The Arlene Berry Case

Arlene Berry died suddenly and unexpectedly at the age of 41, less than 24 hours after being admitted to the Kirkland & District Hospital  on May 23rd of 2000. She had presented initially with "flu-like symptoms with alterations in GI function associated with anorexia, including stomache pain.

In the course of my initial investigation, a computer generated match of Arlene's signs and symptoms had identified Hepatic Encephalopathy, a brain dysfunction caused by the accumulation of toxic chemicals in the blood stream, marked by Acute Liver Failure, or liver encephalopathy due to liver impairment.

Coagulopathy and altered mental status define the syndrome of acute liver failure. Because acute liver failure is rare, related data have been sparse and the mechanisms by which infection triggers hepatic encephalopathy require further investigation. Studies have suggested that viral hepatitis is the most common underlying cause of this condition.

Acetaminophen overdose and idiosyncratic drug reactions have replaced viral hepatitis as the most frequent apparent causes of acute liver failure with Tylenol overdoses linked to acute liver failure. Patients with ALF have increased susceptibility to infections. The predominant bacterial pathogens include staphylococci aureus, coagulase-negative staphylococci disseminated frequently between intubated patients in a multidisciplinary intensive care unit) streptococci species and coliform organisms (Escherichia coli and pseudomonas aeruginosa).

In his report the Regional Coroner, Dr. Barry McLellan postulated that Arlene Berry had died of "natural causes" due to "multiple metastatic brain tumors", after eliciting a conflicting interest opinion with favoratism shown, or patronage granted, to one of his fellow colleagues that he knows personally due to being involved with one doctor or hospital or another such as from the Sunnybrook & Women's College Health Sciences Centre where he teaches. The opinion put forth by the coroner's expert also documents evidence of "decreased attenuation throughout both cerebral hemispheres suggesting no cerebral perfusion" that is consistent with pathophysiological causes of shock = definitive evidence of hypotension (inadequate blood pressure to maintain tissue perfusion). Shock is acute circulatory failure leading to inadequate tissue perfusion and end organ injury. With shock, at least one element of the cardiovascular system has malfunctioned = evidence ofHemodynamic Insufficiency and Altered Perfusion.

What causes shock?

The same author also concluded in his expert opinion that "the physicians who looked after Arlene Berry met a reasonable standard of care." The medical record of Arlene Berry for May 23rd and 24th of 2000 however, tells a very "different" story from the opinion put forth, with ommissions, inconsistencies, inefficiency and incompetency on the part of the doctors and nurses evident throughout, including evidence of record alterations with spoliation of evidence and record retention.

These are the facts:

1. In December of 1999, Arlene Berry was sent to Timmins & District Hospital in Timmins, Ontario where she was diagnosed, according to her physician "with carcinoma of the left main bronchus with residual cancer of the aorta due to a complete collapse of the left lung". Her family MD, Dr. Edward Henry Jordan had "misdiagnosed" her in that he had been treating her assumptively for what he termed a "suspected bronchitis ". It took another doctor to read her X-ray chart and to order more appropriate testing.

2. On or about January 12th of 2000 Arlene Berry was admitted to the Timmins & District Hospital under the care of Dr. Claudio De La Rocha where a left lung pneumonectomy was performed successfully on January 13th of 2000. She was released 5 days later.

3. On or about March 16th of 2000 Arlene Berry returned to Timmins where she underwent follow-up study and testing at the same hospital. She was then referred to the Northeastern Ontario Regional Cancer Centre situated at the Laurentian Site (41 Ramsey Lake Road) in Sudbury for consideration of Radiation Therapy under the care of Dr. Hugh Prichard , a Radiation Oncologist.

NOTE: Submit that when a doctor relinquishes the care of his patient to another doctor it is incumbent upon that doctor to take necessary steps to provide for the continued care and safety of that patient which the patient's oncologist, Dr. Prichard, neglected to do, tantamount to criminal negligence causing bodily harm. The same can be said of the healthcare providers at the Timmins & District Hospital, the Sudbury Regional Hospital, and the Kirkland and District Hospital who attended to Arlene Berry - as to corporate criminal liability for which I hold each and the other criminally accountable, and liable.

4. By the end of April of 2000 Arlene Berry had completed a 5 week postoperative course of radiation therapy. In light of this treatment her condition was seen to be stable. Postoperative testing results done on March 16th in Timmins were seen to be very encouraging and from that treatment and testing it seems clear that she had every reason to expect a partial remission or stable condition. What is radiation therapy?

5. At NO time was this patient educated or instructed to be on the alert for or to quickly report "flu-like" or GI illness, i.e. malaise, or abdominal discomfort associated with the common but unpleasant side effects of radiation therapy. Compare: Pathology of Gastrointestinal Bleeding, and flu-like symptoms associated with Hepatitis C. Compare also Ischemic Hepatitis - Shock Liver Hepatic ischemia is a deficiency of blood or oxygen supply to the liver that causes injury to liver cells. Low blood pressure resulting from any condition -- including heart failure, abnormal heart rhythms, dehydration, severe bleeding, and infection - can lead to hepatic ischemia.

Complications: > - congestive heart failure if treatment is delayed (may require valve replacement surgery), blood clots or emboli that travel to brain (stroke, brain abscess), kidneys (glomerulonephritis), lungs, or abdomen causing severe damage, cardiac arrhythmia’s (atrial fibrillation), heart valve damage and jaundice.

Dehydration can be exacerbated by severe or prolonged vomiting resulting in loss of fluid volume and is associated with electrolyte imbalances, including hypokalemia, hyponatremia, hypomagnesemia, and hypochloremia (Bender et al., 2002). The combination of inadequate fluid intake and excessive output from vomiting in patients who already are compromised by cancer or its treatment puts patients at an even higher risk for life-threatening complications.

7. At all times material, Arlene Berry had been suffering from undiagnosed and untreated intracranial hypertension (a disorder characterized by increased intracranial hypertension), with cerebral edema (swelling of the brain) believed to to be associated with side effects of radiation therapy due to radiation damage to the nervous system, such as seen in radiation reactions and injuries.

8. Headache, vomiting, and lethargy are classic symptoms of increased intracranial pressure. Clinical Presentation.

9. In addition to the radiation treatments (nuclear medicine) Arlene Berry was also prescribed and given MS Contin, and Statex (morphines) for pain management. She was a small woman with a low body weight and although she had a diminished lung capacity her right lung was seen to function quite well after surgery.

10. Following her postoperative course of radiation therapy, Arlene Berry had remained quite well until about one week prior to her admission to the Kirkland and District Hospital on the 23rd of May 2000. Over that week she had developed headaches that at times had become increasingly severe. A severe headache is a common but not invariable accompaniment of intracranial causes of nausea and vomiting. In this case, as the facts reveal, it seems clear that the headaches were associated with increased intracranial pressure and cerebral edema associated with her treatments. Compare: Hemorrhage -->increased ICP and blood toxicity. COMPARE: DURAL HEADACHES - Perhaps the most common type; those resulting from autotoxicity or an excess of blood metabolites, such as from liver dysfunction

11. In the last day or two she tended pulling to the right when walking, a sign of toxic ataxia, lack of motor coordination, or vascular limb ischemia. Compare also transient ischemic attack (TIA) such as caused by an interruption of blood flow to brain cells for example, and for the two-week period prior to her hospital admission her headaches were accompanied by nausea, vomiting and drowsiness that were thought to be associated with a bout of the "flu".

Patients with limb ischemia present with the classic signs of pulselessness, pallor, and paralysis due to SHOCK (= cardiovascular collapse), or clinical insult.

12. The emergency record from the hospital dated May 22nd of 2000 seen at OP-54 documents a recent history of hematuria (blood in urine) for three days and a prescription for Ciprofloxacin (Cipro), for treatment of Urinary Tract Infection. Cipro is an antibiotic indicated in the treatment of a variety of infections, including the flu, common side effects of which include nausea, headache, restlessness, and abdominal pain. Notably also, the same drug is given when superimposed bacterial infection from RT is present. Ciprofloxacin (Cipro) can potentiate existing renal insufficiency and may enhance concomitant drug toxicity with enhanced potential for ototoxicity.

Fatal liver failure associated with ciprofloxacin was reported in the Lancet in 1994. Ciprofloxacin has been implicated in several cases of acute renal failure and is the most established fluoroquinolone to cause such renal dysfunction.

13. The same record documents "blood when voiding", and also that she had been given "antibiotics for 1 week". She was also given more of the same at that time, as evidenced by the "1 given now". The same record also documents nurse's observations of "large blood trace leukocytes", also called White Blood-Cells.

Compare leukocyte estrace in UTI. Compare also Proteus spp: A gram-negative, motile, aerobic rod shaped bacilli, urease positive, characteristic swarming; part of the normal flora of the GI tract. Further, if alkaline urine is found in presence of UTI symptoms and positive leukocyte esterase, likely urea splitting such as Proteus, allowing urea to be split into CO2 and ammonia, causing a rise in the urine's normally acid pH.

A leukocyte response suggests leukocyte recruitment which may point to the likely offending organism as being a Gram-negative pathogen. Leukocyte recruitment is the hallmark of the inflamatory response.

14. According to my research, a negative urine test can suggest the presence of unusual bacteria or viruses causing symptoms of UTI. Compare Pseudomonas aeruginosa, a "gram-negative" opportunistic pathogen that frequently causes hospital-acquired infections producing symptoms of UTI. The major offender in the sterile bladder environment is the indwelling urinary catheter, or in the alternative, test or procedure related. For example, Urine: coagulase-negative staphylococcus (S. epidermidis), due to presence of the germ "coagulase negative staph". This is a common skin germ but can be pathologic (cause infections) in the body, as it appears to have done here.

The same healthcare provider (whose signature is illegible) also made a notation with respect to the "flu" which had then been directed to the attention of the patient's "family MD", Dr. Jordan. The healthcare provider who saw her made a provisional diagnosis of UTI. The test result from that diagnosis however, what I assume to have been a urology test or a blood culture test, evidenced at OP-55 of the Outpatient Record later returned a finding of "NO GROWTH"

The commonest isolate from blood cultures nowadays is Coagulase Negative Staphylococci (CNS) mainly due to contamination of the blood after being taken for culture.

Compare: INVESTIGATIONS: >>- Culture NO Growth.

Major contributors to this increase in nosocomial infections include the emergence of antibiotic-resistant bacteria, poor hygiene practices by healthcare providers, incompetent staffing, substandard practices and apathy on the part of healthcare providers. Nosocomial, derived from Latin, means hospital-acquired. The term is used to shield hospitals from the "embarrassment" of germ-related deaths and injuries, injuries exacerbated by hospital cutbacks and carelessness by doctors and nurses. To a distinctly greater extent or degree, nosocomial nosocomial infections often can be identified by clinical criteria alone, such as through ongoing concurrent medical record review, for example.

Compare also Genitourinary Emergencies associated with the GI tract, and also Genitourinary Tract Infections, INCLUDING Hospital Acquired Infections. The record at A-28 documents a Saline/Heparin Lock. Compare: coagulase-negative staphylococci in the presence of heparin.

An indwelling intravenous catheter/device includes any capped catheter that is inserted into a patient’s vein or artery including, but not limited to, saline/heparin locks. Saline or heparin lock: a short peripheral catheter (1-2”) usually present in the hand or forearm intended for intermittent infusions. A small length of tubing may or may not be present between the hub of the catheter and the locking cap. Saline or heparin flushes are used to maintain patency. Various authors have cited potential problems when using heparin as a flush solution, such as coagulase negative staphylococcus, including allergic reactions.

It is also clear clear that the same physician or healthcare provider who saw her failed to consider the patient's most recent treatments consisting of "radiation " and/or chemotherapy or associated drug regime. It was noted however that the patient's recent head CT scan showed "NO METASTASIS", and her mediastinoscopy, samples of the cells and lymph nodes that had also been done on the same date were found to be "NEGATIVE".

15. Notably, mediastinoscopy is used to stage lung cancer. From that record it is also clear that NO clinically detectable metastasis (the process by which cancer is spread) and NO mediastinal changes were found. What the family had found to be peculiar however, was the dramatic voice change following the procedure. However, the patient had began to regain her voice in the days prior to her death.

16.0 The Outpatient Record at OP-53 documents "pale-looking and lethargic". Lethargy is also associated with Moderate Dehydration. COMPARE: PROBLEMS OF THE GASTROINTESTINAL SYSTEM. DEHYDRATION (HYPOVOLEMIA).

16.1 The same record with respect to Tylenol and Aspirin documents "daughter states takes a lot", suggests use of drugs that can break the gastric barrier and damage the gastric mucosa, ie, aspirin, NSAIDs (non-steroidal anti-inflammatory drugs). Compare Salicylate Toxicity.

Acetaminophen toxicity may result from a single toxic dose, or from repeated ingestion of large doses of acetaminophen. When the liver and kidneys are not supported and kept clean, the body begins to store toxins in the tissue with any number of damaging symptoms resulting.

Hepatotoxicity can result from acute overdoses or from chronic use (i.e., several months of daily administration). Tylenol side effects include: light headedness, dizziness, drowsiness, and slurred speech.

Antibiotics may not cause side effects until they have built up in the body for several days, while an overdose of analgesics containing acetaminophen may cause damage within hours.

If plasma half-life exceeds 4 hours, hepatic necrosis can occur, and if the half-life exceeds 12 hours, hepatic coma is likely to develop.

The liver-kidney-heart muscle toxicities associated with analgesic drugs have not been reported by most media sources. Further findings suggest that pain in the upper abdomen, hypoglycemia, encephalopathy, abnormal functioning of brain tissue, and kidney failure may become apparent as drug toxicity increases. Acetaminophen, while generally safe for short-term use, can cause problems with long-term administration. These problems include liver and kidney damage and gastrointestinal bleeding. Acetaminophen iS contraindicated in liver disease in which slurred speech may be associated with toxic shock.

16.2 Also, what I take to be the health management record from the Kirkland and District Hospital at A-21 of the medical record documents her cognitive perceptual pattern as "sedated", a sign of acute or late toxicity, such as seen in drug toxicity or overdosage. Further, an acutely ill, toxic appearance is a common feature in serious infections.

17. Submit that sedation with ataxia, dizziness (can also signal internal bleeding) , and slurred speech are also prominant findings related to the side effects associated with drug toxicity. Indeed, these are also signs and symptoms of a stroke, i.e. ischemic stroke or thrombotic stroke, such as caused from interruption of the flow to blood to the brain by a blood clot. Ischemic stroke is a life- threatening event in which part of the brain does not receive oxygen, usually due to a blood clot.

18. Notably, the same record at OP-53 is totally devoid of annotation with respect to the patient's bowel routine and urinary elimination pattern for toileting marked by a complete absence of nursing care plan as further evidenced at A-21 of the medical record. (The element of duty is usually straightforward and relatively easy to prove because once nurses undertake care for their patients they have a clear duty to provide care for that patient in a competent and reasonable manner.) Further, there is absolutely nothing on record to suggest that any Supportive Care & Symptom Control Regimens were ever implemented. NO abdominal and rectal exam was performed. NO nurse's diagnosis was made.

19. What I take to be a continuation of A-21 of the same record seen at A-23 documents a "slurred" speech as evidenced by a √ in the upper left corner, also sign of iatrogenic drug induced intoxication in which dysarthria is a prominant finding in the setting of Portal-Systemic Encephalopathy. Further, dizziness, drowsiness, lethargy, ataxia, have all been cited with adverse events, including slurred speech, syncope, GI: constipation, nausea, vomiting, incontinence, and urinary retention. These are all findings associated with opiod and acetaminophen toxicity in Hepatic Failure.

Further findings suggest that constipation actually gives rise to a process of self-poisoning. Thus, auto-intoxication is the process whereby the body literally poisons itself by maintaining a cesspool of decaying matter in its colon. During fasting, (tantamount to anorexia) the concentration of toxins expunged from the body and appearing in the urine can increase ten times above normal concentrations. The released toxins can either exacerbate the symptoms being treated or create their own symptoms such as headaches, body ache, joint pain, dizziness, sweating, general malaise, sore throat, nausea and/or flu-like symptoms.

Adding insult to injury, Stemetil/Prochlorperazine enters the enterohepatic circulation and is excreted chiefly in the feces. The drug undergoes metabolism in the gastric mucosa and on first pass through the liver. Anti-emetic effect of prochlorperazine is diminished by its low bioavailability owing to a significant gastric and hepatic first pass effect.

Prochlorperazine is widely distributed into body tissues and fluids (in this case tissues and fluids containing gram-negative bacteria - disseminated bacteria can cross blood/brain barrier) and crosses the blood-brain barrier due to increased penetration of the blood-brain barrier. Infection is rapid once organism crosses blood-brain barrier. Further, findings suggest that from the lungs, S. pneumoniae often invades the blood, crosses the blood-brain barrier, and enters the meninges. Compare hemolytic findings.

Prochlorperazine/Stemetil is a phenothiazine piperazine derivative in addition to being an antipsychotic drug with a piperazine side chain, similar to trifluoperazine and fluphenazine. Because of the similarity in antiemetic action of the trifluoperazine component, Stemetil should NOT be used where nausea and vomiting are believed to be evidence of intestinal obstruction or brain tumor, for the same reasons as Stelabid, for example.

The record at OP-54 dated May 22nd of 2000 documents a "haggard appearance" including "large blood trace leukocytes". Notably also, leukocytes (WBC's) are elevated with dehydration, hyperviscosity secondary to dehydration, and infection.

20. The same record documents a question mark (?) with respect to possible morphine allergies, and that for "2 weeks" she had the "flu". The same record documents bloody bowel movements for 4 days, a sign of possible diverticulitis, a condition associated with constipation with abnormal increase of white blood cell count (indicative of infection), mucous, and occult blood (concealed hemorrhage) in the stool or passage of bloody stool. The majority of people with diverticula are asymptomatic. MORPHINE IS CONTRAINDICATED because of it’s constipating properties. Findings: 1) GI bleeding is the most serious source of bloody stools.
2) patient history of MS Contin (morphine), Tylenol with Codein (acetaminophen), Aspirin, and Demerol (meperidine) use.

Compare: Acetaminophen Toxicity (Analgesic Toxicity). Hepatotoxic drugs including acetaminophen can cause high serum bile acid concentration. Symptoms of acetaminophen overdose include hepatic necrosis, transient azotemia( renal tubular necrosis with acute toxicity, anemia, and GI disturbances with chronic toxicity. Compare microangiopathic hemolytic anemia ComparE Symptoms: Bleeding From the Digestive Tract.

Compare : UREMIC ENCEPHALOPATHY

21. Notably, the record does NOT take into account many other medications prescribed or administered by the patient's oncologist, Dr. Prichard between March and the end of April of 2000. i.e. Senokot for constipation, side effects of which include "severe stomache pain", and unusual change in color of urine , i.e, "tinged-urine". Further, she had also been prescribed sodium phosphate, a hyperosmotic laxative that has many precautions which had not been disclosed to this patient. Compare Hepatitis Central, Hepatic Encephalopathy (highlight matches) associated with the hyperosmotic laxatives search.

22. According to my research, Tylenol long term in doses as low as 3g daily can produce a chronic hepatitis-like picture that mimics liver disease in which Liver Function Tests are typically unremarkable. Medication effects and other systemic diseases as causes mandate a thorough history).

23. According to the record, Arlene Berry had also been given Amoxicillin for infection. Amoxicillan belongs to a class of penicillin-likedrugs, side effects of which include "severe nausea and vomiting", including "abdominal pain". Additionally she had been given Statex (a narcotic: opioid agonist analgesic used to relieve pain) which also belongs to a class of the Morphine family.

24. Morphine has many side effects. The most dangerous is respiratory depression. In frail patients, as the respiratory rate decreases, the patient becomes increasingly sedated. See: Morphine Risk Groups. COMPARE: Opioid overdose

25. From those records it is clear that Arlene Berry had a history of "opiate" use, among other medications. It was also noted that she had "stopped taking the morphine". There is nothing on the record to suggest that the patient was ever tested or examined for possible side effects associated with the MORPHINE she had been prescribed, such as opioid-induced nausea and vomiting, or for possible other side effects such as associated with the "withdrawal" from opiates. Compare Morphine Side Effects.

26. According to family Arlene Berry had stopped taking the morphine at home due to increasing severity of "constipation" requiring extra laxative and tap water douches to assist with stool evacuation, and also due to dizziness marked by a sense of uneasiness progressing to unsteadiness or " lack of motor coordination". There is also evidence of " inappropriate behaviour" as witnessed by family and friends.

27. A-12 of the medical record documents a list of what I take to be doctor ordered medications dated May 23rd of 2000, which corresponds to the medications hereinbefore mentioned.

28. A-5 of the record documents the presenting complaint as "headaches, accompanied by severe stomache pain" that is consistent with the "abdominal pain ongoing for 2 weeks" for which she was prescribed "antibiotics". The RN who saw her noted that she had been taking MS Contin (morphine) for her pain and also that she had stopped taking the morphine, noting also her past medical history consisting of "taking radiation". There is nothing on the record to suggest that this patient had been examined for the stomach pain, either for constipation or possible bowel blockage associated with the morphine. Stomach pain is also a prominent finding associated with dehydration, including constipation.

Notably also, constipation, fecal impaction and bowel obstruction are common problems for oncology patients. Further, when there is a weak area of the bowel that is sluggish and toxic, there is the possibility of these waste products being re absorbed back into the system, usually migrating back into the blood, then settling in the various weak tissue areas through out the body.

29. According to Dr. Jordan "she had presented to the ED (emergency department) several days before with vomiting and it was thought that she had a UTI ", to rule out delay in seeking treatment. Dr. Jordan goes on to state that "she was given antibiotics and sent home" as evidenced at A-8 of the hospital record. It is also clear that she was rejected for moderate dehydration due to excessive vomiting which was grounds for admission at that time.

30. According to the record at A-6 she returned to the ED (Emergency Department) on May 23rd of 2000 with "the very same complaints". On examination the physician who saw her documented positive "bowel sounds" that is consistent with physical findings of hyperactive bowel sounds - obvious abdominal distention with normal bowel sounds early on, but as obstruction progresses bowel sounds become hypoactive. paralytic ileus

31. The same record, what I take to be Dr. Spiller's physical examination also documents a "soft, non-tender" abdomen, with "no rebound tenderness", and "no masses". Rebound abdominal tenderness is common but nonspecific in liver trauma.

admitted Submit that an enlarged liver usually feels "soft" due to hepatomegaly (liver enlargement) a sign of liver disease. It is also associated with fatty infiltration, congestion and early obstruction of the bile ducts. Distinct masses, on the other hand, suggest either a growth or lessions. The record clearly documents "no masses". Hepatomegally is also associated with Clinical Diabetes.

32. According to my research, the first classic symptom of hepatitis is gradual increasing weakness and dizziness which may seem to be the first stages of the "flu" or a bad cold. Soon utter and complete fatigue takes over, along with nausea, pain in the stomach, tenderness with severity, and swelling in the area of the liver accompanied by loss of appetite or anorexia. The urine is noticeably tinged or darker in color. Compare: HOW DO YOU KNOW IF YOU HAVE IT? (SYMPTOMS).

33. What appears to also be a referral at A-6 of the medical record, a chart copy from the admitting physician directed to the attention of the attending physician documents what I take to be a provisional diagnosis of "vomiting". Submit that vomiting is NOT a diagnosis but rather a symptom of many causes. A question appears to have been raised (but also ignored) with respect to possible metastatic cancer of the brain, leaving the etiology of the vomiting and the stomach pain left undetermined for the attention of the patient's family MD. There are NO records to suggest that the ED physician had ever bothered to take the time to perform a Complete Neurological Examination of this oncology patient. Oncologic Emergencies

34. From that record it is clear that NO diagnosis or differential diagnosis was made at that time, or at all, as evidenced by the record at A-3. From the same record it is also clear that nothing was entered as can be seen because nothing was done. A reasonable physician would have correctly diagnosed the patient's condition by doing what Dr. Jordan and all those who attended Arlene Berry failed to get done in his absence.

35. Submit that abdominal or stomach pain concurrent with nausea and vomiting points to the "abdomen" as the source of the problem.

36. N-10 of the Nurses' Notes document the patient's level of care as "routine", which shows very little concern.

37. What I take to be a continuation of the same record at N-11 documents "vomiting, lung CA". There are NO further entries on that two-page assessment.

38. From the RECORD it seems clear that there was every indication that Arlene Berry was about to suffer a catastrophic decline, at least from foreseeable dehydration due to decreased oral/water intake and excessive vomiting over the previous week or more which ought to have prompted immediate medical attention but did NOT.

39. Dr. Jordan's discharge note at A-1 documents that she was "afebrile" (without fever), while the record at A-26 documents a body temperaturArthralgiae above 37.0°C. Further submit that a patient can be "afebrile" (without fever) and still have Toxic Shock Symdrome.

In the upper right hand corner of the same report D. Jordan documents 3 sets of numbers which I have traced to "anorexia, joint pain, and urinary tract infection". Note the hand scripted numerical notations from the ICD (International Classification of Disease) Code, i.e. 784.0 =Anorexia, 787.3 =Pain in joint , and 599.7 =Urinary Tract Infection.

Compare joint pain under the subheading "Endocarditis"

www.meverett.com/index/facts/editor_input.htm

add your comments