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Home My WebLink About94-06844 c o IIJ i llj . ., ~ r <J) E: '- ~ . -2 ~ - >- ~ .1:... .. -or= I, I , .n ~~~ ' : ;~, :"; .;,,. <:,"> .... I '1, \ .- :r. .. -, . .' N ~ :;l UI j ~ <( ~ ~ e ~n~~i cllHUlX) ~18l~~ .J 9..02 o ~ (oa:~ Z l E" g ~ <( A ! It ~ <( 8 ~ N o ~ l l'l ~ ~ t-~ !:: .. ...-, ~ . IrBPBD L. BIUlJtO, JR., IIIQUI" Pa. Supr... Court 1.0. KO. &11~1 RBYHOLDS " HAVAS 101 pin. st....t Po.t Offic. Bo. 932 Bar..ilburg, p.nnl,lvania 11108-093~ or.l.phon.. ra.. [111J 236-3~00 [111 J 236-6863 Attorn., for Def.ndant. lAM c. STBVENSOK v. IN THE COURT OF COMMON PLEAS CUMB~RLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW : NO. 94 6844 CIVIL TERM DEBRA A. GEORGE, plaintiff IAN C. STEVENSON, Defendant JURY TRIAL DEMANDED ANSWBR OF DBPENDANT, IAN C. STBVBNOON TO PLAINTIFF'S COMPLAINT AND NOW, comes Defendant, Ian C. Stevenson, by and through his attorneys, Reynolds and Havas, a professional corporation, and files this Answer to the Complaint of plaintiff, Debra A. George ("Plaintiff"), alleging the following in support thereof: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. 5. Admitted. 6. Admitted. 7. Admitted. 8. (a)-(d) Denied. The allegations contained in this paragraph state a conclusion to which no response is necessary. By way of further answer, it is specifically denied that any . - .- conduct on the part of Defendant was negligent, carelessly, wanton or reckless. 9. Denied. After reasonable investigation, Defendant is without knowledge or information sufficient to form a belief as to the truth of the averments contained in this paragraph and, therefore, they are denied. 10. Denied. The answer contained in paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 11. Denied. The answer contained in Paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 12. Denied. The answer contained in paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 13. Denied. The answer contained in Paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 14. Denied. The answer contained in Paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 15. Denied. The answer contained in Paragraph 9 hereof is incorporated herein by reference as if set forth in its entirety. 2 )~.t DAILY ATTENDANCE RECORD \ ; ; . , FMEDEBlIA GEORlnl DEPARTMENT ri:, l' 3 4 5 6 7 6 910 1112131415161716192f 2122 3[425t)627~93( 311A AI .iAN FEB Ix )( MAR 1>< [>(1 APR Ix X MAY )( [Xl X JUN i~ V r X- X JUL )( ~ AUG IX X [)( Ix Ix 1)(1 IX XX )( X 1)( 1)( I . 1 , x ) 1)( 'j( )( . , ! "\. )( X X )( 1')( 'V~ . 1 x X X k' ~ X )( . l 1 SEP OCT NOV DEe X' I)( X 1')( ~ X r')()( ~IX A - Accident al Work AH - Accident al Home o - DIaClplinary Layoll FO - Family Death IX X X A X IYI 1)( X )( FI - Family lllne.. L - Lea.... of Ab.ence YEARLY TOTALS H - Holiday LO - Layoff '- _ I -lIioo.. P - Personal Ae..ena J -Jury Duty V -VacatiCn X -Unknown Daily Attendi /11tf ~.. DAILY ATTENDANCE RECORD E Ej Eo./C(j l:, J>l!#J1Ur DEPARTMENT 1 3 4 5 6 7 6 9 X lIOO13 14 15 16 1 181~ 4~311AIAH .)AN X FEB )( )( )< I) MAR 1)( IXI X I) APR ~ t><1 IX X X MAY '} ) )( lX 1)( JUN JUL AUa SEP OCT NOV DEe A - Accidenlll VoI:lI1< A - Femily 1l1ne.. L - \.Ia... o' Abaanco YEARLY TOTALS AH - Accident II Home H - Holiday LO - \.Ivotf o -DiacIc>IInarylayo/l I -III..... P - Peroonal Reuons Attendal FO - Femllv Delth J - ""IV Duty V - VacatJon X - Unknown Dail y - /17 ~ II . DAMAGES Pursuant to Pa. R.C.P. 1305, Plaintiff's counsel has provided defense counsel will the Plaintiff's medical records and work loss records. A. Medical treatment Mrs. Ceorqe was seen by her family physician within thirty minutes after the accident. Her family physician is located within two miles of the accident scene. Mrs. George was examined by Dr. sangillo. Dr. sangillo's office note, attached as Exhibit A, confirms that Mrs. George was experiencing left cheek and right anterior knee pain. Dr. Sangillo's diagnosis was abrasion to the left cheek and a right knee strain. B. Dr. Michael Innes - ChiroDractor Mrs. George saw Dr. Michael Innes on March 3, 1994, the day after the accident. She was experience neck and right knee pain, as well as a headache. Dr. Innes provided chiropractic manipulation, as well as various physical therapy modalities on a regular basis until July, 1994. At that time, due to Mrs. George's continuing right knee symptoms, Dr. Innes referred Mrs. George to Dr. Bruce Goodman, an orthopedic surgeon. Attached as Exhibit B is Dr. Innes' August 24, 1994, report and records. C. Dr. Bruce Goodman As instructed, Mrs. George saw Dr. Goodman on July 12, 1994. His diagnosis was chondromalacia of the right patella. He 2 . ., , ., .. .~~~ ~. C,t'D'C'" ~.- ~ L {l,v" ~ f 9 \~ \V\>J .."" 'I... \v I.... ~ C, I ~o.; ,J . . ." , PAGE NO. .3', ,., (0 "~~'l:- pI..", ~} \::...... ~ pt. was oot on Wertzville Road in the snowy weather a short time ago when the car caning towards her loot control and they both slid. Her car struck the side of his ClIr, and she believes she took the :lrrpact going straight fOIWard. Her air bag opened. She was wearing a seatbelt. She now catplains of serne mild pain in the left cheek and right anterior knee, not severe. 0: Exem shows that the left cheek is diffusely erythematoos and s1. swollen, but there's no tenderness of the underlying bony structures. Tiny lip laceration. Exem of the right knee shows mild to rroderate tenderness of the superior aspect of the patella: there's a tendon I'm able to roll back and forth that'!! painfUl there, but the bony patella is not at all tender. Jnol is nollTllll, lllthough she hlls pain with the extreme of flexion. A: StlltUS post MVA with abrasion to the left cheek and right knee strllin. Ibuprofen 500 rrg q. 4-6 hours, heating pad to the neck if it becorrea painfUl, advised her that she may stiffen up over the next day or two, and it mey be I'.Qrse before it jrrproves. Let us know if these areas are becaning severely painful, otherwise recheck prn. PUI. CKS/ag 3/4 OJ .3~ 11,= "v-l \..I...~ ~..., _'-'^"'-':> 3.,..l.;1. qy ~:,;:~~,:;. .~~~ "'/~~P~i ,"'yr. ,..,/a. S';". . tv/4 9:,S- . "'/I~ .. /:,)(/" "3...:...>fl'.. ,P.I). . '>--I. /'). 1:,/. "'((>r~' l:. /,1 I- -tf'- ,'lcpwLc,J .t" 01(' rve ~~. - h Nj'1tJ.. pI u /w&- Effective natural relief from: Headaches Neck Pain Arm/Hand Numbness Carpal Tunnel Syndrome Low Back Pain Leg Pain Leg/Foot Numbness Joint Pains Offering specialty services: Rehabililalive Exercises Nutritional Consultation Physical Therapy Child and Prenatal Cafe -j , Innes Chiropractic Center Long lasting reliel...with a personal touch August 24, 1994 David Lutz 4503 North Front street Harrisburg, PA 17110 RE: Debra George Accident Date: 3/2/94 Dear Mr. Lutz: In response to your letter of August 16, 1994 in which you request information concerning the above named patient, I have included a copy of my initial report, the initial x-ray report, the neck disability index which contains a visual analog pain scale and a personal injury patient history as well as a subjective complaint form. All of the documents are dated 3/3/94 which was the first date that I saw the patient. This will provide you with the initial history, the patient's condition at the time of first contact as well as my diagnosis and treatment plan. The patient was then seen on a schedule of four times a week for two weeks and two times a week for four weeks. I have included copies of office notes from March 4 through May 16, 1994. On May 16 she reported exacerbation due to walking. It was my opinion that this patient would respond well to a strengthening program and she was subsequently referred to Dr. Knight with the request that she be evaluated for the advisability of entry into a rehabilitative strengthening program at the Keystone Rehabilitation Service. We continued seeing her again on May 24 in our office and she received an interim examination on 6/14/94. At that time I learned that she had not followed my advice to consult with Dr. Knight and had instead consulted her HMO doctor who refused to make referral. For the continuing problem with the knee I made referral to Dr. Lippe for the evaluation of that problem. Apparently, due to other situations, Dr. Lippe would not accept the referral so on July 7 we examined the patient again, determined that she had reached a position of resolution as far as the cervical complaint and referred the patient to Dr. Bruce Goodman on July 12 for a full evaluation of the knee. She was seen by Dr. Goodman on July 12 and I have also included a copy of that report for your records. I have not received any additional follow-up from Dr. Goodman as I have already stated as far as this office is concerned she did recover Michael H. Innes, D.C. 1l1plllrll,llt. of IIIl' N.llltHl.lIllu,ml uf Chirtlpr.lCli( (\.lminl'l\ 1',llnll'l C\,lll.~t. of Chiropr.l(hr - M.I~II.1 rurn l.lIlth' 1 (1;-7 Ihl'tnt'., Indu\lri.ll C1mopl,lfhr Ctlrl'ull,UlI\ II\l[~l r 1'1 IIIit'd lI\ Di~;\"il.l~' Il11p.lifllll'fll f\.lhllp ()Il,lllllt'd .1\ Il/l ('Pl'tl\\'llnt'H 3438 rrindll: Road Camp Hill, PA 17011 (717) 737-2121 Effective natural relief from: Headaches Neck Pain Arm/Hand Numbness Carpal Tunnel Syndrome Low Back Pain Leg Pain Leg/Fool Numbness Joinl Pains Offering specialty services: Rehabilitative Exercises Nulritlonal Consultation Physical Therapy Child and Prenatal CMe Innes Chiropractic Center Long lasting relief...wilh a personal touch David Lutz RE: Debra George - Accident Date: 3/2/94 August 24, 1994 Page 2 fully from the cervical problems. We were unable to help her any more with her knee and have referred her out. To conclude, the prognosis in thi~ case is good as tar as the cervical complaints, although she has continued to show positive patellar scrape sign on the knee which I felt was a result of the accident. You will notice from the subjective history of 3/3/94 that the patient did state that the knees went into the dashboard which I believe caused the injury to the patellar. I will, however, defer prognosis on that injury to Dr. Goodman as he is now the treating physician for that problem and it will be under his care that she resolves or does not resolve since we were not successful in helping that area. As tar as your question regarding the cost of future treatments in our office, there will be none as she has been released from our care. In closing, I would like to state that it is my opinion based on a reasonable degree of chiropractic certainty that the client's injuries and treatment that was provided were directly related to the auto accident. This opinion is based upon the history given to me by the patient, the results of my examination and x-ray findings, the progress exhibited by the patient and my experience in cases similar to this. If you have further questions, please feel free to contact my office. !Z2, Attachments: Initial Report - 3/3/94 Initial X-ray Report - 3/3/94 Neck Disability Index - 3/3/94 Personal Injury Patient History - 3/3/94 Subjective Complaint Form - 3/3/94 Report from Dr. Goodman - 7/12/94 Michael H. Innes, D.C. Diplorn,llt' ulthe N.llion.ll Board of Chiropr.lclic h..unincrs r,llrlll" Collt'[l.l' of Chiropr.lC!lC - M.llln.l Cuml.\ude 1977 nU!~inl'~l> 100hl\1ri"I Chimpr,ltlic (omuh.lOh (IlleS) (crh(ll,d in DisJudllY hnpairnwnl RalHlRs QIJ.lhfll.d.H ,10 hpl'rl \\'llm'B 3438 Trindle Road Camp Hill, PA 17011 (717) 737-2121 ) J '- \ ~ Deb George 3/3/94 SUBJECl'IVE: She was involved in an automobile accident on 3/2/94 at approximatelY 1:05PM. Deb was the driver of a 1990 Dodge Shadow which was struck in the front in a head on colliaion. Damage to the car was approximately $3,ODO or more. visibility at the ti.. of the accident was poor and conditions were icy. Patient atate. MI was pushed forward then went back against the seat-. At the time of impact the patient was warned that the accident waG about to happen. she did see the accident but was unable to brace for the impact. Seat belts were worn and she was wearing a shoulder harnesS. The car does have a head rest and it waG po.itioned with the top of the head rest even with the top of her head. Her car was braking and she estimates her speed at about 25-30 mile. per hour. The other car was travelling at approximately the .ame rate of speed. At the time of impact, she had her head n a straight forward position with her body in a straight forward .itting position. At the time of the accident she recalls that her face was hit by the air bag and her knees went into the dashboard. Her head hit the back of the seat. After that she was shaken up but could function. She could move all of her body parts, sh. was able to get out of the car and walk unaided. She did get bleeding cuts in the form of a small cut on her lip and the left side of her face and also a brush burn type injury on her left elbow. Sha also has bruises on her knees. Immediately after the accident she felt like someone had hit her in the face and her right knee was .titf. Later that night she felt stiff allover. The next day she had pain on the left side of the neck with bruised knees and stiffnes. allover. Since the accident the patient has been SUffering from headaches, neck pain, stiffness and mid back pain. Work history: Patient is employed as a bookkeeper at Rubin Brother. Company, Inc. She has missed time from work today. Doctors seen: Immediately after the accident she was seen by the Good Hope Family Physicians where she was examined and no x-rays were taken. She was given treatment in the form of Ibuprofen for pain. She was seen on 3/2/94. Similar symptoms: Patient denies any physical complaints immediately prior to the accident. She had similar symptoms from another accident years ago but those had resolved tor the most part. She had been having some numbness into left hand. That had been under control ~ecently. . Activities of Daily Living: So far she has noticed difficulty in activities of daily living. she is having pain while coughing or sneezing. She has diffiCUlty turning over in bed. She has pain with kneeling, difficulty balancing, climbing, sleeping, stooping I ' , -\ ~- , Deb George 3/3/94 Page 3 and reaching. Also sh~ notes that she is having difficulty just moving long periods. Pain Lev.l: She rat.s on a Borg scal. h.r pain to be acd.rat. graded at 6. She describes the accident as the other car lo.t control and came into her lane of travel. Th. headache i. d..cribed a. a dull constant headache. OBJECTIVE: Blood pressure on the left was 134 over 80. cervical range. of motion; forward flexion 40 degrees with pUlling pain in the baa. of the neck. Extension 40 degrees with a lack of normal motoricity at the upper three cervical vertebrae; all mov.ment. are taking place in the lower cervical spine. Right lateral flexion i. 15 degrees with a lack of motoricity at C1,2 on the right. Left lateral flexion; 25 degrees. Right and left rotation 60 d.gr.... Foraminal compression, Jackson's compression, basilar compr.aaion and Spurling'S compresaion are negativ_.. She doea g.t pain on the left side of her neck on Spurling'S compresaion but with no radiation. She also has pain on extension and flexion but no radiation. Cervical musole strengths are graded at +1 full range and full range of motion in all directions and she doe a get pain on all movements, especially into the left lower part of her neck. Upper extremity muscle strengths are good and equal bilateral. The light touch, vibratory sonsation, cold sensation and clonus are negative bilaterally. She does have reduced sensation at the C6,C7 dermatomes on the left hand. The deep tendon reflexes of biceps, triceps and brachial radialis are +3 bilateral. . Lumbo dorsal examination; lumbo dorsal ranges of motion are full and painless. Gait analysis is normal. No evidence of scoliosis. ASSESSMENT: B47.D Hyper-flexion/hyper-extension injurr to the cervical spine with B39.01 Subluxation of the first cerv cal vertebrae resulting in headaches and neck pain complicated by an unstable aeqment in the mid oervical spine. CHIROPRACTIC PLAN: Treatment will consist of manual manipUlation to the spine. with electrical muscle stimulation eighty cycles per second with moist heat bipolar technique to be applied prior to manual manipulation. We will also be using trigger point therapy and ice massage at home. We will also be instructing the patient in rehabilitative J I, Y J ReI Debra oaorqe DEBRA GEORGE March 4, 1994 SUBJECTIVE I The patient entered the office with Moderately dull, bilateral neck pain. trapeziu. pain. OBJECTIVE FINDINGS I . supine leg length test revealed a short left leg. Posturometer T~sting ~r8v8aled an imbalanced pelvis to the left. Cervical extension wae restricted and pain on movement. cervical right rotation i. restricted with pain on movement. Intersegmental fixation, facetal swelling and tight ropey fibers within the para-spinal musculature was noted at Cl/2. the following complaint. I Moderate, dull bilateral upper ASSESSMENT: See previous diagnosis., The patient adjusted well and easy. PLAN/PROCEDURE: The patient received therapy of moist heat and EMS. The patient recieved chiropractic manipulation of the cervical spine. The opatient has been instructed to schedule appointments 4 times per weak tor 2 weeks followed by 2 times pe~.week for 4 weeks. March 7, 1994 SUBJECTIVE: The patient entered the office with the following complaints I o Moderate, dull, bilateraly headache pain constantly. Moderately dull, bilateral neck pain. Pain in the right knee joint. Pain in the left knee joint. OBJECTIVE FINDINGS: supine leg length test revealed a short left leg. Posturcmeter Testing orevealed an imbalanced pelvis to the left. cervical Extension is restricted. Cervical right lateral flexion was restricted with pain on movement. Intersegmental fixation, facetal swelling and tight ropey fibers within the para-spinal musculature was noted at Cl/2. ASSESSMENT: See previous diagnosis. Patient reported subjective complaints improved after the laet adjustment. The patient adjusted well and easy. PLAN/PROCEDURE: The patient received therapy of moist heat and EMS. The patient recieved chiropractic manipulation of the cervical spine. The 8patient has been instructed to schedule appointments 3-B-94. ,....., ~ ) \ , ) '- Ra. Dabra oaorqa DEBRA GEORGE March 12, 1994 SUBJECTIVE: The patient entered the ottice with tha followinq complaint.. Headache. wera a.ymptomatio. Mild nack pain. Dull to modarata bilataral mid back pain. OBJECTIVE FINDINGS: Leq lanqth. wera equal in tha .upina poaition. po.turomatar raadinq wa. abalanced. Inter..gmental tixation, fac.tal .wellinq and tiqht ropay tiber. within the para-.pinal mu.culature wa. notad at T6/7. ASSESSMENT: Diaqno.i. unchanqed, mild improvement noted. :J and aaay. PLAN/PROCEDURE: The patient received therapy ot moist heat and EMS. The patient recieved chiropractic manipulation ot tha patient has been instructed to schedule appointment. 2 Tha patiant adjusted well thorasic spine. timeD per week. The OMarob 15, 1994 SUBJECTIVE: Tha patient entered the oft ice with the tOllowinq complaints: Headache. were asymptomatic. Mild low hack pain. o OBJECTIVE FINDINGS: Leq lenqths were equal in the supine position. Posturomet~r readinq was balanced. Intersegmental fixation, tacetal swellinq and tiqht ropey tiber. within the para-spinal musculature waa noted at ~5/SI. ASSESSMENT: Diaqno.i. unchanged, mild improvement noted. PLAN/PROCEDURE: The patient received therapy of moist heat and EMS. The patient recieved chiropractic manipulation of the lumbar spine. The patient has been instructed to schedule appointment. 3-18-94. o '. - \.. Re. De~ra aeorge DEBRA GEORGE Karch 36, 151514 ,) The patient received ~herapy of moiet heat and ENS. Karch 38, 151514 The patient received therapy of moiet heat and ENS. Karch 351, 151514 ::> SUBJECTIVE. The patient entered the office with the following complaint.. Kild headache. Moderate low back pain. Patient i. having menstral cycle today. Pain in the right knee joint. OBJECTIVE FINDINGS: J supine leg lenqth test revealed a ehort left leg. Poeturometer Testing -. revealed an imbalanced pelvie to the left. Lumbar left lateral flexion is restricted. Deerifield's'te.t wae poeitive on the left. Intersegmental fixation, facetal swelling and tight ropey fibere within the para-spinal mueculature wae noted at C1/3, L4/5. ASSESSMENT: :) See previoue diagnosis. The patient adjusted well and eaay. PLAN/PROCEDURE: The patient received therapy of moiet heat and EMS. The patient recieved a full spine chiropractic manipulation. The patient has been inetructed to schedule appointmente 3-31-94. o April 4, 15194 SUBJECTIVE: The patient entered the office with the following complainte: Kild, dull pain in the right aide of the mid back. Pain in the right knee o joint. OBJECTIVE FINDINGS: Poeturometer Testing revealed an imbalanced pelvia to the left. Lumbar Extension is restricted. Cervical left lateral flexion wae restricted. Intereegmental fixation, facetal ewelling and tight Jrop~y fibere within the para-epinal mueculature wae noted at T6/7, C1/2. ASSESSMENT: Diagnosie unchanged, mild improvement noted. The patient adjueted well and eas1. Patient reported eubjective complaint. improved aft~r the last adjustment. 'u PLAN/PROCEDURE: The patient received therapy of moist heat and EMS. The patient received Chiropractic manipulation of the spine. The patient received chiropractic manipulation patient hae been instructed to echedule appointmente 3 l.) April 5, 1994 The patient received therapy of moiet heat and EMS. ervical and thoracic of the extremitiee. ti.ee per week. The April 7, 1994 The patient received therapy of moist heat and EMS. r"'; ...... ....-1 ReI Debra aeorge DEBRA GEORGE April g, 1994 SUBJECTIVE: o The patient entered the office with the following complaints: Moderate mid-back pain. Hoderate low back pain. Mode~ate pain in the right knee joint. OBJECTIVB FINDINGS: Interseqmental fixation, facetal swelling and tight Oropey fiber. within the para-spinal mu~culature wa. noted at C1/2. ASSESSMENT: S.e previous diagno.i.. PLAN/PROCEDURE: J The patient received therapy of moist heat and EMS. April 11, 1994 SUBJECTIVE: The patient entered the office with the following complaints: .) Mild mid back pain. Mild low back pain. Mild pain in the right knee joint. ..... OBJECTIVE FINDINGS: Interseqmental fixation, facetal swelling and tight ropey fibers within the para-spinal musculature was noted at Cl/2. o ASSESSMENT: Diagno.i. i. unchanged. Patient finding. reveal the need or continued chiropractio oare consisting of Chiropractic djustments and adjunctive therapie.. o PLAN/PROCEDURE I The patient received therapy of moist heat and EMS. The patient received therapy consisting of ultrasound. The patient underwent passive and pas.ive-a..istive exercise uaing motorized iaokinetio exeroise equipment. April 12, 1994 I.:> The patient received The patient reoeived therapy of moist heat and EMS. therapy consiating of ultrasound. April 14, 1994 The patient received The patient received the~apy of moist heat and EMS. therapy consisting of ultrasound. / 1 , \. j -. Re' Debra Oeorge DEBRA GEORGE April 15, 19!a SUBJECTIVE I The patient entered the office with the following complaints: Neck pain asymptcmatic. Moderate mid-back pain. Slight pain in the right knee joint. OBJECTIVE FINDINGSi Leg lengths were equal in the supine position. posturometer reading was ~balanced. cervical flexion is normal. cervical extension is normal. Cervical right lateral flexion is normal. cervical left lateral flexion is normal. cervical right rotation is normal. cervical left rotation is normal. Intersegmental fixatign, facetal swelling and tight ropey fibers within the para-spinal musculature was noted at TO/g. ABSESSMENT: ~ See previous diagnosis. PLAN/PROCEDURE: The patient received therapy consisting of ultrasound with EMS and moist heat. he patient was advised that they could resume their normal activities. The patient recieved chiropractic manipulation of the thorasic spine. The patient o has been instructed to schedule appointments in 1 week. April 18, 1994 The patient received therapy consisting of ultrasound with ENS and moist heat. o April 19, 1994 The patient received therapy consisting of ultrasound with EMS and moist heat. April 21, U94 SUBJECTIVE: The patient entered the office with the following complaints: Mild neck pain. Mild dizzinese since 4-19-94. Mild pain in the right knee joint. OBJECTIVE FINDINGS: Posturometer Testing revealed an imbalanc9d pelvis to the left. Cervical left lateral flexion was restricted. cervical left rotation is restricted. Intersegmental fixation, facetal swelling and tight ropey fibers within the p~ra-spinal musculature was noted at Cl/2. Right knee range of motion restricted on external rotation. ASSESSMENT: See previous diagnosis. The patient adjusted well and easy. PLAN/PROCEDURE: The patient received therapy consisting of ultrasound with EMS and moist heat. he patient has been instructed to schedule appointments in 1 week. r-.. \ 4 \ .:., , Rei Vebra aeorge DEBRA GEORGE Hay 24, 1994 SUBJECTIVE: The patient entered the office with the fOllowing complaints: Neck pain asymptomatic. Headaches were asymptomatic. Hild low back pain. . OBJECTIVE FINDINGS: posturomster Testing revealed an imbal~nced pelvis to the left. Cervical right rotation is restricted. Intersegmental fixation, facetal swelling and tight ~ropey fibers within the para-spinal musculature wa. notad at C1/2. ASSESSMENT: See previous diagnosis. The patient adjusted well and easy. The patient was adjusted without incident. } PLAN/PROCEDURE I , The patient recieved a full spine chiropractic manipUlation. The patient has been instructed to schedule appointments in 1 week. Hay 31, 1994 SUBJECTIVE: The patient entered the office with the following complaints: Hild neck pain. No low back pain i. present. OBJECTIVE FINDINGS: Posturometer reading was balanced. Gait analysis was normal. Lumbar flexion i. normal. Lumbar extension is normal. Lumbar right lateral flexion is normal. Lumbar left lateral flexion is normal. Lumbar right rotation is o normal. Lumbar left rotation is normal. Kemp's test is normal bilaterally. Cervical flexion is normal. Cervical extension is normal. Cervical right lateral flexion is normal. cervical left lateral flexion is normal. Cervical right rotation is normal. cervical left rotation is normal. Foraminal Compression is normal. Jackson Compression test is normal. Spurling's Compression was negative, cervical pain reported to right side neck. o ASSESSMENT: Diagnollis unchanged, continued subjective and objective improv_ent. The patient adjusted well and easy. PLAN/PROCEDURE: _ The patient recieved chiropractic manipulation of the cervical spine. The Opatient has been instructed to schedule appointments in 2 weeks. ---.... - ....-.- NECK DISABILITY INDEX., ',.',. ...~-..) ~" ,,- l'AmNTNAME:_\J-e'o~o... G~~~~' \GE:.a:LDATE: 3~3-'H PATIENT SIGNATURE:. ,S)..JI-(./L Q: . ~~ INSTRUCfJONS: Read each section of statements, and choose the ONE statement that best describes your condition. Choose only ONE though two may seem appropriate. Leave tho section unmarked if not applicable (i.e. Driving), . .. ' I . I I I., SEerION 1 . PAIN INTENSITY _1 have no pain at this moment. _The pain is very mild at the moment. ..lLThe pain Is modCl1lte at the moment, _The pain is fairly severe at the moment. _The pain is very severe at the moment. _The pain is the worst imaginable at the moment, . ;,',' '0' . . Ii' '0 ! t" ,,". n. :.1...0 ,', :..' . ./ , ',t. SECTION 2.. PERSONAL CARE (Washillg, DrcsslDg, etc..M). 1 . _1 can look after myself without causing extra pain. ..,.., . _c..1 can look after myselfnomuilly, but it causes extra paino....' . _It is painful to look after myseU: and I am slow and careful. I'. . _I need some help but DlAIl8ge most of my personal care, . ......;.....1 Deed help every day iii riiD~1 aspects of self care. _I do not get dressed; I wash with difficulty and stay in bed. I '\ 'I" \ . '. ',~ I, ~ . ", 0 SEerION 3- LIFTING ,.. :.. ~\: ,: _I can lift heavy weights without cxtl'a pain. .. .:1. :.,.'. . AJ can lift heavy weights, but it giyes me extra pain. ! ' . ., , . _Pain prevents me from lifting heavy weights ofrthe floor, but I can manage if they arc conveniently positioned, for example, on a table, _I can lift very light weights. _I CAMot lift or carty anything at all. . . ,t' " 1:1' . .. . .. .. ... .. , \.'., ~I t. , 'O't ' . . t . \. I ' I. .-",' . .. ,; . ,',', " '1 ,,' '.' SEerION 4.READING .i,.:. . ,. . I' }.- .. " il CP.D read as much as 1 want with no pain in my neck. - .. _1 can read as much as I want with slight pain in my neck. _I can read as much as 1 want moderate pain in my neck. _1 can't read as much as 1 want because of moderate pain in my neck. . _I can hardly read at all because of severe pain in my neck. . . . _I can Dot read at all. .. !' ; '\ ~, ~ . ".' " ',,' 1 ...1[.. , '. j Ii' SECflON !Ii. HEADACHES ~~ r . .i'I:. .;. . I have no headaches at all. .1 I have slight headaches which come infrequently,i .:'~.I -,'"..: _I have moderate headaches which come infrequently. _I have moderate headaches which come frequently.... _I have severe headaches which r.ome frequentlY.i~!. ..,2LI have headaches almost all of the time, . ,,' L , . . ,',. ... , .'. " .- .-.\ '- l Name De.\) ('0.. PERSONAL INJURY PATIENT HISTORY 4. 0~cd'3-f' File' WRITE LEGIBLY WRITE LEGIBLV Dati 30 HISTORY OF OCCURENCE 10 Dati 01 Accldenl:. 3 - g - C) '-1'_ 'Time: I: 0 5 0 AM Qg PM Dri'o'Br 01 car: \) e'o nL A. G "0 ~-(' Where wore )'OU seelBd? ~ r NU" '..... ~ ; ole.. WhOownslhBcar?..R~b.'I'" r&-v::. Co .::Ty1C. Year and model of car: DoJ3~ :>~~do.,u 90 WIIal was theapproxlmale damage done to Ihe car you were In? $ .3 aoo . 00 (j ,... /?16 rc. 20 Visibility at lime of accldenl: js(Poor 0 Fair 0 Good Road conditions altlme of accldenl: 'liS!.lcy 0 Rainy end 0 Wal 0 Clear 0 Dark Your car: 0 Hit anolhor car ti( Was hllln the: 0 Righi 0 Len 0 Rear Ql( Fronl 0 Side. 'JYpe 01 accJdenl: ~ead-on collision' 0 Broad slde-colllslon o Rear-end collision 0 Fronllmpact, rear-ended car In front o Non-colllslon: 40 IMPACT/SEAT BELT/HEADREST/SPEED 10 Describe In your own words whel happened to you upon Impael: :c. /AJe'" + (ooo.c.." flran./~ fhe Old you 188 the Iccldenl coming? ):(Yes 0 No Warl you prewarned Ihallhe accldenl was about 10 happen? 0 Yes jl!l No Old you brace lor the Impact? 0 Yes (;i( No Were seal ~llS worn? Ji4 Yes 0 No Were shoulder harnesses worn? ~ Yes 0 No 20 Does your car hava headrests? jjia' Yes 0 No 30 II yes, whal was the poslllon of those headresta compared to your head before the accldenl? o 1bp 01 headrest aven wllh hollom 01 head ~ Top 01 headrasl even wilh top 01 head 0 Top of haadrest even with mlddll 01 neck 40 Was your car braking? ~ Yes 0 No 50 Was )'Our car moving allhe time 01 accldanl? 'til Yes 0 No 60 II yes. how fast would you estlmale )'OU ware going? ~ 5" -Iu 30MPH (eslimale) 70 How fast was Ihe olhar car Iravelllng? {); -lo 30 MPH (eslimala) SO HEAD/BODY POSITION/ABLE TO MOVE BODY 10 Head/Body poslllon al time of Impact: O. Head lurned: 0 Right 0 Len 0 Head looking back f2!( Head strl!lghl forward ;;g Body a1ralght In slnlng position 0 Body rotaled: 0 Righi 0 Len 20 Allha time 01 accldenl, recall whal parts 01 your head or body hil what parts on Ihelnslde 01 your car: -t."ce.. tAla b -fJ; + b'lr Oryo AOfr J ::r ~,.....\c. (l'\~.....na~ .+ Oa:!>h) He'AcI It- bac..k D~S;...;J- 30 As a rasult 01 the accldenl you were: 0 Rondered unconscious 0 Dazed, clrcumstancas vagu~ ~Shaken up but could lunctlon 40 Could you move all parts 01 your body? ~ Yes 0 No 50 II no, whal parts and why? 60 Ware you ablo 10 gel out ollho car and walk unaidad? !2'\. Yes 0 No 70 II no. why nol? -- IA.Ja~ ::S p....:;t-. pl.l~h ~ r...vo..rd) '/-hen FORM 70 Page 1 01 3 REV 9/89 i1lCopyrighl 1989 Michael E. Whinon, D.C., P.C. 60 SYMPTOMS FROM ACCIDENT 10 Old you gel bleeding culS or bruisas? (g Yas 0 No 20 II yes, what bleeding culs did you got from this accldanl? n. .c; fl\O. \ \ (' ...*" "n !-', ~ II yes, what bruises did you gel from Ihls accldenl? ~ n k ~ e e.':) 30 Pleas. deSCtlbt how you fell. PLEASE BE SPECIFIC. Immedlelalyaltertheaccld.nt: \...I<f' """'mtone. h,~ mt 1'1'\ ,""e .<:aU" 40 Lalerlhal 0 Day ~Nlght: ~ff n...\\ O\Jer 50 The ntx1 daY(I): -fO\.... , /'\ \e~ .iiJe. rvec\t.. I br(..l"~rd 60 ehtclt IY"lptoms appBlenl Ilnce the accldent: El'HeadllCh. 0 Dlulnesa ld"Neck paln/stlllness 0 Falnllng l31.Ildback pain 0 Rlnglng/buulng ears o Low blck pain 0 Loss of balance o Eyea sensillve to IIghl 0 Loss of small o Pain behind eyes 0 LosI ollasle 70 WORK STATUll HISTO,RV . ~ 10 Occupation: ~ ooK. ~e r 20 Heve you mllsed lime from work? ~ Yes 0 No 30-40 II Yea: Full lime all work ~ ~ g - q '-l to \..) D~ ~l~~'\- kl'lt'P LUO ~ 5t.:!f knee~ aV\tif: tf al Over o Loss 01 memory o Fatigue Errenslon o Shortness 01 breath o Irrllablllty o Deplesslon o Sleeping probleml o Numbness In loti o Numbness In fingers o Cold handl o Cold leel o Diarrhea o ConsllpatJon o Cheat pain o Nel\'Ouanell o Cold eweall o Anxious o Oth.r Employer: R vb ,n Arob <'0. .::J:i?c., "7 . 10 50 ParHlme 011 work 10 10 60 0 Been unable to work since accldenl. 80 FIRST DOCTOR/HOSPITAL/CLINIC SEEN 10 Old you go 10 seek medical help Immedlalaly/soon eller the accident? ~ Yel 0 No Ilyel. how did you gellhare? a Someone else drove me 0 Drove own car 0 Ambulance 0 Police OOC1OR lIHOSPITAL/CLINIC SEEN:~~pe 1='" m; '-0 Ph ~ . Oala oltlral villi: ::3 .;)-9'-1 20 Were you examined? ~ Yes 0 No Ware X-rays laken? 0 Yes i1l! No 30 Were you given treatmenl? C3' Yes 0 No 40 II yes, whallr.almenl was given 10 you? +0 +0. k e. l.B g...,.. po. t'n Whal btnellll did you receive Irom the Irealmenl? 50 Dele 01 last Ireelmenl: "3 . C) - 'I Y 90 SECOND DOCTOR/CLINIC SEEN 10 OOC1OR 21CLINIC SEEN: Were you examined? 0 Yes 0 No Ware X.rays taken? 0 Yes 0 No 20 Were you given treatment? 0 Yes .0 No 30 II yes, whaltrealmenl was given to you? Whal benefits did you receive from the trealmenl? 40 Date 01 lasltreatmenl: Dele 01 firs! vlsll: 1DO THIRD DOCTOR CLINIC SEEN 10 OOC1OR 3/CUNIC SEEN: Were you elUlmlned? 0 Yes 0 No Wore X-rays taken? 0 Yes 0 No 20 Wera you given lreatmenl? 0 Yes 0 No 30 II yes, whaltrealment was givon 10 you? What benefits did you receive from the trealmenl? 40 Dale of lastlrealmenl: FORM 70 Page 2 013 REV 9/89 Dale olllrs! vlsll: @Copyright19B9 Michaol E. Whillon, D.C., P.C. (- " '\ .-J. '- 110 PRIOR SIMILAR SYMPTOMS 10 DId)'OU hive lilY physical complaints lUll before the Iccldenl1 0 Yes l8( No 20 If yes, please describe In dalaU: 30 fI!!Q!! 10 Ihll accident, have \'Ou EVER had symptoms .lmUar 10 what you're experiencing now? 40 If yes, please explain (brllJlly Include pasf falls, InJurle" accident" operation" etc.): F",.o..,., 'a'po.r-::. a..CVO' 120 ACTIVITIES OF DAILY LIVING 10 Do)'OU notice a:IY aellyltles 01 \'Our home dally routines Ihal are diHerenl now than Irom before Iha accldanl? JZV.I 0 No (] lAte ace. , eP-e(\'t_ BVes oNo 20 If yes, Vat tham 85: 30 Those activities Ihal \'Ou are unlblelo do are (be sp6clfic): 40 Tho.. activities thai ara pelnlullO do are (be specific): 50 Those activities Ihal are dlNlcult 10 do are (be specific): t- : +f I e. cA; ~,. c..... I t- 130 PAIN LEVEL/SCALE OF RECOVERY /no'; '" 3----f1' r \'Q~ 10 On a acale 01 0-10, will'. 0 being (examiner's quole), "lbu'ra peln free and cen function quite we//," and 10 being, "lbu're In pain el/lhe time and cannot function ela/l." where lVCluld you rale )'OUrself? NORMAL LON PAIN MODERATE PAIN INTENSE PAIN EMERGENCY o 123 45~ 789 10 PieD" explain why: 20 Relative 10 where you were before Ihl. Injury. how lVCluld you rale how much you have recovered so far? % fNDICATE ON THESE DIAGRAMS HOW THE ACCIDENT HAPPENED ~,-~~ lIo. I ' ..d ----------------- ----------------- ATTORNEY ON CASE Do you have 111 a"orney on this casa? 0 Yes ItS No If yes, who? Name Address Clly PltlenlSlgnllure: JO..gf,.d- 11. A~ AUTOMOBILE ACC~DENT -INSURANCE DATA Patlent'a Inlurance Company Informatlo,n . I Company Name: f)rH1e3<< \ {l)!d:!t4J :I'll '" . (' n. PH: P.O Box/Streel Number: Cily/SlaIe/Zlp: "1 Q r \ l! 1\ 0.. P A /7::>"" 7 rlor '/ e.+ I:J..."~~ ~-- "".---- -- - --------- "". . II. - n7Jf "'." I ny:>qc...,t Slale Zip Dala' 3- 3- 94 Policy,:f1J €.. 030LJ ;;)'5'5' Adjusler's Name: Inlurad'alnlurance Information Insured'. name II other th-n patlen\: eompanyName: . l1(,_O..,,,'S P.O. BoxIStreet Number: CiIyISlaID/Zlp: Olher Drlver'llnlurence Informellon Olher Driver's Name (iI another car was Involved): CompanvNeme: .:5+.,,+-,., ~(}...".,.., P.O BoxISlreel Number: s~ "J__~ PH: ~I'/ iE htn..:.. 1'l\.<<i\..t?A PH: 170 ~-.J Policy' : Adjustar's Name: PH: PH: Policy ~: Adjuster's Name: FORM 70 Page 3 01 3 REV 9/89 @Copyrigh11989 Michael E. Whillon. D.C., p.e. '. ,\ WRITE LEGIBLY .:iUBJECTIVE COMPLAINTS 10. ExplelnWHENand!:!QWi1happoned: 3-0l-q~ f'rllt1f ~nJ (It)II''~f?J''' 20. COMPLAINTS I SYMPTOMS: 0 Come and go ~ame on gradually 0 CamI on luddenly 30. SymplomS ha.... persisted for. 0 Hours j3.1 Day 0 Dayo 0 Weeks 0 MonthI 0 '1'0811 40. SymplomS developed Irom: 0 A work.related Irjury ~ auto acclderol 0 An Irjury ClIhar then 81 work or an auto ICCident 50. DESCRIBE COMPLAINTS: PLEASE BE SPECIFIC Involving Neck & Head: J 0.. \ " \"Y\ l-e-\+ ? \ de n ~ c:J::. Involving Mld-back I Shoulders / Arms & Hands: 80 c:J<. ;;:51-;-ff Involving Low Back / Hips / Legs & Feel: 50. PAIN LEVEL: On a scale 01 0-10, With 0 being you'ra paln Iree a....d can lunctlon quite well, and 10 being you're In pain all the t1ml and cannolluncllon 81 all, whare would you rala youl58l1? I o 2 3 4 5 . 6 (j) 8 9 10 NO LOW MODERATE INTENSE EXeRUClATlNG PAIN PAIN PAIN PAIN PAIN 70. Whalactlvllles make condillon WORSE? ju .... n ;r, ~ h c: 00.. J) .ro I ~J+ 80. Whal actlvilles make condillon BETTER? no+- rn 0 Ll ."Y' 'iT- 90. Have you aver had lhls condlllon/problam before: 0 Yes l1S.No 100. If yos, whan? 110. Give name(s) and addrass(es) 01 dOC1or(s) previously seen lor Ihe presenl complalnt 120. Whal medications are you presanlly taking? Forwhal condillon? 0) 130-160. INDICATE ABILITY TO PERFORM THE FOLLOWING ACTIVITIES: USE CODES: U.Unable/13D PaPalnlul/14D OaOIHlcull/15D LaLlmiled/15D NaNonnal/16D p e Coughing or sneezing JL Climbing JL Gelling In or oul of a car P J!.. Knealing 7il. Bending forward to brush teeth ~ Balancing Turning over In bad Dressing salf Walking short distances _ Sleeping Slanding lor mora than 1 hour ~D Stooping S1l1lng at a table Gripping Lying on back Pushing lying "at on slomach Pulling lying on side with kneas bant .Q.. Reaching _ Bending over forward N... Sexual A<:livily 170. CHECK YOUR NERVOUS STRESSj:OMPLAINTS o Blurring vision IErHeadaches o Buzzing or ringing In ears 0 How ohen do you o Confusion haVe haadaches? o Convulsions 0 loss of sleep o Depression or crying spells 0 Low resistance o Dizziness 0 Muscla jerking o Fainting 0 Numbness o Paralysis 180. Symploms are BETTER In: 0 AM ~idday 0 PM 190. Symptoms are WORSE in: G1I(M 0 Midday 0 PM 200. 0 Symploms do not change with lime of day 210-220. FAMilY HISTORY: (/or example: Cancer I Diaberes Hearl problems I Back or neck problems) Father: Brother/Brothers: Mother: SiSler /SI5Iers: WRITE LEGIBLY 230. SHADE AND CODE AREA(S) TO INDICATE LOCATION OF PAIN OR DISCOMFORT: USE CODES: P-Paln N _ Numbneee S - Spllrn T - Tendeme..: R L L R :,,1 )V . W 240. (WOMEN ONLY) Ani you pregnent? 0 Yes ~ Dale 01 onset 01 last menstrual cycle 250. Give dale 01 lest X.rays: Wh81 body pal1s were they takan ol? Name Dale ::'GRM 20 REV 7/&1 rt>Copyflgh11991 MIChI,1 E. Whlnon. DC., p.c. File N Occupation . ~ Ul . ATED SUBJECTIVE COMPLA.. l rs Date t, - /II ~ 9'-1 FUel Phone: Hama /../n -~" d/lA - 707 J .- WRITE LEGIBLY Name .s)ol.n~ c'~OaJ-e.. 'Jp.OBoxlSlnteI~eSl /-'5 Sp~u.c~ La(\~ City/SIaIe/ZIp l'o.l'"\.~\e.. PA 170/~ INDICATE IF THERE HAS BEEN AN EMPCOYMENT CHANGE: Employer'. Nama ? P.O BoxISIrNI AddIe.. City/Stile/ZIp WRITE LEGIBLY Work INDICATE ANY CHANGE IN INSUP.ANCE STATUS: IIIJUIIIlC8 Company P.O BoxIStreel Addle.. City/S1aIe/Zlp NlIIM 01 Insured (U 0lhIt Ihan pallerlt) PRESENT SYMPTOMS: . 10. COMPUINTS: HEADAN@ SOMe. ~~~"'t'~"5 .) SIaIe hO\N your condition Is changed Irom when you lir6l came In: WOo. ~ a. \ 0 +- D)tl ~cu- 20. COMPLAINTS: MID BACK, OULDERS, ARMS AND HANDS .:5om ~ SIaIe hO\N your condition Is changed from when you first came In: ~+I~(\e"'S .) 3D. COMPLAINTS: LOWBACK, HIPS, LEGS AND FEET . 'some.4-, me~ po.rn ,'0 SIaIe hO\N your condition Is cIIangod lrom when you firll came In: -? 'e '" \- ~ l! e w a ~ {"\~+ \.(,.nee. hv....~\~ (}jn,"~ 40. CHECK YOUR NERVOUS SYSTEM COMPLAINTS: 0 Headache 0 LDss 01 energy 0 Blurred vision 0 Crying spells 0 DeprassIon J 0 DiuJneII 0 DiffICUlty sleeplng 0 Loss 0/ mamoty 0 Ringing/Buzzing In en 50. OTHER COMPLAINTS: GENERAL (oIher than major lIIea 01 complaint) 60. DESCRIBE RECENT FALLS / ACCIDENTS - WHEN7 ..) 70. IlI11lOCh1r dodot his been seen lor oresent condition since you bogan trealmenl here, give name 01 doclor IIld symplomllor which you _I 1rI111d: 80. UsII1C11vlUes Ihal make condillon WORSE: 90. UsII1C11vlUeslhal mal<e condition BETTER: J100_ 130. INDICATE ABIUTY TO PERFORM THE FOLLOWING ACTIVITIES: USE CODES: U..Unlhle/l00 P..Palnfullll0 D..DIHlcull/120 j L..Umlled/120 N - Nonmall130 I Coughing or sneezlng .E.... Climbing # Gelling In or oul 01 a car .4 Kneeling . Bending fOlW8ld 10 bnJsh leeth ~IJ Balancing 1UmIng l7IIOr In bed Dressing sell WaIkJng Ihot1 dlslances _ Sleeping ;;Z Standing for more then 1 hour ..1d... Slooplng .l:2.. S1nlng 1/ a labia ...J.L Gripping U Lying on back N Pushing ~ Lying lIII on IlornaCh I Pulling Lying on aidl with knees bent Reaching Bending CNef forward Sexual actlvity 140. Symploms lIIe BETTER In: 0 AM ~Midday 0 PM 150. Symploms Q1e WORSE In: fiiI AM 0 Midday !;il:PM , j 160. 0 Symplom1 do noc change WIth the time 01 day FORM 40 REV 9/89 170. SHADE AND CODE AREA(S) TO INDICATE LOCATION OF PAIN OR DISCOMFORT: USE CODES: P - Pain N - Numbneu S - Spasm T - Tlndlmlu: R L L R 'f, T I <lJCopynght 1989 MlCt1aol E. Whinon. D.C., P.C. Angino & Rovner, PC David L. Lutz, Esq. August 19, 1994 Page 2 RE: Debra George Following an examination, she was complaining of discomfort in the right knee as well as some superficial abrasions of the face. In addition, she had generalized back discomfort and in view of the fact she had past experiences similar to that which she was presently experiencing regarding the back discomfort, she returned to the offices of her attending chiropractor. She had been working a sedentary job activity and easily maintained the activities of daily living commensurate with her functions as a housewife and mother. Her complaint was primarily referable to discomfort in the area of the right knee. She specifically denied locking, instability or swelling. A review of her past medical history was noncontributory relative to knee discomfort. Examination of the knee revealed a normal range of flexion- extension to be present. The cruciate and collateral ligaments were intact bilaterally. There was comparable patella mobility without retinacu1ar tenderness. The joint lines were nontender to palpation. . She did have increased discomfort with palpation over the right patella compared to the left and particularly with expansion of the quadriceps. Routine x-rays of the knee was performed and reviewed on July 12, 1994. There was no evidence of an abnormality. It was my feeling this patient sustained a chondromalacia of the patella as a result of striking her knee and, of course, bearing a direct and causal relationship to the traumatic episode as occurring on March 3, 1994. . , Angino & Rovner, PC David L. Lutz, Esq. August 19, 1994 Page 3 RE: Debra George I suggested she be treated with appropriate modalities of therapy consisting of phonophoresis about the joint lines as well as the medial retinaculum and a quad and hamstring progressive resistant exercise program. In addition, she was placed on some nonsteroidal anti-inflammatory medication. She was next evaluated on the 20th of July 1994 and was appreciably improved, although, at this time, I noted crepitation which had not been present initially. I felt that symptomatically she had less discomfort with palpation over the patella, however, she was given a cho strap to use in order to somewhat preclude patella excursion. She was placed on some nonsteroidal anti-inflammatory medication. She was last evaluated by me on the 9th of August 1994 and I felt she made a marked degree of improvement. The crepitation remained present, however, she did have a full and pa in free range of motion. The patella was no longer tender with very light palpation and, of course, her ligamentous integrity remained intact. There was a minimal effusion. In summary, this patient sustained an apparent chondromalacia patella directly and causally related to the motor vehicular accident on Harch 4, 1994. This is a clinical diagnosis and is not capable of demonstration by routine x-rays. Following some conservatism, she appeared to be improved and while I suspect her ultimate prognouis is excellent, certainly, this should be guarded over the ensuing six months in terms of developing further chondromalacia of the patella. ..") :'- , OFFICE NOTES 1. 2. 3. 4. GEORGE, DEB BRUCE GOODMAN, MD 1515 NORTH FRONT STRBET HARRISBURG, PA 17102 TELEPHONE (717) 234-3203 FAX (717J 234-3935 in an accident occurring on or about the 3rd of JULY 12, 1994 she was involved March 1994 at this time, the roads were filled with snow and she was the driver of a vehicle struck by another car which had los control she was restrained with seat belts at the time of impact and was not thrown from the vehicle and did not sustain a loss of consciousness she was in a vehicle equipped with an air bag which immediately inflated she was aware of pain and swelling in the right knee in the immediate post traumatic state an ambulance was summoned however she opted not to ~vail herself of this type transportation she was immediately taken to the office of her family physician where she was examined and complained of discomfort in the right knee as well as some superficial abrasions of her face because of generalized back discomfort and in view of her past experiences, she returned to your offices for chiropractic care she has been working a sedentary job activity and easily maintains the activitfes of daily living commensurate with her functions as a housewife and mother she specifically denies locking, instability or effusion a review of her past medical history is noncontributory examination reveals full flexion and extension cruciate and collateral ligaments are intact there is comparable patella mobility there is no ~etinacular tenderness the joint lines are clear the cruci~te and collateral ligaments are intact there is increased discomfort with palpation over the patella x-rays taken and discussed impression: chondromalacia ~ DEBRA A. GEORGE, plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. JURY TRIAL DEMANDED vs. IAN C. STEVENSON Defendant NOTICIA Le hall demandado a usted en Ia corte. si usted quiere defenderse de estas demandas expuestas en Ias paginas sugnuientes, usted tiene viente (20) dias de plaza al partir de la fecha de la demanda y la not1ficaoion. Usted de be presentar ur.a apar!enoia escrita 0 en persona 0 por abagada y archivar en la corte en forma escrita sus defensas 0 sus objecianes alas demandas en contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y puede entrar una orden contra usted sin previo aviso 0 notificacion y por cualquier queja 0 alivio que es pedido en la peticion de demanda. Usted puede perder dinero 0 sus propiedades 0 otros derechos importantes para usted. LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATEMENTE. 51 NO TIENE ABOGADO 0 SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO, VAYA EN PERSONA 0 LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE 5E PUEDE CONSEGUIR ASISTENCIA LEGAL. COURT ADMINISTRATOR 4th Floor Cumberland County Courthouse Carlisle, PA 17013 (717) 24D-6200 , vs. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO. JURY TRIAL DEMANDED DEBRA A. GEORGE, Plaintiff IAN C. STEVENSON Defendant COMPLAINT 1. Plaintiff Debra A. George is an adult individual who resides in Carlisle, Cumberland County, pennsylvania. 2. Defendant Ian stevenson is an adult individual and citizen of the Commonwealth of Pennsylvania who resides at 206 Fox Drive, Mechanicsburg, Cumberland county, Pennsylvania. 3. The facts and occurrences hereinafter related took place on or about March 2, 1994 at approximately 1:05 p.m. on wertzville Road, Cumberland county, Pennsylvania. 4. At that time and place, Plaintiff George was operating her motor vehicle in a west bound direction on Wertzville Road. 5. At the same time, Defendant stevenson was operating a motor vehicle in the opposite direction, travelling east bound on Wertzville Road. 6. Due to adverse weather conditions, Defendant Stevenson lost control of his vehicle and slid across the middle of the road directly into the path of Plaintiff George's vehicle. 7. The front portion of plaintiff George's vehicle collided into the driver's side of Defendant stevenson's vehicle in the west bound lane of Wertzville Road. B. The foregoing accident and all of the injuries and damages set forth herein sustained by Plaintiff Debra A. George are the direct and proximate result of the negligent, careless, wanton " . and reckless manner in which Defendant stevenson operated his motor vehicle as follows: a. failure to stay within his lane of travel; b. failure to drive his vehicle with due regard for the highway and weather conditions which were existing and of which he was or should have been aware; c. failure to keep proper and adequate control over his vehicle; and d. driving his 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. 9. Plaintiff George sustained painful and severe injuries which include but are not limited to facial trauma, trauma to her right knee, cervical spine injury, and chondromalacia of the right patella. 10. By reason of the aforesaid injuries sustained by Plaintiff George, she was forced to incur liability for medical treatment, medications and similar miscellaneous expenses in an effort to restore herself to health, and claim is made therefor. 11. Because of the nature of her injuries, Plaintiff George has been advised and, therefore, avers that she may be forced to incur similar expenses in the future, and claim is made therefor. 12. As a result of the aforementioned injuries, plaintiff George has undergone and in the future will undergo physical and mental SUffering, inconvenience in carrying out her daily activities, loss of life's pleasures and enjoyment, and claim is made therefor. 13. As a result of the aforesaid injuries, Plaintiff George @ , .I' Ore Z 3 110 PIl'94 .. .lr r!f;~ n~ d "irjT :\!\Y I',:j ..~ t' ':';11 .',:HY ;~ i " . , l',t1 ", d ~ 40SU .... ~, - f s ~(J , ~f. / / d- f) #1 l- I q5/t; r ,.J ~) )-f 33 , !) ~A.~"'I~IN'{ r ... T'_~-'-"-'-"'-< "-'-'~""U'-"-'-"-----~""-'-'~i : . . . ., ., "Y".~ . ~ '.l,;f.p."i- L 'VI'.""'~ ~ . .. " . I ~; 't " . <~.:,"~ - r SIlERIFF'S RE'lURN c:x:r+lCM'lEALTI1 OF PENNSYLVANIA: CClJNTY OF Cl.MBERLAND vs In the Court of Common Pleas of Cumberland County, pennsylvania No. 94-6844 Civil Term Complaint in civil Action Law and Notice Debra A. George Ian C.Stevanson Wesley Cook , ~i'l'tl'f or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, that he seIYed the wi thin Complaint in Civil Action Law and Notice Ian C. Stevenson Upon , The defendant at 4:20 o'clock P .M. EST /XM~, on the 22nd day of December , 1<.P~ at 206 FOK Drive, Mechanicsburg ,CUnberland County, Pennsylvania, by handing to Janet Stevenson,Mother a true and attested copy of t:f\@mplaint in civil Action Law and Notice and at the sane time directing her attention to the contents thereof and the "Notice to Plead" endorsed thereon. Sheriff's Costs: Docketing Sel:Vice Affidavit Surcharge 14 .00 6.72 So answers: 2.00 $ 2 2 . n pd. atty 12-23-94 ,,:~ by R. Thanas Kline, Sheriff Sworn and subscribed to before me this .5'!:: day of(fMld? 19 C;'i A.D. by ~~&4' 9.y<-<- 0 Prothonotary )}I."i.u A.JI~, '- I ' ~ Rl.ED-GFRCF. OF 11!~ r:::}T110NOTN1Y 96 .lMII? Pil 3: 32 CU~.:LC.l.'::1) COUNTY I'I":'''''''(I".'III^ ..",,,.J ~"\:\'''\ c:J~O, (JeY // ~ ttIF-/?4I'51/ ;3.3919 , ' , . T.. " I \ \ I I \ I , ~-_.....'" . _....."'-.."...,..,.,."'.!-,,.", .~C --. .'.' .... fl' ; . .. ~ .-...-' i~~~U~~~+"1lI"~k;.r.t':J2H(~,,!j:.~,,'f,fitl'~..t~~~i:~*n~!, Fit t-{J OF )!,~;:, 'QFFlCr: I, 'i'I.I""'\.I,w , '')).,,..,, . '~I, (l,ow I .,'u/,w.") l'li u, I"~ , II ?: "I w,J C;", ....I'i/:~; .\l",,: \.' ':' ,c, J tJ\'/ '. "j' \" "'c. -II '\"'. .,1 L'h>i --~...._._--......,...>....__...Ut........._.._~-.- tt . t,'.'".-. . ~) [ " I I I ! ~ . , ." .' " ..~. , r