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Home My WebLink About01-4663POST & SCHELL, P.C- BY: AMY L. CORYER, ESQ. I.D. # 82718 240 GRANDVIEW AVENUE CAMP HILL, PA 17011 (717) 731-1970 ARNOLD K. ROOK, LUC1NDA J. ROOK and ARON ROOK Petitioners, ALLEN MCELWA1N AND JOANN MCELWAIN, as Parents and Natural Guardians of AZILE MCELWA1N, a Minor Respondents. ATTORNEYS FOR PETITIONERS ARNOLD K. ROOK, LUCINDA J. ROOK AND ARON ROOK IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW PETITION FOR LEAVE TO SETTLE OR COMPROMISE MINOR'S ACTION AND NOW, come the Petitioners, Arnold K. Rook, Lucinda J. Rook and Aron Rook, by and through their attorney, Post & Schell, who file this Petition to compromise action for approval of settlement and aver the following in support thereof: 1. Petitioners, Arnold K. Rook, Lucinda J. Rook and Aron Rook, are adult individuals currently residing at 143 Brick Church Road, Newville, Cumberland County, Pennsylvania, 17241. 2. Respondents, Allen McElwain and Joann McElwain are adult individuals currently residing at 19 Midland Road, Newville, Cumberland County, Pennsylvania, 17241. 3. Respondents, Allen McElwain and Joann McElwain, are the parents and natural guardian of the Minor, Azile McElwain, who resides with the Respondents at the above-noted address. See Affidavit of Parents attached hereto as Exhibit "A". 4. This petition is filed as a result of injuries sustained by the Minor child, Azile McElwain, as a result of an automobile accident that occurred on April 14, 2000. 5. The Minor child, Azile McElwain, sustained a splenic laceration and a closed head injury. See copy of medical records attached hereto as Exhibit "B". 6. The Minor child has recovered from said injuries and requires no additional treatment. See Exhibit "A". 7. At the time of the accident, the Minor child was under the majority care and control of the Respondents. 8. Petitioners' insurance carrier, Nationwide Mutual Insurance Company, has made a careful and diligent inquiry and investigation into the facts surrounding the accident, the responsibility therefore, and the nature, extent and seriousness of the Minor child's injuries. 9. All of the Minor child's medical bills have been paid. 10. The Petitioners' insurance company, Nationwide Mutual Insurance Company, has agreed to compromise this Bodily Injury claim for Twenty-Five Thousand and 00/100 Dollars ($25,000.00). Eight Thousand Dollars ($8,000.00) is to be paid up front and Seventeen Thousand Dollars ($17,000.00) is being paid to purchase a structured settlement which will result in a total payment of Eighteen Thousand Two Hundred Fifty-Five Dollars ($18,255.00), with three guaranteed annual payments of Six Thousand Eighty-Five Dollars ($6,085.00), the first to be paid on May 30, 2002, and the last to be paid on May 30, 2004. It is a fair and reasonable resolution under the circumstances. See Exhibit "C". 11. The Respondents, Allen McElwain and Joann McElwain, understand and approve the settlement achieved. See Exhibit "A". 12. The Respondents, Allen McElwain and Joann McElwain, have executed both a Release Agreement and a Uniform Qualified Assignment and Release, copies of which are attached hereto as Exhibit "D". WHEREFORE, Petitioners pray that an Order be entered approving the Minor's Compromise and ordering that distribution pursuant to the Court's Order. Respectfully submitted, POST & SCHELL, P.C. DATE: AMY L. cORYI~, t~SQUIRE Attorney for Petitioners CERTIFICATE OF SERVICE I, Sharry D. Semans, an employee of Post & Schell, P. C., do hereby certify that on the date listed below, I did serve a tree and correct copy of the notice of deposition upon the following person(s) at the following address(es) by sending same via United States mail, first-class, postage prepaid: Allen and Joann McElwain 19 Midland Road Newville, PA 17241 DATE: ~'/oz/o! BY Respectfully submitted, POST & SCHELL, P. C. · Sharry D.(~emans Exhibit A AFFIDAVIT OF PARENTS In the Conunonwealth of Pennsylvania: County of Cumberland: state: Allen McElwain and Joann McElwain, being duly sworn according to law, depose and 1. We are the parents and natural guardians of the minor, Azile McElwain. 2. To the best of our knowledge, Azile McElwain has completely recovered from the injuries she sustained in a motor vehicle accident which occurred on or about April 14, 2000. 3. We have reviewed and approved the Petition for Leave to Compromise Action on Behalf of a Minor and the Order Approving Minor's Compromise for Distribution and concur with the distribution. Sworn to and subscribed re me this ~0~ day of ,2001. Notary Seal J~/kNN MCELWAIN · da L Gar6s Notary public_ ~ Dn .~ ~,.,,-.' Cumberland Co_u~nty~ West penns~ro ,-~_', ..~ ~ct. ~ My Corn ' Exhibit B PennState Geisinger Health System EMERGENCY MEDICINE CENTER P.O. BOX 850 HERSHEY, PA 17033-0850 7175318333 TEL EMERGENCY DEPARTMENT NOTE PATIENT NAME: MCELWAIN, AZILE PATIENT N-UMBER: 361921 SEX: F DATE OF SERVICE: DATE OF BIRTH: 04/14/2000 05/30/1984 MODE OF ARRIVAL: Life Lion where she was placed in a cervical collar and long board for immobilization. Large bore IV access was obtained and she was placed on supplemental oxygen. HISTORY: A 15-year-old female was the restrained passenger in a motor vehicle accident. She was in a vehicle that t-boned a second vehicle going an unknown amount of speed. There was questionable loss of consciousness and repetitive speech at the scene. Life Lion crew noted some chest and abdominal discomfort. The patient was hemodynamically stable. Trauma alert was paged and the patient arrived to the emergency department hemodynamically stable. Dr. Dillon was present upon arrival and you should see trauma services note for full evaluation and treatment and disposition. DICTATING MD: ~ Christopher J. DeFlitch, M.D. Assistant Director of Emergency Me ' ' CJD/dmd D: 04/14/2000 T: 04/16/2000 07:43 Page 1 of 1 ~ PennState Geisinger Health System The Milton S. Hershey Medical Center TRAUMA RESUSCITATION ORDERS Datex,x Time~ ORDER (Date and Sign All Entries) __ Signature of Physician Orde~e,~ ~Ordered ircle Orders ed \(:~/)/[-;xygen: Yes~ Ai~ay: Yes ~tubate: Yes~o ~ or ~di~g ,o Ord~ FFP: Yes ~¢~Blood: ~acked cells' Yes(~o X-RAYS ~ C'Spine: Pelvis:/ Chest~ Late ral~P~d°nt°i~Swim me rs ~ Cranial ~bdomin~~ Chest Neck Other: LAB: ABG CBC ~ Diff Amylase/L~ L~es/Re 9ai/rotime/P~ Medical Blood ETOH ~Glucose CWMB Legal B~o~TOH UA ~ Urine Pregnancy~ Urine Drug Screen T& C x3 Units Type& Screen/ Peritoneal Lavage Fluid MEDICATIONS: Tetanus Toxoid: Tetanus Immune Globulin: ANTIBIOTICS: EKG:NG *u~ekes~)~ ~ Y~ Celica, Co,~r ~Yos M.D. Signature:~ ~ ~ Dat,:~ MR 691 4/96 JMA RESUSCITATION ORDERS Original - Mecllcal Record Yellow - Trauma Service Pink - ED PennState Geisinger Health System LIFE LION Critical Care Transport The Milton S. Hershey Medical Center Airmedical EMS/On-Scene Report 00-0597-A 04114/2000 On-Scene N896LL 83 a21ie mclwain 15 Y/O F 05/30/1984 ~! ~ ~ ~ f 361921 multi tram Transported Patient Transported Cumberland County Cumberland I-Iampden Towuship 21910 UNIVERSITY HOSPITAL 01351 Hershey Emergency Department Chris De Flitch 18:24 18:21 18:25 18:34 18:54 19:01 19:03 19:05 Kurtz, Michael P. P, 018961 Kissinger, Krista H, 042639 Emery, Randy Chadwick, Russ 82 14 122/68 14 - Spont. 5 - Orient 6 -'Obey EMS Rendezvous Vehicular Radio 1351 86 None None None 93001829 mp TR£ND 14.84.88 18:,r~ 91 1118 124 / 69 IlS gFF 18:49 188 98 122 / 66 85 [JFF Kurtz, Michael P. / Flight Medic LIFE LION ON-SCENE TRANSPORT NOTE PATIENT NAME: MCELWAIN, PATIENT NUMBER: 0361921 SEX: F SS #: ATTENDING MD: AZILE DATE OF SERVICE: 04/14/2000 DATE OF BIRTH: 05/30/1984 FLIGHT NUMBER: 00-0597-A DISPATCH INFORMATION: Life Lion was dispatched to Cumberland County to assist Medic 86, West Shore ALS, with a motor vehicle crash with injuries, possibility of two patients being flown. Arrived at the landing zone in Hampden Township to await several minutes for ALS/BLS unit with patient on board. The patient arrived with Paramedic Rick Teats on board and Paramedic Teats gave the following history: 15-year-old, white female passenger, right front seat, seatbelted, negative loss of consciousness. Apparently, this vehicle T-boned another vehicle at an unknown rate of speed. Moderate damage to the vehicle. No entrapment. The patient complains of chest pain and abdominal pain., The patient is able to move all four extremities without any compromise. No visible signs of external trauma, no trauma palpated with the exception of extreme tenderness throughout the chest wall and abdominal wall upon palpation. Past medical history: None. ALLERGIES: The patient is allergic to DURICEF. Weight: Approximately 120 pounds. TREATMENT PRIOR TO ARRIVAL: The patient was fully immobilized, receiving high flow 02 nonrebreather mask, cervical collar in place, CID in place, patient secured on a long board with spider straps. The patient had one IV established in the right hand; however, that IV has infiltrated and paramedic Teats is in the process of establishing an additional IV in the left hand. That IV was established by Paramedic Teats, a #18 gauge in the left hand, normal saline at KVO. Physical examination by flight team: Patient presently awake and alert and oriented x 4, anxious. Skin color is pink, warm and dry. Glasgow coma scale currently 15. The patient can recall the entire incident. Pupils are 3 mm, equal, round and reactive to light. NO facial head trauma noted. Neck nontender. Chest is tender Page 1 of 2 PATIENT NA~E: MCELWAIN, AZILE PATIENT NUMBER: 0361921 throughout the chest wall, no palpable deformities felt, equal chest rise, noted bilateral breath sounds clear in all fields. Abdomen - Tender throughout the entire abdominal wall, however negative distention. The abdomen is soft at this time, no masses noted. Pelvis nontender. Extremities - The patient moves all extremities, normal refill, normal pulses. TREATMENT/PROGRESS: This patient was hotloaded into Life Lion secondary patient area. Waited approximately five minutes for patient B, flight 579, to be loaded. In flight vital signs for this patient remained within normal limits. Medical Command Dr. DeFlitch contacted. No further orders given. The patient remained awake, alert and oriented, somewhat anxious in flight, however calmed with reassurance. No other changes. Arrived The Milton S. Hershey Medical Center without incident. IMPRESSION: Motor vehicle crash, status post chest and abdominal trauma. DISPOSITION: This patient was taken to The Milton S. Hershey Medical Center's emergency department for trauma systems evaluation. DICTATED BY: Michael Kurtz, EMT-P ATTENDING MD: Klm A. Salness, M.D. Professor & Director, Center for Emergency Medicine MK/rmh D: 04/15/2000 T: 04/15/2000 15:54 Page 2 of 2 PennState Geisinger ~J Health System g / h, 1 Lr°db' TAT PAGED DATE ~ 1/[~[-/ TIME RESPONSE S PRE-HOSPITAL / AGE ! ~ SEX ( WT ! ~--~c/ · -- YES___ # MIN YES # M I.~,,.__ ~ELF E~XTRICATE.D YES, ~_ NO / / MEC) A.,S / fi -- PICKUP ~PASSENGER _ AIRBAG ~ ~ ~ _ B 0 _ -- TRUCK _ FRONT ~ CARSEAT ~ ROLLOVER ~ SPIDERED ~ BACK ~ ~wuu ~ VAN BACK NONE X BROADSIDED HEAVY ~ ~ UNKNOWN _ UNKNOWN ST WHEEL RENT ~ R L ~TORCYCLE _ BICYCLE ~ A~ ~ HELMET _ NONE _ UNKNOWN OF PICKUP ~ DIVING _ FALL ~ ~ ~ GSW ~ CAUMM ~ INDUSTRIAL BURN ~ DROWNING ~ FARM ~ STABBING ~ PEDESTRIAN :LUID RESUSCITATION PM~ GAUGE ~/~ A~F~ED~ spoma~oo~s [ ~ ~ 4 I CHEST / .~~, MAST TROUSERS '~r~ ~. ABD ,,~'i~"' ~ ,/RESPIRATORY~-~ SPONTANEOUS RATE ~ 02 MASK L/MIN.__ 0B CANNULA L/MIN.__ ASSISTED RATE __ BVM RATE __ AIRWAY (ORAL/NASAL) ETT (ORAL/NASAL) SiZE CRICOTHYROIDOTOMY TRACH SIZE ABDOMEN ~NDEO WHERE ;LE?UNBBNo w BBSRB' None REVISED TRAUMA SCORE SLASGOW 13 15 COMA 9 -12 SCALE(GCS) 6 8 ,T~al Points 4 -5 Systolic · 89mm Hq Blood 76 89mm Hq Pressure 50-75mm H9 1-49mm Hq Total Revised Trauma Score 1 3 5 SBP 80-100 or Pulse 100-140 NO Pulse RR 25-35 Of Breath SBP 50 80 SBP · 50 or O[ Pulse 120-150; Pulse · 150; NO Purse or RR 25 35 RR > 35 or <10 of Breath T-bofle/Lateral Impact Over 80 Years 0Id Original - Medical Record Yellow - Trauma Service Pink - ED ED TRAUMA/RESUSCITATION FLOW SHEET A-ABRASION T WOUND C~CONTUBION 5. STAB WOUND SW-SWPLL NG BURN P-PULSE O WEAK PULSE 8 RASH T-TENDERNESS 9 CLOSE FRACTURE S-SENSATION PUPIL REACTIVITY NEUROLOGIC EVALUATION VITAL SIGNS B = Brisk F = Fixed Time Pupil Pupil Time Warm S = Sluggish D = Dilated Size React Motor Function Cardiac 02 Lites N:Nonreactive i/~.-/ F~/~./ ~ L/)RAL!L~Lt~ /~%[~I/7~ ¢1~¢ Rhyth~ ~ Sat~ ~,.~.H. IIU~ 1~.~ iD ~ ~ ~1~ "~ i; ~, ~1~ '~ ~ ~ 6 ~ 7 ~ ~ ~ 9 ~~ _ ~D' 'P() R Numb~ -- ~0~ '1~ f~lr~ ~ '/~ LABS CHART F LYTE~RENAL GLUCOSE PT/PT~ AMYLASFJI_Fr ("/"6/~)TJ~J RINARI ' ES rv BLOOD AT MEAT tl~ ~ GASTROINTE~IN RECTAL TONE REIV TIME BACK __]'0~ PREGNANCY t/~R DRMEDICAL) UG SCREEN LEGAL/UR1N E DRUG L E .~,~,~,~,~,~,~,~,~{ BLCOD ETOH PREPPED WITF[ PQVIDONE-I~ DRAWN B Y_~,.~_ _..~-~Y~ TONE [] GOOD I. [] DECREASED [] ABSENT PROSTATE [] NORMAL C] ABNORMAL DONE BY DR RETURN [] CLEAR [] PINK [] GROSS BLOOD AMOUNTINFUSED CC AMOUNT RETURNED CC FLUID TO LAB YES NO CARDIOTHORACIC RCT SIZE FR CVP R L LCT SIZE FR A-LINE R THORACOTOMY CUTDOWN L THORACOTOMY BY: PERICARDIOCENTESIS DONE BY DR ~KG YES NO ~ NEUROLOGIC _ ICP BOLT iNITIALREADiNG HALO DONE BY DR / MEDICATIONS / .~. LT, E I , , D ,G rDOSE IRduTF , T CRYSTALLOID .3 TOTALS TIME X-RAY Time $pin~ Iai __ Cystogram Extremities ~1~en Chest Other __ Angiogram .' ,A[(~-) BLOOD PRODUCTS LEVELI PRODUCT ! AMT. INF. INIT. LEVEL I UNIT # TIME SITE TOTALS OUTPUT NURSE'S NOTES ABBREVIATIONS BVM = Bag _CT = Le~t Chest Tube ET = Endotracheal Tube RCT = Right Chest Tube ABD = Abdomen PH = Pre-hospital FP = Flaccid Paralysis RL = Right Leg LOC = Level of Consciousness R = Rigid LL = Leit Leg PMH = Past Medical History DCB = Decerebrate Posturing = Right Arm BH ~- Bair H~g~er '",V/-~ ~C~,-,~ Oeco~icat~Postu~ RA LA = Le~Arm ~ _ ~, ~ ~ ~ ~ ~~ D S.OS T ON _ il L TIME OR NOTIFI~ '( ~ ~ OR READY~~R~ FAMILY NOTIFIED ~ BY ~-(~-~' ~ C-COLLAR ON ~ YES ~NO ASPEN ~ YES ~ ~ VALUABLES ~ W/PATIENT ~ SAFE ~ NONE ~ W/FAMILY ~ EXPIRED CORONER NOTIFIED ~ MATERIAL EVIDENCE TO POLICE ~ YES ~ NO OFFICER BADGE ? Documentim MOTOR FUNCTIONS NAME , J~GED ARRIVED NS = Normal Strength ED DR ~ / / W = Weakness TRSURG_ ,~,4'~1 )(~& i('/~ (,//"iA('j / ~DS ~EDS TNC OR ANESTHESIA NEUROSURG ORTHO X-RAY CT RT CHAPLAIN CONSULT CONSULT CONSULT TRANSFERRED TO VIA JL ~tltl~LCtL~ U ~iDttI~t The Milton S. Hershey Health System Medical Center TRAUMA HISTORY AND PHYSICAL EXAMINATION Date: k~ I Iq EeO Time: '-7: \~- ¢¢"q Type of Trauma Brief History (Mechanism of Injury) ~,,MVC Belted? [] Yes [] No [] Airbag ~,~-'yO ~ ~e((r& ~- ( ~ ~ ~ Pedestrian ~ MCC ~ Assault ~ GSW D Stab ~ Other Field ResuscitatiOn R.O.S. Field Vitals: P: BP: Immobilization: Fluid: ~ Yes ~No Loss of Consciousness? ~ Yes ~o Field Notes: Amnesia? Prima~ Suwey Trauma Hiao~ Ai~ay: ~atent ~ Obstructed Intubated: ~ eT ~ NT ~ Trach Allergies: Breathing: ~ Breath Sounds: Meds: Oisabili~:~Aled ~ Voca, ~ Painful ~ UnFesponsive PMH: Exposure: Procedures: ~ NG-Tube ~ Urina~ Catheter PSH: ~ A-line: ~ CVP(s): Chest tube: ~ right ~ left Last Meal: ~ DPL: Last Tetanus: HEENT: Head: N~ Eyes: ~fl~c~ - - Mouth: Dentures: ~ Neck: Tenderness: ~ Crepitus: ~ Trachea ML: Back: Tenderness: ~ ~ Crepitus: ~ Head: ¢~ ', Abdomen: Distention: ~ ,S: ~ Tenderness: Rectal: Tone: Heme: Prostate: Vascular Exam; Radial , Femoral DP. PT Reside~ g~at.~ I Title Date. T me a ~ ~ ~Ab --abrasion 1R 611 Rev. 3/98 COPYR ~ ~ Orig - Chart TRAUMA HISTORY AND PHYSICAL EXAMINATION Copy- Trauma Services TRAUMA HISTORY AND PHYSICAL EXAMINATION iondary Survey (toni.) ~.mity Exam urological Exam Spinal Cord In nial Nerves; tor: ~sory: Pinprick ProprJoception L f4 s/Studies Evaluated PT: ~. TEE: lays CXR: rd: CSpine: Lat T & ~ines: blem List: ,/ Glasgow Coma Scale/Peds Eye Opening 1 - None 2 - Open to Pain ~en to CommandNoice LEGEND: L -- laceration Clx--closed fracture Ofx--open fracture Ab --abrasion C --contusion 1 - None 2 - Incomprehensible/Moans to Pain 3 - Inappropriate / Cries to Pain 4 - Confused / Consolable f- None 2 - Decerebrate 3-Decodicate 4 -Withdraws .ocalizes Pain Troponin: MyoglobJm Trauma Score Resp. Rate SBP 0-0 0-0 1 * 1-9 1 - O-49 2 - >36 2 - 50-69 GCS 0 - 3-4 1 - 5-7 2-8-10 3 - 11-13 -15 U/A: PTT: T:Bili: o.'? CPK: Drug Screen: ALT: ~.t Amylase: [,iq ALP: ICa: Pelvis: CT Scans: Head: Extremities: Abdomen: AP Others: Odontoid Anglo: U/S: Attendim ETOH: BHCG: ding Signature/Date/Time Trauma Services 611 Rev. 3/98 TRAUMA HISTORY AND PHYSICAL EXAMI ~ PennState Geisinger The Milton $. Hershey Medical Center Health System HISTORY AND PHYSICAL EXAMINATION J / MR9 9/71 SIGNATURE I DATE HISTORY AND PHYSICAL EXAMINATION EOH rlr'JL/[D ON R,' VERSE I TIME A M PM PAGE PennState Geisinger ,.e ~[Iton $. Hersh*¥ Health System Medical Center ~ . h--; - - ~ATE/ TIME PRO.SS NOTES ~ ~ INPATIENT ~ OUTPATIENT NAME-TITLE MR 6'2 (1/91) PROGRESS REPORT PennState Geisinger The Milton S. Hershey 7: 2 ! -_~ - ~ W Health System Medical Center - , ~ I O 5/5 C/' ~ - L ,~23577 PROGRESS REPORT - ,_., I ~ tZlL, DATE TIME PROGESS NOTES ~ INPATIENT ~ OUTPATIENT NAME - TITLE PROGRESS REPORT PennState Geisinger The Milton S. Hershey Health System Medical Center PROGRESS REPORT C 261~0 Date/Time PROGRESS NOTES: (Include Name, Title) MR 8 Rev, 2~5 PROGRESS REPORT PROGRESS REPORT Date/Time PROGRESS NOTES: (Include Name, Title) INDICATION FOR TRANSFUSION - ENTER INDICATION CODE FROM BACK OF FORM OR OTHER REASON IN THIS SPACE. MD KEY TRANSFUSION NO. (F~OM WRIST ~AND) DATE ~ME STARTED TIME COMPLIED IF LES8 AMOUNT GIVEN ( ~OUNT ISSUED ) ML REACTION I I YES, SUBMIT TRANSFUSION REACTION FORM UNIT/POOL/LOT NO. "~67~S~ '~ COMPONENT CROSSMATCH COMMENTS VOLUME :'~:~ MR 6 Rev. 2/95 PROGRESS REPORT ' ~ PennState Geisinger Health System The Milton S. Hershey Medical Center PROGRESS REPORT 26150 Date/Time MR 6 Rev. 2/95 PROGRESS NOTES: (Include Name, Title) PROGRESS REPORT Date/Time I PROGRESS NOTES: (Include Nam~ Titl~ PASTORAL SERVICES Patient: .,~,P/r ~ ,,,~C,~Q42/--~:~:/;P ~,~ / q~/ Location: ~ ~ Date: ~-/¢-O~Time:/~.'Z~ PastoralVisit Pre-op Death Minist~ ~ Code Other ~,//~ . ReferratSource: Name:~-~~~]~/~ Adm ~ Family MD RN SW Clergy Other ~astomlSu~o~: ~ ~ Oommunion Anointin~ ~a~tism ScriCuros Follow-up: will visit ~ Refer to other Ream. MR 6 Rev. 2/95 i p - ^F, PROGRESS REPORT PennState Geisinger The Milton S. Hershey Health System Medical Center PROGRESS REPORT 26 153 Date/Time PROCURESS. NOTES: (Include Name, Title) MR 6 Rev, 2/95 PROGRESS REPORT PROGRESS REPORT (Include Name, Title) ~1,~1oo MR 6 Rev. 2/95 PROGRESS REPORT ~ PennState Geisinger The Milton S. Hershey Health System Medical Center PROGRESS REPORT Date/Time PROGRESS NOTES: (Include Name, Title) %7~ /~P IqOO / ~ tpoo U MR 6 Rev. 2/95 PROGRESS REPORT PennState Geisinger Health System The Milton S. Hershey Medical Center ~ PROGRESS REPORT ~#487301 7244-I 7~BS ~UMA#3blQ21 05/30/I~84 C$#20877 [[=,~lS AXIL[ F ILLON PETER W 26150 /Date/Time PROGRESS NOTES: (Include Name, Title) U F MR 6 Rev. 2/95 PROGRESS REPORT PennState Geisinger Health System Itealth lnformalion Services M.C. HU24 RO. Box 850 Hershey. PA 17033-0850 DISCHARGE SUMF~RY PATIENT NAME: MCELWAIN, AZILE R PATIENT NUMBER: 0487301 DATE ADMITTED: 04/14/2000 LOCATION: DATE DISCHARGED: 04/19/2000 SEX: F DATE OF BIRTH: 05/30/1984 ADMISSION DIAGNOSIS: 1. Status post motor vehicle accident. 2. Splenic laceration. DISCHARGE DIAGNOSIS: 1. Status post motor vehicle accident. 2. Splenic laceration. BRIEF HISTORY: This is a 15-year-old female belted passenger status post a motor vehicle accident. The patient with no reported loss of consciousness, no amnesia. The patient originally on admission complained of some chest and abdominal pain. A full trauma work-up was done including CAT scans of her head, chest, abdomen and pelvis which were significant for a grade IV splenic laceration and a closed head injury. The patient was admitted to the Pediatric Intensive Care Unit where serial hematocrits and examinations were performed. The patient was transfused one unit of packed red blood cells. Serial hematocrits remained stable in the range of 26 to 30. The patient remained on bedrest with bathroom privileges. The patient ' was able to tolerate a regular diet and able to void. The remainder of her hospital course was unremarkable and the patient was discharged to home. 4, DISCHARGE MEDICATIONS: 1. Percocet 1-2 tabs p.o.q.4 hours as needed. DISCHARGE INSTRUCTIONS: 1. Diet regular. 2. Activity. The patient is to remain at bedrest with bathroom privileges for one week, then bed to couch for one week, then the patient may return to school, but with no extra curricular activities for one week. The patient is to have a wheelchair to school and to the prom. PATIENT NAME: MCELWAIN, AZILE R PATIENT N-U'MBER: 0487301 Call 531-8521 and page the pediatric surgery resident with any questions or concerns. The patient is to follow with the Pediatric Surgery Clinic in three weeks. DICTATING MD: Hoan-Vu Tran Nguyen, ATTENDING MD: Peter Wo Dillon, M.D. M.D. HVT/bjc D: 04/19/2000 T: 04/20/2000 05:57 c: WP Clerk JAY A. TOWNSEND, M.D. 100 SOUTH HIGH STREET NEWVILLE, PA 17241 Page 2 of 2 · ~ PennState Geisinger *,e Milton S. Hershey Health System Medical Center SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA'PATIENT SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA PATIENT BRIEFHISTORY OF ACCIDENT AND INJURI_E,~' · . . Data gat,ered from: fl.~//$ LIVES: __ None With Spouse/significant other ~-- With parents -- With friends ~'l~0ther ~~.*~' DRUG/ALCOHOL: __ ETOH above.lO __ Drug Screen __ No drug and alcoholabuseidentified MARITAL STATIJ _S: LIVES IN: __ Multi-story home __ One story home __ 1st floor apt. __ Upper floor apt. __ Mobile home __ Other EMPLOYMENT/INCOMF' y Emp,o,ed .4. Laid off MEDICAL COVERAGE: __ Auto medical limit if known Health insurance through __ No coverage, Medical Assistance application needed __ Workmen's Compensation __ Disability/medical leave __ Social Security SOCIAL SUPPORT: __ Friends __ Neighbors __ Limited social support available INITIAL FAMILY DYNAMICS OBSERVED' __ Denial/avoids talking about injuries __ Minimizing seriousness of injuries __ Optimistic patient will make full recovery Realistic/verbalizes understanding seriousness of injuries ~- Family decision maker identified: __ Family mem~-rs divided or inconsistent in view of situation __ Hospital experience limited or family has no experience with serious illness or injury MR 660 5J96 SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA PATIENT SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA PATIENT OTHER MAJOR STRESSORS WITHIN LAST 12 MONTHS IN PATIENT OR FAMILY MEMBERS' LIVES: PRE-INJURY FUNCTIONAL STATUg: POTENTIAL DISCHARGE NEEDS: __ Patient unstable/unable to determine needs at this time. Will reassess in 48 hours. __ No intervention indicated at this time after patienFfamily assessment. PATIENT/FAMILY MAY REQUIRF: __ Extended care facility/subacute rehabilitation __ Acute inpatient rehabilitation __ Outpatient therapy __ Home health care Skilled nursing __ Physical therapy Occupational therapy __ Speech/language therapy __ Substance abuse follow-up Financial assistance '~ Home equipment Rehabilitation consult __ Drug/alcohol evaluation __ Children and Youth Referral ___ Domestic Violence Program Referral Other S0C A' WORKER'S S NA'rURF' 'q SOCIAL WORKER'S PAGE NUMBER DATE: DISCUSSED WITH: AT[ENDING PHYSICIAN TRAUMA COORDINATOR MR 660 5/96 SOCIAL WORK INITIAL ASSESSMENT OF TRAUMA PATIENT PennState Ge/singer The Milton $..ershey Health System Medical Center TRAUMA SERVICES REHABILITATION ASSESSMENT SPEECH 1. Patient has a swallowing or chewing impairment y 2. Patient has a communication impairment y 3. Patient is able to follow commands 4. Patient has an impairment of memory and/or concentration y OCCUPATIONAL THERAPY 1. Patient has difficulty completing activities of daily living, such as dressing, bathing, toilet/rig, grooming, feeding y 2. Patient is at risk for contractures of the hand y 3. Patient has difficulty with fine motor skills y PHYSICAL THERAPY 1. Patient has difficulty with mobility activities such as transfers, ambulation y 2. Patient has decreased strength or endurance y 3. Patient has problems with coordination or balance y 4. Patient has tone or posturing y After this screening assessment, it is determined that the patient requires intervention of: Physical Therapy y ,/'~ Occupational Therapy Y / N SpeechTherapy Y ~ N J PATIENT REQUIRES AN ACUTE, SUBACUTE OR OUTPATIENT-'F[E'R~ABILITATION EVALUATION CONSULT Y (U) REHABILITATION PLACEMENT RECOMMENDATIONS 1. Patient demonstrates adequate safety awareness Y N 2. Patient has complicated wound care needs Y N 3, Patient is incontinent of bowel or bladder Y N 4. Patient has ongoing Respiratory Therapy needs Y N SPINAL CORD INJURY (SCl) TEAM CONSULT Y N ON EMERGENCY DEPARTMENT EVALUATION PATIENT HAD EVIDENCE OF ALCOHOL AND/OR Y N SUBSTANCE USE (IF YES, COMPLETE CAGE CRITERIA) CAGE CRITERIA EVALUATION 1. Have you ever tried to cut down on your drinking Y N 2. Are you annoyed when people complain about your drinking Y N 3. Do you feel guilty about drinking Y N 4. Have you ever needed an Eye Opener Y N PATIENT REQUIRES DRUG AND ALCOHOL CONSULT Y N Comments: Screen completed by" C/-('~'0- ~ ~'J/~"'~ . Date ~///] 7/~-'~ Date Signature if no rehabilitation or therapy services are required White - Med. Rec. Yellow - Trauma Serv. MR 686 Rev. 5/99 TRAUMA SERVICES REHABILITATION ASSESSMENT Pink- UHRC PennState Geisinger Health System The Milton S. Hershey Medical Center TRAUMA PATIENT RADIOGRAPHIC "WET READS" (PRELIMINARY FINDINGS) The following radiographic studies were performed on this trauma patient, with "wet read" ~'~hest [] Abdomen preliminary interpretations as indicated: ¢ "~elvis / Hip- (L) vs. (R) [] Femur - (L) vs. (R) Knee - (L) vs. (R) [] Elbow- (L) vs. (R) Forearm - (L) vs. (R) [] Hand/Wrist - (L) vs. (R) ~,~ervical Spine rq Thoracic Spine [] Lumbar Spine Foot/Ankle _ (L) vs. (R) Skull Xrays [] Shoulder - (L) vs. (R) [] Other Xrays Humerus - (L) vs. (R) Radiologist's Signature: Printed Name: Beeper#: NOTES: 1. Angiographic/Cardiovascular Interventional Radiologic procedures are documented on other forms. 2. All studies on this patient for whom a "wet read" was provided during the trauma were "checked" in the appropriate boxes. 3. A "minus sign" ("-") indicates "no significant abnormality." 4. By his or her signature, the Radiologist who interpreted the studies "checked/circled" above indicates that the findings were discussed with the clinical team. MR 806 9/99 TRAUMA PATIENT RADIOGRAPHIC "WET READS" (PRELIMINARY FINDINGS) Wh,e- M~ Raco~ Yellow - Radiology 04/18/2000 M.S. Hershey Medical Center Page: 22:53 Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWAIN,AZILE Acct#: 000000020877 Admit: 04/14/2000 F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Disch: DATE: 04/14/00 TIME: 1920 R~F P. NG UNITS Na 142 135-145 mmol/L K 3.7 3.5-5.0 mmol/L Cret 0.7 0.6-1.1 mg/dL Glu H 125 70-120 mg/dL (a) Ion Ca 1.16 1.13-1.32 mmol/L DATE: 04/18/00 04/17/00 04/16/00 [ ..... 04/15/00 ..... ] TIME: n0620 0710 0900 2100 0900 REF RNG UNITS W-BC 6.7 4.8-12.0 K/uL Hgb L 9.5 12-16 g/dL Hct L 27.1 L 28.3 L 26.2 L 25.5 L 27.7 37-47 % RBC L 3.07 4.2-8.4 M/uL MCV 88.3 82-96 fL MCHC 35.1 32-36 g/dL MCH 30.9 28-33 pg RDW 12.9 12.0-16.4 % ---FOOTNOTES--- (a) QA FLAGS MODIFIED BY SEX/AGE UPDATE ON 04/14 AT 2316 CONTI~JED Cumulative Summary (InPatients) Page: 1 361921 MCELWAIN,AZILE 04/18/2000 22:53 04/18/2000 M.S. Hershey Medical Center Page: 2 22:53 Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWAIN,AZILE Acct#: 000000020877 Admit: 04/14/2000 F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Disch: DATE: 04/15/00 [ ..... 04/14/00 ..... ] TIME: 0410 2300 1920 REF P~NG UNITS WBC H 16.7 H 25.5 10.5 4.8-12.0 K/uL CAPILI~%RY Hgb L 9.7 L 8.0 12.2 12-16 g/dL CHECKED Hct L 28.3 L 24.3 L 35.5 37-47 % CHECKED (b) RBC L 3.23 L 2.80 L 4.10 4.2-5.4 M/uL (b) MCV 87.6 86.8 86.6 82-96 fL MCHC 34.3 32.9 34.4 32-36 g/dL MCH 30.0 28.6 29.8 28-33 pg PdDW 13.0 13.0 13.2 12.0-16.4 % Plts 298 140-340 K/uL MPV 11.9 8.7-12.5 fL ********************************** Urinalysis ********************************** DATE: [ ......... 04/14/00 ......... ] TIME: 2130 2045 REF P-NG UNITS Color (u) YELLOW YELLOW Appear (u) CLEAR CLEAR Glu (u) NEGATIVE NEGATIVE NEG mg/dL Bili (u) NEGATIVE NEGATIVE NEG Ketones (u) NEGATIVE NEGATIVE NEG mg/dL~ SG (u) 1.010 1.015 Hgb (u) * TP, ACE * SMALL NEG (b) (h) pH (u) 7.0 7.5 4.5-8.0 units Prot (u) NEGATIVE * 30 NEG mg/dL (b) Urobili (u) 0.2 0.2 0.1-1.0 EU/dL Nitrite (u) NEGATIVE NEGATIVE NEG Leuk Est (u) NEGATIVE NEGATIVE NEG ---FOOTNOTES--- (b) QA FLAGS MODIFIED BY SEX/AGE UPDATE ON 04/14 AT 2316 CONTINUED Cumulative Summary (InPatients) Page: 2 361921 MCELWAIN,AZILE 04/18/2000 22:53 04/18/2000 M.S. Hershey Medical Center Page: 3 22:53 Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWAIN,AZILE Acct#: 000000020877 Admit: 04/14/2000 F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Disch: DATE: [ ......... 04/14/00 ......... ] TIME: 2130 2045 REF RNG UNITS WBC (u) NONE NONE <5 /HPF RBC (u) 1-4 1-4 <5 /HPF Bact (u) * FEW * MODERATE NONE (c) (c) *********************************** Liver/GI *********************************** DATE: 04/18/00 04/14/00 TIME: n0620 1920 REF RNG UNITS ~LT 34 10-50 U/L T Bili 0.7 0.1-1.0 mg/dL D/nylase L 29 44 30-100 U/L ******************************** Cardiac/Lipid ********************************* DATE: 04/14/00 TIME: 1920 REF RNG UNITS Myoglobin H 133 0-116 ng/mL Troponin-I 0.4 <2.0 ng/mL ********************************** Toxicology ********************************** DATE: 04/14/00 TIME: 1920 REF RNG UNITS EtOH med <10 <10 mg/dL ---FOOTNOTES--- (c} QA FLAGS MODIFIED BY SEX/AGE UPDATE ON 04/14 AT 2316 CONTINUED Cumulative Summary (InPatients) Page: 3 361921 MCELWAIN,AZILE 04/18/2000 22:53 04/18/2000 M.S. Hershey Medical Center Page: 4 22:53 Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director 361921 MCELWAIN,AZILE Acct#: 000000020877 Admit: 04/14/2000 F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Disch: *************************** Blood Type and AB Screen *************************** TEST: ABO/Rh Antibody Scr 04/14/00 n 1905 O POSITIVE NEGATIVE ***************************** Crossmatches Ordered ***************************** TEST: Spec Expires R Number Component Type Units Ordered 04/14/00 n 1905 04/17/2000 R22653 RED CELLS 3 ***************************** Red Cell Products Issued ***************************** Component Unit Unit Volume Comments ABO/Rh Number 04/15/2000 n0010 PACKED CELLS O POS N67586 250 CONTINLrED Cumulative Summary (InPatients) Page: 4 361921 MCELWAIN,AZILE 04/18/2000 22:53 n~/~/2oo0 22:53 361921 MCELWkIN,AZILE Acct': 000000020877 Admit: 04/14/2000 M.S. Hershey Medical Center Hershey, Pennsylvania 17033 Michael Bongiovanni,M.D. - Director Page: 5 F 15Y Loc: 7MBS (724401) Dr: DILLON, PETER W Disch: 04/14/00 1920 CANCELLED: IONIZED CA, NA, & K , HGB AND O2SAT, ART PTT REASON:NO SPECIMEN RECEIVED BLOOD GAS, ARTERIAL PROTIME WITH INR END OF REPORT Cumulative Summary (InPatients) Page: 5 361921 MCELWAIN,AZILE 04/18/2000 22:53 Head CT (peds, unenhanced) Result Type: Date of Service: Authorization Status: Subject: Head CT (peds, unenhanced) Friday, April 14, 2000 8:45 PM Final CT HEAD UNENHANCED-PED MCELWAIN, AZILE R - 487301 * Final Report * CT HEAD UNENHANCED-PED ~ATIENT NAME: MCELWAIN,AZILE ~ATIENT MRN: 00361921 ?ATIENT DOB: 30-May-1984 KX~M NUMBER: 590A-041400 EX~M: CT HEAD UNENHANCED-PED )RDERING PHYSICIAN: PETER W DILLON Exam: CT HEAD UNENHANCED-PED UNENHANCED CT OF THE HEAD 2LiNICAL HISTORY: Status post MVA. F9OCEDURE: Standard axial unenhanced CT of the head with 8 mm cuts ~tove the tentorium and 4 mm cuts through the posterior fossa filmed in brain and bone windows. iSCUSSION: There are no comparison studies. The brain parenchyma ~emonstrates normal attenuation characteristics. The ventricles ~na extraaxial spaces are normal in size and configuration. There ~s no radiographic evidence of skull fracture. The paranasal sinuses, mastoid air cells and orbits are normal. IMPRESSION: There is no evidence of an acute abnormality in the head. Bruno reviewed the images and discussed the interpretation with Lobell. ii.STATED: 16227 ~EVIEWED AND SIGNED: MARK E. LOBELL, _ 2or M.D./MICHAEL A. BRUNO, M.D. Printed by: Longenecker, Teresa Page I of 2 Printed on: 05/23/2000 9:16 PM (Continued) Head CT (peds, unenhanced) MCELWAIN, AZILE R -487301 Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05/23/2000 9:16 PM (End of Report) Thorax CT (peds, unenhanced) Result Type: Date of Service: Authorization Status: Subject: Thorax CT (peds, unenhanced) Friday, April 14, 2000 8:45 PM Final CT THORAX UNENHANCED-PED MCELWAIN, AZILE R - 487301 * Final Report * CT THORAX UNENHANCED-PED :~TiENT NAJME: MCELWAIN,AZILE 7ATIENT MRN: 00361921 iATIENT DOB: 30-May-1984 :kAM NUMBER: 591A-041400 £XAM: CT THORAX UNENHANCED-PED }RDERING PHYSICIAN: PETER W DILLON £xam: CT THORAX UNENHANCED-PED Exam: CT ABDOMEN ENHANCED-PED Exam: CT PELVIS UNENH-PED CT OF THE CHEST, ABDOMEN AND PELVIS ;LiNICAL HISTORY: Status post MVA. ~'POCEDURE: Axial 8 x 8 mm CT of the chest, abdomen and pelvis was erformed after the dynamic administration of intravenous contrast. i!SCUSSION: There are no comparison studies. 7HEST: The mediastinal vasculature and structures are all normal appearance. There are no abnormalities of the lung parenchyma. ~here is a marked splenic fracture with enhancement of only the most dorsal aspect of the spleen. There is prominent amount of free fluid surrounding the liver through the region of the spleen '~nd throughout the peritoneum consistent with free blood. There is · linear lucency in the liver just adjacent to the gallbladder ~7~ssa which does not appear to be a splenic laceration, its irobably an anatomic structure. The liver otherwise enhances %ormally and is free of definite evidence of laceration. The ~=ncreas is normal in appearance. The kidneys also enhance ;trongly and are also free of abnormality. The bowel is normal in ~ppearance. The remainder of the structures of the abdomen are ~rmal. Note is made of small amount of fluid in the endometrial Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05~23~2000 9:17 PM (Continued) Thorax CT (peds, unenhanced) MCELWAIN, AZILE R - 487301 :anal, thus the patient is most likely currently menstruating. ?here is a cyst in the left adnexa which is probably an ovarian lhe bone windows of the chest, abdomen and pelvis demonstrate no ~vidence of bony fracture. i![PRESSION: 1. There is a splenic fracture with enhancement of nly the dorsal most aspect of the spleen; the anterior fragments ~re not enhancing. There' is a lot of free fluid in the abdomen which is invariably :~iood in the peritoneum. There is no definite evidence of liver findings were discussed with the clinical team. Dr. Bruno reviewed the images and discussed the interpretation with Sr. Lobell. ~ICTATED: PEVIEWED AND SIGNED: MARK E. LOBELL, M.D./MICHAEL A. BRUNO, M.D. Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05~23~2000 9:17 PM (End of Report) Abd CT (enhanced, peds) Result Type: Date of Service: Authorization Status: Subject: Abd CT (enhanced, peds) Friday, April 14, 2000 8:45 PM Final CT ABDOMEN ENHANCED-PED MCELWAIN, AZILE R - 487301 * Final Report * CT ABDOMEN ENHANCED-PED PATIENT N~LME: MCELWAIN,AZILE PATIENT MRN: 00361921 PATIENT DOB: 30-May-1984 EX~_M NUMBER: 591B-041400 EXA~M: CT ABDOMEN ENHANCED-PED ')RDERING PHYSICIAN: PETER W DILLON E:~am: CT THOP~AX UNENHANCED-PED Exam: CT ABDOMEN ENHANCED-PED Exam: CT PELVIS UNENH-PED CT OF THE CHEST, ABDOMEN AND PELVIS iLINICAL HISTORY: Status post MVA. PROCEDURE: Axial 8 x 8 mm CT of the chest, abdomen and pelvis was ~erformed after the dynamic acLministration of intravenous contrast. ~iSCUSSION: There are no comparison studies. 7HEST: The mediastinal vasculature and structures are all normal appearance. There are no abnormalities of the lung parenchyma. There is a marked splenic fracture with enhancement of only the most dorsal aspect of the spleen. There is prominent amount of ~ree fluid surrounding the liver through the region of the spleen and throughout the peritoneum consistent with free blood. There is a linear lucency in the liver just adjacent to the gallbladder rossa which does not appear to be a splenic laceration, its probably an anatomic structure. The liver otherwise enhances normally and is free of definite evidence of laceration. The pancreas is normal in appearance. The kidneys also enhance strongly and are also free of abnormality. The bowel is normal in !~ppearance. The remainder of the structures of the abdomen are normal. Note is made of small amount of fluid in the endometrial Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05/23/2000 9:17 PM (Continued) Abd CT (enhanced, peds) MCELWAIN, AZILE R - 487301 :~nal, thus the patient is most likely currently menstruating. ?here is a cyst in the left adnexa which is probably an ovarian bone windows of the chest, abdomen and pelvis demonstrate no vidence of bony fracture. iHPRESSION: 1. There is a splenic fracture with enhancement of >nly the dorsal most aspect of the spleen; the anterior fragments ~re not enhancing. ?. There is a lot of free fluid in the abdomen which is invariably blood in the peritoneum. There is no definite evidence of liver [aceration. ?he findings were discussed with the clinical team. .:r. Bruno reviewed the images and discussed the interpretation with _r. Lobell. 2.1CTATED: REVIEWED AND SIGNED: MARK E. LOBELL, M.D./MICHAEL A. BRUNO, M.D. Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05/23~2000 9:17 PM (End of Report) Pelvis CT (peds, unenhanced) Result Type: Date of Service: Authorization Status: Subject: Pelvis CT (peds, unenhanced) Friday, April 14, 2000 8:45 PM Final CT PELVIS UNENH-PED MCELWAIN, AZILE R - 487301 * Final Report * CT PELVIS UNENH-PED ~ATIENT N~LME: MCELWAIN,AZILE PATIENT MRN: 00361921 PATIENT DOB: 30-May-1984 E×~M NUMBER: 591C-041400 ~×AM: CT PELVIS UNENH-PED O~DERING PHYSICIAN: PETER W DILLON Exam: CT THORAX UNENHANCED-PED CT ABDOMEN ENHANCED-PED CT PELVIS UNENH-PED CT OF THE CHEST, ABDOMEN AND PELVIS ?LINICAL HISTORY: Status post MVA. PROCEDURE: Axial 8 x 8 mm CT of the chest, abdomen and pelvis was Derformed after the dynamic administration of intravenous contrast. 3ISCUSSION: There are no comparison studies. THEST: The mediastinal vasculature and structures are all normal appearance. There are no abnormalities of the lung parenchyma. There is a marked splenic fracture with enhancement of only the most dorsal aspect of the spleen. There is prominent amount of free fluid surrounding the liver through the region of the spleen ~nd throughout the peritoneum consistent with free blood. There is ~ linear lucency in the liver just adjacent to the gallbladder £ossa which does not appear to be a splenic laceration, its ?robably an anatomic structure. The liver otherwise enhances normally and is free of definite evidence ~f laceration. The ?ancreas is normal in appearance. The kidneys also enhance ~trongly and are also free of abnormality. The bowel is normal in appearance. The remainder of the structures of the abdomen are normal. Note is made of small amount of fluid in the endometrial Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05~23/2000 9:17 PM (Continued) Pelvis CT (peds, unenhanced) MCELWAIN, AZILE R - 487301 ~nal, thus the patient is most likely currently menstruating. ?here is a cyst in the left adnexa which is probably an ovarian bone windows of the chest, abdomen and pelvis demonstrate no +vidence of bony fracture. ~?!PRESSION: 1. There is a splenic fracture with enhancement of nly the dorsal most aspect of the spleen; the anterior fragments ~re not enhancing. · There is a lot of free fluid in the abdomen which is invariably ~!ood in the peritoneum. There is no definite evidence of liver laceration. i'ne findings were discussed with the clinical team. Bruno reviewed the images and discussed the interpretation with Lobell. DICTATED: 16227 ~EVIEWED AND SIGNED: MARK E. l/jor LOBELL, M.D./MICHAEL A. BRUNO, M.D. Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05/23/2000 9:17 PM (End of Report) CXR (1-view) Result Type: Date of Service: Authorization Status: Subject: CXR (1-view) Friday, April 14, 2000 7:30 PM Final DX CHEST 1 VIEW-AP, SUPINE, INSP, MCELWAIN, AZILE R - 487301 * Final Report * DX CHEST 1 VIEW - AP, SUPINE, INSP, PATIENT NAME: MCELWAIN,AZILE PATIENT MRN: 00361921 PATIENT DOB: 30-May-1984 EXAM NUMBER: 588A-041400 EXAM: DX CHEST 1 VIEW - AP , SUPINE, INSP, IRDERING PHYSICIAN: KYM A SALNESS Exam: DX CHEST 1 VIEW - AP , SUPINE, INSP, Exam: DX PELVIS 1-2 VIEWS - AP , SUPINE, CHEST AND PELVIS fLINICAL HISTORY: Multiple trauma. DISCUSSION: iERVICAL SPINE: Multiple open-mouth views were obtained. On the _asr view the lateral masses are aligned. The dens is intact. ihe cervical spine is visualized from C1 to Ti. There is anatomic ~lignment. The vertebral body heights are maintained. ?revertebral soft tissues are within normal limits. PELVIS: There are no fractures. There is anatomic alignment. 7HEST: Calcified right super hilar lymph node is noted. The ~ardiomediastinal silhouette is within normal limits. The lungs are clear. There is no pneumothorax. There are no fractures. IMPRESSION: Cervical spine, pelvis, chest was within normal limits. Dr. Bruno reviewed the images and discussed the interpretation with Dr. Haught. Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05/23/2000 9:17 PM (Continued) CXR (1-view) iCTATED: 5:EVIEWED AND SIGNED: pas MCELWAIN, AZILE R - 487301 KRISTEN HAUGHT, M.D./MICHAEL A. BRUNO, M.D. Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05/23/2000 9:17 PM (End of Report) C-spine XR (2-3 views) Result Type: Date of Service: Authorization Status: Subject: C-spine XR (2-3 views) Friday, April 14, 2000 7:30 PM Final DX C-SPINE 2-3 VIEWS - LAT, XTAB, AP, MCELWAIN, AZILE R - 487301 * Final Report * OX C-SPINE 2~ VIEWS - LAT, XTAB, AP, ~ATIENT NAME: MCELWAIN,AZILE ?ATIENT MRN: 00361921 ~ATIENT DOB: 30-May-1984 E×AM NgMBER: 588B-041400 EXAM: DX C-SPINE 2-3 VIEWS - LAT, ~%RDERING PHYSICIAN: KYM A SALNESS XTAB, AP , Exam: DX C-SPINE 2-3 VIEWS - LAT, XTAB, AP , C-SPINE ]LINICAL HISTORY: Motor vehicle accident. DISCUSSION: There are no comparison studies. Four views of the cervical spine are presented for evaluation. There is normal vertebral body height, disc spacing, and alignment ~f the cervical spine. There is no evidence of a fracture, ~islocation, or precervical soft tissue swelling. The cervical spine is evaluated to the level of the T1-T2 level. Visualized portions of the lung on the anterior view demonstrate a calcified lymph node in the upper mediastinum on the right. iMPRESSION: The cervical spine is within normal limits for the ~:a~ient's age. i?r. Mosher reviewed the images and discussed the interpretation wi~h Dr. Brian. DICTATED: 16874 REVIEWED AND SIGNED: PAMELA BRIAN, M.D./TIMOTHY J. MOSHER, M.D. !/pas Printed by: Longenecker, Teresa Page 1 of 2 Printed on: 05/23/2000 9:17 PM (Continued) C-spine XR (2-3 views) MCELWAIN, AZILE R -487301 Completed Action List: Printed by: Longenecker, Teresa Page 2 of 2 Printed on: 05/23/2000 9:17 PM (End of Report) PennState Geisinger The Milton $. Hershey Health System Medica~ Center AMBULATORY HEALTH VISIT NAME: UCELWAIN, AZILE R MD; DILLON PETER W MR#: 487301 DOB: 05/30/1984 INS: AUTO INSURANCE LOC: PESU OOS#: 748191 MDg: 26150 SEX: F VISIT DATE: 05/10/2000 [] Health Maintenance Referred by/Address: Nursing Ill Consultation Acute Care Follow-up Medications/Do~age oCr OE3 R[D Ax[3 cm. % 2. 3. 4. Subjective Signature Measurements: Weight &~ Kg ~ Length j MR 167 Assessment/Diagnosis/Plan 3. 4. 5. Next visit: SIGNATURE I ATTENDING ~ AMBULATORY HEALTH VISIT 4185 [~See dictation I I~ Letter to M.D. PennState Geisinger Health System AMBULATORY HEALTH VISIT I The Milton S. Hershey Medical Center NAME: MCELWAIN, AZ~LE MD: BLEWETT CHRISTOP MR#: 487301 DOB: 05/30/1984 INS: AUTO INSURANCE LOC: PESU OOS#: 778213 MD#: 26080 SEX: F VISIT DATE: 05/24/2000 [] Health Maintenance I [] Consultation Acute Care Referred by/Address: Nursing Follow-up Medications/Dosage Subjective 1. 2. 3. 4. Signature ' Objective: % Length cm % Head Circ. cm. % Lab Assessment/Diagnosis/Plan 1. 2. 3. 4. 5. Next visit: SIGNATURE IA'Ir'ENDING [] See dictation / E3 Letter to M.D. DATE TIME MR 167 4185 AMBULATORY HEALTH VISIT PennState Geisinger Health System Children's Hospital The Milton $. Hershey Medical Center P.O. Box 850, M.C. H113 Hershey, Pennsylvania 17033-0850 Telephone 717 ~31=8.342 Fax 717 531-4185 Susan Rzucldlo, M.S.N., R.N. Pcdla~c Trauma Nttr~ Coordinator Jay Townsend, M.D. 100 $. High Street Newville, PA 17241 May 10, 2000 RE: MCELWAIN, AZLAZLE MSHMC #487301 Dear Doctor Townsend: I saw Azlazle in the office today for follow-up evaluation. She is now almost a month out from her motor vehicle accident in which she suffered significant splenic laceration. Since her discharge, she has done well. There have been no new medical issues or problems. She has been maintaining a Iow activity program, but has been going to school. On physical exam, her weight was 64 kg. Abdomen is soft and nondistended. She had no palpable areas of tenderness or masses. The remainder of her exam was unremarkable. Overall, I am delighted with her progress. We would like to see her back in approximately four weeks at which time we will repeat her CT Scan. If the spleen is completely healed at that time, which most are, we will release her to all activities. I have released her for swimming activities for some exercise with the limitation that she cannot undertake any type of diving. She is still to be restricted from gym and sports activities. Thank you so much for allowing us to participate in her care. If I can be of any further information or service, please do not hesitate to call. Best wishes. PWD:asap PennState Geisinger Health System Children's Hospital The Milton S. Hershey Medical Center P.O. Box 850, M.C. Hll3 Hershey, Pennsylvania 17033-0850 See tioll of Pediatric Surgery Department of Surgery Robert E. Cilley, M.D. Christopher J. Blewett, M.D. Coleen P. Greecher, M.S, R.D., Dr. Jay Townsend Graham Medical Center 100 South High Street Newville, PA 17241 May 24, 2000 RE: MCELWAIN, Azalie MSHMC #487301 Dear Dr. Townsend: I saw Azalie in the Pediatric Surgery Clinic on 5/24. This youngster is now about six weeks out from her MVA with a splenic laceration. My partner Bob Cilley saw her two weeks ago. She was doing quite well, however, this morning she woke up with some new left upper quadrant pain. On exam there is no distension and there is a minimal amount of tenderness in the left upper quadrant. Although we are scheduled to repeat a CT scan in two weeks l just went ahead and got a CT scan on Azalie today. It shows excellent healing of the spleen without cyst formation. There is no free fluid seen in the pelvis. I am pleased that Azalie is resolving her symptoms. I plan to restrict her activity for two more weeks and then she is free to return to full activities. We will be happy to see her back on a PRN basis. I have instructed herto contact us with any further episodes of pain. It is a pleasure to participate in Azalie's care. Please contact me with any questions or concerns. CJB:asap Sincerely, Christopher J. Blewett, M.D. Today's Date: Name: Date of Birth: May 8, 2001 Azile McEIwain May 30, 1984 Female 'HT Age: 16 Annual Benefits: $6,085 per year, guaranteed payable for 3 years. First payment is 05-30-2002 (age 18). Last payment is 05-30-2004 (age 20). This is 3 guaranteed annual payments, and then payments stop. TOTAL STRUCTURE AMOUNT: Plan #1. Guaranteed Amount: $18,255 ~ost: $17,000 $18,255. _ $17,000 proposal is effective through MAY 10, 2001. This is the date that the funds for the structure must be at the annuity company or this proposal will expire. This is an illustration, not a contract. (3 l!q!qx:l RELEASE AND SETTLEMENT AGREEMENT This Release and Settlement Agreement ("Agreement") is made and entered into among Azile McElwain, a minor, by her parents and natural guardians, Allen McElwain and Joann McElwain and Allen McElwain and Joann McElwain, individually; Arnold K. Rook and Lucinda Rook, individually and as husband and wife, Aron Rock; and Nationwide Mutual Insurance Company ("the Parties"). The "Claimant" shall colletively mean Azile McElwain, a minor, by her parents and natural guardians, Allen McElwain and Joann McElwain and Allen McElwain and Joann McElwain, individually, their respective heirs, executors, administrators, personal representatives, successors and assigns; the "Insured" shall collectively mean Arnold K. Rook and Lucinda Rook, individually and as husband and wife, and Aron Rook; and the "Insurance Company" shall mean Nationwide Mutual Insurance Company. I. RECITALS A. On or about April 14, 2000, at or near Route ll, Carlisle, Cumberland County, Pennsylvania, Azile McElwain claims to have sustained physical injuries as a result of the alleged conduct of the Insured (the "Incident"). In connection with the Incident, the Claimant has asserted a claim against the Insured based upon tort or tort type claims. B. The Insurance Company and the Insured have entered into a liability insurance contract which provided that the Insurance Company shall defend the Insured against any claim or suit for damages arising from the Incident, has authority to settle any such claim or suit on behalf of and as agent for the Insured, and shall insure the Insured for such liability subject to the limits set forth in the contract. C. The Parties desire to enter into this Agreement to provide, among other things, for considerations in full settlement and discharge of all claims and actions of the Claimant for damages which allegedly arose out of or due to the Incident, on the terms and conditions set forth in this Agreement. NOW, THEREFORE, it is agreed as follows: II. RELEASE A. Release and Discharge. In consideration of the cash payment(s) referred to in Paragraph III.A. and the promise to make the periodic payments referred to in Paragraph III.B. ("Periodic Payments"), the Claimant hereby completely releases and forever discharges the Insured, the Insurance Company, and any and all other persons, firms, or corporations from any and all past, present, or future claims, demands, actions, damages, costs, expenses, loss of services, and causes of action of any kind or character, whether based on tort, contract, or other theory of recovery, whether known or unknown, which have arisen in the past or which may arise in the future, whether directly or indirectly, caused by, connected with or resulting from the Incident. This release and discharge shall be a fully binding and complete settlement among all Parties to this Agreement, and their heirs, assigns, and successors. The Claimant acknowledges and agrees that this release and discharge is a general release. The Claimant expressly waives and assumes the risk of any and all claims for damages and expenses which exist as of this date, but of which the Claimant does not know or suspect to exist, whether through i,gnorance, oversight, error, negligence, or otherwise, and which, if known, would materially affect the Claimant's decision to enter into this Agreement. The Claimant further agrees that the Claimant has accepted the considerations set forth in Paragraphs III. A. and B. as a complete compromise of matters involving disputed issues of law and fact. The Claimant assumes the risk that the facts or law may be other than the Claimant believes. It is understood and agreed to by the Parties that this settlement is a compromise of a doubtful and disputed claim, and the payments are not to be construed as an admission of liability on the part of the Insured, by whom liability is expressly denied. B. In_Juries Known and Unknown. The Claimant fully understands that the Claimant may have suffered personal injuries that are unknown to the Claimant at present and that unknown complications of present known injuries may arise, develop or be discovered in the future, including, but not limited to, subsequent death or disability. The Claimant acknowledges that the consideration received under this Agreement is intended to and does release and discharge the Insured and the Insurance Company from any claims for, or consequences arising from, the injuries which allegedly arose from the Incident; and the Claimant hereby waives any rights to assert in the future any claims not now known or suspected even though, if such claims were known, such knowledge would materially affect the terms of this Agreement. C. Parties Released. This release and discharge shall also apply to the Insured's and the Insurance Company's past, present, and future officers, directors, stockholders, attorneys, agents, servants, representatives, employees, subsidiaries, affiliates, reinsurers, partners, predecessors and successors in interest, heirs, executors, personal representatives, and assigns and all other persons, firms or corporations with whom any of the former have been, are now, or may hereafter be affiliated. III. PAYMENTS TO CLAIMANT. PAYEE, AND/OR BENEFICIARY A~. Payment at Settlement (and Amounts Previously Paid). The Insurance Company and the Insured have agreed to pay Eight Thousand Dollars ($8,000) up front to the Claimant and have already paid Two Thousand Nine Hundred Thirty Nine Dollars and 02/100 ($2,939.02) to the Claimant for lost wages and out of pocket expenses, receipt of which is acknowledged. In addition, the Insurance Company agrees to pay the Health America lien for approximately Two Thousand Dollars ($2,000), receipt of which is acknowledged. These payments include, but are not limited to, all out of pocket expenses, attorney fees, all medical liens, except Health America, all rights of recovery, all medical subrogation claims, all worker compensation subrogation ~laims, known and unknown, and claims for general damages. B. Periodic Payments. The Insurance Company, on behalf of the Insured, agrees to pay or cause to be paid the following Periodic Payments: (1) To Azile McElwain ("Payee"), the stun of Six Thousand Eighty Five Dollars ($6,085) to be paid annually on or about the thirtieth (30th) day of May each year beginning on or about May 30, 2002, guaranteed to be paid for a period of three (3) years, with the last payment to be made on or about May 30, 2004. (2) Should Azile McElwain die before May 30, 2004, then any remaining guaranteed Periodic Payments set forth in Subparagraph III.B.(1) shall instead be paid, subject to the provisions of Subparagraph III.B.(3) below, as they become due, to the estate of Azile McElain ("Beneficiary"), with the last guaranteed Periodic Payment to be made on or about May 30, 2004. (3) The Payee shall have the right, after reaching the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the Annuity Contract. The change will be effective when approved by both the owner of the Annuity Contract and the Annuity Issuer. Any change in the Beneficiary shall not in any way affect or alter any of the provisions of this Agreement. IV. ASSIGNMENT AND FUNDING OF PERIODIC PAYMENT OBLIGATION A. Assignment of Obligation. The Parties understand and agree that the Insurance Company may assign its duties and obligations to make such future Periodic Payments to ("Assignee") pursuant to a "Qualified Assignment and Release," within the meaning of Section 130(c) of the Intemal Revenue Code of 1986, as amended, attached as Exhibit A. Such assignment is accepted by the Claimant without right of rejection and in full discharge and release of the duties and obligations of the Insurance Company and all Parties released by this Agreement with respect to such Periodic Payments. Upon such assignment, it is understood and agreed by and between the Parties that the Assignee shall make said Periodic Payments directly to the respective Payee and/or Beneficiary designated in Subparagraphs III.B.(1) and (2), and that the Payee shall submit any request to change the Beneficiary directly to the Assignee. THE PARTIES EXPRESSLY UNDERSTAND AND AGREE THAT, WITH THE INSURANCE COMPANY'S ASSIGNMENT OF THE DUTIES AND OBLIGATIONS TO MAKE SUCH PERIODIC PAYMENTS TO HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO PURSUANT TO THIS AGREEMENT, ALL OF THE DUTIES AND RESPONSIBILITIES OTHERWISE IMPOSED UPON THE INSURANCE COMPANY BY THIS AGREEMENT WITH RESPECT TO SUCH PERIODIC PAYMENTS SHALL CEASE, AND INSTEAD SUCH OBLIGATION SHALL BE BINDING SOLELY UPON HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO. THE PARTIES FURTHER UNDERSTAND AND AGREE THAT WHEN THE ASSIGNMENT IS MADE, THE INSURANCE COMPANY SHALL BE RELEASED FROM ALL OBLIGATIONS TO MAKE SUCH PERIODIC PAYMENTS AND HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO SHALL AT ALL TIMES BE DIRECTLY AND SOLELY RESPONSIBLE FOR, AND SHALL RECEIVE CREDIT FOR, THE PERIODIC PAYMENTS, AND THAT WHEN THE ASSIGNMENT IS MADE, HARTFORD COMPREHENSIVE EMPLOYEE BENEFIT SERVICE CO ASSUMES THE DUTIES AND RESPONSIBILITIES OF THE INSURANCE COMPANY WITH RESPECT TO SUCH PERIODIC PAYMENTS. B. Annuity Funding. The Parties understand and agree that the Assignee may fund its obligation to make the Periodic Payments by purchasing an annuity contract (the "Annuity Contract") t?om (the "Annuity Issuer"). If such Annuity Contract is purchased, the Assignee shall be the owner of the Annuity Contract and shall have and retain all rights of ownership in the Annuity Contract. For its own convenience, the Assignee may direct the Annuity Issuer to make all the Periodic Payments directly to the respective Payees and/or Beneficiaries designated in Paragraph III.B. Each Payee and Beneficiary designated in Paragraph III.B. shall be responsible for maintaining his/her current mailing address with the Annuity Issuer. The obligation assumed by the Assignee to make each Periodic Payment shall be fully discharged upon the mailing of a valid check or electronic funds transfer in the amount of such payment on or before the due date to the last address on record for the Payee or Beneficiary with the Annuity Issuer. If the Payee or Beneficiary notifies the Assignee that any check or electronic funds transfer was not received, the Assignee shall direct the Annuity Issuer to initiate a stop payment action and, upon confirmation that such check was not previously negotiated or electronic funds transfer deposited, shall have the Annuity Issuer process a replacement payment. C. Status of Claimant. Payees. and Beneficiaries. The Claimant, each Payee and each Beneficiary, as applicable, shall at all times remain a general creditor of the Assignee and shall have no rights, in the Annuity Contract nor in any other assets of the Assignee. The Assignee shall not be required to set aside sufficient assets or secure its obligation to the Claimant, each Payee, or each Beneficiary, in any manner whatsoever. V. NO CHANGES IN PERIODIC PAYMENTS The Claimant acknowledged and agrees that all, some, or any part of the Periodic Payments cannot be accelerated, commuted, transferred, deferred, increased or decreased by the Claimant or by any Payee or Beneficiary and that the Claimant or any Payee or Beneficiary shall not have the power to sell, mortgage, encumber, or otherwise anticipate all, some, or any l~art of the Periodic Payments by assignment or otherwise. VI. ENTIRE AGREEMENT This Agreement contains the entire agreement between the Claimant, the Insured, and the Insurance Company with regard to the matters set forth in it. There are no other understandings or agreements, verbal or otherwise, in relation to the Agreement, between the Parties except as expressly set forth in it. This Agreement is intended to conform with the requirements of Internal Revenue Code Sections 104(a)(2) and 130. All provisions of this Agreement should be construed in a manner so as to effectuate that intent. VII. READING OF AGREEMENT In entering into this Agreement, the Claimant represents that the Claimant has completely read all of its terms and that such terms are fully understood and voluntarily accepted by the Claimant. VIII. FUTURE COOPERATION All Parties agree to cooperate fully, to execute any and all supplementary documents, and to take all additional actions that may be necessary or appropriate to give full force and effect to the terms and intent of this Agreement which are not inconsistent with its terms. IX. DRAFTING OF DOCUMENT AND RELIANCE BY CLAIMANT This Agreement has been negotiated by the respective Parties. The Parties to this Agreement contemplate and intend that all payments set forth in Secion III constitute damages received on account of personal injuries or sickness, arising from the Incident, within the meaning of Section 104(a)(2) of the Internal Revenue Code of 1986, as amended. However, the Claimant warrants, represents, and agrees that the Claimant is not relying on the advice of the Instired, the Insurance Company, anyone associated with them, including their attorneys and the insurance broker placing the Annuity Contract, as to the legal and income tax or other consequences of any kind arising out of this Agreement. Accordingly, the Claimant hereby releases and holds harmless the Insured, the Insurance Company, and any and all counsel or consultants for the Insured and the Insurance Company fi.om any claim, cause of action, or other rights of any kind which the Claimant may assert because the legal, income tax or other consequences of this Agreement are other than those anticipated by the Claimant. The parties signing this Agreement, and each of them, warrant and represent that no promise, inducement or agreement not expressed in this Agreement has been made to them and that this Agreeement constitutes the entire agreement between the Parties and that the terms of this Agreeement are contractual and not mere recitals. The Claimant represents and agrees that the Claimant has read the Agreement and fully understands it, and is aware of the propriety and legal effect of executing it, and neither the Agreement nor the compromise and settlement recited in it were induced by fraud, coercion, compulsion or mistake, nor is this Agrement nor the compromise and settlement made in reliance upon any statement or representation of any of the Parties released by this Agreement, or their representatives, agents or attorneys. X. WARRANTY OF CAPACITY TO EXECUTE AGREEMENT The Claimant represents and warrants that no other person or entity has, or has had, any interest in the claims, demands, obligations, or causes of action referred to in this Agreement, and that the Claimant has the sole right and exclusive authority to execute this Agreement and receive the sums specified in it and that the Claimant has not sold, assigned, transferred, conveyed or otherwide disposed of any of the claims, demands, obligations or causes of actio~ referred to in this Agreement. XI. COURT APPROVAL The Parties agree that the Claimant will file petitions for all necessary court approvals, that all such petitions and orders shall be in a form satisfactory to all Parties, and that this Agreement will not be effective until such approvals have been obtained. XII. CONTROLLING LAW This Agreement shall be construed and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. Dated: "~'-P~-O / Dated: Dated: en Mc-Elwain, j~dividt~ally and as parent and natural ~arfliatn- of Azi/l~cElwain, a Jo~ McElwain, indivtic~ually and as parent anff natural guardian of Azile McElwain, a rn~nor, Claimant Duly Author/zed Representative for Nationwide Mutual Insurance Company Exhibit A Uniform Qualified Assignment and Release "Claimant" Aziie McEIwain, a minor, by her parents and natural guardians, Allen McEIwain and Joann McEIwain "Assignor" "Assignee" "Annuity Issuer'' "Effective Date" Nationwide Mutual Insurance Company This Agreement is made and entered into by and between the parties hereto as of the Effective Date with reference to the following facts: A. Claimant has executed a settlement agreement or release dated '~', ~Lu 23. D_C~I , 2001 (the Settemen~ Agreement") that provides for the Assignor to make certain periodic payments to or for the benefit of the Claimant as stated in Addendum No. t (the "Periodic Payments"); and B. The parties desire to effect a "qualified assignment" within the meaning and subject to the conditions of Section 130(c) of the Internal Revenue Code of 1986 (the "Code"). NOW, THEREFORE, in consideration of the foregoing and other good and valuable consideration, the parties agree as follows: The Assignor hereby assigns and the Assignee hereby assumes all of the Assignor's liability to make the Periodic Payments. The Assignee assumes no liability to make any payment not specified in Addendum No. 1. The Periodic Payments constitute darrmges on account of pemonal injury or sickness in a case involving physical injury or physical sickness within the meaning of Sections 104(a)(2) and 130(c) of the Code. 3. The Assignee's liability to make the Periodic Payments is no greater than that of the Assignor immediately preceding this Agreement. Assignee is not required to set aside specific assets to secure the Periodic Payments. The Claimant has no rights against the Assignee greater than a general creditor. None of the Periodic Payments may be accelerated, deferred, increased or decreased and may not be anticipated, sold, assigned or encumbered. 4. The obligation assumed by Assignee with respect to any required payment shall be discharged upon the mailing on or before the due date of a valid check in the amount specified to the address of record. This Agreement shall be governed by and interpreted in accordance with the laws of the Commonwealth of Pennsylvania. The Assignee may fund the Periodic Payments by purchasing a "qualified funding asset" within the meaning of Section 130(d) of the Code in the form of an annuity contract issued by the Annuity Issuer. All rights of ownership and control of such annuity contract shall be and remain vested in the Assignee exclusively. The Assignee may have the Annuity Issuer send payments under any "qualified funding asset" purchased hereunder directly to the payee(s) specified in Addendum No. 1. Such direction of payments shall be solely for the Assignee's convenience and shall not provide the Claimant or any payee with any rights of ownership or control over the "qualified funding asset" or against the Annuity Issuer. 8. Assignee's liability to make the Periodic Payments shall continue without diminution regardless of any bankruptcy or insolvency of the Assignor. ~10. This Agreement shall be binding upon th respective representatives, heirs, successors and assigns of the Claimant, the Assignor and the Assignee and upon any person or entity that may assert any right hereunder or to any of the 11. The Claimant hereby accepts Assignee's assumptio of all liability for the Periodic Payments and hereby releases the Assignor from all liability for the Periodic Payments. In the event the Settlement Agreement is declared terminated by a court of law or in the event that Section t30(c) of the Code has not been satisfied, this Agreement shall terminate. The Assignee shall then assign ownership of any "qualified funding asset" purchased hereunder to Assignor, and Assignee's liability for the Periodic Payments shall terminate. Periodic Payments. Assignor:Nationwide Mutual Insurance Company By: Title Authorized Representative Assignee: Hartford Comprehensive Benefit Service Co - By: Title Authorized Representative Employee Claim (~ Allen ~l~l'cE~/~n,'~aas~ I~a~r~t aM ~atural gua~'dian of Azile McEIwain, a mino~ Claimant:~ ~ Joanne Mc~(~ain, as parent and natural guardian of Azile McEIf~ain, a minor Approved as to Form and Content: By: N/A Claimant's Attorney Addendum No. 1 Description of Periodic Payments The following Periodic Payments: (1) To Azile McEIwain ("Payee"), the sum of Six Thousand Eighty Five Dollars ($6,085) to be paid annually on or about the thirtieth (30th) day of May each year beginning on or.~about May 30, 2002, guaranteed to be paid for a period of three (3) years, with the last payment to be made on or about May 30, 2004. (2) Should Azile McEIwain die before May 30, 2004, then any remaining guaranteed Periodic Payments set forth in paragraph (1) shall instead be paid, subject to the provisions of paragraph (3) below, as they become due, to the estate of Azile McEIwain ("Beneficiary"), with the last guaranteed Periodic Payment to be made on or about May 30, 2004. (3) The Payee shall have the right, after reaching the age of majority, to submit a request to change the Beneficiary by filing a written request with the owner of the Annuity Contract. The change will be effective when approved by both the owner of the Annuity Contract and the Annuity Issuer. Any change in the Beneficiary shall not in any way affect or alter any of the provisions of this Agreement. Initials Claimant: Assignor: Assignee: POST & SCHELL, P.C. BY: AMY L. CORYER, ESQ. I.D. # 82718 240 GRANDVIEW AVENUE CAMP HILL, PA 17011 (717) 731-1970 ORIGINAL ATTORNEYS FOR PETITIONERS ARNOLD K. ROOK, LUCINDA J. ROOK AND ARON ROOK ARNOLD K. ROOK, LUC1NDA J. ROOK and ARON ROOK Petitioners, ALLEN MCELWA1N AND JOANN MCELWA1N, as Parents and Natural Guardians of AZILE MCELWA1N, a Minor Respondents. 1N THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW NO: O 1 _ ,t.j./,,/.,,3 ~[o ~'Lq'-"~"~ ORDER APPROVING MINOR'S COMPROMISE FOR DISTRIBUTION AND NOW this ~ ~ day of t0ro}~ '~ ,2001, upon Consideration of the Petition for Leave to Settle or Compromise Minor's Action, it is hereby ORDERED that the Minor, Azile McElwain, a minor through her parents and natural guardians, Allen McElwain and Joann McElwain, is authorized to enter into a settlement agreement with the Petitioners, Arnold K. Rook, Lucinda J. Rook and Aron Rook, for the minor child in the gross sum of Twenty-Five Thousand Dollars ($25,000.00), Eight Thousand Dollars ($8,000.00) up front with three guaranteed annual payments of Six Thousand Eighty-Five Dollars ($6,085.00), the first to be paid on May 30, 2002, and the last to be paid on May 30, 2004. BY THE COURT: J. POST & SCHELL, P.C. BY: AMY L. CORYER, ESQ. I.D. # 82718 240 GRANDVIEW AVENUE CAMP HILL, PA 17011 (717) 731-1970 ORIGINAL I U6 0 ATTORNEYS FOR. PETITIONERS ARNOLD K. ROOK, LUCINDA J. ROOK AND ARON ROOK ARNOLD K. ROOK, LUCINDA J. ROOK and ARON ROOK Petitioners, ALLEN MCELWAIN AND JOANN MCELWAIN, as Parents and Natural Guardians ofAZILE MCELWAIN, a Minor Respondents. IN THE COURT OF COMMON PLEAS OF CUMBE~ COUNTY, PENNSYLVANIA CIVIL ACTION- LAW No: ORDER APPROVING MINOR'S COMPROMISE FOR DISTRIBIYTION AND NOW this ~" day of ~o~,--" .2001, upon Consideration of the Petition for Leave to Settle or Compromise Minor's Action, it is bereby ORDERED that the Minor, Azfle McElwaln, a minor through her parents and natural guardians, Allen McElwain and Joann McElwain, is authorized to enter into a settlement agreement with the Petitioners, Arnold K. Rook, Lucinda $. Rook and Aron Rook, for the minor child in the gross sum of Twenty-Five Thousand Dollars ($25,000.00), Eight Thousand Dollars ($8,000.00) up front with three guaranteed annual payments of Six Thousand Eighty-Five Dollars ($6,085.00), the first to be paid on May 30, 2002, and the last to be paid on May 30, 2004.