practice.
MH. KOSIKI At this time we would offer Dr.
Zeliger as an expert in orthopedic surgery.
MIL BIIX'I'1I111 J have no questions and no objection.
BY Mlt. KOB 1 K I
Q
A
Doctor
J have a copy of my
~,___""'~'~_.__r~_~'.,'_~_,_ .'_',- "_ _ _-.______..____~_.>_.__,~.___._____,~,,___
B
1
2
3
4
5
6
7
B
9
10
11
12
13
14
15
16
17
IB
19
20
21
22
23
24
25
o We have covered your qualifications. I was just
going to say that I was going to mark your C.V. as Exhibit 1
to the deposition.
(Curriculum vitau produced and marked Exhibit No.
1.)
BY MR. KOSIK:
o 1 have also had copies made of the records in
this case. I am not going to mark those as an exhibit,
we're going to use those during the course of the
arbitration.
I see that you have the chart in front of you
though, if you want to during the course of the deposition
in order to answer questions, you know, please feel free to
refer to that. Okay?
A Sure.
o If you can explain when you first saw
Mr. Ouackenbush and what the purpose was when he came into
your office?
A Mr. Quackenbush was referred to me by other
members of his family. I had treated other members of his
family in the past for other problems, and I first came to
see him on August 19th of 1993.
Mr. Quackenbush at that time was I believe 2B or
29 years old, right hand dominant. ne provided me a history
that he was involved in a motor vehicle accident on August
9
1 16th of 1993.
2 lie wae the driver of a car, wearing a Beat belt
3 ae well ae the lap portion and ehoulder harneee. The car he
4 etated wae not equipped with air bage.
5 lie wae traveling on a road and etated another car
6 failed to atop or yield a etop sign, went through the stop
7 eign. He was traveling he stated approximately 50 miles an
8 hour.
9 And he thought the other vehicle wae traveling
10 approximately ten milee an hour, he stated to have a head-on
11 collie ion with the front end of his car etriking the left
12 eide or front left driver'e eide of the other vehicle in the
13 front left quarter of the vehicle resulting in a rapid
14 deceleration type of event.
15 lie etated the eeat belt, ehoulder harnese
16 remained intact. He wae jerked forwarde and backwarde in
17 the eeat, but did not come out of the eeat. lie denies any
18 loee of coneciouenese.
19 lie had etruck his right knee on eomething within
20 the vehicle, whether it be the center consolo or the
21 daehboard we're not eure.
22 lie deniAe etriking his -- denied etriking hie
23 head. lie stated he put hie arm up to block the force or
24 with brunt of the impact.
25 0 With the steering wheel?
10
1 A With the steering wheel, but the seat belt held
2 him restrained within the vehicle.
3 When I eaw him in the office, we noted thet he
4 had bruising across his iliac crest aree or across hie
5 pelvis. lie had some bruioing noted across the left side of
6 his shoulder from both the lap portion end shoulder portion
7 of the seet belt.
8 That was telling me there was a fair amount of
9 force involved with the incident. It wee a fairly rapid
10 deceleration event.
11 lie was noting to have pain in his neck along the
12 left side of his cervical spine, along as he described here,
13 let me refer to my notes, it seys pain along cervical spine,
14 baok and central portion of his neck along the base of his
15 skull radiating up the left side of the neck through the
16 trapezius muscle, sternocleidomastoid muscles, he is
17 referring to the muscles in the front of his neck here
18 acrose the top of his shoulder, acrose the shoulder and
19 through the upper porlion of hie back along the shoulder
20 blade area.
21 0 Thio wae primarily on the left side?
22 A Left alde. lie wae complaining of headaohes with
23 lhe pain coming down his arms along the lateral aspect of
24 the arm and forearm occaeionally, BO it would come down
25 IIlonl1 the olher aide of IdB arm through the forearm, not
-'~---',_.''''-'---'-''-'----..'"------ <-.~.,-"-'.__.~---'-------_.~-,-_._----
11
1 really describing it into the wrist or hand as such.
2 He had saine pain in his lower back. It was kind
3 of central, diffuse over the lumbar spine, not real well
4 localized and with some radiation acrose the top of his
5 pel vis on both sides. Dut he was not complaining of any
6 radiation into the buttocks or down either of his legs.
7 We had taken ex-rays at that time of his cervical
8 spine, his collar bone on the left because of the bruising
9 across the shoulder and neck area.
10 Ilia lumbar spine and pelvis because of the
11 bruising across the pelvis and x-rays of his right knee
12 because of the complaints or pain along the lateral side of
13 his right knee.
14 All of the x-rays were unremarkable showing no
15 evidence of fracture or other bony pathology.
16 We did note some straightening of the cervical
17 spine though, which is due to muscle spasm instead of the
18 normal lordotic curve which actually means your spine bends
19 backwards in your neck.
20 When we see the spine real straight on an x-ray
21 from the side-view, it usually means there ia some muscle
22 spasm.
23 Physical examination of him didn't show any
24 neurological deficits at that time. lie had no muscle weak,
25 there were no reflex changes, his reflexes were all okay.
12
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He appeared in my opinion at that time he had a
cervical and a lumbar strain.
He had contusions noted across the chest and
pelvic area from the seat belts. And I thought he just had
a contusion to his knee.
I had written for some physical therapy. He was
having a lot of complaints of pain and the headaches, no
evidence or signs of concussion at that time.
So we had written for some pain medication and
were going to recheck him back in two weeks to see if he was
improving; sooner, if he had problems.
Q The complaints that he made of pain in the area
of injuries as well as the ones which you examined, were
t.hose consistent with the history that he had described for
this accident?
A Yes.
Q Do your have an opinion to a reasonable degree of
medical certainty based upon your examination and the tests
that you performed as well as your training and experience
as to whether these injuries which you have alr~ady
described were directly related to this automobile accident
on August 16th of 19937
A I believe so, yes.
Q Doctor, reviewing your office notes, it appears
that you saw him in follow-up treatment during this initial
13
1 period September 7th, September 2let, October 5th and
2 october 26th.
3
A
Uh-huh.
4 0 1 don't neceesarily want to go into each office
5 visit with you, but maybe if you could describe oxactly what
6 type of treatment that y:>o prov idod to Wayne, how he
7 progressed, give oome idoa of --
8 A Wayne was treatod with phyoical therapy. lie 10
9 from this aroa, had gone down to Shipponoburg where hio
10 family was reoiding and was treated with phyoical therapy
11 down there.
12 lie had aloo at pointo complained of a lot of
13 nightmares. We did get an evaluation with a poychologiot.
14 It was aloo I'Bcommended all MRl scan of his brain which wao
15 unremarkable.
16 lie -- the bruising cleared up with the phyoical
17 therapy. lie gradually otarted to get better. And through
18 the couue of the next few monthll, as we IItated, elowly got
19 better and beller.
20 We otarted to see more lIignificant improvement
21 and on October 26, 1993, actually on October 5, 1993, 1 had
22 rolened -- he was working light duty already by that
23 point. 1 wall looking for the point at which 1 releaaed him
24 to light duty.
25 1 t.hink we -- it WIlH 1I0lllllUme followinl] Septembllr
14
1 21st, we had released him to light duty. Then on October
2 26th, 1993, we returned him to regular duty, you know,
3 without any restrictions at that time because he was doing
4 extremely well.
5 Q So he was off work totally for appoximately four
6 weeks up until September 21st?
7 A If that's what the time frame worked out to be.
B Q At that time, I saw some notation in your office
9 notes that he actually requested the return to work. Do you
10 recall whether that was something which you suggested or
11 A It I S in my September 21st note. At that time he
12 felt that he was doing well enough he wanted to return to
13 work light duty.
14 And we -- that Thursday of that week, that's why
15 I don't know the exact date what September 21st was, but the
16 Thursday of that week we returned him to work at about 20 to
17 25 hours a week still enabling him to go for the PT.
18 He did so, and ultimately through the course of
19 physically there, eventually we did release him on October
20 26th to return to full duty.
21 Q If you could just briefly describe, you know,
22 what is involved in the physical therapy and why that is
23 prescribed for someone with this type of symptoms?
24 A Following an accident, with the amount of trauma
25 involved in this accident, he had enough trauma or there was
15
1 enough of a rapid deceleration injury that there was snough
2 force at least of the seat belts against him in holding him
3 restrained that he had bruising across his neck and shoulder
4 and bruising across his pelvis.
5 So in those kind of injuries these patients can
6 develop fairly severe cervical dorsal lumbar strains on
7 occasions and in this case it appeared to be muscular.
8 We treated him using modalities, the object of
9 the modalities iB to try to relieve the muscle spasm, loosen
10 up the areas.
11 And once we have been able to break up the spasm
12 and the cycle of the muscle spasm, we're then trying to
13 strengthen the areas because through the course of this
14 generally patients will develop muscle weakness.
15 So initially his PT was directed at symptomatic
16 relief followed by functional improvement meaning working on
17 hiB muscle strength and trying to get him back to his
18 pre-injury level of activity.
19 Q As of the office visit I think on October 26th
20 when you discontinued the therapy, I think you also had a
21 follow-up visit in December, did you recommend that he
22 continue doing some type of exercise program?
23 A Yes. 1 had recommended to him at that time and
24 on a number of occasions that he continue to work out on his
25 own. But he had been doing dramatically better, and I told
16
1 him that it was important that for the next soveral months
2 he continue to work out on own his own, but if he did not,
3 he could end up with recurrent symptoms.
4 Some patients, they stop all together, just they
5 start feeling better and they stop doing it, they' 11 tend to
6 tighten back up. If all of their strength hasll' t returned,
7 they can develop some recurrent muscle spasm.
8 He said he understood the importance of it, and I
9 was going to see him back I think just as needed. I think I
10 was discharging him at that time.
11 Q Were you satisfied with his recovery given the
12 the significance of the initial injuries especially physical
13 therapy for --
14 A Yes. He had done over a period of a couple
15 monthl, done exceptionally well. He recovered I thought at
16 a reasonable period of time. I mean this was 8 couple
17 months following October, but as of October in a period of,
10 what, a three-month period of time, if that long, he had
19 recovered significantly from this trauma.
20 Q Subsequent to 1993 and the visits which we have
21 ah'eady disoussod, did Wayne come back to you complaining of
22 any problemu?
23 A You lout Ine.
24 0 After the vialla which we have already gone over
25 which] think were thUllllJh lleoember ]993?
__ _ ____ _.___.._____.._~__'__~._~__~_.._____'..___..__,___'.'_~..,..,..~.."m.,',_,_","_~___~__________
17
1 A Right.
2 Q Did Wayne ever come back to you? Did he have any
3 problems after that?
4 A Oh, after that. Okay. Yes. I did soe him back,
5 there was a phone call to our office on May 20th stating
6 that he was having left arm and left shoulder pain for a
7 period of about two months.
8 And we wanted to make an appointment to see him.
9 My partner was on call and called him in a prescription for
10 some anti-inflammatory medication. And then I Baw him on
11 May 24th.
12 Q What were hia problems at that time? Let me ask
13 you for clarification, this was the following year, 1994?
14 A Right, May 24, 1994.
15 Q Okay.
16 A Approximately six months after, five, six months
17 after I had seen him last.
18 Q What problems waB he having at that time?
19 A He waB complaining of pain in the left side of
20 his neck across the left ahoulder blade, in hia left
21 shoulder, down the latter aapect of hia left arm, some
22 occasional radiation on to aeroaa hia forearm Ulen into
23 the ring and Bmall fingers on one oecaaion. And another
24 occasion it was the index and long finger.
25 It wasn't renl Bpecifie to one nerve distribution
III
1 or another. It was very similar to his original complaints
2 from the accident.
3 He was having problems, but it didn't seem to be
4 as severe as initial, but he was having complaints of
5 discomfort.
6 Q From your evaluation and the complaints he was
7 making, were you able to determine whether this was a new
8 injury or continuation of the previous problem?
9 A From the distribution of the pain and he had not
10 described to me any intervening trauma, he did tell me he
11 had not really been doing his exercising. And so it was my
12 opinion that it was just a re-exacerbation or a continuation
13 of his previous condition.
14 Q Did you recommend any additional treatment for
15 him at that point?
16 A I had ordered an MRI scan of the cervical spine.
17 And then was concerned whether he could have a herniated or
18 bulging disk in his neck, that was a source of the symptoms,
19 but it really wasn't any -- specific to anyone level. I
20 really thought it was more muecular than it wae the disk ae
21 such, but with continuation of theee symptoms, I thought an
22 MRI was indicated.
23 We ordered it and the MRI scan showed some
24 bulging disks in his neck. They were described as very
25 minimal.
19
1 It WIlS still my opinion that this was really more
2 of II muscular and ligamentous condition and not necessarily
3 related to the disks.
4 0 Until you got the results of the MRI, did you
5 hold off prescribing any additional physical therapy?
6 A Yes.
7 0 Okay. After you got the MRI back, what did you
8 recommend to him?
9 A I recommended to him -- he had these bulging
10 disks. His symptoms in particular didn I t match. 'l'here were
11 three bUlging disks. The symptoms down his arm could have
12 potentially come from one of these disks because you are
13 talking three nerves and where it went down his arm, he had
14 symptoms that went down different nerve root distributions
15 at different times and where they went could have been one
16 of these three levels.
17 There was no muscle weakness, no reflex changes.
18 I offered him the option of physical therapy, epidural
19 steroid injections. If it truly was coming from the disks,
20 then an epidural injecUon should quiet the symptoms down in
21 his shoulder and down his arm.
22 'I'hat I s the direction that he w,l shed to go at that
23 time hoping that would give him the quickest relief.
24 He had the epidural lnjeetion and] saw him back
2~ on 6-24 of 1994.
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1 He had not had any relief from the epidural
2 injections. That kind of confirmed my opinion that it was
3 not necessarily from the disks, I thought it was more
4 muscular, ligamentous.
5 We had written for physical therapy at that
6 tims. If he wasn't having improvement, he was going to get
7 another opinion as to whether or not this might be a
8 surgical treatment or what another opinion as to what othsr
9 options we had in the way of PT.
10 He -- when I saw him back he really was not
11 improving on July 26th of 1994. And I had Dr. Walter
12 Peppelman who is a spinal surgeon take a look at him.
13 Dr. Peppelman agreed with me that it was not
14 nscessarily disk in nature, he really thought it was more
15 muscular ligamentous, did not feel surgery was indicated and
16 recommended continued PT.
17 I saw Wayne back again on 11-1 of 1994. That's
18 the last time I saw him, and on that date he actually -- he
19 was improving at that time. Ilia arm was getting better.
20 His mobility in his neck and shoulder shoulder blade area
21 was better, he had improvement in his strength.
22 1 felt he was doing well enough we could stop the
23 physical therapy and that he could continue to do it on his
24 own.
25 I really stressed the importance to him of doing
21
1 it on his own. And I told him that I would see him back in
2 three months, if he was having problems sooner if necessary,
3 and I have not seen him since.
4 0 Okay. Let me just go back.
5 You talked about the epidural injections. Could
6 you briefly explain what those are and why they're
7 attempted, what they're Bupposed to do?
8 A Okay. In an epidural injection, what we're doing
9 is we're if you look at the spinal cord, we call the
10 space right around the spinal cord where the -- you can
11 think of the spinal cord kind of like a tube within a case.
12 And within -- and the spinal cord floats in this
13 casing which is filled with fluid, synovial fluid, which we
14 call the spinal fluid.
15 That space with that fluid fluid is called the
16 dural space. So right around the spinal cord itself is
17 called the dural space.
18 The next layer outside of the case that contains
19 the fluid and spinal cord is called the epidural space.
20 An epidural space is where if a disk bulges or
21 herniates, it's will actually press up against this casing
22 that contains the fluid and spinal cord and so the disk
23 actually will herniate or bulge in epidural space. It's
24 also where the nerves come off and exit the spine.
25 So in an epidural injection, you are injecting a
22
1 cortisone or cortisone-type preparation the choice of which
2 is up to the anesthesiologist giving the injection, into
3 that space, the goal of which ie to reduce the inflammation
4 around the spinal cord and around the nerve roots, aleo
5 reduce the inflammation to the disk itself.
6 And in some caSBS the epidurals can actually
7 shrink up the size of the bulge or herniation by a
8 millimeter or two.
9 The end goal being to try relieve pressure on all
10 of this, relief inflanunation, the end result being to try to
11 relieve pain. Epidurals are not indicated to relieve neok
12 pain or back pain.
13 They're indioated to relieve the shoulder blade,
14 shoulder and arm paln, hand palu, in other words, the
15 radioular complaints that go down the extremity. And he did
16 not improve from those injections.
17 0 As I understand from your notes, this is actually
18 a course of three different injections.
19 It starte with one injeotion, can be a serious of
20 up to three injections spread a couple weeks aparl from each
21 other.
22 Another thing you uoed to know with epidurala,
23 only seventy porcent of lhe patients thal gel them rBepond
24 to them.
25 That meaus seven oul of ten wi II gel hel ter,
, ,
23
1 three out of ten won't get better any way. Even if you give
2 them -- even if it ie a diek -- no matter what the pathology
3 is three out of ten people, you know, average, juet will not
4 reepond to the medication, meaning that their celle of their
5 body, the receptote juet don't reepond to the medication and
6 they don't react in a poeitive faehion. So 70 percent of
7 people will improve, 30 percent will not.
8 Q After two injectione, Wayne noticed no
9 improvement?
10 A Correct.
11 Q Then if I underetand correctly what you have
12 already eummarized ie that at that point you started him
13 back on phyeical therapy, formal phyeical therapy?
14 A Right. I really etreeeed to Wayne that I thought
15 that it wae more of a muscular ligamentous-type condition,
16 more of a eprain and strain and that he had some muecle
17 spaem which had reoccurred and that his neck and shoulder
18 blade area wae tight, that he needed to looeen up this area
19 improve the mobility and strengthen it up, eo I sent him
20 again for phyaical therapy. lie did eventually improve.
21 When I saw him last, he wae doing much better.
22 Q I gueee in conjunction with that, if I underetand
23 correctly, you also made thie referral to Dr. Peppelmanl wae
24 thie eesentially just to confirm your diagnoeiu?
25 A Yes. Wayne was really complaining about the
. ,
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discomfort and what else can be done. He thought maybe
there might be surgery needed for him, I really didn't think
so.
But I told him that I would Bend him for another
opinion to Bee if, you know, oee what Dr. Peppelman fel to I
told him Dr. Peppelman'o opecialty wao opine ourgery.
And Dr. Peppelman did oee him, and agreed with me
that there wao no indication for ourgery.
o And I think actually you had Dr. Peppelman'o
report toward the end of Auguot of 1994, about the one year
anniveroary?
A Correct.
o Around the oarne time period Wayne wao ohowing
oome improvement with the phyoical therapy?
A Right, at that point he wao starting to Dhow oome
improvement. lie went on to continue to get better when I
saw him laot in November of 1994. It was I gueoo is, what,
about nine montho ago, ten months ago, he wao doing much
better at that time.
o Ao of your last evaluation and based upon your
experience and treatment of Wayne, can you let us know what
your prognosis wao at that point as far ao what yo,u expected
in the future?
A At that point, my prognoole was excellent for
him. lie had improved enough 1 thought that if he continued
. .
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to exercise he would go on to full recovery.
I don I t know how he I a doing in the interim, I
have not Been him aince, but at that time I expected that
at lea at hoped he would go on to full recovery, be able to
return to, you know, gainful employment of whatever kind he
wanted. Really didn't Bee -- if he had fully recovered, I
didn't really Bee any or anticipate any restrictionB on him.
Q Okay. Let me jUBt follow it up with another
opinion queation.
Baaed upon the hiatory that waB provided to you,
your evaluation and office viBitB with Wayne and the testB
that were performed, do you have an opinion to a reaBonable
degree of certainty in your field as to whether the injuriea
which you deacribed and the coune of treatment over a
period of a year and four monthB, were directly related to
thia automobile accident on Auguat 16 of 1993?
A Yes, it 10 my opinion that they are.
MR. KOSIKI Thank you. I have nothing further.
CHOSS-EXAMI NA'l'lON
BY MR. BAXTER I
Q Dootor, just by way of review, your initial
diagnosis was that of a oervical lumbar sprain and strain
along with the bruising and the cantu lion on the knee?
A Cornwt.
Q
Based on that diagnosis you ordered physical
.
26
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5
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7
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therapy for which he evidently did recover initially?
A Yes.
Q As of October it was your opinion that he could
resume full-time work as opposed to the light duty work he
was initially on after September?
A Right. We had initially reetricted him I think
20, 25 hours a week, then released him later to full forty
hours a week.
Q And in a letter to Attorney Koeik dated December
14th, I believe that you indicated that at this point he's
working two jobs and you are going to discharge him from
your care?
A Correct.
Q Okay. During that initial period when he was in
to see you, you said that you did take x-rays of the
cervical spine and you noted that there were no bony
abnormalities. What do you mean by that?
A I mean we found no evidence of fracture. We
found no evidence that there were tranelational changes,
meaning there wae no evidence one vertebrae had moved on top
21 of another. For example, there weren't any dislocations or
22 subluxations.
23 'fhe only thing we did note is there was some
24 straightening of the spine which is typical that you see for
25 muscle opaom.
.
27
1 Q
2 that?
If there was a bulging disk, would an x-ray show
3 A No.
4 Q Is that something that can only be seen through
5 an MRI or another type of test?
6 A Yes, you can generally if you want to find that,
7 you need to perform an MRI or a CAT scan.
8 Q And juet for the jury, what is an MRI?
9 A MRI goes by two names, MRI which is magnetic
10 resonance imaging and the older terminology which went under
11 NMR, nuclear magnetic resonance is an old technology. It's
12 not used -- it's been used by scientists for fifteen years
13 to define things in the laboratory, but only used by
14 medicine maybe ten years.
15 It's a process by whlch you use a large magnet to
16 lmage the hydrogen 10ns in the cells of the body,
17 specifically the nucleus of the cells that contain the DNA
18 and therefore it allows you to get a very accurate picture
19 of the anatomy.
20 Accurate enough it glves you about a seventy-five
21 to eighty percent accurate picture, it is not 100 percent.
22 Q Obviously, lt is much more accurate than an
23 x-ray?
24 A It's different than x-ray. X-ray is still the
25 best method we have for looking at the bony pathology. But
. ,
.
1 when you are talking about soft tissue pathology, you have a
2 choice of CAT scan or an MRI.
3 CAT scans are better when you really trying to
4 define again the detailed intricacies in the bony anatomy I
5 whereas for soft tissue pathology, you are better off with
6 an MRI.
7 Since later on there was a question about could
8 there be a disk problem, an MRI was done because a disk is a
9 soft tissue pathology and not a bony pathology.
10 Q Because an MRI was not performed initially in
11 August of 1993 shortly after the accident, is there any way
12 for you to be able to determine whether these bulging disks
13 were present before the accident or after the accident?
14 A No, I am not trying to contend whether they were
15 or weren't present prior to the accident.
16 Q I understand, I just want to make sure that --
17 A Right.
18 Q That's clear.
19 A Right. In fact, it's my opinion that I don't
20 necessarily think the bulging disks are symptomatio in him
21 at all.
22 Q So in other words, so I am clear, your pplnlon io
23 that it was a muscular type of injury?
24 A Right.
25 Q That reoccurred some five or slx months after it
" .
28
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" ,
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29
1 initially had resolved itself due to perhaps a laok of
2 exercise?
3 A Yes. He was given a prescription to exercise at
4 a health club and when I later on checked on it, he hadn't
5 really utilized it. I mean he had kind of really slacked
6 off on doing the exercises.
7 But now, as I said earlier, I don't think that
B the disks in him necessarily were his problem. It was a
9 muscular, you know, ligamentous condition quote, unquote.
10 You can also refer to it as a sprain and strain
11 in layman's terms if you want.
12 Q When the epidural injections did not provide him
13 with any relief, did that further support your opinion?
14 A Yes.
15 Q Other than the light duty restriction that you
16 initially put on him with regard to work, were there any
17 other restrictions that you placed on him?
IB A I need to review my records. You are referring
19 back to like September of 1993?
20 Q Yes.
21 A Okay. I am looking at the actual -- I am just
22 trying to find the actual note that 1 wrote for him to --
23 what I wrote for at that time was -- let's see.
24 1 had written that he could return to work, it
25 says 25 hours a week only. May continue with light duty
.
. 1\ .
.
30
1 times three weeks. Next appointment 10-26-93.
2 Q And after he had this reaggravation of his
3 injuries and he was treated again with physical therapy. At
4 that point, did you place any restrictions on him?
5 A You mean at the time when I first saw him back in
6 May 2lst -- 24th rather?
7 Q Did you release him to work again?
B A I don't see it in my note, but I need to --
9 sometimes I don't always document that in my note. I need
10 to look through the notes that were written for him and find
11 out.
12 Q Go ahead. Sure.
13 A And find out if hs was or wasn' t off.
14 MR. KOSIKI Jeff, I think Wayne's testimony will
15 indicate that at that point at least he had taken a new
16 job.
17 I don't think he had any physical requirements,
IB so it's probably unlikely.
19 MR. BAXTER I I didn't see anything in the
20 reoords. I just wanted to confirm that.
21 TilE WI'l'NESS I Yes, I don't have anything in my
22 reoords, so I mean it's very possible he was working through
23 that time.
24 BY MR. BAXTERI
25 Q Okay.
.
. ,\ .
. ,.
31
1 Q And am 1 oorreot that the last time that you did
2 sse the plaintiff in this case was November 1st, 1994,
3 that's the last offioe note that you have recorded?
4 A Yes. November 1st, 1994 was the last time that I
5 saw Wayne in thio offics.
6 Q To the best of your knowledge, do you have any
7 further plans to see him or are there any appointments
B scheduled?
9 A lie had one appointment scheduled three months
10 following that if he was still having problems and I have
11 not seen him back. 80 there is no plan to recheck him at
12 this time, it's just that if he has difficulties or
13 problems, he'll call and schsdule an appointment.
14 MR. DAXTERl Okay. Thank you, doctor.
15 MR. 1<0811<1 No further questions.
(Whereupon, the deposition was conoluded at 2103
16
17 p.m. )
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'.~ERG VISIT 1115 26610
','ERG VISIT 1625 26615
'.~ERG VISIT 2640 26620
'~ERG VISIT 4155 26625
'~ERG VISIT 55B5 26630
I~ERG VISIT CLASS 8 26635
6SERVATlON, EACH HR 26017
;'VATE EXA'~ CHARGE 280 I 0
'.IPLOYEE HEALTH VISIT 26018
:"1T SOURCE FOR SPECULUM 26645
, VAGlljAL SPECULUM 80068
'r Cl10lHEE 26009
, 1.\O'1110R 26031
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NURSING DOCUMENTATION - EMERGENCY DEPARTMENT
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NAME ~'l~~,J<<.., bu.tr
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VIT AL SIGNS TIME __cJS .~_. ___ . T _ ~-j.:;::---
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TETANUS STATUS:
o W,lh,n 5 V.."
o 5"0 Vea"
o More Ih.n 10 V....
o Nev.,
. TREATMENT IN PROGRESS ON ARRIVAL:
o CPR Down Tim.
o AI"".y - 0 0,." 0 N...I - '.
o Ai"".y, Endoll.che.1 - SIz.
o Ai"".y, N..Ollieh.., - Size
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o Sh.llow 0 Rapid 0 Audible liK1bl
o O..p a Slow Wh..ze "IT W~rm
o L.bo,ed 0 SlIido, 0 Rel,aclion. 9-9"
Right: 0 RaIn 0 Wheen Mental AaM..ment:
o Rhonchi 0 Absenl ~oodl fflet
left: roprllle
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. INITIAL NURSING ~NT VIEW:
REASON FOR VISIT: TRAUMA
PAST MEDICAL HISTO V:
~'
TRIAGE NURSE 61GNATlJRE
o Monilor - y1hm Rete
o Oxygen - 0 .k, 0 NC - UMm
o Splnallmmobih..lio ,
01.4..1,
a P,essUl. Dressmg 0 Olh.r
o Flushed
o Jaund'c.d
o Cool a Ecchymo.i..
o Clammy a Re.h,
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o Oiioriented
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OBJECTIVE: Phy.,clllnlo,mahon (w~u .,. able 10 .ee)
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PATIENT PROBLEM: NUl sing D,lgnos's
_ Nonr.umpliance
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_ Coping. Ineltecll~'e
~__ Fl>).d Volume. A1Iel811On5 Itl
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DRUGS:
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o T,lklti\l1 0 R,cent
o RepetiUve 0 OiSlanl'Pas'
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PLAN OF CARE:
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o TIME TIME ""'- TIME Trpe AmI. Trpe AmI. Urln, Olh"
o OnGEN llMII0
o INTUBATION, SIZE ~ m_ . ./
-- ------- /
o ABG'S TIME TIME --- ----
o PULSE OX TIME TIME "- /
o AIRWAY, TYPE TIME ""- /
o I/ASQGASTRIC TUBE, SIZE TIME "- . NOTIFICATION OF: /
o GASTRIC LAVAGE I.I.'T .- ~t 6ocII' WOI'" o Family Doctor
o mil)' / o Cofoner
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o FOLEY CATHETER. SIZE TIME o C"'~I'On, ,/ o Olhll
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DISPOSITION: DISCliAI!9E:
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_______ U "",wllnet
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INSTRUCTIONS:
.
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WAYNE QUACKENBUSH
FlI.E
NOTES
8119/93
Wayne presents for ev,1]uation. On 8/16/93, he .'as thft driver of a car, wearing a
seatbelt, both lap and shoulder harness on, The car waa not equipped with air baga.
While traveling, another car failed to stop or yield to stop sign, pulling out in
front of him, he was traveling at approximately 50 mph, the other car 10'08 tre\'eling
somewhere around ]0 mph which resulted in him 8lrildng ~ead on to the other car in
its left front quarter area, As a result of the accident, he was significantly
bounced around. denies loss of consciousness, but arms up to block him from going
forward into the steering wheel, struck his forearms on the steering, but the
shoulder restraint did hold him in the sest as well as lap belt. He did strike his
right knee in the car along the lateral "Bpect, there .'ss some bruising noted end
that was struck possibly on the dashboard, centra] console, we're not sure. There's
some minor bruising to his foresrms but this ia not very significant. There ia some
bruisil}g from the lap belt along his iliac crest bilaterally, He has significant
bruising along the left side of his neck and his c1svic18 down onto his chest from
the shoulder harness. He complains of pain in the cervical spine, back and central
portion along the base of the skull radiating along the left side of the neck along
the tCSperius and sternocleidomastoid muscle. up to the esr and across the base of
tha jaw. He has significant headaches as a result of this with pain radisting down
the arms along the lateral aspect of the crm and forearm occasionally, He has pain
in the lumbAr spine centrally with radiation bilaterally across the lumbosacral
junction area, but so specific radiation do.on the legs and some pain on the lateral
aspect of the right knee.
X-rays are unremarkable of the cervical spine, clavicle, lumbar spine and pelvis
and right knee.
1 fee] he has an acute cervical snd lumbar strain and sprain and a contusion to the
left side of his chest, a contusion to his right knee and ~ contusion to his pel-
vis. 1'11 treat him with aggressive physical therapy, Tylenol with Codeine for pain
control. ]'11 see him in two weeks, In the interim, he'll remain off of work.
Should he set worse. he'll let me know,
KLZ I set"
8/25/93
Wayne and his mother stopped by the office this afternoon requesting a referral
to a physical therapy clinic iq Shippensburg. Wayne will be staying with his
parents there. Also requesting the name of a psychologist in Shippensburg
area because of nightmares snd HAs re]at i \'e to the auto accident. Referral
given for P,T, and patient's mother will call with name of a psychologist in
their area so that we may make the referral per Dr. K, ZeHser. t]b
9/7/93
Seen today in follow-up. After consultation with his physician in Shippensburg,
an HRI was ordered of his brsin because he felt his hesdsches msy be somewhat more
neurological snd the MRl .'as normsl. l1e's actually feeling s little bit better in
relation to his lumbar spine, oversll is still bothersome but 1 don't think is ss
bad ss 1t .'as, lIis neck snd shoulders are still somewhat bothersome, p,T, hss been
getting more aggreGs1\'e, They can now UBe more aggressive deep tissue mS&6sge,
"tretching, cervicsl traction and 10'111 SI'p])' a 11,5 unit to help decrease his
I're,hle"" I lee] .'e need to give this th,e as he had a very Significant accident.
I saw the l'inures today in the (,ffice Bnd 1 think he's very lucky from the force
involved In the accident. The bruisIng on h18 che.t seems to ho1ve heo1led up, l' 11
<,l't: i1llil IiI l'~'\l \<,'l't:kH alld b~ll1 Icl~:ajn L'lf ld \I.'lnk iJnd al that timo 11 helt; ready
to, will retorn him to work, If net, th.n h.'I] be off unti] at Euch time he's o1ble
tll return to Io'('rk, I'll fll'e Idm IJ"rlnal to hIll' w1th hendaches,
LIZ: Set
WAYNE QUACKENBUSII
FILE NOTES
9/21/93
Seen todey in Collow-up, 1110 back and neck is doing much better. He's having some
occasional discomfort in the posterior aspect at the base of the cervical spine with
occasional headsches, but nothing Ilke they were, lIis back overall Is feeling much
better. He feels he has hsd enough improvement that he'd like to return to work
to light duty this Thursday at 20-25 hrs/week and still go for J',T. and I'm in
sgreement with that, I'll see him In two weeks, if all is doing well at that time.
hopefully we can return him to full duty and discontinue formal P.T.
KlZlser ,
rJ..), 3-f3 Ilc. ~,-l6.L JL ,; '3 1 ~ .:J.L~ 4 r G"-4..u..~_
~ t!.r JI,,( -~ntJ-v g.,/-'l7tJ 7 '
~7, I;'''. I ..:JM-J i-! 'f..t; ;-'- I" : ' #- ::~~ ,
9/29/933- Phone Call
Received call from therapist who states patient 15 having a problem wo,rklng and
trying to get to phYSical therapy. She would like to know If there Is any prOblem
If the patient transfers his therapy back to Harrisburg so he does not have to
drive long distances to therapy,
Told therapist I felt Dr. Zellger would have no problem with patient transferring
his care to P.T,. Inc. if that what the patient wishes to do. They will forward
his records to p, T., Inc.
klr
10/5/93
His neck and shoulders are a little better. There's little 1eBB tightneas. his
motion is improved, lie haa begun atrengthening to them. lie still gets the head-
aches, they are not aa frequent, but they are still severe. As time goes on, I feel
the frequency wil1 decrease, although the severity will probably stay the same and
eventually the severi ty will decrease. Cont inue P. T., tranaferring to p, T, Inc.
as he spends more time up here'than he doea in Shippensburg and we'll do that, I'll
see him in three weeks, He'll continue light duty,
KlZ I &Sr
10/26/93
lie is doing very well since we saw him Isst. lie has had a dramatic improvement
in his back and in his neck. He h8B mostly soreness only with extension of the
neck backwards, but this Is slowly improving also. He has done well enough in
therapy that we are g~ing to dhcharge him from formsl p, To, and give him a
prescription for strength training to the neck, shoulders, upper and IOWAI'
extremities, and lumbar spine, at the Central Pann Fitnen Center for six
months, 1'11 recheck him in December and sea how he's dOing at that point, We
are also giving him a note to return to work full duty. 40 hours a week,
KlZ/ jep
FILE NOTES
WAYNE QUACKENBUSH
5/20/94 - Phone Call
Patient called stating he has had arm and shoulder pain on the left side for
the past two months, He has an appointment to see Dr, K. Zellger on Tuuday
and wants to know if he can have something for pain tll then.
Per Dr. Kaneda pattent given prescription for Anaprox 27& mgs. lq4-6h prn for
patn, 130. with no refl1H;. Called to pharmacy.
klr
5/24/94
Ile wae doing well until februery when he hed the onlut of plin in hie nack with
radiation acr088 the It, Ihoulder blade, It, Ihoulder and down tha literal IIpact of
the It. arm. Occ8Bione1 radiation of pain In the pOlterlor aepect of the upper arm,
ecroBS the back of the forearm and Into the ring and small Hngeu on one occlllon
and another occasion In the Index and long fingerl.
Phyeical exam shows slight mUlcle lleaknen of thumb and index finger pinch to both
handl. 8B wall BS finger abduction and adduction, No other mUlch weaknnl II noted
on telting. Compression of the head ceusu no Plln, Impingement Ilgnl In the It.
shoulder.
I'm concerned whether these symptoml may be related to C5-6 diec herniation, Ile did
Improve In the put with therapy. Since it haa returned, we'll Invlltlgate it fur-
ther. Ile'll obuln an MRl of the neck, I'll give him T)'lenollo'ith codeine, I'll
see him following tlie MRI to determine further care,
KLZ I ser
6/2/94
Seen today In follow-up, IHs MRI sholo's bulging dhcs at C4-5, C5-6 and (6-7.
There's no direct compreuion on the Iplnal cord or nHve rOllts, but 1 do believe
they're cauling enough inflammation to maka him symptomatic from hie neck dolo'l1 to
his arms, I'll &end him to CAI'HC Io'hore the doctors cen evaluate him and if they
feel Indlcsted, provide epidural Injection fcr his neck, 1 think that could provide
him enough relief to meke hia peln dlminiehed or go alo'ay, If it only dimlnllhea
it, then P,T, can be used and probably be more effective. 1 lhlnk by relieving hll
pain, he'll also be able to slup better at night and hopefully the I)'mptoml dOlo'n
his arms Io'ill go alo'a)' and hil Io'eskne.. resolve, I'll .ee him 5 da)'1 after hi. firlt
epidural injection.
KLZ: ser
6/8/94
Telephone csll from .'a)'nl Itatinl epldur.l Injactlon he received Hond.y hll
not much helped back pain, II. ie &t1l1experhnl~ . lot of pein In back,
neck and dOlo'n hie .rms, Requlltlng pain medicatioN, Per Dr, Kaneda, Tylenol
/!3, /!30, I q4-6h prn pain, Calhd to lUte Aide pharmacy, 744-026\, tlb
6/22/94 - Phone Call
Patient called requesting prescription lor pain medication, States he Is having
problems sleeping at night. "a$ an appointment to see Dr, Zellger on Friday,
Per Dr, K, Zellger given prescription for Tylenol ~), ,30, lq4-6 h prn for pain
\;ith 1111 refills.
kir
/--..
!
\iA\'NE QlIACKEl\~llSH
FlU: NOTES
6/2~/94
Seen today in follow-up, lie has 110t h.1d allY relief from the epidural injections, 1
will 110t ha\'e him take the third. 1 re-Io'rile physical therapy to his neck with dx
of bulging dists C4-5, 5-6 and 6-7, modalities aa needed including hot packs, ultrs-
sound, cerdcal trocti,'n And deep tissue manage, \,'ork on stretching, exercises to
the cervical spine, trapezius and strengthening to the cervical spil1e and associated
musculature. I'll see him after a week and a half to two weeka of therspy. If thers
is no impro\,ement, I'd like to reCer him to Dr. Peppelman,
KI.Z:ser
7/11/9~
Telephone call Cram Wayne requesting pain medication, States he has one week of
physical therapy to go, and the psin has spread to both shoulders. Per Dr. K.
Zeliger, Tylenol 113, Iq~-6h prn pain, /130, NR, Called to Rile Aide. 7~~-0261. tlb
7/26/9~
He's not improving with P.T. He has been through P.T" medicetion, epidurel
injection, ell nonsurgical treatment to this point and haa failed to improve. Be-
cause of these three discs in his neck and with the symptoms dolo'l1 his srm, 1 feel it
might be an indicstion for surgery. 1'11 hs\'e Dr, Peppelman to take a look at him
to evs1uste him. 1'11 recheck him after Dr. Peppelman's appt. In the meantime if
the physical therapy is providing relief. he should continue it, if not, then he can
probably stop it,
KLZlur
11/l/9~
His neck, shoulder and It. arm is slowly improving, His mobUity is better, hia
strength is getting better. He's still having discomfort, but he's doing well enough
that 1'11 stop the formal P,T. and ad\'ance him to doing it on his own. I'll see him
In (3) months, sooner if there are any problems.
KLZ lser
eAST SHORE ORlliOPEDIC ABSOClAre8, P,C.
ORnKJffiJIC, m~u~t-\ nc. H~ND C; ~L SlJROERY
SmRTS MEDIONI' r. n~N<T()Rn/()I'f{)/t:'i
450 Powers Avenue, SUlle 101
lisrri.burll, Penm)'lvsnls 17109.5926
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INITIAL EVALUATION
RE. Wayne A. Quackenbu.h
Page 2
Auqu.t 19. 1993
Activ. Rang. ot Hotion,
c.rvical tl.xion - dec~ 75' ..condary to p.in
c.rvical .xt.n.ion - d.cr.a..d 90' ..condary to pain
right l.~ tl.xion - d.cr.a..d 90' aecondary to pain
l.ft lat.ral tl.xion - d.cr....d 90' ..condary to pain
rot.tion - right d.cr....d 80' ..condary to pain
- left d.cre...d 95' ..condary to pain
lumbar tlexion - d.cre.sed 90' s.condary to .tittn...
lumbar .xten.ion - d.cr.aa.d 90' ..condary to pain
bil.t.ral side b.ndinq - decreaaed 75'
rotation - d.crea..d 75' bil.t.rally secondary to pain
.hould.r tlexion - 0-90" bilat.rally secondary to .tittn..a in
anterior .houlder
.hould.r abduction - 0-90" bilat.rally secondary to .tittne.. in
ant.rior shoulder
hip fl.xion - 0-80. bilat.rally s.condary to pain
kn.. tl.xion - 0-100. bilat.rally secondary to pain
hip abductio~ - 0-25" bilaterally secondary to pain
Sensation. The patient has loss of numbness to the bilataral t.et
and hands when sleepL~q. This disappears upon wakinq. S.nsation i.
intact at this time.
Palpation. The patient has tsnderness to the right knee. bilat.ral
iliac crests, ASIS ... cervical. paraspinals, bilaterally, thoracic parupinala
bilaterally, and bilateral shoulders.
ASSESSMENT: The patient is a 28 year-old. white male with a diagno.is
of acuta csrvlcal and lumbar sprain and strain, contusion ot the left sid.
of the ch.st. bil.teral iliac crests, and right kne.. The patient pr...nts
with a guarded posture to movement, pain with palpation, po.tural dy.function,
decreased active ranq. ot motion, functional disabiliti.o, vocational dY'M
tunctions.
SHORT-TERM GOALS
,1. Increase posture awar.n.ss
,2. O.crease guarded movement patterns
. 3. Oecrease pain with palpatlon to areas of tenderne..
4. Oecreaae p.ln 1-2 points wi~~ active ranqe of motion
5. Increase actlve range of motlcn to the cervical spine and trunk
by 10'
'6. Increa.e actlve range of moticn to the bilater.l upper extremities
and bilateral lower extremities by 10.
07. P.tl.nt educ.tion
,8. Horn. exerclse Frogram
.'
INITIAL EVALUATION
REI Wayne A. Quackenbush
Page 2
June 27. 1994
OBJECTIVE
Posture I The patient present I with a forward head posture and a de era a led
thoracic kyphosis.
palpation. The patient has a palpable trigger point in the left upper
trapezius and complaints of tenderness to deep touch throughout the entire
left upper trapezius and left cervical spine paraspinals.
Active Range of Motion.
cervical flexion - decreased 10\ (9 em). limited by posterior neck
tightness
cervical extension - limited by 50\ (19 em) I secondary to suboccipital
pain
cervical left lateral flexion - decreased 10\ (17 em)
cervical right lateral flexion - (18 cm) decreased 25\. limited by stiffness
cervical rotation - bilaterally decreased 10\. limited by tightness (19 em)
Left Right
shoulder abduction 0-84' "',L
shoulder flexion 0-90' "'NL
shoulder internal rotation 0-55' 0-48'
shoulder external rotation 0-40' 0-65'
The patient is dominant in the left upper extremity.
Strength I All cervical spine pivots are graded at 4-/5 tested isometrically
and limited by pain. JAMAR grip strength is as followSI
pos i tion 11
posi tion III
position IV
Right
54/35/37 (45.3)
66/49/46 (53.6)
41/37/27 (35)
Left (dominant)
53/45/44 (47.3)
57/40/44 (47)
40/36/38 (38)
.rhe value in parentheses is the average.
Special Testsl
cervical compression - positive with pain increasing
cervical distraction - negative with pain increasing
ulnar nerve glide test to right upper extremity - positive with increasing
symptoms in ulnar distribution of right upper extremity at 43. of
glenohumeral flexion
supraspinatus test - negative for left upper extremity
EXERCISE SHEET
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EXERCISES " / i~
I ~ 1.\ tl H
"LEGS" / / / / / / 1/ / / 1/ / / / 1/ 1/ /
(1) Hip & Back / / / / / / 1/ / / 1/ / / / 1/ 1/ /
(2) New Leg Extanslon / / / / / / 1/ / / / / / / 1/ 1/ /
6fJ) Leg Extanslon COM...... ~ % Z % A /' / / / / / / / 1/ 1/ /
--
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-.....
(5) Duo Squat / / / / / 1/ / / / / / / !/ / / /
(6) Leg Curt / / / / / 1/ / / / / / / 1/ / / /
(7) Adduction / / / / / 1/ / / 1/ / / / 1/ / / /
(B) Abduc~on / / / / / 1/ / / 1/ / / / 1/ / / /
(9) Call Ralsa // / / / / 1/ / / 1/ / / // 1/ / / /
I
"UPPER TORSO' BACK"I"SHOULDERS"I"CHEST"
(1) LowerBeck
(2) Hyperextenslons
(4) Pullovel Torso
F',
(5) LAT Pulldown
161 Cable Rowing
! 71 Chest Press
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HEALTHooaJJ7T1J=U
SpoIlS MedICJI1e & RehabllrtallOl1 Cenllll
AuguII: all, ull'&
WaIter C, Peppe1man, 0.0,
B05 Sir Thomas court/suite 3
lIarrisburg. PA 11109
Dear Dr. Peppelmanl
INITIAL EVALUATION
~El WaYne A. ouackenbush
I had the pleasure of evaluating your patient. The pstient
arrives with a diagnosis of acute cervical spine strain and sprain
with an indication of treatment being active and resistive therapeutic
exercises as wel1 as cervical strengthening, general conditioning
starting isometrically, with special considerations being no cervical
spine traction and may transfer to central Penn Fitness Center for
independent conditioning when done and no cervical spine range of
motion exercising.
SUBJECTIVE HISTORY' This patient's present injury stems from a
motor vehicle accident from August 29, 1993. He is familiar with us
as he has had several bOllts of physical therapy since that time. He
terminated his most recent bout of physical therapy secondary to
Dr. Zeliger feeling that "physical therapy had gone as far as
possible," lie was referred to Dr. Peppelman for a consult, Wayne
reports that Dr, Peppelman feels that the kyphotic position of the
cervical spine along with his history of an \IllP are creating his
symptoms and feels that they can be corrected with physical therapy,
lie wil1 then make another appointment with Dr. K. Zeliger for a
recheck, Medications being taken include vitamins and Excedrin. No
tests have been perform~d recently, although the patient has had
previous MRI's and x-rays. lie has an unremarkable past medical
history. Wayne's social history includes being employed as a
packaging agent for the Camp Hi 11 Art Press. This job does not
require any lifting. He has litigation pending in this case. "My
lawyer will not press charges until 1 feel better."
pUBJECTIVE COMPLAlHTS, "1 am at a constant state of 6-1/2 (on a
lo-point pain scale) in my neck, shoulder, and back on the left side."
lie has a loss of feeling in his left hand middle and index finger and
his right hand small and ring fingers, lie is also unable to put his
left al"m over his head secondary to shoulder and neck pain. When
questioned on functional limitations, he is occ~sionally dropping
items at work due to his numbness,
OIlJI:cn VE
lnsoection/Dbael"Vatien' The patient ambulated into the physical
therapy clinic demonstrat ing a gual"ded cel"vical posture, postural
assessment reveals a decreased thoracic kyphosis and cervical spine
lordosis"
INITIAL EVALUATION
RE: Wayne A. Quackenbush
Page 2
August 29, 1994
Active RanQe of Motion:
cervicel flexion - decreased 10\ (6 cm)
cervical extension - decreased 2S\ (19 cm)
cervical left lateral flexion - (lS cml, limited by neck pain
cervical right lateral flexion - (17 cml, limited by neck pain
cervical rotation - bilaterally within norma 1 limits (WNL).
no increase in symptoms
left glenohumeral joint flexion - (tested in supine)
0-100 degrees, limited by pain in left shoulder
strenQth: Al1 cervical spine pivots are tested isometrically and
are graded at 4/S and limited by shoulder and neck pain. Left upper
extremity glenohumeral joint flexion and abduction are graded at 4+/S
isometrically and limited by pain. AIl other upper extremity pivots
are graded at S/S isometrically.
Palpation: Central posterior-anterior mobilizations (P-A's) to
C3 elicit symptoms in the left posterior shoulder area. C6 central
P-'" s elicit symptoms in the posterior uppel- arm of the left
extremity, There are mild restrictions noted at these levels,
Special Tests: Nerve glide testing is as follows for the left
upper extremity: positive ulnar test for numbness in the middle and
index fingers, poeitive median nerve test for shoulder pain, and
positive radial nerve test for increasing left shoulder pain, For the
right upper extremity, testing reveals positive ulnar nerve test for
increasing numbness in the small and ring fingers, positive median
nerve test for vague arm pain, and positive radial nerve test for
numbness in the middle and ring fingers,
[iSSESSMENT: This patient reports with decreased cervical spine
and left upper extremity active range of motion as well as decreased
strength to the cervical spine and left upper extremity, The patient
reports with positive neural findings to the bilateral upper
extremities upon nerve glide testing.
SHORT-TERM GOALS
1. Decrease pain and
2, Increase postural
3. Increase strength
extremity
Improve nerve gliding
Home exercise program
Patient education
numbness in bilateral
awareness
1/2 grade to cervical
upper extremities
spine and left upper
4,
S.
6,
to the bilateral upper extremities
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SHIPPENSI3URG HEALTH SERVICES
1'\ \\,,,1111111111111'111 Ull.1d . ~h'l'llt'tl\.hll g. 1',\ 1 :-;li~ . (71 7} r; 'tlS'.ll . I ^ \ 171;) ~ 't1.1~4C;
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(IIffIll"(lt/'III,C ",ITd,rl
TO:llIt Knill 7.ELlGEH
FIWIII: EllIEL III, NELSON I',T,
IlA TE: SEI'TEIIIIIEH I, t 993
nEF: WA \'NE A, QlIAKENIIlISII . SIIIISEI)lIENTINITIAL E\'ALIIA 1101'1 AS T1tANSFERRW TO
SIIII'I'ENSlIlIIHlI',T,
~14I ~, l.~ 'P.l:
ACl'nrdll1g111 ~""1 Irlel,nl 01 AIII'II~I 2\ 11i4.\ I hnv~ clnluAled Wn~'ne, Ihe 2ft ) eAr old male diAgnosed lIith ocute cervlc:
& lumhAr shnin, ",,"lusion or Ihe kO chest. hllntnal iliAC cleslS, and ,ight knee. Ill' liDS involved in an III V A Ihol occu,n
August 1(, and hc liftS IIcnling a seal hclt Ilesnlls fir the initial evaluation or Augusl 27 lollo\\':
ItANG.: 01' MOHON: I hs em icn!. Ihmaeic and lumhAr spine 'e\'eAlno isolated segmental mobilily as he is hal'ill
sel'ere muscle gua,ding or Ihe illlolled Aleft Ilis fight kllee has improled and he 11011' re\'eals full octil'e olld passh
mobility.
SlItENGHlJ Ill' is Il('h\\\ nllllllal IlIlIclional sl'l'lIglh In cis sl'((JIIdar) 10 Ills pain Ill' displays acule pain in Ihe spi!
mnking it difficult to IUllclionAI
NEtIIH)~SOJn: ills "lid (I'l11l'lallll is II sell'le ht'adacl1l's 1I11t'Ck ami shoulder pAm and ~IIO\I' back pain.
lIis muscles ate in spAsm And Il'I cal mllllmal pAll'alltll1loklAllce Oenlle el1l11plessil'e Imces 10 Ihe cranium cause increasc
poin lJistraction docs nol olfe, an~ rehel
Ill' indicates that Ills IIghl klll'e has IIl1pfOlrll and Ihalllls IS nlleast able 10 lIalk nOlI'
OllU:nllle indll'ates plObkms IlIlh '"ghlma'l's 01 Ihe acclllent alld is ,cccil mg pwlessional counsehllg to deal with Ihis.
FliNn IONAI SI AI \IS Ill' is "IT ""Ik IInh Ihis nrrllt"II1 and is rl11l'l(1\ed alBurlinglon Coal Faelol)' as an assistal
del'al1menlmanAgrl illS .Iob drmands long h'HIIS !'nllls Iccl as IIdl as IIOnlJ!, Wa~lIc has been I'eleran olthe anned fore(
lur l11an) ) cars and has bN'n (lul for ab(lul I \' l'at
l"rsl'l1ll~, he hAS kl\ IllS Al'allm"lIlmlhl' IIAlIl!blllg Alea III siAl IIllh IllS lanlll)' in Shippensburg Ill' is unoble to dril'e an
she 1\ oITellnJ!, SlIl'l'o'l '(11 hn son 11(' nllIhlllal"s 1('11 lIgllll1 nlld SllllllS nn rrllleal or lrunk rotation. Ill' 1110l'ers rrO!
sland In sit to sUl'me Itl\ SI!,1I11 and 'alrllllll lie tolt"alrs sUl'lne IIlth his legs del'aled on a slool. He tolerates silting in
chair and dlSl'lals \('11 Ilgid \II,SIU'C
Wa\lIe mdlcAll'S Ihal ht' has II('('n 11('1 II nil 111 Ihe lIIil11mlnlll1(~11 al home and Ihis makes him frel good Ill' is encouraged I
l'Ontll1ue this fOlm (11 squalit' Iht'lal'~
U\Lt\l~lLNII'tr\Ni M,,,\;,lilll'! 101 pall1managl'lI1l'1lt such as mOlsl heal. cI('clll('al stnllulatloll (TNS),gcntle massagl
1Illln'ollllll 111,,1 a 1'1I'VIIII1\ 1'1 l1\ohlhll l'\t'llIses 11111 be pll'"ded Whl'n he can tolc/att' grcaler trunk mobilily he willi'
l'I"I"o"d 0111" HII h 'qull'lI1l'1I1 as Iht, slall(lllalY bl~l' and tlt'adnllll 111('n he lIill be ellwlIragl'd III lollo\\' through with
~(,lInAI (ol"llllonIIlV I'loglltl11lf1 th(' 1\111111' to 1"I'pa'c him fllf Ihe dl'malllh (II IllS ,job
t 'I JI . /11. J ,,/ 11,. 'I'! . I 1"1,,,'/',01 .ill). '.'/'11' "'1',(, /) /':dl,'/"I'll
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SHIPPENSBURG HEALTI-I SERVICES
-.. _.._._-~--'." -- - ......--.--------.---------.-----
~r.II'"I""III,,II"I1IIl".'t . ~hll'I"''',I,lII~, I'A 1;2,7' (717) ,~Il.,.l~~' FAX (717) ,~(1.194,
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TO: OR. KEITII 7.EI.IG[1{ a, A,
FROM: [TIIEt M. NELSON 1'.'1',
IlA TE: OC TOllEtt 20, 1993 ~. ~ 'P.'r.
REF: WA \'NE A, QlIAKENlIlISII . I>ISCIIAI{GE I{EI'OIH
'J1lis is a I1llalnole al1(1nl Wa~'ne. Ihe 2R )ear old male diagn(1sed with acule cervical and lumbar strain; contusion
10 the len chesl. hilatel al iliac crests and right knee lIe was in a MV A that occurred August 16, According to your
referral of Augusl 2~, he receil'ed a lotal of 10 I'isils His initial el'aluation was August 27 and his latest on
September 24, 1993.
At the time of his last I'isil he had retumed to work in Ihe Ihrrisburg area and was no longer staying wilh his
parenls in Shippensburg I recommended 10 him lhal he transfer back to the office under Peter J. Ray P.T. I did feel
that he would need continued Iherapy for his cervical and lumbar dysfunclions.
lie had retumed to work in anolher jnh capacily and he e'pressed Ihal he was not happy wilh the way they were
treating him since his occident. He e'llIessed signil1cant an,iety and hostility about the situation.
RANGE OF MOTION
Ol'erall, his ccrl'icalmobilily lias slalting to gain acli\ e nlObtlily. hut slIlIlilllited secondary to sharp catching pain.
He mOl'ed wilh I'ery limited segmental mobilily.
lIis lumbar spine was more improl'ed Ihan his cerl'ical. hut he had difficulty perfonning nexibility e,ercises with
his spine because of pain.
fA.Jli
lIe presenlrn \\ ilh most of Ihe pain and sliO'ness in the eerl'ical area lIe persisted to complain of headaches but I
feci they lIele lessening compared to inilially. lie conlinued 10 use the TNS unit and c'prcssed lhat hc fell il helped,
lIe on en lemarked of more len cerl'ical pain and a localized alea at the lower (-spine at (7, on the spinous
process. Onen his cen'ical musculature was presenting \\;Ih spasms in the anterior and posterior muscle groups.
OTIIER
lIe did lolelate more palpation pressure frnm a massage than originally. lIe lias initiated on a progressil'e ond
pent Ie conditioning progrom such as bicycling and perfonning high leI'S and light weighls on Ihe CYUEX
EXERCISE equipment. lIis program was c10scly 1110niloreJ for any difficulty or exacerbations of pain.
(II ernll. he dldmn~e prClgress, hul he sllll displayed significanl pAin and spasms of the cerl'ical orca His full
tl1"htlil~ orthe spine lias stilllncking and he amhulated lIilh apparent sliffilCSS in his torso mobility. I did
enCClurR~e hun to talk II ith ~ ou abouttrnnsferrinll back to Ihe other (1ffice for continued thcrapy.
~
lie is dlschnrped from our Cllllent nics ll1Bnk ~ou for this referral
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CAPITAL AREA PAIN MANAGEMENT CONSULTANTS
INITIAL PAIN MANAGEMENT EVALUATION
Patient'e Name: \..U,,\{,N~~ &1AA('c.r"Jn~
Referring Physician: \<. r(!.u..~~(Z., Date: LP~ ~ '1l(-
Diagnosis: 1. ~'~, \);.w e,l1-l-_ 2. (V"pc.\'-/ f11L(Y\. PtV\'".. ()
History C?f Pr..:se~t Complaint: )~'\1IvY\ ~'ffax\~"l~ k ~ ~
Iff-iV"" htJJ.y f"v,^ if \t'\VAt.l.t~\.j",,;- 1'''\ lM'\ ~~'\0T ill\ f'J93., f,,"V.iJ,;'T \JJW\1
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FAMILY /SOCIAL IIlSTORY I
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Walter C. Peppelman, Jr., D.O.
805 Sir Thomas Court
Harrisburg, Pennsylvania 17109
Phone: (717) 540.3993
Fax: (717) 652-2630
~uqust 24, 1994
Keith Zeliger, D.O.
450 Powers Ave.
Harrisburg, PA 11109
Dear Keithl
I had the opportunity of seeing Mr. Quackenbush in the office today
for his complaints of neck and radicular-type signs and symptoms.
This all started from a motor vehicle accident for which you know
the complete history. This patient has been through periods of
conservative care. He has been treated with physical therapy and
actually had significant relief of all his complaints and was able
to return to work. After returning to work for a period of a few
months he developed some recurrent symptoms. The patient 's
symptoms continue. He was restarted in physical therapy to include
cervical traction. This actually had irritated his symptoms and a
recent MRI was performed which revealed some mild bulging annuli at
the 4-5, 5-6 and 6-1 areas with no evidence of any frank
herniations.
REI Wayne Quackenbush
On my physical examination he is a slender white male. His deep
tendon reflexes are all equal and symmetric. There is no evidence
of any motor or sensory gross deficits. He does have decreased
cervical spine range of motion and tenderness throughout the
posterior cervical-paracervical region.
Due to no evidence of any specific or hardcore findings on his MRl
and his response to physical therapy in the past I do feel that it
would be best to restart him back up on his physical therapy but
have him avoid the traction. I will have him start on a
strengthening and conditioning program and I am going to have him
see you back in a few weeks. If his symptoms worsen, I would be
more than happy to reevaluate him or reassess him at sometime in
the future.
I want to thank you very much.
Sincerely,
OJ/- ~
Walter C. Peppelman, Jr., D.O.
WCPldc
IlEALTH~(QXJ)J{J'i}={J
SpoIlS MedK;me & ReMbMatlOn Center
Augult U, U,.
'.
Walter C. peppe1man, D.O.
BOS Sir Thomas Court/Suite 3
Harrisburg, PA 17109
Dear Dr. Peppe1man:
INITIAL EVALUATION
REI WaYne A. Ouackenbush
I had the pleasure of evaluating your patient. The patient
arrives with a diagnosis of acute cervical spine strain and sprain
with an indication of treatment being active and reeistive therepeutic
exercises as well as cervical strengthening, genere1 conditioning
starting isometrically, with special considerations being no cervice1
spine traction and may transfer to Central Penn Fitness Center for
independent conditioning when done and no cervical spine range of
motion exercising.
".
",
SUBJECTIVE HISTORY: This patient's present injury stems from a
motor vehicle accident from August 29, 1993, He is familiar with us
as he has had several bouts of physical the~apy since that time. He
terminated his most recent bout of physical therapy secondary to
Dr. Zeliger feeling that "physical therapy had gone as far as
possibla." He was referred to Dr, Peppelman for a consult, Wayne
reports that Dr. Peppelman feels that the kyphotic position of the
cervical spine along with his history of an HNP are creating his
symptoms and feels that they can be corrected with physical therapy.
He will then make another appointment with Dr. K, Zeliger for a
recheck. Medications being taken include vitamins and Excedrin, No
tests have been performed recently, although the patient has had
previous MRI's and x-rays. He has an unremarkable past medical
history. Wayne's social history includes being employed as a
packaging agent for the Camp Hill Art Press, This job does not
require any lifting. He has 11 t igat ion pending in this esse, "My
lal>'}'er will not press er.arges until I f~el bet~er,"
SUBJECTIVE COMPLAINTS, "I am at a constant state of 6-1/2 (on a
lo-point pain scale) in my neck, shoulder, and back on the left side,"
He has a loss of feeling in his left hand middle and index finger and
his right hand small and ring til1ge~s. He is also unable to put his
left arm over his head secondary to sholllde~ and neck pain. When
questioned on functional limitations. he io occasionally dropping
items at work due to his nwnbness,
OBJECTIVE
Inscection/ObservatiOIl' The patient ambulated into the ph}'lI1cal
therapy clinic demonstrating Il guarded cervical posture, Postural
assessment reveals a decreased tho~acic kyphosis and cervical spine
lordcsis,
450 Powers Ave, SUI/e 102. Hafflsbur9..PA 17109. (7171558.8511 · Fa~17'7L~~!:~~'L-.
INITIAL EVALUATION
RE: Wayne A. Quackenbush
Page 2
August 29, 1994
Active Ranoe ot Motion:
cervical t1exion . decreased 10' (6 em)
cervical extension - decreased 25' (19 em)
cervical left late=al flexion. (15 cm) I limited by neck pain
cervical right lateral flexion - (17 cm) I limited by neck pain
cervical rotation - bilaterally within normal limits (WNL) I
no increase in symptoms
left glenohumeral joint flexion - (tested in supine)
0-100 degrees, limited by pain in left shoulder
Strenoth: All cervical spine pivots are tested isometrically and
are graded at 4/5 and limited by shoulder and neck pain. Left upper
extremity glenohumeral joint flexion and abduction are graded at 4+/5
isometrically and limited by pain. All other upper extremity pivots
are graded at 5/5 isometrically.
pa1oation: Central posterior-anterior mobilizations (P-A's) to
C3 elicit symptoms in the left postericr shoulder area. C6 central
P-A's elicit symptoms in the posterior upper arm of the left
extremity, There are mild restrictions noted at these levels.
Soecia1 Tests. Nerve glide testing is as follows for the left
upper extremity: positive ulnar test for numbness in the middle and
index fingers. positive median nerve test for shoulder pain, and
positive radial nerve test for increasing left shoulder pain. For the
right upper extremity, testing reveals positive ulnar nerve test for
increasing numbness in the small and ring fingers, positive median
nerve test for vague arm pain, and positive radial nerve test for
numbness in the middle and ring fingers.
ASSESSMENT. This patient reports with decreased cervical spine
and left upper extremity active range of motion as well as decreased
strength to the cervical spine and left upper extremity, The patient
reports with positive neural findings to the bilateral upper
extremities upon nerve glide testing.
SHORT-TERM GOALS
1, Decrease pain and
2. Increase postural
), Increase strength
extremity
Improve nervo gliding
Home exercise progrsm
Patient education
numbness in bilateral upper extremities
awareness
1/2 grade to cervical spine and left upper
4.
5,
6.
to the bilateral upper extremities
WAYNE A. QUACKENBUSIl, ,
,
PLAINTIFF I
I
I
V I
I
GENEVIEVE V. 1I0CK, I
I
DEFENDANT I
IN TilE COURT OF COMMON PLEAS
CUMBERLAND, PENNSYLVANIA
CIVIL ACTION - LAW
NO. 94-3382-CIVIL TERM
JURY TIUAL DEMANDED
DEPOSITION OFl KEITH L. ZELIGER, D.O.
TAKEN BY'
PLAINTIFF
BEFORE I
MARIA N. O'DONNELL, RPR
NOTARY PUBLIC
DATE'
JUNE 29, 1995, 1124 P.M.
PLACE'
450 POWERS AVENUE
HARRISBURG, PENNSYLVANIA
,
I
APPEARANCES I
ANGINO , ROVNER, P.C.
BYI MICHAEL E, KOSIK, ESQUIRE
FOR - PLAltl'l'lFF
LAW OFFICES OF DONALD R. DORER
BY' JEFFREY BAXTER, ESQUIRE
FOR - DEFENDANT
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1 WITNESSES
2 NAME DIRECT CROSS
3 KEITH L. ZELIGER, D.O.
4 BYI MR. KOSIK 3
5 BYI MR. BAXTER -- 25
6
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12 lUCHIBITS
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14 ZELIGER DEPOSITION EXHIBIT
15 1. CURRICULUM VITAE
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P~OOUCBD AND MARKED
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1 KEITH L. ZELIGER, D.O., called as a witness,
2 being duly sworn, testified as follows.
3 DIRECT EXAMINATION
4 BY MR. KOSIK.
5 0 Dr. Zeliger, could you state your full nama for
6 the record.
7 A Keith Lawrence Zeliger.
8 Q And, doctor, do you practice in association with
9 any other doctors?
10 A I am in partnership with Robert Kaneda at East
11 Shore Orthopedic Associates.
12 0 If you could explain the type of medicine that
13 you practice and what is involved in that practice?
14 A I practice orthopedic surgery which is that
15 branch of medicine and surgery that deals with injuries to
16 the musculoskeletal system.
17 Q It you can, doctor, please briefly describe what
18 your medical educational background is?
19 A I attended medical school at the Philadelphia
20 College of Osteopathic Medicine from 1981 to 1985. After
21 which I served a one year rotat ing Internship at Community
22 General Osteopathic Hospital in Harrisburg, Pennsylvania.
23 After whIch passing Pennsylvania state boards, I
24 received a licenss to practice medicine and surgery In the
25 State of Pennsylvania.
4
1 I then served a four year residency in orthopedic
2 surgery at Community Osteopathic Hospital also with
3 fellowships during that time at Jackson Memorial Hospital in
4 Miami, Florida, which was a fellowship in orthopedic trauma
5 surgery.
6 I also spent three months with -- during that
7 time my residency with Dr. Lannie Johnston in Lancing,
B Michigan doing arthroscopic surgery which I completed my
9 residency, served one year fellowship in sports medicine and
10 arthroscopic surgery in Philadelphia, Pennsylvania with Dr.
11 Nicholas Dinubile and Dr. Vincent DiStefano in Graduate
12 Hospital and Delaware County Memorial Hospital, after which
13 I entered into practice at Susquehanna Orthopedic Associates
14 here in Harrieburg, Pennsylvania.
15 And this last year Susquehanna Orthopedic
16 Associates was disbanded, and Dr. Kaneda and myself stayed
17 here at this location reforming a new group called East
IB Shore Orthopedic Associates.
19 Q But essentially you have been at the same
20 physical location?
21 A Five years.
22 Q Five years.
23 The fellowships that you described in addition to
24 your residency, what is the difference in going through
25 these varioue fellowships?
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A When you finish a residency, you have been
trained in general orthopedics and you are expected in four
years to try to learn all of that, during which time you
have the opportunitiee to spend whatever amount of time that
your residency allows and then post residency training for
whatever period of time, either six months or a year to try
and subspecialize within the area of orthopedics, and 1
chose to subspecialize in the areas of orthopedic trauma,
sports medicine and arthroscopic surgery.
Q You mentioned licensing in Pennsylvania?
A Yes.
Q You are licensed to practice medicine here?
A Yes. I received my license in I believe 1986.
Q The license that you have from Pennsylvania, do
you have any certifications in that field?
A Yes, I am board certified.
Q If you can, explain what board certification in
the area of orthopedic surgery means?
A Board certification in any field is a process by
which the people who specialize in that field are trying to
regulate the expertise or level of competency within that
field.
In orthopedics, in the osteopathic prof.s.ion,
there is -- the process of board certIfication Is a
three-part process. It's a wrltt'lIl examillatIon, 1111 oul
-.------.. ~--~....-.."- - ".,~._.,- "-'-'~-'-'--
6
1 examination and a practical examination.
2 The written examination is taken a year after you
3 graduate from your residency, or in case if you do a
4 fellowship usually the year following your fellowship.
5 Once you have accumulated at least 200 major
6 cases, or I -- correction there, after you -- once you have
7 completed the written part of the examination, then the
8 following year, you take the oral examination.
9 Once you have completed the oral examination, you
10 have accumulated at least 200 major cases and the American
11 Olteopathic Board of Orthopedic Surgery defines what those
12 major cases are, you are then allowed to apply for part
13 three. From the time that you apply, within one year the
14 Board of Orthopedic Surgery will find two or three examiners
15 to come to the hospital or hospitals where you practice,
16 review YOllr records, which they can pull all or some, that
17 il up to them and to the rules and regulations.
18 After they have reviewed through those records,
19 they watch you perform surgery, you are required to perform
20 lit least three major cases.
21 And if YOII perform those cases to their
22 satisfactIon, YOllr records are 1111 lip to date, considered to
23 be to their satisfactIon and to the board's satisfaction,
24 and you hllve completed part one and part two successfully,
25 YOII arB then deemed board certified.
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Q So this is a process over and above the licensing
requirements for the state?
A Yes.
Q And it's essentilllly a review by peers of yours,
other doctors who do what you do?
A Yes.
Q Are the requirements more stringent than the
state licensing requirements?
A Yes. State licensing requirements is just a
written examination and an oral examination.
Q You talked about the fellowships. Since becoming
board certified, do you see patients that have traumatic
injuries euch as those which we're going to discuss in Wayne
Quackenbush's caee on a regular basis?
A Yes, we did see a lot in our practice, both my
partner and myself see a lot of patients from -- with trauma
from both motor vehicle and industrial accidents.
We do a lot of workmen's comp and a lot of auto
in our practice.
MR. KOSIKI At this time we would offer Dr.
Zeliger as an expert in orthopedic surgery.
MR. BAXTER I I have no questions and no objection.
BY MR. KOSIK.
Q Doctor
A I have a copy of my --
B
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Q We have covered your qualificatiolls. I was just
going to say that I was going to mark your C.V. as Exhibit I
to the deposition.
(Curriculum vitae produced and mllrked Exhibit No.
1.1
BY MR. KOSIK.
Q I have also had copies made of the records in
this case. I am not going to mark those as an nxhibit,
we're going to use those during the course of the
arbitration.
I see that you have the chart in front of you
though, if you want to during the course of the deposition
in order to answer questions, you know, please feel free to
refer to that. Okay?
A Sure.
Q If you can explain when you first saw
Mr. Quackenbush and what the purpose was when he came into
your office?
A Mr. Quackenbush was referred to me by other
members of his family. I had treated other members of his
fllmily in the past for other problems, and I first came to
see him on August 19th of 1993.
Mr. Quackenbush at that time was I believe 28 or
29 yellrs old, right hand dominant. He provided me a history
that he was involved in a motor vehicle accIdent on August
9
1 16th of 1993.
2 He was the driver of a car, wearing a seat belt
3 ae well as the lap portion and shoulder harness. The car he
4 stated was not equipped with air bags.
5 He was traveling on a road and stated another car
6 failed to stop or yield a stop sign, went through the stop
7 sign. He was traveling he stated approximately 50 miles an
8 hour.
9 And he thought the other vehicle was traveling
10 approximately ten miles an hour, he stated to have a helld-on
11 collision with the front end of his car striking the left
12 side or front left driver's side of the other vehicle in the
13 front left quarter of the vehicle resulting in a rapid
14 deceleration type of event.
15 He stated the seat belt, shoulder harnels
16 remained intact. He was jerked forwards and backwards in
17 the seat, but did not come out of the seat. He denies any
18 loss of consciousness.
19 He had struck his right knee on something within
20 the vehicle, whether it be the center console or the
21 dashboard we're not sure.
22 He denies striking his -- denied striking his
23 head. He stated he put his arm up to block the force or
24 with brunt of the impact.
25 Q With the steering wheel?
11
1 really describing it into the wrist or hand as such.
2 He had some pain in his lower back. It was kind
3 of central, diffuse over the lumbar spine, not relll well
4 localized and with some radiation across the top of his
5 pelvis on both sides. But he was not complaining of any
6 radiation into the buttocks or down either of his legs.
7 We had taken ex-raye at that time of his cervical
8 spine, his collar bone on the left because of the bruising
9 across the shoulder and neck area.
10 His lumbar spine and pelvis because of the
11 bruising acrose the pelvis and x-rays of his right knee
12 because of the complaints or pain along the lateral side of
13 his right knee.
14 All of the x-rays were unremarkable showing no
15 evidence of fracture or other bony pathology.
16 We did note some straightening of the cervical
17 spine though, which is due to muscle spasm instead of the
IB normal lordotic curve which actually means your spine bends
19 backwards in your neck.
20 When we see the spine real straight on an x-ray
21 from the side-view, it usually means there is some muscle
22 spasm.
23 Physical examination of him didn't show any
24 neurological deficits at that time. He had no muscle weak,
25 there were no reflex changes, his reflexes were all okay.
1 He appeared in my opinion at that time he had a
2 cervical and a lumbar strain.
3 He had contusions noted across the chest and
4 pelvic area from the seat belts. And I thought he just had
5 a contusion to his knee.
6 I had written for some physical therapy. He was
7 having a lot of complaints of pain and the headaches, no
B evidence or signs of concussion at that time.
9 Do we had written for some pain medication and
10 were going to recheck him back in two weeks to see if he was
11 improving; sooner, if he had problems.
12 Q The complaints that he made of pain in the area
13 of injuries as well as the ones which you examined, were
14 those consistent with the history that he had described for
15 this accident?
16 A Yes.
17 Q Do your have an opinion to a reasonable degree of
IB medical certainty based upon your examination and the tests
19 that you performed as well as your training and experience
20 as to whether these injuries which you have already
21 described were directly related to this automobile accident
22 on August 16th of 1993?
23 A I believe so, yes.
24 Q Doctor, reviewing your office notes, it appears
25 that you saw him in follow-up treatment during this initial
12
1
13
1 period September 7th, September 21st, October 5th and
2 October 26th.
3
4
Uh-huh.
A
Q
I don't necesellrily wllnt to go into each office
5 visit with you, but maybe if you could describe exactly what
6 type of treatment that you provided to Wayne, how he
7 progressed, give some idea of --
B A Wayne was treated wIth phyeical therllpy, He is
9 from this area, had gone down to Shippensburg where his
10 family was residing and was treated with physical therapy
11 down there.
12 He had also at points complained of a lot of
13 nightmllres. We did get an evaluation with a psychologist.
14 It WBI also recommended an MRI scan of his brain which was
15 unremarkable.
16 He -- the bruising cleared up with the physical
17 therapy. He gradually etarted to get better. And through
IB the course of the next few months, as we stilted, slowly got
19 better and better.
20 We etarted to see more eignificant improvement
21 and on October 26, 1993, actually 011 October 5, 1993, 1 hlld
22 released -- he Will workillg light duty already by thllt
23 point. I wal lookIng for the point at whIch I relellsed hIm
24 to light duty.
25 I thillk we -- it waD sometime following Septembel
14
1 21st, we had released him to light duty. Then on October
2 26th, 1993, we returned him to regular duty, you know,
3 without any restrictione lit that time beclluse he WIIS doing
4 extremely well.
5 Q So he was off work totally for appoximately four
6 weeks up until September 21st?
7 A If that's what the timeframe worked out to be.
8 Q At that time, I saw some notation in your office
9 notes that he actually requested the return to work. Do you
10 recall whether that was something which you suggested or
11 A It's in my September 21st note. At that time he
12 felt that he was doing well enough he wanted to return to
13 work light duty.
14 And we -- that Thursday of that week, that'e why
15 I don't know the exact date what September 21st was, but the
16 ThursdllY of that week we returned him to work at about 20 to
17 25 hours a week still enabling him to go for the PT.
18 He did so, and ultimately through the course of
19 physically there, eventually we did release him on October
20 26th to return to full duty.
21 Q If you could just briefly describe, you know,
22 what is involved in the phys1cal therapy and why that is
23 prescribed for someone with this type of symptoms?
24 A Following an accident, with the amount of trauma
25 involved in this accident, he had enough trauma or there was
15
1 enough of a rapid decelerlltion injury that there was enough
2 force at least of the seat belts against him in holding him
3 restrained that he had bruising across his neck and shoulder
4 and bruising across his pelvis.
5 So in those kind of injuries these patients can
6 develop fairly severe cervical dorsal lumbar strains on
7 occasions and in this case it appeared to be muscular.
B We treated him using modalities, the object of
9 the modalities is to try to relieve the muscle spasm, loosen
10 up the areas.
11 And once we have been able to break up the spasm
12 and the cycle of the muscle spasm, we're then trying to
13 strengthen the areas because through the course of this
14 generally patients will develop muscle weakness.
15 So initially his PT was directed at symptomatic
16 relief followed by functional improvement meaning working on
17 his muscle strength and trying to get him back to his
IB pre-injury level of activity.
19 Q As of the office visit I think on October 26th
20 when you discontinued the therapy, I think you also had a
21 follow-up visit In December, did you recommend that he
22 continue doing eome type of exercise program?
23 A Yes. I had recommended to him at that time and
24 on a number of occasions that he continue to work out on his
25 own. But he had been doing dramatically better, and I told
16
1 him that it was important that for the next several months
2 he continue to work out on own his own, but if he did not,
3 he could end up with recurrent symptoms.
4 Some patients, they stop all together, just they
5 start feeling better and they stop doing it, they'll tend to
6 tighten back up. If all of their strength hasn't returned,
7 they can develop Borne recurrent muscle spasm.
B He said he understood the importance of it, IInd I
9 was going to see him back I thillk just as needed. I think I
10 waB discharging him at that time.
11 Q Were you satisfied with his recovery given the
12 the significance of the initial injuries especially physiclIl
13 therapy for --
14 A Yes. He had done over a period of a couple
15 months, done exceptionally well. He recovered I thought at
16 a reasonable period of time. I mean this was a couple
17 months following October, but as of October in a period of,
IB what, a three-month period of time, if thllt long, he had
19 recovered significantly from this trauma.
20 Q Subsequent to 1993 and the visits which we have
21 already discussed, did Wayne come back to you complllining of
22 any problems?
23 A You lost me.
24 Q After the visits which we have already gone OVer
25 which I think were through December 1993?
17
1
2
3
4
5
6
7
B
9
10
11
12
13
14
15
16
A Right.
Q Did Wayne ever come back to you? Did he have any
problems after thllt?
A Oh, lifter thlll. Okay. Yes. I did see him back,
there was a phone call to our office on May 20th stating
thllt he was having left arm and left shoulder pain for a
period of about two months.
And we wanted to make an appointment to see him.
My pllrtner was on call and called him in a prescription for
some anti-inflammatory medication. And then I saw him on
May 24th.
Q What were his problems at that time? Let me ask
you for clarification, this was the following year, 1994?
A Riqht, May 24, 1994.
Q Okay.
A
Approximately six months after, five, six months
17 after I had seen him last.
IB Q What problems was he having at that time?
19 A He was complaining of pain in the left side of
20 his neck across the left shoulder blade, in his left
21 Ihoulder, down the latter aspect of his left arm, some
22 occllsional radiation on to across his forearm then into
23 the ring alld small fillgers on olle occasion. And another
24 occAsion it was the illdex and long fInger.
25 It wasn't r~III specIfIc to one nerve distributIon
_..__.~._- -"- -......._~.<~.._..~-~._.~~-_...~,.~---+.~----------
18
1 or another. It was very similar to hi5 original complaints
2 from the accident.
3 He was having problems, but it didn't seem to be
4 as severe as initial, but he was having complaints of
5 discomfort.
6 Q Prom your evaluation and the complaints he was
7 making, were you able to determine whether this was a new
B injury or continuation of the previous problem?
9 A Prom the distribution of the pain and he had not
10 described to me any intervening trauma, he did tell me he
11 had not really been doing his exercising. And so it was my
12 opinion that it was just a re-exacerbation or a continuation
13 of his previous condition.
14 Q Did you recommend any additional treatment for
15 him at that point?
16 A I had ordered ~n MRI scan of the cervical spine.
17 And then was concerned whether he could have a herniated or
IB bulging disk in his neck, that was a source of the symptoms,
19 but it really wasn't any -- specific to anyone level. I
20 really thought it was more muscular than it was the disk as
21 such, but with continuation of these symptoms, I thought an
22 MRI was indicated.
23 We ordered it and the MRI scan showed some
24 bulging disks in his neck. They were described as very
25 minimal.
19
1 It was still my opinion thllt this wss really more
2 of a muscular and ligamentous condition and not necessllrily
3 related to the disks.
4 Q UntIl you got the results of the MRI, did you
5 hold off prBscribi 119 any addi Honal physical therapy?
6 A Yes.
7 Q Okay. After you got the MRI back, what did you
B rocommsnd to him?
9 A I recommended to hIm -- he had these bulging
10 diskl. nis symptoml in particular didn't match. There were
11 three bulging disks. The symptoms down his arm could have
12 potentially come from one of these diska beclluse you are
13 talking three nsrves and where it went down his arm, he had
14 symptoml that went down different nerve root distributions
15 at different tImes and where they went could have been one
16 of thele three levels.
17 There was no mUlcle weakness, no reflex changes.
IB I offered him the option of phyoiclIl therapy, epidural
19 steroid injectIons. If it truly was coming from the disks,
20 then an epidural injectIon Ihould quiet the symptoms down in
21 his Ihoulder IInd down hll arm.
22 'fhat' a tho di recti on that he whhed to go lit thllt
23 time hoping thllt would give him the quickelt relief.
24 He had the epidurlll injection and I saw hIm back
25 on 6-24 of 1994.
20
1 He had not had any relief from the epidural
2 injections. That kind of confirmed my opinion that it was
3 not necessarily from the disks, I thought it was more
4 muscular, ligamentous.
5 We had written for physical therapy at thllt
6 time. If he wasn.t having improvement, he was going to get
7 another opinion as to whether or not this might be a
8 surgical treatment or what another opinion as to what other
9 options we had in the way of PT.
10 He -- when I saw him back he really was not
11 improving on July 26th of 1994. And I had Dr. Walter
12 Peppelman who is a spinal surgeon take a look at him.
13 Dr. Peppelman agreed with me that it was not
14 necessarily disk in nature, he really thought it was more
15 muscular ligamentous, did not feel surgery was indicated and
16 recommended continued PT.
17 I saw Wayne back again on 11-1 of 1994. That's
18 the last time I saw him, and on that date he actually -- he
19 was improving at that time. His arm was getting better.
20 His mobility in his neck and shoulder shoulder blade area
21 was better, he had improvement in his strength.
22 I felt he was doing well enough we could stop the
23 physical therapy and that he could continue to do it on his
24 own.
25 I really stressed the importance to him of doing
1
it on his own.
And I told him that r would see him back in
21
-----1
2 three months, if he was having problems sooner if necessary,
3 IInd I have not ssen him since.
4
Q
Okay. Let me just go bsck.
5
You talked about the epidural injections. Could
6 you briefly explain what those are and why they're
7 attempted, what they're supposed to do?
8 A Okay. In /in epidurnl injection, what we're doing
9 is we're if you look at the spinal cord, we call the
10 space right around the spinal cord where the -- you can
11 think of the spinal cord kind of like a tube within a case.
12 And within -- and the spinal cord floats in this
13 casing which is filled with fluid, synovial fluid, which we
14 call the spinal fluid.
15 That space with that fluid fluid is called the
16 dural space. So right around the spinal cord it8elf is
17 called the dural space.
18 The next layer outside of the case that contlllns
19 the fluid and spinal cord is called the epidural space.
20 An epidural space is where If ft disk bulges or
21 herniates, it's will IIctually preas up against this casing
22 thllt contaills the fluid and spillal cord alld so the disk
23 IIctually will herllillte or bulge 111 epidural space. It's
24 also where the nerves come off IInd exit the spine.
25 So ill IIn epidural injection, you are injecting a
22
1 cortisone or cortisone-type preparation the choIce of which
2 is up to the anesthesiologist giving the injection, into
3 that splice, the goal of which is to reduce the inflammation
4 around the spinal cord and around the nerve roots, also
5 reducs the inflammation to the disk itself.
6 And in some cases the epidurals can actually
7 shrink up the size of the bulge or herniation by a
B millimeter or two.
9 The end goal being to try relieve pressure on all
10 of this, relIef inflammation, the end result being to try to
11 relieve pain. Epidurals are not indicated to relieve neck
12 pain or back pain.
13 Thoy're indicated to relieve the shoulder blade,
14 shoulder and arm pain, hand Pllinl in other words, the
15 rlldicular complaints that go down the extremity. And he did
16 not improve from those injections.
17 Q As I understand from your notes, this is actually
IB a course of three different injections.
19 It starts with one injection, can be a serious of
20 up to three injections epread a couple weeks IIpart from each
21 other.
22 Another thing you need to know with epidurals,
23 only seventy percent of the plltients that get them respond
24 to them.
25 That moans eeven out of ten will get better,
26
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
therapy for which he evidently did recover initially?
A Yes.
Q As of October it was your opinion thllt he could
resume full-time work as opposed to the light duty work he
was initially on after September7
A Right. We had initially restricted him I think
20, 25 hours a week, then released him later to full forty
hours a week.
Q And in a letter to Attorney Kosik dated December
14th, I believe that you indicated that at this point he's
working two jobs and you are going to discharge him from
your care?
A Correct.
Q Okay. During that initial period when he was in
to see you, you said that you did take x-rays of the
cervical spine and you noted that there were no bony
abnormalities. What do you melln by that?
A I mean we found no evidence of fracture. We
found no evidence that there were translational changes,
meaning there was no evidence one vertebrae had moved on top
of another. For example, there weren't any dislocations or
subluxations.
Tile only thing we did note is there was some
straightening of the spine which is typical that you see for
muscls spasm.
27
1
2
3
4
5
6
7
B
9
10
11
12
13
14
15
16
17
IB
19
20
21
22
23
24
25
Q If there was II bulging disk, would an x-ray show
that?
A No.
Q Is that something that can only be seen through
an MRI or another type of test?
A Yes, you can generally if you want to find that,
you need to perform an MRI or a CAT scan.
Q And just for the jury, what is an MRI?
A MRI goes by two names, MRI which is magnetic
resonance imaging and the older terminology which went under
NMR, nuclear magnetic resonance is an old technology. It's
not used -- it'e been used by scientists for fifteen years
to define things in the laboratory, but only used by
medicine maybe ten years.
It's a process by which you use a large magnet to
image the hydrogen ions in the cells of the body,
specifically the nucleus of the cells that contain the DNA
and therefore it allows you to get a very accurllte picture
of the anatomy.
Accurate enough it gives you about a seventy-five
to eighty percent accurate picture, it is not 100 percent.
Q ObvIously, it is much more accurate than an
x-ray?
A It's different than x-ray. X-ray is still the
best method we have for looking at the bony pathology. But
20
1
when you are talking about aolt tiasue pathology, you have a
-. ------- ------------1
j
2
choice of CAT scan or an MRI.
3
CA'l' scans are better when you really trying to
4
define again the detailed intricacies in the bony anatomYI
5
I/hereas for soft t1asue pathology, you are better off wi th
6
an MRI.
7
Since later on there was a question about could
B
there be a disk problem, IIn MRI was done because a disk is II
9
soft tissue pathology and not a bony pathology.
10
Q
Because an MRI was lIot performed initilllly in
11 August of 1993 shortly after the accident, is there any way
12 for you to be able to determine whether these bulging disks
13 were present before the accident or after the IIccident?
14
A
No, I am not tryillg to contend whether they were
15 or weren't present prior to the accident.
16 Q I understand, I just want to make lure that --
17 A Right.
IB Q That's clear.
19 A Right. In fact, it '8 my opinion that I don't
20 necessllrily think the bulging dhks are symptomatic in him
21 at all.
22
Q
So in other wordl, so I 11m clear, your opinion 18
23 that it was II muscular type of injury?
24
A
Right.
25
Q
That reoccurred some five or sill monthl attor It
29
1 initilllly had reeolved itself due to perhaps a lack of
2 exercise?
3 A Yes. He was given a prescription to exercise at
4 a health club and when I later on checked on it, he hadn't
5 really utilized it. J mean he had kind of really slacked
6 off on doing the exercises.
7 But now, as I &aid ellrlier, I don't think that
B the disks in him necessarily were his problem. It was a
9 muscular, you know, ligamentous condition quote, unquote.
10 You can also refer to it as a sprain and strain
11 in layman's terms if you want.
12 Q When the epidural injections did not provide him
13 with any relief, did that further support your opinion?
14 A Yes.
15 Q Other than the light duty restriction that you
16 initially put on him with regard to work, were there any
17 other restrictions that you placed on him?
IB A I need to review my records. You are referring
19 back to like September of 1993?
20 Q Yes.
21 A Okay. I am looking at the actual -- I am just
22 trying to find the actual note that I wrote for him to --
23 what I wrote for at that time was -- let's see.
24 I had wri t ten that he could return to work, it
25 Bays 25 hours a week only. May continue with light duty
30
1 times three weeks. Next appointment 10-26-93.
2 Q And after he had this reaggravation of his
3 injuries and he was treated again with physical therapy. At
4 that point, did you place any restrictions on him?
5 A You mean at the time when I first saw him back in
6 May 21st -- 24th rather?
7 Q Did you release him to work again?
B A I don't see it in my note, but I need to
9 sometimes I don't always document that in my note. I need
10 to look through the notes that ~ere written for him and find
11 out.
12 Q Go ahead. Sure.
13 A And find out if he was or wasn't off.
14 MR. KOSIKl Jeff, I think Wayne's testimony will
15 indicate that at that point at least he had tllken a new
16 job.
17 I don't think he had any physical requirements,
IB so it's probably unlikely.
19 MR. BAXTER: I didn't see anything in the
20 records. I just wanted to confirm that.
21 THE WITNESS. Yes, I don I t have anything in my
22 records, so I mean it's very possible he was working through
23 thllt time.
24 BY MR. BAXTERl
25 Q Okay.
1
31
----_...__.._._--_.~-
Q
And 11m I correct that the last time that you did
2 see the pi ainti ff in this case WIIS November 1st, 1994,
3 that's the last office note that you have recorded?
4
A
Yes. November 1st, 1994 WIIS the lllst time that I
5 saw Wayne in this office.
6
Q
To the best of your knowledge, do you have allY
7 further plftlls to see him or are there IIIIY appoilltments
8 schsduled?
9
A
He had one appointment scheduled three months
10 followll1g that if he was etill havillg problems and I have
11 not seen him back. 60 there is 110 plan to recheck him lit
12 this time, it's just thllt if he hilS difficultiel or
13 problems, he'll call and schedule an appointment.
14
15
MR, BAXTERI Okay. Thank you, doctor.
MR. KOSIKI No further queltions.
(Whereupon, the deposition WIIS concluded at 2103
16
17 p.m,)
18
19
20
21
22
23
24
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450 Powers Avenue
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HISTORY AND PHYSICAL
NAME Wr 6<.4-<Q{ ~~
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DECEASED CAUSE OF DEATli
SIBUNGS: ~.k _ ~a.I~
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HABITS:
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FILE
NOTES
8119/93
Wayna presents for el'aluation. On 8116/93, he .'as the driver of a car, .'uring a
seatbelt, both lap and shoulder harness on. The car was not eGuipped with air bags.
lI'hl1e traveling, another car failed to stop or yield to stop sign, pulling out in
front of him, he was traveling at apprC'xiltately 50 mph, the other car .'as trel'eling
somewhere around 10 mph .'hich resulted in him &triking bead on to the other car in
its left front quarter area. As a result of the accident, he .'as significantly
bounced around, denies 10ES of consciousness, but arms up to block him from going
forl/ard into the steering .'heel, struck his forearms on the steering, but the
shoulder .restraint did hold him in the seat as .'ell as lap belt, lie did strike hiB
right knee in the car alC'ng the lateral aspeot, there .'as SOlLe bruising noted and
that was struck possihly on the dashboard, central console, we're nC't sure. There's
some minor bruising to his forearms but this is not very significant, There is some
bru1sil)g from the lap belt along his l1iac crest bilaterally, He hss sign1ficent
bruiSing along the left side of his neck and his clavic1. dC'l," C'nto his chest from
the shoulder herness, He complains of pain in the cervical spine, back and central
portion along the base of the skull radiating along the left side of the neck along
tha trapezius and sternocleidomastoid muscle, up to the ear and across the bas~ of
the jal/. He has significant headaches as a result of this I/ith pain radiating do.~
the arms along the lateral aspect of the Hm and forearm occasionally. lie h81 plin
ill the lumbar spine centrally I/ith radiation bilaterally across the lumbo&acral
junction area, but EO specific radiation do.~ the legs and some pain on the lateral
aspect of the right knee,
X-rays are unremarkable of the cervical spine, claVicle, lumbar spine and pelvis
and right knee,
1 feel he has an acute cervical and lultbar strain and sprain snd a contusion to the
left side of his chest, a contusiC'n to hia right knea and a contusion to his pel-
vis. I'll tteat him with aggressive phYSical therapy, Tylenol with Codaine for pain
control. l' 11 see him in tl/O weeks, In tha interim, he'll remain off of .'ork.
Should he get worse, he'll let me know,
KLZlser
8/25/93
"ayne and his mother stopped by the office this afternoon reque.ting a rafarral
to a physical therapy clinic iq Shippensburg. Wayna I/ill be .taying I/ith hla
parents there. Also requesting the name of a psychologist in Shipp.nsburg
area because of nightmare a and HAs relative to the auto accident. Referral
given for P.T, and patient's mother will call with name of a psychologi.t in
their area so that we mey make the referral per Dr. K. Zeliger, tlb
917193
Seen today in follo"'-up, Aftsr consultation .'1th his physician in Shippenlburs,
an MRI was ordered of his brain becauEe he felt his headaches ~ay ba somewhat mora
neurological and the HRl .'85 nomal. He's actually feeling a little bit bitter in
reletion to his h;:uhr spine, ol'srall is still bothsrsolts but I don't think 1& ..
tad as it was, His neck and shoulders are still somewhat botherse~s. P,T, h.. been
getting ::ca sHrHsi\'e, The)' cr.n now use more .ggressi\'e deep tissue mlnage,
Hretching, cerl'ial tractien and "'111 atply a T!iS unit to help decteau hia
;:rcblett, ! feel "'e need to gi\'e this tit:e 6S he h.d a vsr)' sip1ficant accident,
I sa.' the ;:ict'~res tC'cay in the dfice and 1 think he's I'ery l~ck)' frem the ferce
involved :n t~e Eccid~nt, r~e truising cn his chest Eee~s to hE\'e healed up I'll
~c\t hi..l ::: l-.,..~~ ....\:tKS c:iid ~.t:'ll 1'c;:'.51:1 eli e,f ',,'C'rk ar.d lit that ti:r,~ i1 Le's lead\'
te, will return ~::: to ..erk, If net, t~~n ~e'll te eff ~ntil at such ti:e he's abl~
to rtturn to ....tr~:. :':1 ~i\'€ :~::o F:.cri:-:al to hel;1 \..'ith Leadact:eE.
f:LZlEer
WAYNE QUACKENBUSH
FlLE NOTES
9/21/93
Seen today in f~ll~~-up, His back and neck is doing much better. He's having some
occasional discomfort in the posterior aspect at the base of the cervical spine with
occasional headachea. but nothing like they were. His back overall is feeling much
better, He feels he hu had enough improvement that he'd like to return to work
to light duty this Thursday at 20-25 hrs/week and still go for P. T. and I'm in
agrument with that, I'll see him in two .'eeks. if all ia doing .'e11 at that time.
hopefully we can return him to full duty and discontinue formal P. T.
KLZlser
,
(1.~3.f3 ~.el-tCd-~ 1'~~r~r~
fI. (l~ 1I,(l.. 'f-C,OJ,. ntJ->.J sr,/-9 7tJ 7 .
c:.t I;' ~. . I ~.;- J '1-";" F-'- r .. :. :;I- ~rJl....
9/29/933- Phone Call
Received call from therapist who states patient Is having a problem working and
trying to get to physical therapy. She would like to know if there is any problem
If the patient transfers his therapy back to Harrisburg so he does not have to
drive long distances to therapy.
Told therapist I felt Dr. Zellger would have no problem with patient transferring
his care to P.T., Inc. If that what the patient wishes to do. They will forward
his records to P. T.. Inc.
klr
10/5/93
Hh neck and ~houlders are a littla better. There's littla leu tightnus. his
motion is improved, He has begun strengthening to them, He still geu the head-
aches. they are not as frequent, but they are still severe. As time goes on. 1 feel
the frequency will decreese. although the severity will probebly stay the same and
eventually the &tverity will decrease. Continue P.T., transferring to P,T. Inc,
as he spends more time up here'than he does in Shippensburg and we'll do that. 1'11
see him in three ~eeks. He'll continue light duty.
KLZ: ser
10/26/93
He ia doing very well since ~e law him lalt. He has had a dramatic improvement
in his bsck snd in his neck. He has mostly soreness only with extension of the
neck backwards. but thia is alowly improving also. Ha has done well enough in
therapy that .'e are going to discharge him from foru.al P. T., and give him a
prescription for strensth training to the neck, shouldere. upper snd 10.'P.r
u\trelL1tiu, and lumber spine, at the Central Penn Fitnu3 Center for six
mentha. I'll recheck him in December snd see how he's doing at that point, ~e
are allo giving him a note to return to work full duty, 40 hours a ~eek.
KtZljep
FILE NOTES
WAYNE QUACKENBUSH
5/20/94 - Phone Call
Patient called stating he has had arm and shoulder pain on the left side for
the'past two months. He has an appointment to see Dr. K. Zeliger on Tuesday
and wants to know if he can have something for pain til then.
Per Dr. Kaneda patient 9iven prescription for Anaprox 275 mgs. lq4-6h prn for
pain, #30, with no refill~;. Called to pharmacy.
kir
5/2~/9~
lie "as doing "ell until February "hen he had the onut of pain in his neck "ith
radiation ecrcES the It. shoulder blede. It. shoulder end dolo'll the lateral aspect of
the It. arm. Occaaional radiation of pain in the posterior aapect of the upper arm,
Bcroaa the back of the forearm end into the ring and amell fingers on one occaaion
and another occasion in the index and long fingera.
Phyaical exam aho"'a alight muacle .eakneaa of thumb and index finger pinch to both
hands. as well ea finger abduction and adduction. No other muacle wuknus is noted
on teating. Compreasion of the head cauaea no pain. Impingement aigna in the It.
shoulder.
l'm concerned whether these symptoma may be related to C5-6 diac herniation. He did
improve in the peat "ith therapy. Since it haa returned. we'll inveatigate it fur-
ther. He'll obtain an MRI of the neck. I'll give him Tylenol "ith codeine. I'll
see him fol10"ing the MRI to determine further care.
KLZ:ser
6/2/9~
Seen todsy in follo,,-up. Hia MRI ahOlo'a bulging diacs at C~-5. C5-6 snd C6-7.
There's no direct ccmpresaion on the spins 1 cord or nerve roots, but 1 do believe
they're causing enough inflammation to make him aymptomatic from hia neck dolo'll to
his arms. I'll send him to CAFMC ,,'here the doctors can evaluate him and if they
feel indicated, provide epidural injecticn fer his neck. I think that could provide
him enough relief to make hia pain diminiahed or go e"ay. If it only diminishes
it, then P.T. can be uaed and probably be more effective. I think by relieving his
pain, he'll also be able to sleep better at night and hopefully the aymptoms dolo'll
hia arms "'ill go a,,'a)' and his ,,'eaknesa resolve. I'll see him 5 ds)'a after hie first
epidural injection.
KLZ: ser
6/8/94
Telephone call from .ayne stating epidural injection he received Monday hal
not much helped back pain. He ia Itil1: experianu.~ a let of pain in back,
nack and do.n his arms. Raqueating pain madicatioH. Par Dr. Kanada, Tylenol
('3, (130, I G4-6h prn pain. Callad to Rite Aide pharmac)', i44-0261. tlb
6/22/94 - Fhone Call
Patient called requesting prescription for pain medication. States he is having
problems sleeping at night. Has en appointment to see Dr. Zeliger on Friday.
Per Dr. t:. Zeliger given prescription for Tylenol ~3, '~O, lq4-6 h prn for pain
with rJ refills.
kir
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INITlkL EVALUATION
REI W.yn. A. ~u.ck.nbu.h
PaV' 2
AU9Un 19, 1993
Act1v. Rani' ot ~otionl
c.rvic.l tl..ion - d.c~ 75' ..condary to p.in
c.rvic.l ..tan.ion - d.cr....d 90' ..condary to p.iD
r19ht l.~ tl..ion - d.cr....d 90' ..condary to p.iD
l.tt l.t.r.l tl..ion - d.cr....d ge' ..condary to pLin
rotation - right d.cr....d 80' ..condary to pain
- l.tt d.cr....d 9~' ..condary to p.~
lumbar tl..ion - d.cr....d ~o, ..condary to .titfn...
lumbar .xt.n.ion - d.cr....d 90' ..condary to pain
bilat.ral .id. b.ndinq - d.cr....d is'
rotation - d.cr....d 75\ bil.t.r.lly ..condary to p.in
.bould.r tl.xion - 0-90' bil.t.r.lly ..condary to .tittn... ~
Ant.rior .hould.r
.hould.r Lbduction - 0-90' bil.t.r.lly ..condary to .tittD". in
Ant.rior .hould.r
hip flexion - 0-80' bil.t.r.lly ..cendary to p.L~
kn.. flexien - 0-100' bl1.t.r.lly ..cendary to p.in
hip Lbduction - 0-.5' cil.t.r.lly ..condary to pain
San.ationl Tb. p.ti.nt h.. 10.. ot numbn.., to the bil.t.ral t..t
and nand. wh.n .1..pL~q, ~i. di..PP.Ll. upon wakinq. S.n..tion i.
intact at t.'l1a ti.:D.,
Palpatlclll Th. F.t~ant h.. t.ndle::." to the r ~9ht ltnu, hUataral
ili.c crnts, "515,. clevicd Fu..pin.la. bil.urally, t.'loncic pua.pillAlI
bil.tually, and bil.t.r.l .hould.r.,
ASSESSJol.EllT. Th. fat1er.t a . .8 i'Ll-old, IIhn. mala wi~ . dhljIlo.h
of .~~t8 c.rvlc.l and lumb.r .pr.ln &r.d .tr.in. ccntu.ion of the l.ft lid.
of the ch..t, bll.ter.l ili.c cr.lt., and right kn... Th. p.ti.nt pr...nt.
with a yuud.d pc.tur. to movem.nt, P'L1 wit.'l pI1F.tion, po.taIal dy.function,
d.cr....d activ. rang. at mot~cn, !~1ct~cn.l di.atiliti.., vocation.l dy.-
function. .
SBORT-Tl~~ GCALS
. 1. Incr.... polt~r. .1I.un...
,2. O.er.... iuazded mev.mlnt f't~.rh.
, J, D.cr.... p.L1 "1 t.'l F.lp.t~cn to .U" ot andun...
~. ;,.cr.... f'ln :-. Felnts IIn.'l Ictiv, u.r.q. ot moticn
!. :~,cr.... act~v. unql ct :nCt~'1 "0 tr.. arlH;1l .1'1.:'.. and tr'"W
by :c,
'i. :ncr.... .Ctiv. r.nq. ot :not~cn to tr.. el1.t.r.l upp.r ..czaaiti..
Ln~ ~11.t.r.l lcwer .xtr~t~.. ty le'
P.t~.nt Ic~c.t~cn
':. Hcrn. .xu::.. ,rc,tc.
,I
11UTIAL EVALUATION
REI wayne A. Queckenbush
Page 2
June 27. 1994
OBJECTIVE
Posture I The patient presents with a fo~'.rd haad posturs and a decreased
thoracic kyphosis.
Pelpationl The patient has a palpable trigger point in the left upper
trapezius and complllints of tendarness to deep touch throughout the entire
left upper trapezius and left cervical spine paraspinals.
Active Range of Motionl
cervical flexion - decreased 10\ (9 em), limited by pcsterior neck
tightness
cervical extension - limited ty ~O\ 119 em), seccndary to suboccipital
pain
cervical left lateral flexion - decreased 10\ (17 em)
cervical right lateral flexion - (18 em) decreased 25\, limited by stiffness
cervical rotation - bilaterally decreased 10\. limited by tightness (19 em)
Left Right
shoulder abduction 0-'64 · ..',L
shoulder flexien 0-90. ..1,L
shoulder in te rnd rotation 0- 55. 0-48.
shoulder external rotation 0- 4 O. 0-65.
The patient is dominant in the left upper extremity.
Strengthl All cervical spine pivots are graded at 4-/5 tested isometrically
and limited by pain. J~~R grip strsngth is as follows!
pCli tion 11
position 111
pOlition IV
Right
~4/35/37 (45.3)
66/49/46 (53.6)
41/37/27 (35)
Left (dominant)
53/45/44 (47.3)
57/40/44 (47)
40/36nB (38)
The velue in parenthesel is the average.
Special Tutsl
carvical compression - positive with pain increasing
cervical distraction - negative with pain increasing
ulnar nerve glide test to right ~pper extremity - positive with increasing
I)~ptoml in ulner dietribution cf right upper extremity at 4). of
glenohumeral flexion
supra.pinatus test - negative fcr left uppsr extremity
EXERCISE SHEET
?,A,TIENT'S NAME: Wc-yv.'f:- QVGc.(..'M1 bL.'"S(
DIAGNOSIS: Ik:{.... (~.J.... l\Jw.~~.... .q~-V-~h"f ~~\'fMo,.J(f)d.J tf)l~ Ct-*@(n-
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EXERC:SE SHEE'i
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PROGRESS NOTES
;:
i
PATIENT'S NAME
D~TE
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"LEGS" 1/ 1/ 1/ 1/ / 1/ 1/ 1/ 1/ / 1/ 1/ 1/ / 1/ /
(1) Hip & Back 1/ 1/ 1/ / / 1/ / 1/ 1/ / 1/ 1/ 1/ / 1/ /
12) New Leg Extension 1/ 1/ / / 7 1/ / 1/ 1/ / 1/ 1/ / / 1/ /
(t3l) Leg Extension ""'''''''' I~ ~ % ~ Ih 51 / 1/ 1/ / 1/ 1/ 7 1/ / /
--
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(6) Leg Curl I i/ 1;1 1/ 1/ 1/ 1/ 1/ / 1/ 1/ / 1/ 1/ / 1/ 1/
(7) Adduction I 1/ I~ 1/ 1/ 1/ 1/ 1/ / 1/ 1/ / 1/ 1/ / 1/ 1/
Ie) Abduction I I 1/ 1/ 1/ 1/1 / 1/ / 1/ 1/ / 1/ 1/ 1/ / 1/ /
I ,/ 1/ 1/ 1/ / 1/ / 1/ 1/ / 1/ 1/ 1/ / 1/ /
(9) Call Raise I
, \ 1) Lower Back
(4) Pullover Torso
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HEALTHoowm
SpOilS MedICine <\ Aehabilnal.On Cenler
Au;uat ;I', UU
walter C. Peppelman, D.O.
aos Sir Thomes court/suite 3
Harrisburg, PA 17109
Dear Dr. peppelmanl
INITl1\L EVALU1\TION
~Et Wavne A. Quackenbush
1 had the pleasure of evaluating your patient. The patient
arrives with a diagnosis of acute cerviclIl spine strain and sprain
with an indication of treatment being active and resistive therapeutic
exercises as well as cervical strengthening, general conditioning
starting isometriclll1y. with special considerations being no cervical
spine traction and may transfer to central Penn Fitness Center for
independent conditioning when done and no cervical spine range of
motion exercising.
SUBJECTIVE lilSTORY: This patient'S present injury stems from a
motor vehicle accident from August 29, 1993. He is familiar with us
as he has had several bouts of physical therapy since that time. He
terminated his most recent bout of physical therapy secondary to
Dr. zeliger feeling that "physical therapy had gone as far as
possible." He was referred to Dr. Peppelman for a consult. Wayne
reports that Dr. Peppelman feels that the k)'Photic position of the
cerviclll spine along with his history of an HHp are creating his
symptoms and feels that they can be corrected with physical therapy.
He will then make another appointment with Dr. K. Zeliger for a
recheck. Medications being taken include vitamina and Excedrin. Ho
tests have been performed recently, although the patient has had
previous MRl's and x-rays. He has an unremarkable past medical
history. wayne's social history includes being employed as a
packaging agent for the Camp Hill Art Press. This job does not
require any lifting. He has litigation pending in this case. "I~y
lawyer w111 not press charges until 1 feel better."
SUBJECTIVE COHFLA11lTS: "1 am at a constant state of 6-1/2 (on a
10-point pain scale) in my neck, shoulder, and back on the left side."
He has a loss of feeling in his left hand middle and index finger snd
hls right hand small and ring fingers. He is also unable to put his
left arm over his head secondary to shoulder and neck pain. When
questicned cn functional limitations, he is occasionally dropping
items at ,",ork due to his numbness.
C!!JEC:'1'.'E
1nsoeoticn/Observllticn: The Fat lent ambulated into the physical
therapy clinic aen,cneu'ati:.? B guarded cervical posture, rostural
assessment reveals a decreased thoracic k)Thosis and cervical spine
lordcsis,
JlIITIAL EVALUATlOlf
RE: WI)'l1e A. OUlckenbulh
Page 2
lIugult 29, au
ActivI Ban~e 9f Motion:
cervicIl flexion - decreased lot (6 cml
carvicsl extension. decrealed 25' (19 cm)
cervical left lateral flexion - (15 em), limited by neck pain
cervical right laterlll flexion - (17 em), limitad by nack pain
cervical rotation - bihterall}' within normal limits (WlfL),
no increase in s}'1llptoms
left glenohumerlll joint flexion - (tested in supine)
0-100 degrees, limited by pain in left shoulder
Strenath, All cerviclll spine pivots are tested isometrically and
are graded at 4/5 and limited by shoulder and neck pain. Left upper
extramity glenohumeral joint flexion and abduction are graded at 4+/5
iBometrically and limited by pain. All other upper extremity pivotl
are graded at 5/5 isometrically.
Faloltion: Central posterior-anterior mobilizlltiona (P-A'I) to
C3 elicit s}'1Ilptoms in the left posterior shouldar area. C6 central
P-II's elicit s}'l11ptoms in the posterior uFpel' ann of the left
extremit)'. There are mild restrictions noted at these levels.
Soechl Te~, Nerve glide testing is as follow/! for the left
upper extremit}', positive ulnn test for numbness in the middle and
index fingers. positive median nerve test for shoulder pain, and
positivs rsdial nerve test for increasing left shoulder pain. For the
right upper extremity, testing rpveals positive ulnllr nerve test for
increning numbness in the small and ring fingers, positive median
nen'e test fcr vllt;lue ann pllin, an(1 positive radial ner....e test for
numbne.. in the middle snd ring fingers.
A5SESSI1E111', This patient reports with decreased cll"vical spine
and left upper eRtremity active range ~f motion as well al decreased
strength to the cervical spine and left upper extremity. The patient
reports with positive neurlll findings to the bilateral upper
extremitie. upon nerve glide testing,
SHORT-TEl\l1 gOALS
1. Decreasa pain al1d
2. IntraaBe postural
1. Iner..se strength
extremity
Improv. l1.rve gliding
Homs .x.rcls. prOgrBm
Fatient education
l1umbneu in blhter/ll
aWllrel1eSS
1/2 grada to cervical
upper extremities
apin. snd left upper
4.
I.
I.
to the bilateral upper .xtremities
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SHIPPENSBURG HEALTH SERVICES
~(. \\"'\00111,'11"", tl,,".1 . ~1"1'I'l'o'I'u,~.I'A 1:2,i' 1:1:1 ,W.,'.'J . I A \ 1:171 ,,1I.lul~
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TO: DR. KEITtI l.ELlGER <.~ Il1 k.eO- ~
FROM: ETIIEL M. NELSON I'.T. . .~ r. I ·
DATE: SEPTEMBER I, 1993
REF: \VA YNE A, QUAKENBlISII. SlIBSEQllENT INITIAL EVALlIA TlON AS TRANSFERRED TO
SllIrl'ENSIJllRG r.T.
According to )[lur referral of AlIgUfl 2~, 199~ I hal'e el'aluated Wayne, the 2R year old male diagnosed with acute cer\'1
&. lumbar Flrain; contusion of the \eft chest, bilateral iliac cresll, and right ~nee lie was inl'oll'ed in an MV A that OCCUfl
August 16 and he was wearing a scat bell Rcsnlls of the initial el'aluation of AlIgust 27 follow:
RANGE OF MOTION: lIis cmica\. thomcie and lumbar spine rel'eal no isolated Fegmental mobility as he is ha\"
sel'ere musde guarding of the inl'ohed area Ilis right knee has improl'ed and he now rel'eals full aetil"e and pau
mobility.
STRENGTH: lie is belol\' 1I0lmal fllllctiollal slrength Incl! seeondar) 10 his pain lie displays aeule pain in the 51'
making it difficult to functional
:'lElIROSENSOR\" Ilis chief e[lmplainl is II selcrc "ea,laches 21 neck ami shouldcr pain and~) 101\' back pain.
Ilis musdes are in spasm and rCl'cal minimal palpation tolerance. Gelllle compressilc forces to the cranium cause increa!
pain Distraction does not offer any relief.
lie indicates that his right knee has improl cd and thai his is alleall able to walk nol\'
OTIIER: He indicates problems lIith nightmares of the accident and is reeeiling professional counseling to deal \\;th thi!
JT'\CTIONAL STATlIS: lie is off IIOI~ lIith this accident and is e"'rlo~ed at Burlington Coal Factory as an assist.
derartment manager. lIis job demands long IWIIIS on his fect as \\ell as "fting Wayne has been I'eteran of the anned for<
for many y'ears and has been out for about I ~ car
Prescntl), he has left his apartment in the IlArrisb\ITg AreA to SIA) 1\llh his fan1l1) in Shippel1!burg lie is unable to dril'e f
she is offering support fN her s~n lie amhulates Ie" rigidl~ and sho\\s no cmical or trunk rotation. He mOl'ers fro
stand to !itto supine I'ery !lol\l~ and carefully. He wlerates supine lIilh his legs delated on a stool. He tolerates sitting if
chair and displays \'e~' rigid posture.
lI'a~ne indicates that he has been gelting in the s\\ imll1ing pool at home and this makes him feci good He is encouraged
continue this fonn of aquatic therapy.
JJlE:\ DIENT PLAN: Modalities for pall1managell1cnl such os 1I10lSt heat, electrical stimulation (INS), gemle massa
I,'"'ound and a pr~gram <'f mohility e~ereises 1\111 be rrC'lIded \\11en he can tolerate greater trunk mobility he will
;""~'rmd (1nto fuch equipment as the !tati(1nR~' hike and tn'Admill Then he will he encouraged to foliaI\' through witl
,,,nml conditioning program inlhe f\ltme to prepare him for the demands of his job.
I
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SHIPPENSBURG I-IEALTI-I SERVICES
4" \\',111", ""ll"rnl\"..j . ~I"I'I''''''\>'''~' I'A 17~57' (717) 5~O.5:;33' rA\ (717) 530.1945
;\ MIl'irr ,t' '"r
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TO: UR. I\EITII ZELlGER 8,
FROM: HIIH M. NELSON I'.T.
IlATE: O(lOIlEIl 20, 1993 ~~. ~ 'P.T:
nEF: WA YNE A. QlIAJ<ENlllISII . U1SCIIAnGE REPORT
l11is is a fmal nole al>Clut \\'a~11C. Ihe 2R year Clld male diagnClsed wilh acule eer"ieal and lumbar strain; contusion
to the lell ehest. bilateral iliac crests and fight knee He was in a MV A that occurred August 16. According to your
leferralof Augusl 2\ he I(ceil'ed a total of 10 I'isils. His initial el'aluation was August 27 and his latesl on
September 24. 1993.
At the time of his lut I;sil he had lelllmed 10 \l'ork in the Harrisburg BreB and \l'as no longer Slaying with his
parenlJ in Shippensburg I re.ommended 10 him Ihat he transfer back to the office under Peter J, Ray P.T, I did feel
that he would n~ continued theraI')' for his cerl'ical and lumbar d)'sfunctions.
He had relumed to I\'ork in anolher job capacil)' and he e'pressed Ihat he was nol happy with the way they were
tJulina him since his accident. He e'prmed significant anxiet)' and hostilily about the siluation.
RANGE OF MOTION
Ol'erall, his cerl'ical mobilit)' lias starting to gain aclil'e mobllil)', bul wlllimiled secondary III sha'1' catching pain,
He mOI'cd lIith I'ery limited segmental mobilit)'.
Ilis lumbar spine lias more improl'ed lhan his ce"ieal, bul he had difficulty perfonning flexibility exercises with
his 'pine beeause of pain,
I'...illi
lie presented lIilh mNt of the pain and sliffness in the emical area He persisled to complain of headaches bull
fcelthey lIere lemmng rompared 10 initially. Ile contll1ued to use tile TNS unit and expressed that he felt it helped.
Ile oil en remarked (If more lell emical pain and a localized area althe lower C-spine at (7. on the spinous
process. Ollen his .m'ical rnmculature \1'81 presenling lI;tll spasms in the anterior and posterior muscle groups.
J,H1JER
I Ie did tolmle more palpation pressure flom a massage than originally He lias inilialed on a progressil'e and
penIle condtlic,"ing program such as bic~cling and perfomling high leI's and lisht weights on the (YBEX
t: X I:' RC ISE equipment Hi. program II as closely monitored for any difficulty or exacerbations of pain
(IIrllll. he did rna~e pfl'llrel5. but he filII dilpla~ed lignifieanl pain and 'palms of tile ee"ical arel His full
Innhllll~ "r the Ipme lias 1IIIIIacklnll And he ambulare.! lIith apparent IIfffileSS in his torso mClbilily. I did
rnC('Uflwe hlll1lo lalk II lth you about trlmlhring back to the other [llftce for continued therapy
lie Is dlHhnrprd flom our CIII rent flies l11ank ~ou for this refmal.
'4- _... I '~p"". ,., . \. ''',. ..--. /.....' ';
September 2, 1993
RE: QUACKENBUSH, WAYNE A.
137 Kline Rd.
Shippensburg, PA 17257
AGE: 28
SS/: 189-50-4759
STUDY: MRI of the brain.
REFERRING PHYSICIAN:
John Breneman, MO
PO Box 130
Shippensburg, PA 17257
Excruciating headaches since motor
vehicle accident 8/16/93.
CLIllICAL HISTORY:
I{RI PULSE SEQUENCES:
1)
2 )
3 )
4 )
sagittal Tl
Axial PO & T2
Coronal PO & T2
Axial Tl, GRE
COMHENTS:
The midline sagittal structures appear normal.
There is no evidence of a Chiari malformation. The pituitary gland
does not appear enlarged.
There are no abnormal areas of increased or decreased signal
intens i ty wi thin the bra in parenchyma. No bra in lesions are
evident. The brain stem, cerebellum, and cerebrum appear normal.
There is no mass effect or midline shift.
COIlCLUSIOH:
Negative brain MRI.
Thank you for referring this patient to us.
sincerely, . 1
'l Jtfi(diC"'1:tt!
William B. Mi~1e~, Jr., MD
W/lH/arl
cel Keith Zel1qlr, NO
.. , . ....
CAPITAL AREA PAIN MANAGEMENT CONSULTANTS
INITIAL PAIN MANAGEMENT EVALUATION
Patisnt's Nams: \.!J~l{tJ~" ~\AA(\(.r"JaU'iH
Rafsrring Physician: \<. ~(!'U~(i.(l.,. Oats: '-.P~~'1Lf
Diagnosis: 1. Gv.\-:i'lJ..- ~;'m ~L(-L 2. 'fV(!C.\c../.~,IY\. Pliv\'''- ()
Tv
History ~1' Pr-=-se~t Complaint: ).~ '\.VV'Y\ ~YfM~^l~ \W... ~ f
'ffJ.'r h~~ ('loA"'- f \t'\VJ.lt.lJ.A\~,,^",\- \,^, LU\ f~"\\/;l- 11-\ ?h '3.. fl~"\'JJ.'\-'r 1;)1).,,\'
\"r-..~ r To ~ J .uJ W\ ~,,~ r t Wi! W' ...d.. .,..... ""'-'- ~ v--:. " 1- -p.. liT ~ \Q.
'->.J~ ~\'L ~ v'Ov-nll -k W\II\{... "+......... Vl"IW~. \CA..:l1l{ PIt.1'J.......T l'\oAL~
~oQ... \~J....t.IJ.\,')J ~1uvV\. } Q/1.l.tJ...l...lsA.r-V.JJIlr~LL l1')r\,M ,(JQ..AoI'\. CMvr'I,A"J?
\",W. W'l\b-1lM.; Q~hlAL ~J ~vvvUcJ/6'n ~- "^\ttJ/;;;.r/iJJo/'IT ~ovf fr.iJ.:M
...... Clu.IJl.)'1'\,. ~\(~ lie. -T\l'\fA,^~(.l1 ',\~_,"\'l:!CW~1 c(lv'IL'IW'l-",.t.04-
;..,,11 -\.~ iUY.../fW...v.....J _ '.....- j)...IJ (J.M. l.W\(.\v o...",J. 'f..u..,.)l.. ~
p...........r. V\f\y..-r.." P"'\rr r\.u tL(-[-~'r. Y-w,rr.J...-tw ~~~"".
"0 ~1: \'f-.
" 5ignif..:..cant Past Medical History: l.,'6 rIM H ~. lM..-v UI\+ IMv.A)p; 't
\1-">, J A.f (uJ '( I \ "\ \ ~ ~ 'It J.. 'V" cu.lt.11' .2A-- .
Examination: ~~' S. ('1-...<.... ,."",.J....
\""-"\f Ll>>-.
)f"-(l/V'I CQN...;uJ ro.kt4p I",~
Plan/Recommsndationsl ~ vr,H of ~r~, 1'.
~~~'''J'',\". \'i ly: ':. ~-\,.~{,
\)~(~ t
. /'AtAF~~
Physician Signature
CAPMC
,
\
Capl..::11 Area PaIn ManogL..nent Consultants
2t./J.7 N. il111d St!eG!.
- r - 1- -1" .. " 1-'-, "" ,,-,
r;Qrr:~DJrg, Ftnn:I'\'Jn<J 'I/~I"U' {-fEO:)':'~(le i'I/, .::.t..:.:: I ,....~) ,"',J, ..:::': II,
'~~icrIOtl J WI,ek' I.~ 0
.'eo" l So',le. M 0
DelmoM J r.tll!V. t.\ D.
Elnel' 1. KollomDel.I~ D
Egon Mone.l~ D.
I.~ukull. Porlkh. M D.
Mou.een fol1:lrotherl~ D.
Chorlel D. GrOnltO. M D.
Snorod K Khtlorpol. M D.
17 ..
\.... .
.
JUly 0, 1".
Keith L. Zeliger, D.O.
450 Powers Avenue. Suite 101
Harrisburg. PA 17109-5926
RE: Wayne Quackenbush
Dear Dr. Zeliger:
Thank you for referring Mr. Wayne Quackenbulh for .valuation
and treatment in our pain clinic. I fir.t had the plealure of
meeting Mr. Quackenbush on 6-6-94. At that time Mr. Quack.nbush
agreed to proceed with a series of epidural steroid injections a.
treatment for his left ar-m radicular pain. Accordingly. Mr-.
Quackenbush received cervical epidural injections of eo mg of
Methylprednisolone suspended in 10.0 cc of normal saline on
6-6-94 and 6-20-94.
On 6-30-94 Mr. Quackenbush telephoned our office to cancel
his remaining appointments, At that time he reported that
neither of hia first two cervical epidural ster-oid injections had
provided him with any significant pain relief. Therefore. no
additional treatments were recommended at this time.
Again. thank you for allowing us to participate in the car.
of your patient. Please let us know if we can be of any
additional assistance,
Slnc.rely yours.
{r\\Lk JY 1\jJ\ ~
nlohl.l J. Wi.cks. M.D.
MJW/fb
D 7-HJ4
T 7-6-94
nn'~lI~1\ lu II~lll~l"llU1, J'h, I/.U.
CE"TRAL PE""StLVAHLA SPl"! ASSOCIATE8
80S SIR TIl01W1 COURT ;..,', .
UARRlSBURG, rA 17109'
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^ddlUl 1((0 1~;3>Ai.:r tc City
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RESPONSIBLI! 1'Nm' INFORMATION
liem, Sher a l-lEQS9;10 O_..:>:..I~.lIJI'>:<;~\ -...dl---.ReJ~U~;;_'hl~.V\-\(HfVr.s.
^ddlUl(II OlllellnlFlom^bovel ':;;\.."''"'''''\...';-;:' ~ \1).)1 ' .......'. . .
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liome rhOIlI' ") I) $"9' 7;;l?,,'1 WOlk rhonl' 5odel6tcu~I)'.
Employer
Add,e.. Of Employer
OCClJpeUon
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t:-
P~mery
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~r:~-;- .-~
-
:~Yu__x
INSURANCE INFORMATION .. _. ____, ,..... . .. . "
{""'?~:tfH~..i~ ~l ^ddll:'. f.lc,~. ?ll~-:;. 1J ""':)~t:.,,iC r>'\tv ~
\~'1- :C-47~5 OIOUp Ir~9(\"c.--<:lC:SO
IdenUncIUon · 01 SocIel Seculll)' .
Secondery Celller
fdenUnceUon · or SoclelSecull1)' ·
Sub,cllbellliem, To '",u",nce r, /AY,,'E
^ddleu
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HISTORY OF INJURY'
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'J
1.lnJulY Releled To: Work ^ulo ^ Home OU"n
Dele or Injury Il".. J<:- q 3 II on WOIk, Dele LA.I Worhd .. .' '.
fielu,e Of Problem (Whel Are We lleeUng You rOI)? 10 o..c. \!. , ~.>ll.~ '[""'I.' e~l
Heve You eeen Tleeled Fot^bove Problem? Ye..... Where? .S..:':.<."~I......."""" (), \J'_';-:'>t.~,r A.,(Cl.';; \--t "'-
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W.reX.Re)'llltken? "..~ tio_ Where? c..'......
Femlly Doclor 1:(,1..1,.., L' '2,<-\. c.'.r ^ddlt" ')~.....-L.
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IlEALTlllNFORMATION
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SYSTEMS R!Y!!l!
NAKE_
:1 .
/'.:,-
I
(
( ) STROKE
( ) HEART ATTACK
( ) ANGINA
( ) CHEST PAIN
( ) CIRCULATION PROBLEMS
( ) IIICH BLOOD PRESSURE
( ) CONTROLLED
CARDIOVASCULAR I
RESPIRATORY I
( ) DIFFICULTY BREATHING
( ) ASTHMA
( ) ALLERGIES
"
...J- ( ) MORNING COUGH
/
CASTRO-INTESTINAL.
( ) STOMACH ULCERS () ACTIVE
( ) NERVOUS STOMACH
( ) RECENT CHANGE IN BOWELS
( ) HULED
'\ '.-----
'''-
, ,
,
( ) CONSTIPATION
( ) DIAlUUltA
"
i'..;,.~
( ) FREQUENT NOSE BLEEDS
( ) EASY BRUISING
( ) I.lVER DISEASE
BLEEDING PROFILEl
"
! :....-
.'
.
( ) DIFFICULTY VOIDING
( ) BLOOD IN URINE
( ) INCONTINENCE
( ) PAINfUL URINATION
GENlTO-URINARYI
t;.:-/
( ) FREQUENT HEADACHES
( ) SEIZURE DISORDER
( ) ARTHlIT15
NEURO-MUSCtlLARl
FAHILY/SOCIAL HISTORYI
FATHERI
MOTIIJ!RI
S IBLINGSI
HABITS I
LI VING /
DECEASED
LIVING v/
DECEASED
, OF SISTERS I
, or BaOTIUI\I .~
CIOWTTU/IlA't
CIOAl./IlAY
PIPEI/DAY
corrU/DAY
TEA/DAY
BEER/DAY
LIQUOR/DAY
NAME
IlUJ.T1I STATUS (I"".".
II
CAUSE OF DEATH
( . .
,
HEALTIl STATUS .J.;.1"_'-
.,
CAUSE OF DEATH (
IlEALTI! STATUS C ,;7.,; \...
IlEALTR STATUS
~/", ,/..
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I
-~
,/
-
I ..
~ ,
"I
.
/''1\ ,II "
......' .-...'..
"
(,.,.....l
~,
Walter C. Pappe/man, Jr., D.O.
B05 Sir Thorn.. Court
Harrilburg. P'nnlylvanla 1710;
Phon,: (71 7) 5~0.39;3
Fax: (717) 652.2630
~UOUBt :24, 1994
Keith Zeliger, D.O.
450 Powers Ave.
Harrisburg, PA 17109
Dear Keithl
I had the opportunity of seeing Mr. Quackenbush in the office today
for his complaints of neck and radicular-type signs and symptoms.
This all started from a motor vehicle accident for which you know
the complete history. This patient has been through periodS of
conservative care. He has been treated with physical therapy and
actually had significant relief of all his complaints and was able
to return to work. After returning to work for a period of a few
months he developed some recurrent symptoms. The patient's
symptoms continue. He was restarted in physical therapy to include
cervical traction. This actually had irritated his symptoms and a
recent MRI was performed which revealed some mild bulging annuli at
the 4-5, 5-6 and 6-7 areas with no evidence of any frank
herniations.
REI Wayne Quackenbush
On my physical examination he is a slender white male. His deep
tendon reflexes are all equal and symmetric. There is no evidence
of any motor or sensory gross deficits. He does have decreased
cervical spine range of motion and tenderness throughout the
posterior cervical-paracervical region.
Due to no evidence of any specific or hardcore findings on his MRI
and his response to physical therapy in the past I do feel that it
would be best to restart him back up on his physical therapy but
have him avoid the traction. I will have him start on a
strengthening and conditioning program and I am going to have him
see you back in a few weeks. If his symptoms worsen, I would be
more than happy to reevaluate him or reassess him at sometime in
the future.
I want to thank you very much.
Sincerely,
IJ~~
Walter e. Peppelman, Jr.', D.O.
WC?ICC
HEALTH~OOm
soons M/Id'D.'e a RehIbMa:l()~ Ceme.
I
,
i
Augult 28, 18114
..,
Walter C. peppelman, D.O.
B05 Sir Thomas Court/Suite 3
Harrisburg, PA 17109
Dear Cr. Peppelmanl
INITIAL EVALUATIOI~
RE, WaYne A. ouackenbush
........
I had the pleasure of evaluating your patient. The patient
arrives with a diagnosis of acute cervical spine strain and sprain
with L' indication of treatment being active and resistive therapeutic
exercises as well as cervical strengthening, general conditioning
starting isometrically, with special considerations being no cervical
spine traction and may transfer to Central Penn Fitness Center for
independent conditioning when dcne and no cervical spine range of
motion exercising.
SUBJECTIVE HISTORY, This patient's present injury stems from a
motor vehicle accident from August 29, 1993. He is familiar with us
as he has had several bouts of physical therapy since that time. He
terminated his most recent bout of physical therapy secondary to
Dr. Zeliger feeling that "physical therapy hart gone as far as
possible." He was referred to Dr. Peppelman for a consult. Wayne
reports that Dr. Feppelman feels that the kyphotic position of the
cervical spine along with his history of an liNP are creating his
symptoms and feels that they can be corrected with physical therapy.
He will then make another appointment with Dr. K. Zeliger for a
recheck. Medications being taken include vitamins and Excedrin. No
tests have been performed recently, although the patient has had
previc~s MRI's and x-rays. He has an unremarkable past medical
history. ~ayne's social history incl~des being employed as a
packaging agent fcr the Camp Hill Art Fress. This job does not
require any lifting. He has litigaticn pending in this case. "Hy
lB."'1'"er ",'ill net Frese c;-.arges .~~til r fael bet':.er, II
S1JBJECTIVE COI~FLA!NTS: "I am at a constant state of 6-1/2 (on a
lo-point pain scale) in my neck, shoulder, and back cn the left sid~."
He has a loss cf feeling in his left hand middle and index finger and
his right hand small and ring fingers. He is also ~'able to put his
left arm over his head secondary to shoulder and neck pain. When
~~estioned cn f'~ctional limitaticns, he is occasionally drcpping
items at work due to his n~~~ness.
CB:ECT!VE
:nsoection!Cbservaticn: The patient arr~ulated into the physical
therapy clinic demcnstrating a g~arded cervical pcsture. postural
~ss~&smen: revea:s a decreased thcracic k)~hcsis and cervical spine
.crccs:.s.
450 Powers Ave, SUlle 102 . Hamsburg, PA 17109 . (717) 558.8511 . Fax (717} 558.9317
IIUTlAL EVALUATION
REI Wayne A. Quackanbuah
Page :I
Augult 29, 1184
ActiYI B.na. of I~otionl
cervic.l flexion. d.cr....d 10\ (I cm)
c.rvic.l exten.icn . decr....d 25\ (it em)
c.rvic.l left later.l flexion - (15 cm) I limited by nick pain
cervic.l right later.l flexion' (17 em), limited by nick p.in
cervic.l rot.tion - bilaterally within normal limit. (~~L).
no increase in s}~ptom.
11ft glenohumer.l joint flexion - (tested in lupine)
0-100 degrees, limited by pain in left shoulder
Str.nath: All cervical spine pivots .re tested ilometricelly and
ure gr.ded at 4/5 and limited by shoulder and neck pain. L.ft upp.r
uxtremity glenohumeral j~int flexicn .nd abduction are graded at .+/5
isometric.lly and limited by pain. All other upper extremity pivots
nr. gr.ded at 5/5 isometrically.
Paloaticn, Central pesterior.anterior mobilizaticns (F-A's) to
C) elicit Iymptoms in the left posterior shoulder area. C6 central
P-A" elicit symptoms in the posterior upper arm of the left
extremity. There are mild ustricticns noted at these levels.
SDecial Testsl Nerve glide tasting is as follews for the left
upper extremity, positive ulnar test tor numbness in the middle and
index fingers, positive median nerve test tor shoulder p.in, .nd
pe.itive r.di.l nerve test fer increasing left shoulder pain. rcr the
right upper extremity, t..ting reveals pOlitive ulnar nerve te.t for
incre.sing nu~~nesl in tte small a~d ring tingers, positive median
n.rve te.t for vague at~ rain, and rcsitive radial nerve test for
numbne.. in the middle lnd tin.. fingers.
ASSli:S5MENT I This ratient repertl with decreased cervic.l spine
and l.ft upper extremity active range of motion .s well .1 decreased
&tren~th to the cervical spine and left upper extremity. The patient
rapcrt. with positive neural tindinSI to the bilater.l upper
.xtremities upon nerve glice telting.
SHORr-TERM QChLS
1. Decr.lle pain lnd
~. IncrBII. pCitural
). Incre... strength
exturr.!ty
Improve n.rv. glld1ng
Heme .x.rci.. program
pati.nt education
!i\:IT,bnlll& in bi lat.ral
.......r.n.l.
1/. graca to c.rvical
upper extremities
Ipin. .nd left upper
to the bil.teral upper extremltiel
. .
I.
I.
WAYNE A. QUACKENBUSII, : IN THE COURT OF COMMON PLEAS
: eUMBERLAND, PENNSYLVANIA
PLAINTIFF :
I
: CIVIL ACTION - LAW
V : NO. 94-33B2-CIVIL TERM
I
GENEVIEVE V. 1I0eK, I
:
OEFENDANT : JURY TRIAL DEMANDED
DEPOSITION OF: KEITH L. ZELIGER, 0.0.
TAKEN BYI PLAINTIFF
BEFORE I MARIA N. O'DONNELL, RPR
NOTARY PUBLIC
DATE I JUNE 29, 1995, 1:24 P.M.
PLACE I 450 POWERS AVENUE
IIARRISBURG, PENNSYLVANIA
APPEARANCES,
ANGINO & ROVNER, P.C.
BYI MICHAEL E. KOSIK, ESQUIRE
FOR - PLAINTIFF
LAW OFFICES OF DONALD R. DORER
BYI JEFFREY BAXTER, ESQUIRE
FOR - DEFENDANT
..- ,.- ... ...
PLAlNTlFF'B
EXHIBIT
2
1 WITNESSES
2 NAMS DIRECT CROSS
J KEITH L. ZELIGER, D.O.
4 BYI MR. KOSIK 3 --
5 BYI MR. BAXTER -- 2&
6
7
8
II
10
11
12 BlUfI81'l'8
13
14 ZRLIGRR DBPOSITION BXHIBIT
1& 1. CURRICULUM VITAl
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2:J
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PRODUCBD AND MARKBD
8
3
1 l<EITH L. ZELIGER, 0.0., called as a witness,
2 being duly sworn, testified as follows:
3 DIRECT EXAMINATION
4 BY MR. KOSIKI
5 0 Dr. Zeliger, could you state your full name for
6 the record.
7 A Keith Lawrence Zeliger.
8 0 And, doctor, do you practice in association with
9 any other doctors?
10 A I am in partnership with Robert Kaneda at East
11 Shore orthopedic Associates.
12 0 If you could explain the type of medicine that
13 you practice and what is involved in that practice?
14 A I practice orthopedic surgery which is that
15 branch of medicine and surgery that deals with injuries to
16 the musculoskeletal system.
17 0 If you can, doctor, please briefly describe what
18 your medical educational background is?
19 A I attended medical school at the Philadelphia
20 College of Osteopathic Medicine from 19B1 to 19B5. After
21 which I served a one year rotating internship at Community
22 General Osteopathic Hospital in Harrisburg, Pennsylvania.
23 After which passing Pennsylvania state boards, I
24 received a license to practice medicine and surgery in the
25 State of Pennsylvania.
4
1 I then served a four year residency in orthopedic
2 surgery at community Osteopathic Hospital also with
3 fellowships during that time at Jackson Memorial Hospital in
4 Miami, Florida, whioh was a fellowahip in orthopedio trauma
5 surgery.
6 I also spent three months with -- during that
7 time my residency with Dr. Lannie Johnston in Lancing,
8 Michigan doing arthroscopic surgery which I completed my
9 residenoy, served one year fellowehip in sports medicine and
10 arthrosoopic surgery in Philadelphia, Pennsylvania with Dr.
II Nicholas Dinubile and Dr. Vincent DiStefano in Graduate
12 Hospital and Delaware County Memorial Hospital, after which
13 I entered into praotice at Susquehanna Orthopedic Assooiates
14 here in Harrisburg, Pennsylvania.
15 And this last year Susquehanna Orthopedic
16 Associates was disbanded, and Dr. Kaneda and myself stayed
17 here at this location reforming a new group called East
18 Shore orthopedic Associates.
19 Q aut essentially you have been at the same
20 physical location?
21 A Five years.
22 0 five years.
23 1'h. fellowship. that you dBlcribed in addition to
24 your residency, what i8 the difference in going through
25 these various fellOWships?
5
1 A When you finish a residency, you have been
2 trained in general orthopedics and you are expected in four
3 years to try to learn all of that, during which time you
4 have the opportunities to spend whatever amount of time that
5 your residency allows and then post residency training for
6 whatever period of time, either six months or a year to try
7 and subspecialize within the area of orthopedics, and I
8 chose to subspecialize in the areas of orthopedic trauma,
9 sports medicine and arthroscopic surgery.
10 0 You mentioned licensing in Pennsylvania?
11 A Yes.
12 0 You are licensed to practice medicine here?
13 A Yes. I received my license in I believe 1986.
14 0 The license that you have from Pennsylvania, do
15 you have any certifications in that field?
16 A Yes, I am board certified.
17 0 If you can, explain what board certification in
18 the area of orthopedic surgery means?
19 A Board certification in any field is a process by
20 which the people who specialize in that field are trying to
21 regulate the expertise or level of competency within that
22 field.
23 In orthopedics, in the osteopathic profession,
24 there is -- the process of board certification is a
25 three-part process. It's a written examination, an oral
6
1 examination and a practical examination.
2 The written examination ie taken a year after you
3 graduate from your residency, or in case if you do a
4 fellowship usually the year following your fellowship.
5 Once you have accumulated at least 200 major
6 caoeo, or I -- correction there, after you -- onco you have
7 completed the written part of the examination, then the
8 following year, you take the oral examination.
9 Oncu you have completed the oral examination, you
10 have accumulated at least 200 major casee and the American
11 Osteopathic Board of Orthopedic Surgery defines what those
12 major caees are, you are then allowed to apply for part
13 three. From the time that you apply, within ono year the
14 Board of Orthopedic Surgery will find two or three examiners
15 to come to the hospital or hospitals where you practice,
16 review your records, which they can pull all or Borne, that
17 is up to them and to the rules and regulations.
18 After they have reviewed through those recordB,
19 they watch you perform surgery, you are required to perform
20 at least three major cases.
21 And if you perform those casee to their
22 eatisfaction, your records are all up to date, considsrsd to
23 be to their satisfaction and to the board's satisfaction,
24 and you have completed part one and part two successfully,
25 you are then deemed board certified.
7
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Q 50 this is a process over and above the licensing
requirements for the state?
A Yes.
Q And it's essentially a review by peers of yours,
other doctors who do what you do?
A Yes.
Q Are the requirements more stringent than the
state licensing requirements?
A Yes. State licensing requirements is just a
written examination and an oral examination.
Q You talked about the fellowships. Since becoming
board certified, do you see patients that have traumatic
injuries such as those which we're going to discuss in Wayne
Quackenbush's case on a regular basis?
A Yes, we did see a lot in our practice, both my
partner and myself see a lot of patients from -- with trauma
from both motor vehicle and industrial accidents.
We do a lot of workmen's comp and a lot of auto
in our practice.
MR. KOSIK: At this time we would offer Dr.
Zeliger as an expert in orthopedic surgery.
MR. BAXTER: I have no questions and no objection.
BY MR. KOSIKI
Q Doctor
A I have a copy of my --
8
1 0 We have covered your qualifications. I was just
2 going to say that I was going to mark your C.V. as Exhibit 1
3 to the deposition.
4 (Curriculum vitae produced and marked Exhibit No.
5 1.}
6 BY MR. KOSIKI
7 0 I have also had copies made of the records in
8 this case. I am not going to mark those as an exhibit,
9 we're going to use those during the course of the
10 arbitration.
11 I see that you have the chart in front of you
12 though, if you want to during the course of the deposition
13 in order to answer questions, you know, pleass feel free to
14 refer to that. Okay?
15
16
17
18
19
20
21
22
23
24
25
A
Sure.
o If you can explain when you first saw
Mr. Quackenbush and what the purpose was when he came into
your office?
A Mr. Quackenbush was referred to me by other
members of his family. I had treated other membera of his
family in the past for other problems, and I first came to
see him on August 19th of 1993.
Mr. Quackenbush at that time was I beHeve 28 or
29 years old, right hand dominant. He provided me a history
that he was involved in a motor vehicle accident on AU9uot
9
1 16th of lli113.
2 He was the driver of a car, wearing a seat belt
3 al well a8 the lap portion and shoulder harness. The car he
4 stated was not equipped with air bags.
5 He was traveling on a road and stated another car
6 failed to stop or yield a stop sign, went through the stop
7 lign. He was traveling he stated approximately 50 miles an
o hour.
9 And he thought the other vehicle was traveling
10 approximately ten miles an hour, he stated to have a head-on
11 colli.ion with the front end of his car striking the left
12 .ide or front left driver's side of the other vehicle in the
13 front left quarter of the vshicle resulting in a rapid
14 deceleration type of event.
15 He stated the seat belt, shoulder harnese
16 remained intact. He was jerked forwards and backwards in
17 the .eat, but dio not come out of the seat. He denies any
10 10.. of consciousness.
19 He had struck his right knee on something within
20 the vehicle, whether it be the center console or the
21 da.hboard we're not sure.
22 He denies striking his -- denied striking his
23 head. He stated he put his erm up to block the force or
24 with brunt of the impact.
25 U With the steering wheel?
10
1 A With the steering wheel, but the seat belt held
2 him restrained within the vehicle.
3 When I saw him in the office, we noted that he
4 had bruising across his iliac crest area or across his
5 pelvis. He had some bruising noted across the left side of
6 his shoulder from both the lap portion and shoulder portion
7 of the seat belt.
8 That was telling me there was a fair amount of
9 force involved with the incident. It was a fairly rapid
10 deceleration event.
11 He was noting to hav~ pain in his neck along the
12 left side of his cervical spine, along BS he described here,
13 let me refer to my notes, it says pain along cervical spine,
14 back and central portion of his neck along the base of his
15 skull radiating up the left side of the neck through the
16 trapezius muscle, sternocleidomastoid muscles, he is
17 referring to the muscles in the front of his neck here
18 across the top of his shoulder, across the shoulder and
19 through the upper portion of his back along the shoulder
20 blade area.
21 Q This was primarily on the left side?
22 A Left side. He was complaining of headaches with
23 the pain coming down his arms along the lateral aspect of
24 the arm and forearm occasionally, so it would come down
25 along the other side of his arm through the forearm, not
11
1 really describing it into the wrist or hand as such.
2 lie had somB pain in his lower back. It was kind
3 of central, diffuse over the lumbar spine, not real well
4 localized and with some radiation acroas the top of his
5 pelvis on both sides. But he was not complaining of any
6 radiation into the buttocks or down either of his legs.
7 We hsd taken ex-rays at that time of his cervical
8 spine, his collar bone on the left because of the bruising
9 across the shoulder and neck area.
10 Ilia lumbar spine and pelvis because of the
11 bruising across the pelvis and x-rays of his right knee
12 because of the complaints or pain along the lateral side of
13 his right knee.
14 All of the x-rays were unremarkable showing no
15 evidence of fracture or other bony pathology.
16 We did note some straightening of the cervical
17 spine though, which is due to muscle spasm instead of the
18 normal lordotic curve which actually means your spine bends
19 backwards in your neck.
20 When we see the spine real straight on an x-ray
21 from the side-view, it usually means there is some "macIe
22 spasm.
23 Physical examination of him didn't ahow any
24 neurological deficits at that time. lie had no muscle weak,
25 there were no reflex changes, hia reflaxeB were all okay.
12
1
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lie appeared in my opinion at that time he had a
cervical and a lumbar strain.
He had contusions noted across the chest and
pelvic area from the seat belts. And I thought he just had
a contusion to his knee.
I had written for some physical therapy. lie was
having a lot of complaints of pain and the headaches, no
evidence or signs of concussion at that time.
So we had written for some pain medication and
were going to recheck him back in two weeks to see if he was
improving I sooner, if he had problems.
Q The complaints that he made of pain in the area
of injuries as well as the ones which you examined, were
those consistent with the history that he had described for
this accident 7
A Yes.
Q Do your have an opinion to a reasonable degree of
medical certainty based upon your examination and the tests
that you performed as well as your training and experience
as to whether these injuries which you have already
described were directly related to this automobile accident
on August 16th of 19937
A I believe so, yes.
Q Doctor, reviewing your office notes, it appears
that you saw him in follow-up treatment during this initial
13
1 period September 7th, September 21st, October 5th and
2 October 26th.
3 A Uh-huh.
4 0 I don't necessarily want to go into each office
5 visit with you, but maybe if you could describe exactly what
6 type of treatment that you provided to Wayne, how he
7 progressed, give some idea of --
8 A Wayne was treated with physical therapy. He is
9 from this area, had gone down to Shippensburg where his
10 family was residing and was treated with physical therapy
11 down there.
12 He had also at points complained of a lot of
13 nightmares. We did get an evaluation with a psychologist.
14 It was also recommended an MRI scan of his brain which was
15 unremarkable.
16 He -- the bruising cleared up with the physical
17 therapy. He gradually started to get better. And through
18 the course of the next few months, as we stated, slowly got
19 better and better.
20 We started to see more significant improvement
21 and on October 26, 1993, actually on October 5, 1993, 1 had
22 released -- he was working light duty already by that
23 point. I was looking for the point at which 1 released him
24 to light duty.
25 I think we -- it was 80metime following Beptcmbol
-~.~--_._._----_._-----------,.-
14
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3
4
5
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7
B
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20
21st, we had released him to light duty. Then on October
26th, 1993, we returned him to regular duty, you know,
without any restrictions at that time because he was doing
extremely well.
Q So he was off work totally for appoximately four
weeks up until September 21st?
A lf that's what the timeframe worked out to be.
Q At that time, I saw some notation in your office
notes that he actually requested the return to work. Do you
recall whether that was something which you suggested or
A It's in my September 21st note. At that time he
felt that he was doing well enough he wanted to return to
work light duty.
And we -- that Thursday of that week, that's why
I don't know the exact date what September 21st was, but the
Thursday of that week we returned him to work at about 20 to
25 hours a week still enabling him to go for the PT.
He did so, and ultimately through the course of
physically there, eventually we did release him on October
26th to return to full duty.
21 Q If you could just briefly describe, you know,
22 what 1& involved in the phydcal therapy and why that is
23 prescribed for Bomeone with this type of symptoms?
24 11 Following an accident, with the amount of trauma
2!\
involved in Lilia accident, he had enough trauma or there was
15
1 enough of a rapid deceleration injury that there was enough
2 force at least of the seat belts against him in holding him
3 restrained that he had bruising across his neck and shoulder
4 and bruising across his pelvis.
5 So in those kind of injuries these patients can
6 develop fairly severe cervical dorsal lumbar strains on
7 occasions and in this case it appeared to be muscular.
8 We treated him using modalities, the object of
9 the modalities is to try to relieve the muscle spasm, loosen
10 up the areas.
11 And once we have been able to break up the spasm
12 and the cycle of the muscle spasm, we're then trying to
13 strengthen the areas because through the course of this
14 generally patients will develop muscle weakness.
15 So initially his PT was directed at symptomatic
16 relief followed by functional improvement meaning working on
17 his muscle strength and trying to get him back to his
18 pre-injury level of activity.
19 Q As of the office visit I think on October 26th
20 when you discontinued the therapy, I think you also had a
21 follow-up visit in December, did you recommend that he
22 continue doing some type of exercise program?
23 A Yes. I had recommended to him at that time and
24 on a number of occasions that he continue to work out on his
25 own. nut he had been doing dramatically better, and I told
16
1 him that it was important that for the next several months
2 he continue to work out on own his own, but if he did not,
3 he could end up with recurrent symptoms.
4 Some patients, they stop all together, just they
5 start feeling better and they stop doing it, they'll tend to
6 tighten back up. If all of their strength hasn't returned,
7 they can develop some recurrent muscle spasm.
8 He said he understood the importance of it, and I
9 was going to see him back I think just as needed. I think I
10 was discharging him at that time.
11 Q Were you satisfied with his recovery given the
12 the significance of the initial injuries especially physical
13 therapy for --
14 A Yes. He had done over a period of a couple
15 months, done exceptionally well. He recovered I thought at
16 a reasonable period of time. I mean this was a couple
17 months following October, but as of October in a period of,
18 what, a three-month period of time, if that long, he had
19 recovered significantly from this trauma.
20 Q Subsequent to 1993 and the visits which we have
21 already discussed, did Wayne come back to you complaining of
22 any problems?
23 A You lost me.
24 Q After the visits which we have already gone over
25 which I think were through December 1993?
17
1 A Right.
2 Q Did Wayne ever come back to you? oid he have any
3 problems after that?
4 A Oh, after that. Okay. Yes. I did see him back,
5 there was a phone call to our office on May 20th stating
6 that he was having left arm and left shoulder pain for a
7 period of about two months.
8 And we wanted to make an appointment to see him.
9 My partner was on call and called him in a prescription for
10 soms anti-inflammatory medication. And then I saw him on
11 May 24th.
12 Q What were his problems at that time? Let me ask
13 you for clarif ication, this was the following year, 1994?
14 A Right, May 24, 1994.
15 Q okay.
16 A Approximately six months after, five, six months
17 after I had seen him last.
16 Q What problems was he having at that time?
19 A He was complaining of pain in the left side of
20 hil neck across the left shoulder blade, in his left
21 shoulder, down the latter aspect of his left arm, some
22 occasional radiation on to across his forearm then into
23 the ring and small fingers on one occasion. And another
24 occasion it was the index and long finger.
25 It wasn't real specific to one nerve distribution
18
1 or another. It was very similar to his original complaints
2 from the accident.
3 He was having problems, but it didn't soem to be
4 as severe as initial, but he was having complaints of
5 discomfort.
6 Q From your evaluation and the complaints he was
7 making, were you able to determine whether this was a new
8 injury or continuation of the previous problem?
9 A From the distribution of the pain and he had not
10 described to me any intervening trauma, he did tell me he
11 had not really been doing hiB exercising. And ao it was my
12 opinion that it was just a re-exacerbation or a continuation
13 of his previous condition.
14 Q Did you reconunend any additional treatment for
15 him at that point?
16 A I had ordered an MRI scan of the cervical spine.
17 And then was concerned whether he could have a herniated or
18 bulging disk in his neck, that was a source of the symptoms,
19 but it really wasn't any -- specific to anyone level. I
20 really thought it was more muscular than it was the disk BS
21 Buch, but with continuation of these symptoms, I thought an
22 MRI was indicated.
23 We ordered it and the MRI scan showed some
24 bulging disks in his neck. They were described as very
25 minimal.
20
"
1 He had not had any relief from the epidural
2 injections. That kind of confirmed my opinion that it was
3 not necessarily from the disks, I thought it was more
4 muscular, ligamentous.
5 We had written for physical therapy at that
6 time. If he wasn't having improvement, he was going to get
7 another opinion as to whether or not this might be a
8 surgical treatment or what another opinion as to what other
9 options we had in the way of PT.
10 He -- when I saw him back he really was not
11 improving on July 26th of 1994. And I had Dr. Waltor
12 Peppelrnan who is a spinal surgeon take a look at him.
13 Dr. Peppelman agreed with me that it was not
14 necessarily disk in nature, he really thought it was more
15 muscular ligamentous, did not feel surgery was indicated and
16 recommended continued PT.
17 I saw Wayne back again on 11-1 of 1994. That'a
18 the last time I saw him, and on that dat~ he actually -- ho
19 was improving at that time. His arm was gotting bottor.
20 His mobility in his neck and shoulder shoulder blade area
21 was better, he had improvement in hiB strengl.h.
22 I felt he was doing wsll onol1l1h we could atop the
23 physical therapy and that he could cont.inue 1.0 do it on hls
24 own.
25 I really strollllod I.ho JIIl(lO/ t nlwu III hllll of doing
21
1 it on his own. And I told him that I would see him back in
2 three months, if he was having problems sooner if necessary,
3 and I have not seen him since.
4 Q Okay. Let me juat go back.
5 You talked about the epidural injections. Could
6 you briefly explain what those are and why they're
7 attempted, what they're supposed to do?
8 A Okay. In an epidural injection, what we're doing
9 is we're if you look at the spinal cord, we call the
10 space right around the spinal cord where the -- you can
11 think of the spinal cord kind of like a tube within a case.
12 And within -- and the spinal cord floats in this
13 casing which is filled with fluid, synovial fluid, which we
14 call the spinal fluid.
15 That space with that fluid fluid is called the
16 dural space. So right around the spinal cord itself is
17 called the dural space.
18 The next layer outside of the case that contains
19 the fluid and spinal cord is called the epidural space.
20 An epidural space is where if a disk bulges or
21 herniates, it's will actually pre8s up against this casing
22 that contains the fluid and spinal cord and so the disk
23 actually will herniate or bulge in epidural space. It's
24 also where the nerves come off and exit the spine.
25 So in an epidural injection, you are injecting a
22
"
1 cortisone or cortisone-type preparation the choice of which
2 is up to the anesthesiologist giving the injection, into
3 that space, the goal of which is to reduce the inflammation
4 around the spinal cord and around the nerve roots, also
5 reduce the inflammation to the dhk itself.
6 And in some cases the epidurals can actually
7 shrink up the eize of the bulge or herniation by a
9 millimeter or two.
9 The end goal being to try relieve pressure on all
10 of this, relief inflammation, the end result being to try to
11 relieve pain. Epidurals are not indicated to relieve neck
12 pain or back pain.
13 1'hey' re indicated to relieve the ehoulder blade,
14 shoulder and arm pain, hand painl in other words, the
15 radicular complaints that go down the extremity. And he did
16 not improve from those injections.
17
Q
As I understand from your notee, this is actually
19 a course of three different injections.
19 It starts with one injection, can be a serious of
20 up to three injections spread 4 couple weeks apart from each
21 other.
22 Another thing you nSBd to know with epidurals,
23 only seventy percent of the patients that get them respond
24 to them.
25 That IIIBans SBven nut of ten wi J J (Jet better,
23
1 three out of ten won't get better any way. Even if you give
2 them -- even if it is a disk -- no matter what the pathology
3 is three out of ten people, you know, average, just will not
4 respond to the medication, meaning that their cells of their
5 body, the receptors just don't respond to the medication and
6 they don't react in a positive fashion. So 70 percent of
7 people will improve, 30 percent will not.
8 Q After two injections, Wayne noticed no
9 improvement?
10 A Correct.
11 Q Then if I understand correctly what you have
12 already summarized is that at that point you started him
13 back on physical therapy, formal physical therapy?
14 A Right. I really stressed to Wayne that I thought
15 that it was more of a muscular ligamentous-type condition,
16 more of a sprain and strain and that he had some muscle
17 spasm which had reoccurred and that his neck and shoulder
18 blade area was tight, that he needed to loosen up this area
19 improve the mobility and strengthen it up, so I sent him
20 again for physical therapy. He did eventually improve.
21 When I saw him last, he was doing much better.
22 Q I guess in conjunction with tha~, if I understand
23 correctly, you also made this referral to Dr. Peppelmanl was
24 this essentially just to confirm your diagnosis?
25 A Yes. Wayne was really complaining about the
24
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discomfort and what else can be done. He thought maybe
there might be surgery needed for him, I really didn't think
so.
But I told him that I would send him for another
opinion to see if, you know, see what Dr. Peppelman felt. I
told him Dr. Peppelman's specialty was spine surgery.
And Dr. Peppelman did see him, and agreed with me
that there was no indication for surgery.
o And I think actually you had Dr. Peppelman's
report toward the end of August of 1994, about the one year
anniversary?
A Correct.
o Around the same time period Wayne was showing
some improvement with the physical therapy?
A Right, at that point he was starting to ahow some
improvement. He went on to continue to get better when I
saw him last in November of 1994. It was 1 guess is, what,
about nine months ago, ten months ago, he was doing much
better at that time.
o As of your last evaluation and based upon your
experience and treatment of Wayne, can you let us know what
your prognosis was at that point as faf as what you expected
in the future?
A At that point, my prognosis was excellent for
him. lie had improved enough I t.hought thllt it he continued
25
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to exercise he would go on to full recovery.
I don't know how he's doing in the interim, I
have not seen him since, but at that time I expected that
at least hoped he would go on to full recovery, be able to
return to, you know, gainful employment of whatever kind he
wanted. Really didn't see -- if he had fully recovered, I
didn't really see any or anticipate any restrictions on him.
Q Okay. Let me just follow it up with another
opinion question.
Based upon the history that was provided to you,
your evaluation and office visits with Wayne and the tests
that were performed, do you have an opinion to a reasonable
degree of certainty in your field as to whether the injuries
which you described and the course of treatment over a
period of a year and four months, were directly related to
this automobile accident on August 16 of 1993?
A Yes, it is my opinion that they are.
MR. KOSIK: Thank you. I have nothing further.
CROSS-EXAMINATION
BY MR. BAXTER:
Q Doctor, just by way of review, your initial
diagnosis was that of a cervical lumbar sprain and strain
along with the bruising and the contusion on the knee?
A Correct.
Q Based on that diagnosis you ordered physical
26
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therapy for which he evidently did recover initially?
A Yes.
Q As of October it was your opinion that he could
resume full-time work as opposed to the light duty work he
was initially on after September?
A Right. We had initially restricted him I think
20, 25 hours a week, then released him later to full forty
hours a week.
Q And in a letter to Attorney Kosik dated December
14th, I believe that you indicated that at this point he's
working two jobs and you are going to discharge him from
your care?
A eorrect.
Q Okay. During that initial period when he was in
to see you, you said that you did take x-rays of the
cervical spine and you noted that there were no bony
abnormalities. What do you mean by that?
A I mean we found no evidence of fracture. We
found no evidence that there were translational changes,
meaning there was no evidence one vertebrae had moved on top
of another. For example, there weren't any dislocations or
subluxations.
The only thing we did note is there was some
straightening of the spine which is typical that you see for
muscle spasm.
27
1
2 that?
3 A No.
4 Q Is that something that cen only be seen through
5- an MRI or another type of test7
6 A Yes, you can generally if you want to find that,
7 you need to perform an MRI or a CAT scan.
8 Q And just for the jury, what is an MRI?
9 A MRI goes by two names, MRI which is magnetic
10 resonance imaging and the older terminology which went under
11 NMR, nuclear magnetic resonance is an old technology. It's
12 not used -- it's been used by scientists for fifteen years
13 to define things in the laboratory, but only used by
14 medicine maybe ten years.
15 It's a process by which you use a large magnet to
16 image the hydrogen ions in the cells of the body,
17 specifically the nucleus of the cells that contain the DNA
18 and therefore it allows you to get a very accurate picture
19 of the anatomy.
20 Accurate enough it gives you about a seventy-five
21 to sighty percent accurate picture, it is not 100 percent.
22 0 Obviously, it is much more accurate than an
23 x-ray?
24
Q
If there was a bulging disk, would an x-ray show
A Il's different than x-ray. X-ray la still the
bell melhod we have fOI looking at. t.he bony pat.holoqy. nut.
25
28
1 when you ar~ talking about soft tissue pathology, you heve a
2 choice of CAT scan or an MRI.
3 CAT scans are better when you really trying to
4 define again the detailed intricacies 1n the bony anatomy I
5 whereas for soft tissue pathology, you are better off with
6 an MRI.
7 Since later on there was a question about could
8 there be a disk problem, an MRI was done because a disk is a
9 soft tissue pathology and not a bony pathology.
10 Q Because an MRI was not performed initially in
11 August of 1993 shortly after the accident, is there any way
12 for you to be able to determine whether these bulging disks
13 were present before the accident or after the accident?
14 A No, I am not trying to contend whether they were
15 or weren't present prior to the accident.
16 Q I understand, I just want to make sure that --
17 A Right.
18 Q That's clear.
19 A Right. In fact, it's my opinion that I don't
20 necessarily think the bulging disks are symptomatic in him
21 at all.
22 Q So in other words, so I am clear, your opinion is
23 that it was a muscular type of injury?
24 A Right.
25 Q That reoccurred some five or six months after it
29
1 initially had resolved iteelf due to perhaps a lack of
2 exerciee?
3 A Yes. He was given a prescription to exercise at
4 a health club and when I later on checked on it, he hadn't
5 really utilized it. I mean he had kind of really slacked
6 off on doing the exercises.
7 But now, as I said earlier, I don't think that
8 the disks in him necessarily were his problem. It was a
9 muscular, you know, ligamentous condition quote, unquote.
10 You can also refer to it as a sprain and strain
11 in layman's terms if you want.
12 Q When the epidural injections did not provide him
13 with any relief, did that further support your opinion?
14 A Yes.
15 Q Other than the light duty restriction that you
16 initially put on him with regard to work, were there any
17 other restrictions that you placed on him?
18 A I need to review my records. You are referring
19 back to like September of 1993?
20 Q Yes.
21 A Okay. I am looking at the actual -- I am jUlt
22 trying to find the actual note that I wrote for him to __
23 what I wrote for at that time was -- lel's see.
24 I had written that he could retuln to work, It
25 says 25 hours a week only. Hay continue with light duty
30
1 timee three weeks. Next appointment 10-26-93.
2 Q And after he had thie reaggravation of his
3 injuries and he was treated again with physical therapy. At
4 that point, did you place any restrictions on him?
5 A You mean at the time when I first saw him back in
6 May 21st -- 24th rather?
7 Q Did you release him to work again?
8 A I don't see it in my note, but I need to
9 sometimes I don't always document that in my note. I need
10 to look through the notes that were written for him and find
11 out.
12 Q Go ahead. Sure.
13 A And find out if he was or wasn't off.
14 MR. KOSIK: Jeff, I think Wayne's testimony will
15 indicate that at that point at least he had taken a new
16 job.
17 I don't think he had any physical requirements,
18 so it's probably unlikely.
19 MR. BAXTER: I didn't see anything in the
20 records. I just wanted to confirm that.
21 TilE WITNESS: Yes, I don't have anything in my
22 records, so I mean it's very possible he was working through
23 that time.
24 BY MR. BAXTEH:
25 Q Okay.
\
31
1 Q And am I correct that the last time that you did
2 see the pleintiff in this case was November 1st, 1994,
3 that's the last office note that you have recorded?
4 A Yes. November 1st, 1994 was the last time that I
5 saw Wayne in this office.
6 Q To the best of your knowledge, do you have any
7 further plans to Bee him or are there any appointmente
8 scheduled?
9 A He had one appointment scheduled three months
10 following that if he was stHl having problems and I have
11 not seen him back. So there is no plan to recheck him at
12 this time, it's just that if he has difficulties or
13 problems, he'll call and schedule an appointment.
MR. BAXTER: Okay. Thank you, doctor.
MR. KOSIKI No further questions.
(Whereupon, the deposition was conclUded at 2103
14
15
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17 p.m. )
18
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