page 1 · page 1 reporteri s record volume 5 of 5 volumes trial court cause no. 32004 court of...
TRANSCRIPT
Page 1
REPORTERI S RECORD
VOLUME 5 OF 5 VOLUMES
TRIAL COURT CAUSE NO. 32004
couRT OF APPEALS NO. 12-15-00280-CR
STATE OF TEXAS
VS.
RICHARD GROSS
) IN THE DISTRICT COURT
)
) ANDERSON COUNTY, TEXAS
) 87TH JUDICIAL DISTRICT
EXHIBIT INDEX
©©E9W
The following proceedings came on for the hearing in
The above-entitled and numbered cause on the 13, 14,
day of July/ 2015, and October 23, 2015 before the Honorable
Deborah Oakes Evans/ Judge presiding/ held in Palestine/ Anderson
County/ Texas:
Proceedings reported by computerized stenotype machine.
Susan A. Wa|drip Reporting1-800-949-7984
Page 2
A P P E A R A N C E S
FOR THE STATE:
MS. ALLYSON MITCHELLSBOT. NO. 24026884DISTRICT ATTORNEY OFFICE500 NORTH CHURCH STREET, ROOM 38PALESTINE, TEXAS 75801
TELEPHONE: (903) 723-7400
FOR THE DEFENDANT:
MR. MARK CARGILLSBOT 00787201701 NORTH ELM STREETPALESTINE, TEXAS 75801Telephone: (903)729-9011
Susan A. Wa|drip Reporting1-800-949-7984
Page 3
1 Volume 2 July 13, 2015.
(No Exhibits)2:56
78
9::
1::
wi_I.1
Susan A. Wa|drip Reporting1-800-949-7984
Page 4
July 13, 2015. VOLUME 3
EXI]IBIT INDEX JULY 14, 2015 VOLUME 3
STATES
NO. DESCRIPTION
1 DVD
2 PHOTOGRAPH
3 PHOTOGRAPH
4 PHOTOGRAPH
5 PHOTOGRAPH
6 BUSINESS RECORDS
7 BUSINESS RECORDS
8 BUSINESS RECORDS
DEFENDANT I S
NO. DESCRIPTION
NONE, 2015.
OFFERED ADMITTED.
77
88
88
88
88
92
92
92
77
89
89
89
89
92
92
92
OFFERED ADMITTED
VOLUME 3.
Susan A. Wa|drip Reporting1-800-949-7984
Page 5
EXHIBIT INDEX.
STATEIS NO. DESCRIPTION
PI Pen packet
P2 Pen packet
DEFENDANT I S NO. DESCRIPTION
VOL. NONE
OFFERED ADMITTED VOL.
r7 4
rl 4
OFFERED ADMITTED
Susan A. Wa|drip Reporting1-800-949-7984
Page 6
VOLUME 5 OF 5 VOLUMES
TRIAL COURT CAUSE NO. 32004
COURT OF APPEALS CAUSE NO. 12-15-00280-CR
STATE OF TEXAS
VS.
RICHARD GROSS
) IN THE DISTRICT COURT
)
) ANDERSON COUNTY, TEXAS
) 87TH JUDICIAL DISTRICT
I, Susan A. Wa|drip/ Official Court Reporter in and for
the 87th District of Anderson County/ State of Texas/ do hereby
certify that the above and foregoing contains a true and correct
transcription of a| portions of evidence and other proceedings
requested in writing by Counsel for the parties to be included in
this volume of the Reporter's Record, in the above styled and
numbered cause, all of which occurred in open court or in
15 chambers and were reported by me.
16 I further certify that this Reporters Record of the
17 proceedings truly and correctly reflects the exhibits/ if any/
18 admitted by the respective parties.
19 I further certify that the total cost for the
20 preparation of this Reporters Record is $380.00 and was/will be
21 paid by Anderson County, Texas.
/s/ Susan A. Waldrip.
Texas CSR 3377, Exp. 12/31/2016.
P. O. Box 1507 Fair field, Texas 75840.
(903)389-4827
Susan A. Wa|drip Reporting1-800-949-7984
1Z/a9/Zg15 u9: " 9©g72e7491
THE STET.I OF TEXAS aCOUrrmr OF WALKER a
AN CO Drat CU(
A_FrmAVIT
PAGE 86/|3
"y T]ame iS Kullj. Emtoe, I am over twentyone years ornge, of sound minds capab]g Qfmalting thisaffidavit and persoTlally acquainted With tire fasts herein stafadT
I am EmPlnyed as the Chailrman of CIassification and Records for thgL Texas Daparfuerlt ofcfim].rlalJustice - Correctiona! Tnstifutiions Diyision, and ny offlce is loEated in fiuntSYmeT Texas'I do hereby certify that the ahached infbmlatiOn Provided On I'nmae ggC)SSL J3J£I]±gQTDCJffiPP# ££3±JScanse# I 9672, I 8560.. are true and conect capies Q"e Originfll reaprdS TIOW On ffleJ'n my Office maintairled iJl the nggular colJrsg ¢fb+lSineSS Wi±hin the Cfa±sffical¢n and RcoQrds C)fficg tifthe lt*as Depa-out nf CrindTlal rfustiCS - Correctiiollal lr] stifut]'CmS Division.
Tn winess where of, I have frere to sat my hand this tile Jj!]in day qfJedin 20] 5_
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Ketly EnloeChaITm apCiassificatioTl and Records
The d'ue¢tor sh al.i cem'.fy under the seal of the cotte¢tiona[ InsL.ItutitmS D ivi£fon [hc documents 7¥Ce;Vetundel. Subsections (a) and tc) ofArticTEi 42.09 Cads prCriniual Froeedure. A dac'JmCnt ¢ertifed underthis sut]sectioTl :-i Self-anthentI'Ciated -for th.a Purpose ¢f Rules 90I and 9021 Texas Ru]eS Qf CriminalEvidE=nCeI
Article 42.¢9` `%sectton 8(a), as amended by a. B. ,1 061` Ac+a I Pg`1.1 73d leg.
I CRer.12/02)
CERTHI EBDOCURE REi
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COncurrerit tJn|esE; Othe twiEe §. ±¢ified" . _
On' this dayJ Set Earth. abOVeJ tt`iS _t=ause 5ame on Ear t*j.a| andcame The State' of rexas| by iEs atlOve. named art.ckfi£yr and ttle
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I IT IS, quER€FOItE, Cch'Sm5REb JL«D anD'EE.ED a.y the court/ in thenrh€an+A ^f LLJ. 't\-J=__a__I_PreSsnee o£ Etie be£endant+ tHa±__Gal-i i_u-a-a-trl-;-n_thilrEby ln lil thlrlga.apP[OPea and t:J3n{lrmed'.
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And th€ gala SefendarlE ls r`EmarLded t® jail uTltil Said Sherif£ _cafl obey the alreetiorl q£ thlg Judgment.` ._ .
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PflOaA*rc]N O£PAR."ERE IN Am#ncrrm hh"Hm|J -_._
ii5&isT-ili "#i-1"i>EL=L.5it=nS$8:j^1* 1 _t_h.a " _5ta:I.? _ os *exBSIAfiderSom a"a Wblle du..-ing the ltecm a.E Said prchaEiOntepolt tO the probation off.I,lOer in 'Aflde'son €Qu.tr+
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£aurl¢y o£€ai|ed taTe*aG fatSeFtemberJ
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m) my TO "E BI5"ICT anBbP PRPB*=m«.'OfFI-CE SL"._00 EB"BgRgE-flEHT " AI"HB¥,£ FEE. -D PROEfaRIORER'-a APPalun£D CouRTSEb INEaUfiT, WON"* IusmL"ENT§ OP S-4 mcH, E8"rEE'! IHE RIRSI END"" bay o'.EVERY mNIE, B¢¢-ING. Itt mE N.Exp "Our,I POLLOurNgEnIRT aF "IS caDgft AiNa COh'mNUIpr.G ONgI£ SUCH r!g"ga§gtiEur lgPAID IN FuLL'. as fo||c}wt5=I" that Eh€ D££efiaaflt. Ri€bara Gross, in th.a state of Texasr
fao !lbetf ±oof p¥rd =o£oEnheanOdl a E!iE: fauurft"gprEohbea.a 1!,:n-Of¥i.¢Sga iae i:btuo:::::::£Q' |ttO'"€Y'S F@8 Pals ptabationarta appqin¢ed cchnsel ifl monthlyinsEa"mE"t5 0f.$8.34 a.ach for the months o£ Jan'ar" FgtryaryrttafEh, April,.H3yt '-a, I.uly, AuqHSt+ September, o€tqberJ ryQVerR-ber and DE€®.mbGt "BS..'anuarrr February, It#FChr AElrii, my. Junefdh|y. jlu9uSt. £€Ptett\b€r. Occober, November and.December.l986. Jan-uar¥' February, tt3¥€h. xplil. "ay+ Ju,ne.. July, fau9uBt, £€ptgnber,october, wavems.gr, peggmber. ]g8? a tpta'= o£ $3OO.OO in arrears..
(ol Ear Si3?.25 REST="T=aN rO "E oISmICT ABUT,I FcoREIOrfoF£ICE' ItJ EQUAL HonIELY IN8TflmttEN.S or sl2.15 -8A€flp BE"EgN. "gFIR§I rmD ±EIJI.tt Oex OF Bt-y EN", BS.CrENING IN I.Erg NEXI #C)N"FOLLO'wINI, Eti"Y QF "IS ORDER.AraD €ONTIh.UJNG uNIIrJ SUCHHE5TI"TIOt' I5 FA}Q IN Fun, Sj9.oa IO.SQmy rolti\SJ $378.25 TQCunSE; €lZ3¢ wI" A rOrAL OF S437.23r. as roll.aaptI?
c1%nmtchvbto£ tE\a=H=_£n€_Thd±BnnTuhR+5`¢^is=*=€LiEio=_€r=-1-i _`CLt - sng`te o€ nexes |!:!I:! :f inadye=lo2n. 1a5ndpeWrh lmlo€nt;urfio¥ rtfS€t i::.:gof,€|qs.aihdE a.qEmOobuan¥Ogfs437+25 tor the mPntbS' O£ ta-ry, pebruarr, March., xpri1' "ar,.Jtm€. 'u|¥, J\u9u5E, 5€pt€mb€r,. october, uovembErr De'cembgi.. 19e5JJEftauty. FebEbarW .llayChr April, nay. Ju.ne, au±y, - fi"gustf5BEt€"ber, dCtOb££, roy8mbe', December/ 158£, January, Feb'uaryJItrmd:eC:f€ I?pD'i ::fflbf:? + 1.gflJ7u,nE£,or '=J.fo+t alAuog£u:gEJS T.iegPtienmba:rr;Erg :.ober ,
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IT IS THE OftnER OF -E COm= Eha.I tb,a s.aid.De£gndanL ouoaajLlagt?a ou11Eu'nf I.t1- -C<____ _~ _ - _:g#dlg::d9ou"11Ey' o£ the ¢€fense a.f
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a Chj..|ahas.been
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y€ar8: 8Dd lt is £u'€her gourd.bi, the court that:a lncarr:f'rJarqfi ~na lnearceratea _orl-+---`.-_ +'tu,_+i_.__ _ _ I.,-a-a8
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Not:ice af Appt=al._
DIS":let JuDGii
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''rtyttanB is mly Enlofa I an overtwenty-on£years ofnge, ofsound mind= capablg ofmcking this
affidavI.I and persma"y acquainted ixpith chS facts herein gtded_I. am employsd 8LE the Chfr!.rman ofc:lassification and Rerards for the Texas Dapatmnt ofc!riminaI
Justi.cc - Conectl-anal histr'[ufaE§ "Yl-gion,. al my offiSc i5 !acaed in EL"5Vi"a. i-exas-T do hgreby certify that 1-hB attached I,nformedOn provided on i"male GROSS- RI£tIARDTDunPP# fflJjS.cause# 2Q2J±- ae tr"B and C¢rroC. COPiBS'Ofthe Original rBCOrd5 now on file in myoffice "rfulitted in the regular course of business w1.th;n !hg I:lassificatio" and Rrmrds Qf#cg gfthcTexas DapaTtment of Grim inaI Justice - ¢one¢tional ]nstttutiolis Dl.vision.
in witness where of, I have here to Sgt my hand this theJ4th day of un 2Ol 5.
/-K+-+-.k-€} ±:I.a.-..-
Kelly ErlleE: ,C,bat rmquClassificat]'Qn.and Reeo rdS
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The a J'.reaeOr chal I certify undcr the seal a ftha Cormtr-,-I InStiunions ,I)ivtsion (hg dacuunts receivedunder Subsectio"s ® and (c! ofA.rtjcle 42.O9 CoaE OfCtindm! Procedure, A decunent gerdfEed uns.erthis subsechon is sclf-anthent;=atSd for thg puTPQge Of Rules gfl T and gO£, Texas Rules of Crirm.natEvidencel
Article 42_O9, Subsecrfu S¢), as amended by s- i. l¢£7rdcts 1993J3d lcg.
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THE STATE OF TEXAS
VS.
RICHARE GROSS
CAUSE NO. 320fl4
IN TILE TIIIRn JtJBICIAL3>
DrsTRICT COunT ifeg{1.+-\£4.-.¢r? -':2-
AJrmERSON a OtINife-¥:;.I ,rfuf?-.E3`|:- :rat.i-.i-.II
ECH-CE--OF FELINE. OF-apCqRI)Sl-±}TD-AFEPAVI± =5? `rRI i;I;:¥:ii
You as herEtry mtffi£d that Allyson Mitehen, CRIMINAIJ DrsTRICT jLTTORPunY
FOR APunERSON COtINTYI TEXAS has fled in th£ abovei3ntitled and flum.bSred Cause Cerfein
records of DON RflThRS SR together with an affidsvit by Rffisty Wflcher a custodian of the
records of Dr. Wa]- Brown. Theserecords will be offiredin eiridence as business records at fie
hial of the captiond canse.
pursut to Rule 902 (10) (a) of the Texas rmles of Evidence, these rec6rds will be made
awiJifele by the Court Clck to counsel for parties to the litigation for inapection and copdyg at the
expense offi]e person desiring The copies_
I)ATED: June25` 2015'
Ann)ERSON COunTY CC)tJRTIIOUSEPAIJESTRE] TXJ5 8O 1(903) 723-7400(903) 723-7818.TBC# Z4¢26884
1:
ENFj]
CERTIHCATE OF SERVICE
Tis is to certify that a true and gonect Sopy of Noficg of ming Records and
Affidavit was fasd on ike 25tfi day of June, 201 5, was dctivered via fax to the attomey of
record for fie Defendant:
Mr. Mark CargrlAttorney at LawPalestine, Texas 75801
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• THE STATE OFTEXAS
VS'
RIG- GROSS
CLiUSE Pr[mmER. 32004
IN DISTRICT COtmT OF
AIELRESOH COununr, TEXAS
TREE J[JDI€IAL DISTRICT
AEFIDArm
B rforG me, the undrSigne i authOrfty, P ersom]ly
- - - '_'l
whol bins tymeduly swom' deposed as foflows:
rty nana isLmifeihhidsl£ I am ofsoundminft Capable ofmrfug this affidrwii, ndpersrmallyacquainted with ths faofs fierein statedr
I an ihg oustodiafi ofbndne§s reaords ofDR,WAYRE REOWN. Attacked harfro arg|_ pnggs
of fusiness records ofDRVAIRE BROWN, pedaining to DON REffiRS SR. These said i pages
ofleCC]rdS art= kept try DR.WAYNI3 BROThIN in the regrllar COurSe OfbusineSS, and it Was the regular
course of business ofDRWA|RE EROrVIIN, fir an Employee or represenfafroe ofDR-WA|ZNE BROWN,
with inowiedg3 of the actl event, condifron, opinion, or diagnosis) recorded tcl make fie reaord or to
tranrmit information tlereof to be incindsd in such record and ffie record was made at or near the time or
SWORN TO JII" SUBSCRBEB before mgi on the
My oorisien expkes:
.,5-
Banald Myers
Date of Encounter: i1/20/RE14 03:09 "
mstory of present Illness
Patient #: 3792OO
WA"E i BROWrj, DO i]J20peOl4 a3:4g "
BROTar, TrH"Ephpoanifogie:,,-i%o7-P!382105I6
DOE: iO/03/1959 (5S years)
The Datlent is a 55 year old male
History
aAlleray
Sulfamethorazc) le isu lJ=O NAN IDIrs*Problem List/Past Medical
HYPERCHOLESTEROLEMIA/ PuREPeried id5
Other Problemsi++ I__
open \round: heanrfg without signs 2ndary inffroinfinger hactwe, rightEnvfrorm Bnfal al lergies
Past SurqicaITchs]l I rfu my
EL#±esinREdf=\ Thesan, lgiv wHst and right [ng
M edfcations
i:ukvea"dsafa(#no;310gggJGaib#h#vOen'e) fablet 0 ra I da "y,
FAavunegtiE:eoT[g::hnt- #fkuoertlfu2#:krFfc#pl#ng; [3n/:#£/o!##ee)tteAOdqte.
f#itfija7ri:;g:orfobll4irAlct(iov::)(mT:bylefatkoera2#aa#,r#:
iugi!ve:a:aodir)ilo!weai€o:inmgta;ebog:Fl:tdpf!efknu!gaed!g€hatosbad!jio:iii:bofi::pie2hI:Fa:zioi54a)y#aag#esTuaih gnleugQ#ahtl:e(f5k5nMqd+ab leL 2 fablets ore Ionce da)lv) Active.
3rmti#sttiaesri nfof8£#G¥aOb[gte,r10 g=c[aiDal#T#dive.Aclphex f20MG Thblct DR, 1 Oral daily) Active_
Social
RJevieWOfSysterns "N£"RO"ooumma4:0"
a
Tobacco use: former smokerAIcoho! use: occasional alcoha! use
gi:air:a:ndii:;faiie:NiSe!Iiiin:oe:N-::;;i;piOeSr;i;;enyn;i:ann::i:ihi;ll;apfriP;hoTgre;o#o:gpo;iah;ej:ne£:;idi:i;e;hi;ig5mw:jnc:i;:sin#;:ngDW;iEahgikaO3;;he:adpn;nd:BP:oamwst:;eaHeSapa;;ts;e;::llg:e:a:rD5yhsop:ogfiaBraenadthe#a:!Is¥gcSuG:!:e:¥eiuergnI: FrgeonthpjeofnetntpiPnysaunrjas:en #rI:q uen ey.
H¥S:Y:Cr:O!a:f:ii£:rfefiNtootptrpPerrsefee;i_iE!;Eye#un;s5llnaDSgf;aedrgesf3j#a?:ad. chan ge in H -CHE I ntensfty or paife m.
e vital S`ign5Date:Temperature:Pul5e1.
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1i/20/2014 03,.10 "97,5 0F
B7
kespirafi a ns : i 6Peak Flaw;Blood pressurS: 104/80REadingTypi]i Manual
#bRE®nEol!ac ha ant mid thigh ari
Heighti 6B !nWeight: I |5G!b
Wa i5t:BMI; 23.63 kg/m2
ESA: I.88 mZ
Note! -
Physical Exam vA"g"RowH"1xpO#o";2"
- ffi:!piE:ngei!ne;Crf:o¥en?tnoped:aafs#r!:;Onhnati:a;iin!F¥#Frnc:;griahdt::ntggfaf:i#;fme¥n:v:ro:: lbsayhno-ivs:n:":pegva:#opteapddadFnsn/:##eo:#£Ti;ahtle:nth
ffipEffiment.. - na gross rash, bru].sing, or 5u5P[CiOus shin [esious ky observatlon (nan-d]5robed)`_i____ .
gPer:gahbtDLEole5acxh2y; nO local lymphangitis/lymphadenltis or s;gns 2ndary
EIf'. -.I ,8lobeJ Assessrneut - neck is Supple Without ftyramegaly. nob-fender and no lymphadsnopathy.
EELTff±the ears, nose, mouth and throat - no nated cough, snrme, sneae, or 'ctgaring' of throat,
ffRE-scles - no apparan[ Increased eifeit of resplratIQn,Zaeyae¥tist?ouuRsdsS:: nod?g; _b#oaELseo#nd;, eyraTeg/eotrr!crionch I I
E±enmlnation revesis - no obvious chest paint shQrfuess of breath/ or dyspnga on gRErd.On byobservaion of activltles_AFTuuSr€muitrasti&a no#er#ema=R§eg9uUiadr=r:hA#sTur:gornatQe; the hgarfe revea ls - No Murm uns and No aicke.
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vREREnNSQPecCytalnnongl-s I(#/-5fFdklg5lkin#g##ov:su=E]::dm): EOdeC#abgftg]uELhgt (-4ELn/#gTg(l4tsthn/o5tthevd# i/tspalpation! hadi@I pulse - Left - 2+. Right - Note.- mt palp d/tapHnE ELema _ ffifateral - Na edema.
RErvfuesi'c-ongon:tbi?T:ufsu ;ffioenfic-ifeNob;mapbasl#ea#e#gafttaectl:#.or in pa lrm ent of un en hation.
ffiffiffi and aife[t arc described as _ apprapriate. nat sad' No iITifable.
-isffid eydems ravea]s - normal coordlnatlon Galt an~d sfathn - overt" appropriate balance,
caordlnatlon, and muscular drength by obse"tion af activifes.
weari"g cIEan ulnar guttEr5PliutWith ACE to rightdlsfal fem and 4/5Eh digits, nut removed for exam; s"ng on rightErrfuJ_a_tJ£Ecg-Fo§narE#E#nLoc=: y - no regional llrmPhadenOPatily found_
A55es5ment & Plan rlyHr"fl Srmow, oa,. I,/pty2ouiou.Jg+nyJ
#faByr.sfiTr:=g:::sr!g!: gt8hla6#?l4thELrent PJaflfr
. SFEenL REPORTS GR roRMS (9908B); RQutlne
. starfed ultram 50MG, 1 (one) Tablet fourtimes da"y, as needed for pelfty #40, ll/20/2014 No REfiIII
. sfarfed "Gbi€ 7.5MGl 1 (onEj Tablet da"y, #30, ll/2a/ZO14, No Refill, Mail Order #90, No Rch".
. reviewed ER findings / treatment,. radiology note.
. Referral to orthopedics- Disc"5sed Rest Ice? Cornpresslon and Elevation detai)s. elevate hand over heard ]f olrobbing. Iufppia#m/ei#i#_g persist /WOrsEn Or lf COOlneSs, blueng5S, Or numbness develop atthe injury site or dlsfaliy, follow-
TOapdEany¥9Iu#r(e8£fg8i! ri ght ant th igh-Current P!_aJE
I sfarfed Augmendn sod-125MG, 1 (one) Tablef every e19ht hours, #21, 7 days sfartlng ll/20/20i4, No Refl.[LI started Truvada ZOO-3"G, 1 (one) Tablet drily, #5, l1/2dy2014' No ifefliLI discussed:
I - reffimmerld ProbiOtl'C While On abeI thgiil:i:m:dc;'.:s:w¥e;:gi:ng!:Gee:ane::dede[ai;os#;nofrueesnffi8"gn/a::::;:pfeiviifE:fawgoodarn:gE:wct:/::gdrijseab#aaos:!gaen!o5:oibirgtacoaTdTa:rnsoe:zat#:::#boaa#s#T#ncbrr-i::enfdws:::,
. follow up in 4 claps ora5 needed
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a ct&_WAyNE I BROWN DO
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aDoJ1=ld Myers
Date af Encounter'. ll/2q/2o14 07:4g
History of prest=r]t IllnessAM
Patient #: 3?g2Oq
WENE i 8ROm, oo 11J2±/Za14 12:a+ pM
BROrm, WTAFIVE
phpoan?:2f91nae:i"¥DzP!!2!5116DOBi 10/G3/l959 (55 years)
thieh, #e#gti::-ntrfu5E#+#ti,REffi:#gfi#tinu.p on -fry initiated treetwErfu Hen to fo]tow ap on hurm b]te to
H I'§tOry
AIler"suifemcthine "LFONAMmES*
Problem List/Past MedfcatHYPERCHOLESTEROLEMm, PuREPerth iHs
Other problems
I-_-_= Iopen wound: healing without sit]ne 2ndary infectolnFinger frrfure, rightEnvironmental aHergles
Past SurctcalTous"e ctomv
ii;¥##!dd# ngtesap, len wrist and rtht ng
M edicati a II a
IEHk¥eandsa#Fnoq-¥10#aG/2Toalbtgtheltl(voer a) Ta bi at ore I da "y,
ii!5Y:a:a:aodi!5no5!erff#eeT#jffetdp:£s:efknuTe#g£;:of#en#;iinif:eopiue2h#agom=4alyheaw machinefv while tak!mJMagne5l'Um Glucanate (25DMG Tablct, 2 tablets oralOnce dai!v) Actlve.antibiotics for §kln disorder on scalp Active.s!-5fatin f8"G Tablet. 1 Oral daily) Active.AciDhex f2"G Tablet m. 1 Oral dalm Active_
Social
Review ofsystenls rm"8roWrtyDOn/avae|4n:oow
a
IE±@hcoru:gg :oFcocasrmFornasra#oe: a I use
G€n£rak preent- Appatie has and Heedacha. Not preserfe- fever, chi"s, wiight sweats, Djzlpaus and uninfentienalwslght loss_
a:Hak#E"dpf3:;N:soefqi:Ne!tOeN¥idSp£eiufnenynCdtan_Suo;feheh¥n:i!s£o:#n:ai:d;kspDnOeEa..Ga=trojntBSti"al: Present- Nausea. Nat present~ Abdominal pain, change in Bowe] Habife and €ariy satlety-MusculuskeletaI.. Present- Joint pain and see HFTINeuralogicaI: Not present- paresthesia5.
Vital SI'gnS
Date: ll/24/ae1¢ 1 1:45 j"Temperatu re: 99 0FPuis8: 88Respira tlt}ns : 16Peak Flaw:Blood Fressura;_ 128/90REfadingType: Manual
Height: 69 inWeight: 162 lbWaist:BMI: 23.92 kg/m2
BSA.. 1.89 m2
Note: -
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Physical Exam wA¥RELBREWftybo/ll/ZV201+12:1"
E-gaerni#cAopmpfi¥ft= nacceco-mgpoaondfesdplglyts/-Aspppoeuasre: ##g #h ewpe;[Fernota/i;sd[.Qa#VTIg-ELdggPaavnidorfigguoswedn.a a p pa rent
right wn'st/hand in splint
REffiments - no gres5 rash, bmlslngr or su5PICfaus Skin [eslons try observatlQn (nOnrd]apbed),
ELREthe ears, no=i mouth and throat - no noted cough, snffl=, meRE, Qr lClear[qgl of throat
EN:epaalfr irn=pp#aartieonnt,[nRESed respTratory e- ky abservafron,
gxamlnat!on reveals - no obvious Chest Pain, chorfuBSS Of heath, Or dyapnERE Qn exertion bydivities-tibservaion of adiviiiis:
Th± and affect are described as _ apprapride.
-isffied systems revea(g - normal caordmtlon Gait and sfatlon - ovgra« appropriate halance,
coordlnatlon, and muscular strength dy observation of actlvltes.
nearing dean ul"r gutter sp"nt with ACE to rigitt dlsfa: 4arm and 4/5th digits. not removed for gram; no s"ng today
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As5ۤSment a PIatt m!"tyg{ coprrty GO,, 1j/ayanqt?..JJ jREJ
TOopdBan#.¥#e8§7sr:8n3 healing wlthout signs 2ndary infedelnfroen-. dlscussed:
a- rlo change ill Wound tX
FIJIger fracture, right (816.aO]Current PJar
. SPEmL REPORTS OR FC"S [ggOgO),. Routing
. dlsouseed:
ir:##btoe5Ei#:l'ruelt##/I?for:n:tE`#av,#v:etLfEitB)i pwgonrdk(I(gpt most be able to use use of force and Safely handle/discharge fire-
rf r3-MAINE i BRCIWN DO
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TILE STATE OF TEXAS
ThS.
RIG- GROSS
CAtJSE ilo. 3ZOO4
Eff=;I I,E:'"
-.||'\+-
NOTICE OFFILIRE OFRECORESJINDAFFIDAVIT -=5t:i 5?\Er_
IN THE THIRD JTJI}ICIAL-+t- =~-Ei:THms"cT £OURf STF:if:;-: i.:
c\..i= +ANRERE ON CO INng,;:TPXi'§
C=r|- '. t
* CJJ
You are hereby notified that AIkyson Effitchen, CRThThIAL DrsTRICT ATTORI"Y
FOR ANDERSON COTINTYS TEXAS has filed in the inove-endtlgd and numbered cause cutain
records ofDON ELT]RERS SR together with an affidavit ty Lisa Musick a clTlstC)dian Of the records
of Palestine Rectonal Medical Center, These records will be offered in evidence as business reccnds
at the trial of the captioned Gauge.
Pusuant to Rule 902 (10] (a) of the Texas rules of Evidence, these records will be made
available by the Court Clerk tc) counsel for parties to the litigation for i]xpection and Copying at the
expense of the.person desirfug the copies.
DATED: June25_ 2015. -
Resp entfufty submitted,
.+
..
LEI;t``t!`
# 'T CRELL
DrsTRICT ATTaRrHEY 1ER I)OUNTY COURTEOUS E
PALESTn"J TK. 758B1(903) 723 -7400(9O3) 723-7818TBC# 24026884
*-TiSilREITsE-.?S',i!iI
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CEErmI CATE¢F SERVIfCE
Tis is to certify that a true and correct Copy of Nrfue of Ffling REcords and
Affidawh was farsd en the 25th dffy of June, 20I5, was dctivgred via fax fo the afromey of
record for tis Drfendant:
Mr. Mark CargivAiferney at I,.awPalesfue} Terns 758ti1
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cAusE rmRERE jiafiTHE STATE OF TERAS IN TEE DISTRICT COURT OF
ANI}EESON COunmr, TEXAS
mmn JtmICIAL nrsTRICT C:aunt
#_FThJLVIT
Brfero me, the undersigned authority, peneonally appeared .sA M.Hl
1whO, being by me rfuly SWOm] deposed as follows:
Mynane isLsA It`J5 i C*i ,I anofsoundmind, capablerfndchgthis affidavit
and persomlly acqualuted with the facts htnein stated:
I am the enstodian aft)usingss records of Attached hereto
ae Jl pages of busdess r€cnds of _ _____----Pg--thcJ _________ Patal[:ling tO
These saldJJJageS Of reCends ac kept by
-- --- - --- PR-lrdL ---------- ---- in ds regular course afhainess, and it was th: regularcouse of business of __-, --P_gr-|E+ _ _ fior rm rmployse or represenfafroa of
- , - --.----I--:PELthfJ --- -. - _ --i,I-vyi.tb kngiV-ledge pf-th-a_ act e-veife. cgndiSppl apfqiP-rty -qu_
diagmsis, recorded fo mdee the record or to transmit information thereof to be inrfuded in such
ifecord; and foe record was madt: at or near thti time or reasonchly soon thereafteL The reetirds
attached kereto are thB OriSnal Or exact drPlieates of the oriSnal.
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PALES"NE REGZORAL MEbl±AL CENTER2900Saulh Loop 256, PalcalFno, Th- 7S8qi , (god.73Wrm)
REGISTRATION At}M ISSION•i!j±8EU!#i!
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Physician DocumentationPalestinE Regional Medical CenterName:Donald Myeis aAge..55 yr5Sex:MaleDOB'MRN:3|0949BArrival Date:ll/19/2014Time:21:|7A|cou nt#.i9583658Eed8Private MD:ED PhysltianGarcia, !smaEIHPlt[ll/1921..22 This 55 yrs old White Male presents to ERvia Ambulated withkr
complalnts of Human Bital.21:22 The patient was bitten on the right'quadriceps, by T:i--,=L--kr
person in attempt to sudLie, at a Parking lDt, Pt officerl hashumanbite to right thigh, no break in clc)the5[ break ln Skin aPPEarsaS
pinch wound. Onset: The symptoms/episode began/o|curredjust prior toairital.. 5€€6'ri`d5fy t6i.h`E.biEE' frfiiit'ii.rfe-Fe-fifts_ i-il'h; i I ,_. - ~iwelling|bleedlng. A5SOCiated Signs and Symptoms: Pertinerlt POSitjVeg:Er]rfhema at 5lte, Pain at Site, tendEme5S, Severity ofsymptoms,. AtthEir Worst the Symptoms Were mild, in the emergencydepartment thesymptoms are unchanged, It ls unknown whether or not the
• #ie#i::5ymPtomg inthg Past. Thepatignthas nctrecentlySeenaphys`iciam Pt also complains of right fingers pairl.
H istor'lca l'I- Allergies: SULFA (SULFONAMIDE5];- Exposure RiskITravel Screening.,: Patient has nat been out of the
I :soiirtthrya: nh :a$5[tr:vOeieadys:uHtealvrdee yoofuthbee::i:tcryoT:ati:el:tsh[ E3nO¥Dne Whoda\J5? Nol
Legally atltheatJc:ated by !SfulAEL i;ARC;iA, MD ±O14-ll-Za Z3:Zg:qI
.`ryr .
- Family history:: No immediate family members are acutely ".- Social history:.. Thbacco Status.. unknclwn if patient has ever
smc)ked. Thg patientls primary language ls English. The patient'5preferred language ls English.
- Tuberculosis screening:: No symptoms or risk factors identified'
===+-.-I-I I--I- Illl ---- lllli-I I unlllll -.i-:I.H:m:..l{`5}..g'.+I ` : /a:.
RO51'21:27 All other systems are negative. except aE dOCumented beiaw_kr
MS/extremity: Positive for bite' of the right quadriceps, pair! tQright 4th and 5th fingers.
Exam:21:27 constitutional: This is a well develtipecl, well nourished patientwhokr
is awake/ alsrt/ afebrileHead/Face: Narmocephalic, atraumatic_Eyes: I Conjunctlva and sclera are nan_icteridefld not;i.ty f,.injected'
Perlorbital areas with no swelling, redness/ Or edema'CEIrdiaVaSCular.. Normal and'rhythm with a normal Sl andS2, No
gallops, murmurs, ar rubs, Normal PMI, noJVD, ND Pulsec]efi|its.
21:27 Re5Piratory`, Lungs have equal b-th saunas bilaterallyl cleartD kr
auscultation and per=ussion, No rates, rhanchi or wheezesnoted, NoincreasEd urOrk Of breathing, nO retractions 0r nasal flaring'
21:27 Musruloskeletal/extremity.. Extremities: grossly normal except:naked
in the right quadriceps: bite, confusion, noted in the righthand:laceratlarll tendeme5SI RON: infect in. all extremities,Circulation!s inta=t in all extremities, Sensation intact. Joints: All jointsappear nclrmal With full range of matlom Tendon exam:5PeC[flC terldOntesting normal through actrve and pas5]Ve range Of mOtiOn
21:27 5kln: Appearance: Color: pinkJ Temperature: warm, Moisture:dry.
injury, bite(a), deep, of the right quadriteps, approx 2.Q[mecchymotlc area appears ta be a Pinch, bleeding, Woundclbtained from
Legally auther!tjcaled ty ISMAEL GARC:lA, givlB m14-i 1-20 23:Z9:01
bite on thigh through pants, positive break ln skinl nQ tear inclothes.
Vital Signs:21:20 BP 117/78,. Pu]sgl18; Resp 18;limp gg.2; PulsEC)x gg% on+R/A; ..tbp2 ¥,
weight7O.76 kg; Heights ft, 9 Jn, (1?5.Z6 cm); Pain 5/|0;23:25 BP llU 84; Pulse 9B; Reap lB,.Temp gg,2f. Pulse-ox gg% ;tlg21:20bp2
Body Mass Index Zi$4 (70,?6 kgJ 175,26 cm)
MDM:•Z1.,19 MSE Initiated by provider. kr22:45 Differential diagnosis; guperfjcjal [aceration' i- _,-i---I--_Ii_i
!mmunhation is not indicated. Data rev;ewed: vita( Signs;nursesnotes/ radI'OIOgiC studies/ plain films, counse"ng;i had adetaileddiscussion With the Patient and/or guard;an regarding,. thehistoricalpoints, exam findings, and any diagno5t!C results supportingthedischargefadmit diagnosis, radidI'ogy reguit5, the need foroutpatientfollow up/ for definitive care, a family practitioner/ ac)r[hopedicsurgeonl tO return tD the emergeney deparinent if symptomsWorsen OrPersist Or if there are any questions dr concems that arise athomeI
1|/192|..43ll/19
order name: _± i:21:43 Order name:EDMSIll/|921:19 Order name: BIGHT FINGERS 2Vll/1 921:32bp2
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Order name: Dressing; completeTime: 2|:32
||/1922.,04 Order name; splint; complete T[me: 22;04
Legally authenticafeq by lsfuljqEL enR€/A, MD 2O14-ll-2O Z3:2g:O1
EDMS
kr
bp2
lDispensed Medications:
21:3Z Drug: Neomycln-Bacitracin-Palymyxin Ointment 1 app[icatiQn;Route: bp2
Thplcal; infused over: 1 continuous; Site; affected area,.
3!if26 Eor#oa#DP#_€SDFbohn:pe:itNl:gFivfTsfo:eaan:,I:all ,BE` A I _L bP2Drug:TDAP- Dlph,Perlu5(Acel),TetanusVac (PF) 0.5 ml; "r£
"anufacturen Sanofl Pasteur [jtwan[ig). Exp: OIflg/201?, Lot#:
bp2
C46S9AA. i Route: lM,. Site: !efE de!toid;23:27 Follow up: Response: No adverse reaction
Disposition|1/2¢enal.1#AEtestation: I am the Attending ED Doctor pf recc)rd for thispatient. ig
Dlspc)sition..I1/19/14 22:09 Discharged ta Ht)me. Impression.. DigfaI PhalanxFracture,
Human BiteJ- Canditian is S- PPF+_arg± IrstrJCtlOnS: -==L-==:-_ Fin-gel I,racture, I• I__'Ji=_i
- Work Release Farm Medic@IIan Reconciriatlon form_- Follow up: NORTON, C, MD-; Wheri: I i 2,day-si.R6.agbn-: fie-crietk
todayl5complaints. Follow up_- Private Physician; Wham 10 _ 14 days'.Reasom Recheck todayls =omplaints'
- Problem is new..- Symptoms are unchanged'
- Notes: Fa!law up with private physician in I_2 days and call orthclfor finger froctures (numbers provided)
Signatures:D'rspatEher MedHostMcCIendon, Tiffany, RNGarcia, lsmael, MDPeckinpaugh, Briar, RNReeves, Kimberly, FNP
EDMSRN tlg
MD igRN bp2FNP kr
Legally authenticated try lSMAEL GARen' MD ±a14_ll-aa Z3:2g:O1
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*#***###*#****#!c#*****#>!otry=*#*#=3*#*#**#us*#**#*#3EL**-#*
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Legally alJtherltiCated hy iSfulAE± €ARCIA, MD 2O1411-2O 23:29:a1
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Nur5els NotesPalestine Regional Medical CenterName:Donald Myer5Age:55 yrsSex:MaleDOE: ,_L=.I_MEN:3109498Arrival Date:11#9#0|4time..21:17Account#:95B3658BedsPrivate MD:.¥gro=is.'Dlstal Phala" Fracture;Human Bite; = ----:I-___i
/
Press ntatiam11fl92r.17 Presentimg complaint; Patient states; Sheriff EffiCer bitten byknown bp2
Bite to right leg through pants skin broken_21:17 Semi-Urgent (4) bp2
Triage A5SeSSment:21:19 Bite description: bite sustained to right quadrlcepg by anotherbp2 person, animal info,ring,tjon"I.-ii,:=,,:,i::,===:±=±==
Pain:Complains of pain in right quadriceps, A'l"ay patent, patientbreathing without cljfficulty. Color within normal [imits' skin ,Igwarm and dry] M.owes appropriate extremities'
H istorical:- AIlergies: 5ULIA (5ULFONAMIDES);- Exposure Ri5[RTraveI Screening:: Patient has not been out of the
country ln last3¢ days. Have you been in co,ntactwjth anyone whc)ls " that has traveled outside of the gountry `m the lEiSt 30
.. day.s7Na.- Family history:: No immediate farni]y members are acutely ill.- Social history:: Thbacco 5tatu5: unknown if Patierlt has ever
smoked. The patientls primary langtJage iS English. The patierltlspreferred larlguage iS English_- Tuberculosis sc:reeningi: Nc) symptoms Qr rf5k factors identified.
inFL-_I.- - I--l
Legally authendcafed by lsMAEL GARC:fA, MFI ZOI4-1+aa Z3:2S;a1
'ScreEni ng:
21`'Z2 Influenza Risk: Fever: The patient has-no camplalnts of fever'bp2
Sulfide Scraenlng: Have you recently had thoughts abouthurting
jE?i yOl]FSe# Or Others? No,21:29 Fall Rlsk: History af Falls: Nc) (0 points): The pat!EntdOeS nC)thave bp2
a history of falls. Seconc!ary Diagntisis: No [g points): TheI patient
has.m chronic condltlons. Total Paints.. Lew Risk (a_24); Bed inlowposition, Call light placed wlthln reach,f!f patient. Instructed £Q
a,i..i:. call fey assistance. Provide safe env!ronmerit' Abuse 5€reen;i¢. Patle.nt
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verbally denies physira!, verbal and emStlonal abuE;a/neglect.Cultural/Spirit Needs: There are na cultural/spiritualccms'lderaticmsfor care needed for this patient.
Assess m E!nL'21:27 Pain: Complains of pain in right quadrlgeps The level of pain thEitisbp2
aceeptablE IS 0 Out Of 10 an a.pain sEale, General: App.ears ,lnnO
. _ap.parent d.istre5S, Well deneloped, well nclurished, B.ehavior js-appropriate for age, cooperative+.Neurcl: No defiEit5 nOtedrRespiratory: No deficits noted. Derm: Skin ls healthy wI.th gaOdI turgarl Skin is normal, Injury Description: Bite su5fained to
rightquadriceps caused dy a human, is full thickness' red, Tore tclplayersof shinl Bleeding hated`
21:27 Method Qf Arrival: Ambulated bpz
Vital Signs..21:2q BP 117 /7E]; Pulse 118; Reap lS; Temp gB,2). Pulse Ox gg% onR/A; bp2
Weight?a.76 kg; Height 5 ft, 9 im (1?5.26 cm); Path 5/1O;Z3:25 BP 111 /84; Pulse g8; Reap 18;rfemp gg,a; Pu)se Ox g9% ;tis'21:20 Body Mass Index 23.04 [70L76 kg, 17i26 cm)
bp2+ ck,
ED Course:tl*
+i`
£egaiiy authenticated dy lSMAEL GAIRCIA, MD 2a14-1.1-ZO Z3:2g:01
bp2.21:|7 Pat!entamved in ED.
2:i2I;3 iB:eiaekNi::SpiaOoKumgPh[eeiri;i;ttD;TR5PNAsfpHnr;:nagryphNyuS,.sC:n "bPp-2 kr b#21:29 Patient has cDrreCt armband on for p#sitive identification. Bed jnbp2
low pasitian. call [lght ln reach. side rlns up x 1'21:29 Na physician assisted procedures -a completed. wound caret¢bI'te bP2
was cleaned with Betadlnef dre5ged With Neosporin, iferljx,te[faI
22 !::3! E#HaTblFel NX;r;g5CO2mVP;estn€t: at bedside, bp2b P2z2:O5 Lnnar-gutter spllnt applied on right foreaml' post immobiHzation'bp2
=irculatian, motor and sensation remain intact_
33::n8 r!g¥9_N_,_:i TP._j5 Referral Physician. kr23:10 No apparent distress'
a
23:19 Garaia, lsmaeI, MD isAttend,lng Physician. L'= kr
Administered Medications:21:32 Drug: Neomycin-Bacitracln-Polymyxin ointnlent 1 applicat[on;Route: bp2
Topical; Infused Over: 1 continuous,. site: affected areaI`21.,46 Follow upi Response! NB adverse,reactiom bp±
--'g#-I-P-ru-a_:-TP4T- _-- -EIpEL,-Pe-It_u!lA-a-el)JT-e±-amu_s- V_a.a -(Ej=) -a.5-m Ill - - - - - -. -
"anufacturer: sanofl pasteur (Avantis), Exp : a1/16/2O17. Let#:C4£8gAA' i RQute: m; 5i[e'. left cleltciid,_
zs:27 Fo]iow up: Response: No adversE reaction t[g
Outcome:
2!a3.!'zoE9 a:!s5fufE]oeegOs#g:hvroeeiteba¥ap#aiu:InT,af¥#;I,hl nfast#Icyied a n a I.sc:a ng e tlginstmctions, "low "p and referral plan-i. medication usage,Prescriptions given x 1. Patient and/ar fa"y voicedunderstandirlgof medicatic]nsl instructions using teach back method.
£3;Z5 Discharge JtsSeSSment: Patient awake and alert, Griented toPerson,
Place and time, patient verbal,IZed understandl.ng ofdispc]sition
t!g
Legally authenticated by ISMAEL SARC:iA, Mf] m14-1mg 23:2g:01
instructions' Patient has na fun±tional deficits'23:28 Patient left the EDl
Signatures:McClendon, Tiffany, RN'Pecklnpaugh, Brian, RN
Reeves, Kimber[y, FNP
RN tlgRN bp2FNP kr
tlg
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BikGEfiE!TIEc RIEffi8!*GL MREE5cRtL CEIITER
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8Rii 5 B3|09498
ARCIA, ISMAEL
ORDER ID(5) ItlCLUBEO.. 95a36580BO8100
Bagel Bfl
EX": FINGER(S) MIN ZVIEWS RT
DATE/T"E: , ,ll./19/2O|4 21..19
CLINICAL HISTORY: C:msh tltJury'
TECHNIQUE: AP, lateral and oblique images`
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!!iLAR "C-a nyI" 1 " DISPLA"ENT ImLVINS " 5" OISTh|NONDISPLAGED FRACTURE OF ThE 4TH DISThL PHALANX`
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ghgislg*OgTment was electroflically signed dy BARE M. NADDELL M.D. an ll/gD/£Ol4
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Discharge ln5mctlOus foE Donald Mysrv
Palestine Regional Medical Center29@O South Loop 258
Pa!estlne] Texas 75BO1 -- ------ -903-731-1 aOO 1 rm+ERS DartALD a
B9Bl :_T=L JlffI SE tt§V! ERSSEXI M
Emergency Dapartmentlnstructlons for:Arrival D'ate:
A"ITf 1|/19/14j\ml caR£Ia =s+ihEtf
Myers, Donald R lffl][i]]OI]i1];]914[i]8"]ll
W8drlOgday, November 19, EO14
"/E£O' #"6,/Pt #! 95B365B
Thank you for choosing Palestine Ftegional Medical Center foryour €are today. The examinatiQrl andtreatment you have reOeiVe'd lit the Emergency Department today have been rendered on an §mgrg'eneybasls only and are riot intendeCl te be a Substitute for an Effort to Provide COmPfefe medical care, Youshould contact your follow-up physician as ll is lmpohant that you let him or her check you and report anynew or remaining problems since it is lmpassib!e to recognize and treat all elements Qf an injury or i[lngss'ln a single emergency care center visit
Care providtid by: lBONll ROIAND! MD
Reevesl Kimberly' FNP
Dlagnosis: D!sfal Phalanx Fracturg'. Human Bite;
D!SCHARI=E I NSTRuCTIONS FC)Rm§
I Medication Reconci!lat!on
FTn_fer FrachreWork Release Form
FC)LLOW uP INSTRuCTIONS PRESCRIP"C)NS
NORTON] CI mDVIthem1-adays; Reason,. Recheck todaylscomplaintsPrlvat¢Prtyslcianwhen:10-14days;Rea'son:RechBCktOdaylSGOmPlairite__-__-I_- _ -___-- ----------- --- -- -- --_--._-._-None
SPECIAL NOTES
FolI¢w up with private physician in 1-2 days and call Ortho for finger fractures (numbers provided)
Sulclda Natlonal Hotllne: 1-800-ZT3-8Z55 (800-2?3-ThLxp
I hereby acknowledga that I have roct]lvBd a OOPy of my tranSmOrl Care record and urldergtarld theve instructions and presaript!ons'
My8ro
e mRN # 31ti9498
IX.RAYS and LAB TESTS:1ryou had x-rays-!aday theywor8 read by the em8rgeney PlySiCian, Your I-rays Wll! a]SO ba read by a radiQIOgist Wlthin Z4 hours. )I yqu
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Dlschnngc fnst"ctlom for: Dot!utd Myer]
had a Eultur.e done ltWlll t8k8 24 fo 72 hour3 tO get the results, lf lhar9 is a change in the X.ray dlagnOSiS Or a POSitlVg ouliurel W8Lwi]lcontact yc]u. Platse vt]rI.fy your Current phone nunbgr Prior to dI8chBrgEl at the chBEk Out desk,
MEDIEATIONS:lfyou received a pre8¢rlPHon formadlcalan(a) todayl ll is impahant that when y¢u fill tn!E you lot the Ph,armulSt know all the PthEr
:3!iieaca!i3R: ]lnh¢a[lu¥d?Tgafh8aOpnreag"cd'i;ti5na!l;:9jefa¥yO?pT!!yhat (ha3d=;.ll lE 8lSO imPOHant thE! ydu flOlfty.your fO"0-¥-tip Fbeictan Of all your
TESTS AND PROCEDURES
BadBIGHT FINGERS 2V
ProcedurB8Splirlt- Disfa! Upper Erdremity
OtherDressTngI Spllilt
Chart Copy
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Discharge lnsinledons far; Donald Myc7S
FCILLOW uP INSTRUCTIONSNORTDN, C, MD (Surgery - c)riho)
1 16 MEDICAL DRIVEPALESTINE 75801903-729-3Z1 4When.I 1 -2daysReason: Recheck fadayls cDmPIain[s
Private PhysicianWherL 10- 14day§Reason.. Recheck todayls complaints
I
in_=TTTc-I-- ----- - - - -.ItxasDepartmentofstateHga1[hServic
I. tagree2,I-receivaccin
Dqu4rnenl af&'"oHo£l!hjin.lfc£ Vacelne [nformatiQn gta IeS
tim enTthat th£ perm named bElOW Will g€t the vacc1.ng Chgeked below.v€dorwasofferedacapyofthEVaccinelnformat.IonStaternent(VIS) for theelistedabove.
kflow tire risks ofthg disease this Vaccine Ere-ts'knavy rhe benefits and risks ofth¢ -cinet.hquE had a-ch3nCCJo ask. qu.estiong`+-abp'ut th? a.iseas.5 the veceing p-nrs!. I,he 'vaccine,nd how the vacaine i5 given.
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6. I Itnow that the person n-amed below w" havethB YaCCinC Put in his/her body to prgveutthe disease this vaccine prgvgnt§'
7. I am an adult who ca" I€ga"y consent ferthg p:rson named bglSw to gal the vaccine'I freely and voluntarily give nly signed pgrmiss" for this va.cl.ne.
vaccine tobegi'¢n.. H TeranusaRd Diphtheria(ThjVac=ine Prfetanus
CAUSE NO. 32004
` r _
aTHE STATE OF TEXAS
VS.
RICHIARD GROSS !IN TIIE TEED JUDICIAL
DISTRICT COURT OF
AIunEREON COUNTY, TEXAS
NOH€E OF RIJNG OF RECORDS rip,ro AFFIDAVIT
You are heretry mtified that AIlysan MitcheH] CRIMIr\IAL DISTRICT ATTCmPunY
FOR ANDERSON COUNTY, TEXAS has ffled in the above-entitled and numbered cEmSg certin
records af Donald Myers Sr. together with an affidavit fry Traci Tippent a custodian ofihe records
of Larry Bavis} I.I.)M.ed. These records wfil be offered in evidBme as business records at tire trial
of the captioned cause'
Pursuant fo Ruts 902 (10) (a) of the ifexas nifes of Evidence, these records will be made
available ky the Cout Clerk to counsel for parties to the litigation for inspection and copying at ire
expense of the person desirfug thB Copies.
DATED: 6-30-15
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PAIJESTRE, TX, 758OITBC# 240268 84(903) 723-74OO(903) 723-7818 Fax
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CERTmICATE OF SERVICE
This is to certify that a true and correct cagy of Notice ofFilintacr REcords and Affidavit
was ftxed on Juus 3D, 2015, to the attomey of record for the Defendant:
Mark Cargil1
PALESTRE, TX- 758OITBC# 24026884(SOS) 723-7400 .(903) 723-7818 Far
CAUSE nrmmER: 3Z 004
THE STATE OF TEXAS
VS'
RIG- GROSS
EN DrsTRICT C:OtJRT tm
anDERSON COtmunr, TE2IAS
THmD JtH}ICIAL DrsTRICT
JLFREAVIT
Bsfore me± ffie undersigned authority, penonally
who, being ty me drly swam, deposed as frflows:
My name |S I am of sound nrirty capable of rmking this
affidavit, and persrmally acquainted wi:th the, fasts herein §fa:ted:
I am the cTIStOdin OffuShe8S raeords ofIJARE:Y rains, P.I.M.ed. AttachedfierBfo ae 2 I
pages of business records ofIAnRY DAVrs, P.I.,M,ed? pertaling to DnELiID REZERE SR Thesesaid #L pages of records ae kept tryIARRY DAVrs, I.-.ed in the regular corse ofbinesg,and it was fro regtllar oourse o=.business qfIAREYDAIus; P,I.,Med. , for ap enpiepee or
representative ofLAREY DAVIE, I,I.,M.ed4 } wiffl kunwledgg of the act, gVut, condifen] opinion, ar
diagnesis, regarded [o make the record or to transmit info-dien thereof to be inalnded in such record and
ire rgmrd was made at or near the) time Or reasonably goon thgrgafter. The records attached hereto are thei
original or exact drphaates of the rfuginal.
.ffiant
SWtlRN TO AID S"±SCRIBED boforE: me on the
My conrisien expires:- jt,
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I.LJ I vuli,:i'_LAND-A;rTiVrrv FL.W Sire=i
/ NAME . D_ATE/ liEZ.. '}a-furl 3'; Lf,3/t 5,.fo 7 I cp' z3/ 7c) /; /:
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FROM/JT..inO BS:I |
v7 //,I. Fingers.I
I wri;i ..Elbow
lso m etrics I;'l IFinger Blocking Lnp ufty / `,\lfr I .in 51' H 'Il 3` L1`. q`_ +I sGripper
`1O / Lj5 tfo i-I.H #3S tss` C\S ill _a L\t\ -\SS 41*qnI
ET?1. ,__ _ IIE lO \O t5 IRESISTIVE: _ .I-zZ-
5tt I..3i# I ..-mstFlexlon . I ytlb .LRE6O ngQ3#g3 tqol tt)L>O S#1o!
I a enSIOn |\ - ufty 3C> I
. Radial deviation +I) *<O 7+SO t St) 5Q SOSc)SOILC).I
I
Ulnar deviation Lf t} +. SO J{SC)_+ t>I fu. 4qu|/ •( ,a
fal/a_u p ng parafus z^l so 5O 6o1C)te\O to5O&3''6 I-C-a& 3b3OaLEX` JIG I
I-I
Twister q.b 5.a So I
Power Web '21 u &*\ a \\\S an\ wa'nd/ Bicep Curie
Tricep Exension
N uts/Bolts
Wrist Roll-upsI I
FOREARM MACHINE:: I
1&S P lls L-F I ex/Ext A1/ I. bl3OI|3ct3.a - H tic) L|n a®P ro/Su p
` ~5 ipJis - L\* \Q uH I
I 'PC\I
TUBING:JlllllllllI_ I
IFlexion
Extension
Radial deviation II
U!nar deviation I I I I
I I IIIIIIIII- IUBE I quGrip Strength
'l I) 1q 1 LJ\ - €5 =ffl - 5*.
_II
I`/I a C) -i oho I J
I
Pain dr3 \ I I I IriceI I
r\ -iiiiiSTA RT ' lap
EL{\ '\ t
t'3 5&i\D \estrf£I
: 6¢_Iii.3®
I* :u®'-5S £air.,aa I-IIIIIIIIIIi Isto p +
•J'>~l 1 ,,a5/-.,a 0
iiiiiiii=iI-a€*i6- Dr. -i _'T _)., l'-. Cm
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ja ui5[.l<, pip-?-3(./S~,. /
please rate your abinty fo do the:fo"owing actMties ln the last w.eek fry ctrc"ng thg number below [fag appfjpriate response.
1. Ope'p a tight ar flewjar.
3. Tuma.key.
NO MILD fun.QDERATg SgVERE'DjFFICuLtt DIFFICIJLTY I DIFFICuLTY. DIFFIC,ulfy
2 3. 4 I. 5
2 3 4 55+ Push open a fieavy door.
7. Do heavy household chafes [g+.a" wash walls, wash floors),
•9. Makeabed.
i.I. - Carry a heavy abject (over lo Iba)_
13. Wash or.blow dry you.I ha.ir.
15. Put orl a Pu]!OverSWeater.
1.7, RecreatiQnal achVities Which require l]ttie efft)rt. (a.a.I cardplayingl krlENng) eto.)..
1 9, Recrea'tl.a.rfu actMties. in inhiEh you move your
na_r=_i::._:`I.: I:._.1g:ll :.I.a.f.n:I._fiiSbEe. -badmintOnr BteJ.
2 +3 4 5..
2 3 4 5
3 4 5
2 3 4 5.I.I,i.?:i;i..: :.I?:'ii..::.I
2 3 4 E
2 3
z2. sDhuorii!efoe;phaa5ntdTgreqkriiiom%l9#eed" #ahSy¥oOuurrnaormin; al
social aCrfuities With family,. friends, neighbour5 Or groups?(cirale nurilbat) _
t|-- - h , .
23. Bqring the past we.ek, were ybu limited in your worfuor other regular deity activities aS a result OfyPur arin'shoulder or hand peblgmi rcjrrfe,"ndgrJ
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f3 .3NO##jLTED. 5LIGHTly
LI M ITED
I- 4. .5
VERYLIMITE D
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+ |
UNA ELEi. .`. ` " . . \.
I I )| . +| \a
please rate thB 5eVgfty Of the fo".owing symPtorns ln the last week.. fcjrdg "mberJ
2 3 i . 5
SO MUCHS_EV_ER-E . DIFFICu|jt'NO .
clFFICULTY Dl#UDur. #F?CE5ELTE BISFFryCEuRfTY
29+ s:#:r#g!#ti:egFa€a:;gWQe#hehS#nThcyh:.!1TrE#shhoauvFdeyroourhh@adnd? G)
STRO W a LYDl5AGREE
3O. I feel lees capabler less gOr]ffdent or less uSefu'lbecause of ny arm' shoulder or hand problem'
[d|de humbe{)
a DISAEIuTY/SYMirC" SCORE =';RE -3£
caEHT¥lIEEP
2 3 4. 5
+
Dl5AGREE NNEJTRHDEPsAAGGEfEE AGREE 5T'RONGtr. AGREE
' 2 3 4_ 5
( [isum pin responsesJ n; - 1]
A Dash scar.a may flEIb± €alcuJafed if there are greater than 3 migsl.ng items.
x z5, wher,a n lg the mmber of corbpletea respD.rfSesj
f, ap T\.
? et. 'ng t I .c` -+ |_++.
a,.;.+,....,_,.i...3._.i,'Z:.' +. . :.,`.
|.. .|`.. - $3 '''I-`t
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3 ;. r.-.` I.1-.g,.; :P.lil.?.,I....f*::i;:.? ~..,.+_r...'J:.P I :I , I.'`Try..-I.I I;._;Y.`f,,_.i+-I ;j...;?;g'.1'+I+-.i I.+,.?..¥ t;¥ |] -'Jd {`4-i.++I.: : `:..: ::.:-`....:``:.; :..±.:` :.-.;[ _ `j::``t:...: :-:.+..._
'`'.**.'...y :.i ;i_i.''.¥?'-'1:-I..-i:I: :.I.:fj;i '.I:f}f:;'J-.'* :-: I 'i.~''F{:'.f'rr''.il:'tS.' '..¥i=ct.i-.:'.i:.:' I:'l.:_:T S¥:'.: : `:..: ::.:-`....:``:.; :..±.:` :.-.;[ _ `j::``t:...: :-:.+..._
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.'-.;:_`:`__._.:..:. ;`:`_.i -_... :.: :.`:_=.`.::.`_ `. +.:._. '_ _?..' -
i..+_:. ii:i._:.: ,....i:_:i...,_:: I,;- i.1 :.:...I...f',..:..,....:...:'t.::i...i,I-i_,:-.::..iI..ij: :*..._`...?is..!,....:r. :
l. - \. +
Rcase rate yo*r ability I-a do the,following. acti'vities iFT the lgSt- Vies; dy. Cireiing. thg number.below chg appripriate rErsPQ_nee.;` .I ,I . .. . .-
|1 ;Ll..+I~ I l..'``-+ .- .. I
..t .
| **
NCl thlLD. fu.aDERATE. SEVERE.
_I_---,. -,. _.... _ _. - , ,___,___ - -I:IEE±!:=JD-IFftCuLTY., DIpeS,TTr -a.lFFICI±::U NABLE
1' Opap a ttigh`t arfiewjar.
3. rum a`key.
5_ PL!Sh Open a heavy dour.
1 i 2
hgavy househcl!d chores (e.,a., wash walls, wash firmrs).. . 1
9' Makeabed.
1t= Carry.a heavy objact (aver lO lbs).
1 3_ W`ash or-blow dry your hair.
15. Put Dn a PullqVerSWeater.
|7. RBCreatiqnal aCtj'Vities Which require little effortI (a.g" cardplaying-I knittirlg) BtC.)_ I
:,a. ,4
2 ± 4
2 a 4 .- 5
3I 4 5-
2 3' 4 5
3 4 5
2 3 4 5.•` - '.ir.. _l"'=''\T
3 4 5
::::;::::i::;::':i:i:-i::::;::-I:::;=i::::=gi::::=i::;i.I:::::.-::I::€-;:;=:i:::;i::::::::i:::;::i;:;:':;::::-ii:::::;:::::::::::_:::;::---:::-::;:---:_;:;;:i-i;:;:::i:::::i::::::i:i:::::i:5iii::-::::.--:::::I_;::::_::::i--:;-::i:-:I:::.--::::,:.g;-.::::::':-,:::::i::::;:::::-::-::ii
21._ SE!Xual activities. •=--:- i. -.--_.-_ '. J5--' ,
22' :T3lu#gaecTa:ri:hi5nt:T#reofik#o#y?n#etrnfedT;ed:#t:h5b'a'a:u[rnofgoa[p§? +
lcirde"rfebeF) . - . i_--:--i-'T-;-31_:Y.' i ,, +
23. During the past week, wefeyau limited in ysur walkar other regular dafty activities as a result oFyour arf"'
Shoulder or hantl problem? /c;rde."mbgrj.
. . .. I.I I.I•`.: -._.. I
`|. . |
2 I
.I.
:.-.
i;
+
Si.I.
rI.::
t+
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PO.IrLLthLprP. sLilfutRELpT MO,DEftA"YLIMITED
I VEfiYLIMITED
4
uNfiEhi
5
M!LB MODERATE 5EveRE - EXTREME
please rate the seuerty of the fell.owing eyJTIP[orne ;n the last week.. rcirfe mm&erJ
24.. Arm,.shoulder a.i harld Pain'.
2a' |ingltry (pins and needlesi in your arm, shoulder or hand.
_ ' I i - ' -I T_"m - 'r V rYL- 'V>:m_lml9rirP+rJlle'qiL±5r£ia;tqPi#a'4J}Sso'.r^;EJiri=.i:ii;;
Zg. I Stffless in your ainl thauider or hard.
2 i .. 4
1 2
-'-''I -- . . :- I- _i.lFF#O"LT; DIFFaptLhi Elig#cE5g# DIS#cEuRFTY D5l?F#CugEL
cA TNHTA5Thap29. a:#f"rift;ng!Iu"b;g#,stewo8f¥ft#-#nTnHCyh:.#grm',tyshhoauv,ed#ourhhaadnd, a
- ~
3O. I feet less capable' tesstonffdent or less usefu'l.because of ray.am shpu]der or hand problem.
• : _:(circle riumbed
3 4.
Dl5AGREE N«EdTRHDEFsAAGGRREEEE AGREE
aquARGORNEGEtr
I!i!_!!ii=i!E!I = EEquH miffl iqEm!] i iiHEpH irmEiiFEii=i!ii! I *Ix z5, whet.e n is the number af comp[gted rB§Pa.noes.)
+sl.3D= i.so -.i-- ,=OA DASH scar-a may flstb: calculated if there are greater than 3 missing items.
- - --.I_ _----- - - +.** ```
I . 'a4/01/ZEiE g7:g7 "'#18 tIAusPT. !'''; PAGE a£/©2
L\h VIE mSSTC1_EL._Tng"¥£E\"Elg]'pquedienmp% hohatipapltzfl=?5apt (9831729d€I¢ ha(?try TZ9.8€i8
Tut ny*tr Patttr8on M.B-Rc! bnnnldFTyer.€
pat±= 0131-i5.Q;ng-l±; R]EntS-"*tha€ i-!uri
LaEt 5o¢nz #5.27-I5mB.. 1O.fl3[59
Erf:E k`;E;:£di:i;ytry"&#oi''riife jri'prfe llmllitts fu"tlonp ]mL[m¢rful keouenl tiRE t¢ aa9-PTti±un
foyed, ruttctim ult¥ lndqunrfel.I gm# q_a,!EJ hap[ared, but d]rrfulWtlqrmmainr
a g*E##:#u
AesesSmBnt; W¢Saw RIr' m¥Brs g finieS for Progression m.tl his bHnfl rchflbmfaflm. ifehB§ -d¢ gand P'Ogres5`g+:I:hnlgi;nFj#iEggtghtho.n #;i:lng,hi ge;:ngd7e=nf;g£g=PJ:tb¢fl d#f#tt=gh"lI:GIB¢1atmE`l'n I:gnp m#EEmLteH:nff5TrE:.i:i4rlft.
b-ps hit fifiger D# rmmgthlng' ffi hag been iREtruutnd I.n H hitPmgr`q" rf€XFCiSes flfld he 'l' Tmk!ng " thosefaEm funI.. H a Thn5 di5dr-.angEd from PtryS`tE8l thefflPy On Oa-27rl5.
TbanJ{yml rPr allowing u.i to a£Trsl in the ¢nro aryO"r Pflaent.
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DAVIE PH¥SreAL TfIERAf¥ ¢Lrm€Lrty Dath! REdr, P.I.
l23.E MRE#1 Erivp} Pife!riinq H[ 7£E$1?ou-729ti616 * fax 9C£-729-ffl lEth#,¥:@ESEsm#RE!.gSpl
PRTSI£EL REENYmrmdL Ei?ALtj-ATh" +rm FIch|i flF t=AHE
"anE: "yaco. thaflld
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5: 54 vr old pelt who stEnd mat fug injunti hlErigivt trrmd jn an altemntw"nd ENstBined a m]!ct in€turB in bin righiJlttie finger , He rmerfthatthey put him lfl.a 5PIIm and hE m.Ed to VIEar it ¢an£lflen[ly bus hEd dfflulfykepJng it onand -Bring it ±angistBmtry , Nin that-ne lg 3 "htb5 t]u= he WES efearad.ta hagrn REjV! and 5trengthgriing E#grrfuEg tOregalfi fullfunenafl ut hiS tight upper sRTremlny_ Hg rate± hk pafu a as toagy.O! Active roM of his Hgbt fiftn dlgi[ DIE erfendsn !s 4tr , DIE fte#lpn i? 1Sql MPtlg*lan iH75¢. ErJB strength-t5 EO #g9n the ifeht =onpered to 7B#lB en thE left' HE ftaS #RErEtenrferfles9 Over hfa "Pj¢ith M].nlmE[ ENreJl[ng 5tll prEsent.All gth#rtlIOfrolt Js iffltry rmrml limits. Nb signmtantseur" ahang±s. un iftitiated ±-thaflt g@misting of gngiveR" d=xerifefy and tEndrm gliding and finger blocking ekerdS¢S. I qise inftyB¢Ied hirIT he a home PrograTn ofagiveRIM e*emlses and tendDn gliding agtiuttles. Hq defnanFtffied ufldgrstand]ng of a" exercises , He fild ¢amp]a[n ofjfroderate palm lflth armre E¥erCi§gS tut it rmHld 5gttIE ¢¢unn thlhtn lt £tapped.A;' PEifeftt REEL dE±tea5ed thfflOn S#CSndrtT tB r]gh£ rdletf-tune of h]S nghe fifth d]glLHis Qfi§H §ca rg [g 1±g6_P= -W¢ urEtl be 8asi#g Penlent Zxwh x 6/its Th progrSB§fou filta a hrmd rBifeilitanpn pelg]Th fo jnelqde "ti"]therapy rmd thELpgutia exorcise and iusrfuctlqn ln a homti exeroisg apgrm to ([) inENgas RIM to withi tlarmE.1limits ¢l tn¢rEase ifengiv tQ ha inal tD fiiS left [3] demp"frote goed mdeELrdfng ofhi§ trotne pmffrm of ffirmirai±) be chle to retlrm to all pTeriaus ored¢ 8arfu,itias, ag9E4ri SEg&5CH
rmuranesthaedicara mqtrirES fro Pkysical Thrq;fry Flan tip Can bp pndfted gray 3gxpO day& Phag signbalow that quu ngEEce lrfu the rfuVE Pta nf rmg for yOur#atiexi Tharfe you fu tilg asferm].
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ORTHOPEDICS.
(9B3] 939-7599
Patient Name:
Frequency
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hysicaI TherapyEvlluafo and Treat
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I Aquat[cTherapy
E Exerolse/Rehabmtatlon I AeroblgCQndlt[on]ng
and Therapy H foci ortht]tiis
I spinal stabiIIzatlan D BraSmgrfeplng
I F]exioth=xtension Exefoises I Madallties
# Occu national TherapyE TENS
I Eriremfty a.ompress]on pump+|-`
tl whirlpool '.
I wound care fllfhlrlpaoI a Dresshag)
I rfesls and Measurements:
domputerized Strength and Hangs Motion.EvaIL[atiOn
H Each - E2t]O isoc[ynarfucTests
I Erd'emfty_ Bradex
H other:
I Work Hardening
H work condjtjaning _.
Comments :
H funt:tlenal capapfty Evaluation
H prerEmployment Functional screen
I Jab Sire fraluatltlr|
•Education
I Eactt/Neck scht]ol
H Hems program Instruction
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PROGRESS..itorES (Cow+. )
O2-04-15 Myers, Donald INITIAL E.VALuA"ON.
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-s: 54 yr old male who *ated that he injured his right hand in an.altercation and sustained a ma"etfracture in hl.S right Httlefinger , He stated thatthey put him ln a sp"nt and he tried to wear itconsistently.but had difficulty keeping it on and wearingl't cons!'stently. Nowthat he ls 3 -nths out he was cleared to begin RON and strengthening exercises to regain fu" functionof his rI.ght upper extremity. He rates his pain a 2':3 today.a: Actl've RON o"s right fifth digit DIP eutension is -4. , DIP.flexion is 15o, MP flexion in 75a. Grip strensth is 60#s on theright compared to 78 #s on the left. He has severe.tendemess over his DIPjoint. Minimal swe"jng st" present A" othermotion. is vyithin -mal ll.mite. No significant sensory changes. we initiated treatment consisting of actl.ve ROW exercises, andtendon gHding and finger blocking exercises. i also Instructed him in a home program of active RON exereises and tendon
g"ding a'ctivities. He''demonstrated underfunding of a" exercl.ses. He did complain of moderate pain with active exercises butit would settle down when it stopped..A.. Patient wl.th decreased function secondary to right ma"et fracture of his n.ght fifth digl"is DASH score is 13%.p: we wi" be seei.ng patient 2x/wk x 6/wks for progression into a hand rehab"itation program to include manual therapy andtherapeuticexerclse and instruction in a home exercise program to (1) incre!se ROM to wlthI.n nOrma; limjts (2) increase
`ailrep:estvlotuO: bweoerkq uaaci,Itv:tl:i I ::ft8;38):dce:mGO:n9st8r5a:eHgOLOa:i nDdaev[Ss:apnTd I,nMg OEfd h lSiferffipr!se (4) be a b I e to retum tol2-l6-l5 Myers, Donald ,.I----I I
i" ) and blocking aercises now. we progressed with additiounal strength_e_iii'g_:-x;-i;its_;jL;;tiLIfzrn'guauI3';;I;,eWi;;t%Grt.`;nrfstOn]ex'un, tension, radial deviation, ulnae deyiatI.On eXerC!.SOS. I added supination/ pronation with apparatus as. well as 40 raps on
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nt states that !\is hand is doing heifer. states that he can gr.p much better. He is having DO Problems with the tendonanri h1^nL/:rt~ A\J^--:I|-- -.-I+I t1/_ ______ __ _ _I .}t
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03-27-i 5 Myers, Donald D[SCHARGE NOTES: Patient isO:HehasJ1A:H_ehasa;Wewill making good progress but states his finger is st" tender but overa" doing good'aextensionand45onerdon.Hl.sgl.ipstrengtIliS75#swhichisgreaterthanfile left.a:socohdarugnedferros,tmanp:l'ynsgieo:htiserh:p:etoe:,:sr:isoemperop::agrma:nodfs:..:eur'cdisbees.a.b'::rorycoDn:i;li:,e#.: #::a,.a h iS Own. /
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DAVIS PrmSICfl TRERAPY CrmcPATIENT HISTORY DATE:
T:uee::i[:=:#flq#geEh!:lOd#n::firer:epdnermd#%#oour ihaapist to devalap the best plan of care fior you. dswerS fo theseqtlesttous will be held in strict corifedruee.1. Forwhatreason are you SeekingThyshalThaaTJy §ervicSst ZanlaE±Tb fl A ; -_f2
iioTpbh:e::1Pifi:ffiWhen did the2. Have you receind other keatmen| for dig
If yes, mme ofprclvider and date Seen'.3. Have you received physical TherapyJ
H yes jEngo lfyss, when?Occupational TherapyJ er Speech Ther", durfug the
4. Isthis visife because ofaninjny? E yes H Noa+
b.
previous year?
Ifpyyese;shaff#ou e#;ebs;&wnri¥#d or suffered pwhus pains/petlens in fro seats) brfere this injury?
Didysu rscover front this injury? I yes H Noa. ELveysu had areceutE§x-ray, Hat or HMRI ofinjuredaea? HNQ
rm en.-5. kemale T}a,ti£Il
MovementThenELerSirfug -ExerciseStandingOfler:.
a_. Female paLdellt: Are you Pregnan? H yes H No-.+-I--,.--.-..-..-..-I.-_.-.__.6- Aggra:vatingFact¥s (whatmakes pin worse?,)
RERERE
- - L*t+" -i._iAt iroist 'aast 3-5 days) -
VAene``
E Ma:ybe
keifeving Factors (urhat makes ;air heifer?)Heat ICold INoMovrmGnt ELyingDorm - IMedieatinus IOfier .
7. Please rate your Pain WEE ¢ befngno pain and lo bchg Sxtrenaly iuten§e;++-\-I
- . ~+ . - + _ _
.3At best (Iast 3-5 days)
8. Please list prior rmrgedes.I JfEatrdLJfI:Zffi-9, Do you ha:a am adverse reaction to heat or card? H yes EE No
10.Do you have orhave you hnd any offro ENowifigP .
DizzinessS trokeArthritisAstlmaDfabgtesP acemakerTBREP. E
rasto"ch diseaseLung DiseasePatioMeningitis fEHEHE
PHHEHEFChest painhegular herfu eatffich blo a a pressureCancerShortness of breath
*EdisgaseEncephalffisHgart MrmurPn8un an! aFree Bleeding in fani]yPsychiatric H lness
IpiHEisNEEEHE#;
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'J DAVISPriYSICkiiHERirY CLINIC
PATIENT REGISTRATIONPlease print clgaly and complete al pages- Thank youj
PATIENT INIF ORMATION
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SOCEL SECURITY # _
HOME PHDnrE hJlnaeER
REEF_RRB\r€ PHYSICIAN
3| 3i i+tirlF
TREJ|TTNG PHYS IC:lJEN
DATE i
Ea Full-Time I part-Time H Rrfu€d I Non-EmployedERnEenn/mIT STATtJS
REquEEFfREE=iHEEEEEifi m
EE MaleI Female.
GrmER
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bunTAL S TATHS
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OATH FIRST CONS LrLTEDPHYSICEN
±#ff6T5T5=Effi.H#T=Efr#TTlffE=i¥E:i2oMri:E¥Who is financially responsible forheatment? H Myself H fry spouse I My Parent(a) E] otller;
Qs-enIREO-mow: ,ffirfe
PHYSICLEN
SECOREARY INSUENCE €OMPJRT*Ify.ou irusuranee carxpany requires a rofierral #, piecttie let us inow. Four bgnofide are greatly reduced if this is not ohained.*
POELCY HOLDER'-S.IfITORMAFTON: (ffNOT the patient)
NAME RELATroNS:m TO P ATusNT
ADDRESS, CITY, STATE, Zm (ifdirferent from above)
ENfflRGENCY CONTACT (mt living with you) :
I-inf±wiE±qEisg=:un£dtsfu£1pe----. - -----
ADDRESS. I:ITV, STATE, Zm
Do yonhave an attomey? Ifsq
worker's c;ony on.the.job injury? E] yes H No
P fF-tBRELOYZEL JTTJRE
SOEL SECunTY EL'REER
HOME PHDRE NuMEER
FdifeJ1
DA:TE OF EmTH+
CELL PHONE NLJREER
RELAT!ONSIrm TO EAT"
HOhm PIIORE I,nJhasER
AITOREY'S NAME
Date ¢fmjury:
I *titoR_COhrrAer PEES ON
Jfafa#DRE¥FHffRE±ap
A;TTORNI3Y'S i,njMBER
r EEiEfflEEH=EEffiREff EREELERE
1-23 a Medical Drive I Palesttry, Te,a-ap J5-8-a.I I-a-iH.c-a: 9-a-3.-729..85.16 -1 -Fa3X: 903 J29#gl afq aTJi et1+r'l1'1.:J`Jiha,'n1`n-^- J1 ---
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Palesilfl£, " 75gB|
J" De#ripti on815.OO FX PHALANX
7 RE.44 JO [hlT PAIJ!.HAM a
be a uested Services:
ff -pea_Etien
REEJiELFj=iI
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!8??) "DO41 Fax (a?7J g74-1g62
PreauthfllriENlon Determinatl-an Lengr
Response aate: #O/2a 15ErtlPIOyee fuama: Mysrs Sr, Donald
esN ; XX#_XXLO751Pale Df Injury: 1IflB/2abI
Requesting a-ider= qysn patfgrsonJ hiTE[tlaim NumbeT= 2m4aO50en123?
Employer: AfldBrsOn ¢¢urrtyTreating provider; ftyan patterson, MD
rarrl er- " Pt]Ii¢ical subdivi§'tEJnFad"lty: Dayis pt!ys]ca( Therapy cliff)g
Esfl± EEEm ifefro Data £¥ifed¥2E|# E=aof£EP!!ggL ±±g;stb±
=LLIFEEL-Fapi-ri\rfeL=Tap:i-L=EFEi=LrferiJfiEF=::_Jlmo has peeutharfeEd medical ne=eSityfpr 12 Ees5iOnS ¢f lnitlal ftl,ghtSmall finger/Hand physical Thgrapyat I times a week for auecks t¢ be front fin an Outpatient Ea5is'
ri8! OffldaI DIIHbllky Guide""RI. F-utM,istlHand Cha pier - Physical theram Mailct_ fin_gel (lCPg ¥6,._1):_I.6_uj!RE _a_irer a+ |
- - - tr-E€k-8. ,G§H-Er-arty-th8re.§hO"ld bB n'mre-than 4 -dalitie5/Pro.edural unErs. in.totaf rfer vtsitl 3llQWln#hB PT utSlt to foms mth'sB ifeatmerfe "hE'e there i£ e"idence offunctional improvement, and "miring thetQtal lgngth pf gach pT wlglt to 45_rm minH{esunless additipnaI.drcumstamE5 exlet requiring extended length of treatment.
?nte[f=/#atftn=ds®neuirhoTbri:=m®p:n:5pltd= [%B-Uf#=f.±TT_a?± \ PreamidREtfon ts band en medial rREe5Sity tm dlQr uhr€ Iatgdin]uryfdlagntx€ls per Tt" amended rule ±3¢`€RE subi;gcdon [rti.
yDU -Y f€ach lMtl at l877)?89-1* 1¢3 ff additional trement is nguJred Snyond datjg §hbrm,
SevErly Davis, RN
usliz'atian RErfeW Iturso
Page 1 I MyenSr, Dor]ald
TRAN5MIS5mN VERIFICATmN REPDRT
TI MENAMEFAXTELrm.#
DATEJ TIMEFAX riO. /NI)MEDURATI ONPAGE (5]RESULTMODE
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DJENIS PHYSICAL THEFIAPY CLINICLarry Davis; P_I.I M_Ed_
FJng a.OVER123.a mod!aal Dtlve. Palestlne] TX?5EOI
TE)iePhOne: 9qur72g-BSI SFax: 9O3#Z9-86i 8
CAUTION: CONTAINS CONFREENTLEL IIEELTH CARE
FROM: Mohelle
DOE.I
TEE:
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T'HfiNKS+
IF YOU IIAVB ANY QUESTroRE, CONTACT: Mi che| i aFAXNIJT\diER [903-729-8618) .
COFH?IDEhELALITY NOTICE
"TEE DOCUMENiS. ACCC)MFANYING TEES TELECC)PY TRANSRESSIEN CCmAIN CONFIDENTIALREORm"N BELONGIN.a.TO THE SENDER TriT IS LEGAELY PRIVRECm. TEE REOFRATION ISINTENDED ONLY FOR TEE USE OF TIE INN)IVIDUAIJ OR ENTITY RERED ABovB. n? YOU ARE NOTTEE INTFJDED RECIPENT, YOU ARE REREBY NOTrm3D fHAT ANY DISCLQSUxp, COPENGJ
FTE£pEDENrfeoRffiE#rsGsOri;#yApCRTgO=ilTE=LA¥TCAEjiND E:rfioNTMEED¥CSrf Fp#cSTRE ACT,SJICT. 5.08 ©. IT YOU'HAVE RECEIVED TIIIS TELECOPY IN ERROR} PI,RAgE ro"Y US BYTELEPHONE "MiDiAT±LY TO ARRJENgE FC)R RETURN OF TEH3 ORIENAL DC)CURENTS TC) USll.
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CJ DAVIS PHYSICdi THRIFT CIJINICOFFICE POLICY
ihreLCOt\ael ..
nfronthly sfaieJHent: Ifysuhave a balance on your account, w8 whl Send you a monthly Sfateme]1tJ Na more than 2 sta±enents willbe sent if pa)ment i§ not received.PHymentS: UalBSS lue aPpeve Other arratlgeneut81 ire bafanee OfyOur statement ii due and papal)1g when ike statement is issuect andis past due if net.paid within 2 1 days, Any co-pa]ments requried by an insurance co]1lxpany -St' b8 Paid at the tine of SerutB. ][:±jalis|qqu±ed by _your lps,urancq Any dedrctfl]1_es HF duP atqc time OfSndCe. Cchslrmce ,rm be lindled m a rfue by cas t"irfe
I you quve no insurance ysu choose to pay cask or check on fro day fhatkeatrnent -ls rendered. Pa]mentplans may be a.vailable on acase by case basis, Please let us lmow today if you will be needing amangBrmnts flOr aPayIILent PlanCharges to Acentlnt: We shall have the right to cancel your privilege to malce dirges agrinstygur a#cctut at ay time. Futue visitswouldthen need to bg paid at fro tine ofservke.Payment optic!us ifynu have insurance:1. You winbe asked to pay derfucfrole, col)a;ys andpossii)ly coinsurance (i.a. % instlfance does nC)t cover) atihe tine ofsgrvhe_
This is paysble by cairn or cheofL2. Your insurance will be called prior to tpeammt and ve irdl anqupt to contact yquto discuss fir:rmoial arangenents ifiourI insurapee poHey busfits state the you have a deductiblq go-pay, or coinsuranc9 a]nOuut in Which you win be reaponrfele fer'
3, Any defucthles rot yct met 1^ffll be die and Pa]rahle by you on ffie day O£Se].Vicel4` Any coi3ay Win be due and Payable dy you Onthe day OfSeryice.Insurance: H]surance is a corfuaof between you and }/t]ur ms1]rance company. An insurance card mus[t be mE[ds AVal]alJle tC[ us befde)JO¢1 are Seen as aPafient. Even thallgr We may estimate what your inSunnce will pay' it is the iusltrmee coHpry that makes the fraldsterminafron of your eligidiuty. You are responsible for any amotut mt paid by thg insurallce reESLthg anouat wh]ifen off due to aonntrat we may riave with ysur inslrmce GOmPany. If your insunnce requiras a rerinal ur anthorizatkrm, you are requnsib]e forobtaining ir C)ften rye can de this for you+ Failure to obtain the refintl or arfuorization ]pay rE;{;lllt in rdrgd pquut from thei-e comptry'
such as credit bllreaus+•Refumed cheales: Than is a #5.00 fee fur any decks retlrmed dy the harfu We pefer Fa]men± in Gash On accounts Wife history ofarethedchckThiver of canfidendality: You understand if this accouat is sutmitted to an attorney Or COIIeGtion ngeny] if We haVg to ]jtigatg in
- , court ¢r.ifysutreTast die Status iS reputed to- a Credit.rePOrfug agenC!t the fact that ysm rfegivg.trgainriii at ode office, may a;inmBa mffi DfPubtiC rewhWorkersI Compensation : We reqlrie athorization by your -rkers, apxpensation carrier (not employer) prior to ysur initial visit'Jfyrm clain is deniedl ysu whl be responsiidle for papmeut in fiI]]. If your case is in dispufeI We Wi]] inquire pqynent at fro tine ofsenfiee until ue receive info-ation stating your employer)s caries will pay for services.PeusanaI Iqiury: If you are tieirlg froated as part ofapersona] injur)/ lawsuit or ctalnfty wB requke a ProlulSe tO Pay within 6 monthsletter from your.attoinby priorto your initial visit or pa]ments are to be made atthe ti]ne QfStavke, El addifron to this, we xphethat you allow us to bHl your health insurance. Pa)ment aftbe bfll remains your re§POusibi]ity. Wg canfrot hill your athaey forcharges inrmd due to a pusonal injlny Base. You also acknewleqge that your signrfure also gen/gs -as an Ass;grmen£ ofEtealth froBeneffis and ]"1 authorize your attOney or liabflity cater to pa5f those Hen amrmts to us out of any sett[eneut proceeds wifroutfirfuer alrfuOriZation from you.Co-Bignafurg: ¥this Or another Financial Pofiey is sigrsd by armther person, that co-signatue remains in gifect urdl canedBd inwhthgl lf whiten canearatien is reEBil/edi it becomes effeCtil/g with any Sut}Sequeut changes.Effective dais: Once you have signed this agreement, you agre¢ to all oftke terms and condifious comined herrfu and the grErmentlnrill be in ffil fame and effect+ This agreement applke to. previous, cunent, or future tra]asasfrous`Due to ins11rance' liabflity! nO Children are allowed in the FTl area_If you would lite a copy of this agrSenent, Flease
ELelatiousbip to Patied
123.J3LMedical..Drive+.P.alesfroer Texas.75 Sol.i -SfficB:- 9&-3-.7-2-9=86.I 6. -I.. -Fax:--9 0g.7-2g..g6t8 -1 t '* * - ' .-+
DAVIS PHYSIC_rfukAPY dLINIc
INFORMED 'CC)NSENT FOE TR'EATMENT
CunmL-ETE IF OiELRTHB -A-G-E OF |8 YE-4RS QF AG-E:The undersigned, being over the agE: Of eighteen (1 8) years and being under no disabiHty or prohibitionthat would in any way prevent or aifect the Consent and Release, 'does hereby represent that'I
G]afient), consent io rcha:bifitatinn treainent as prE:Sndbedby m.y provider.
conneIJETE m rm PATIEFT IS A MINOR OR |REmN THE ADtELT PATIENT rs NOT CCmffETENT:in the treatineut of
®
(ininor/adult patient),.Ipa:tient rquesenfative, of said minor/adult ct)usent to
rehabiELafron ifeafroent as prescribed by minor/adulr s provider My relationship to ire patient is (i.e`parent, son, daugber, gto)
`r
I cehify that the informRE:tiOn I have provided is complete and true to the best ofny kI10WIE:dge`
I ripe my authorization for trearfuent records to be released to the reapousfole payor for reinbursemeutcousideratiqu or nedical facility recess.any for treatment or futher care. Additionally I request that anymedical records requested by this facilrty, neoessary for treathent or furfuer care, be forvlrded to thisfacility. upon its request.
I undirstand that I am finanoially responsible for all charges whether or rot paid for by said insurance(i.e. dednetible amounts, co-insuranGe, CO-Pay' Or any Other balance not Paid ty my insurance). If tldsaccoun:I is assigned to an a.ttomey for collection and/or suit, the facilfty will net accept any discenutsupon settlement due fo the time delay in receiving reimbursement and shall be entitl ed to reasonableattomey! s fees and costs of colle,edon'
I request that paJunent Of authorized benefits be made On my behalfto this facility. I assign the benefitspa;Fable to which I an entitled to this fachity for services rendered. This assigrment will remain ineffect until revoked by me in iwhting. A photocopy and/or facsimile Of thiS assignment is to becousideled as Valid as an Original.
I have received a copy of the Notire of Privacy Practices for Davis Pkysical Therapy Clinie, DAVIEPkyrical Therapy Clinin reserves the right to modify +he privaey practices ounhed in the notiae'
I have read ire folegCIing and I understand it Any quesfiGnS that have arisen Or OCoumed to Ine have.been answered to my satisfaction.
Witness
Date
.123 _B..Medical`Dri~vel -EalE2Stke, Isxas-7`5801.I.8ffroe: -903.7.2-9fB6.l6 i.Far:.908.729.-86.1-8.i I 1 I + Jr- ~
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I I
I. Ac.knGwledgenrfu ofri'i)evigw of
fystice ofprivaey practices+ ~
I givg ny pemis8ion for the fellowing persqn(a) to recgivg my nedical jnfomanon:
Name and relafrouship
Nana and rehatiouship
Name and relalauship
Narie and rdrtionship
Name and relationship
ohave been given the opporfurty fo review this officels Nofise of mhaey prathcesl which explains howny medical information win be used and disclosed. I understand that I an entitled to rgcdre a copy ofthis docu`mend.
NamB of Patient or persoml
nI-_/
Representative Des cription offers onal Representativ a.s Authorfty
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