Acetaminophen (APAP) - Drug-induced liver injury (DILI) – Vehicle Theraflu Nighttime Overdose – Complication of COPD - By Keith Torkelson for PCP Chester D Mojica MD

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Feature Image

[Dr. Schwabe]

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Dedicated to:

[Dr. Bruss]

Keith "Buster" Torkelson MS's

Liver Professor

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Name of this report

Acetaminophen (APAP) - Drug-induced liver injury (DILI) – Vehicle Theraflu Nighttime Overdose – Complication of COPD - By Keith Torkelson for PCP Chester D Mojica MD

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Source Report

Metadata > Global_Health_Annual_Physical_19072201_Liver

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Acetaminophen (APAP) - Drug-induced liver injury (DILI) – Vehicle Theraflu Nighttime Overdose – Complication of COPD - By Keith Torkelson for PCP Chester D Mojica MD
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https://brandnewdayhmo.blogspot.com/2019/09/feature-image-dr.html
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Keith E Torkelson MS - Date Chartered 9/4/19

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Abstract – Executive Summary

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Presenting Problems

This report addresses some problems that Keith “Buster” Torkelson MS is facing with regard to Chronic Obstructive Pulmonary Disease (COPD).  I particular we here at Mentalation Solutions Group (MSG) are investigating Buster’s elevated liver enzyme value As Measured By (AMB) clinical laboratory testing.  We feel it is likely that Buster is suffering a Drug-Induced Liver Injury (DILI).  The culprit drug appears to be Acetaminophen (APAP) contained in Theraflu Nighttime and other Over-The-Counter cold preparations.  The last “Cold & Flu” season Buster Over-Dosed (OD’d) on Theraflu Nighttime.  We also have a physician error to share here in this report.  Buster’s Primary Care Physician (PCP) appears to be an Over-challenged User of Health Technology (OCUHT).  For our PCP transactions this year (2019) we offer up the MSG Billy Award.

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[INSERT BILLY]

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Laboratory Support Materials

Buster’s last liver enzyme tests were run roughly on July 11, 2019.  For this round of lab testing we here at MSG were focused on Buster’s Glucose results.  They came in normal.  Only one item was flagged in the lab report.  The flag pointed to his ALT liver enzyme value.  His ALT was 52 U/L.  Quest Diagnostics preformed the work.  The Quest Normal Range (QNR) for ALT is 9-46 U/L.  Knowing this lab result Buster met up with his PCP to go over the latest panel of lab results.  His PCP said your “liver results are normal”.  Buster did not question the doctor’s interpretation of his ALT (liver) level.

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Prognosis

Using a semi-standard drug finder work sheet we eliminated some potential causes for Buster’s elevated ALT.  For the most part we find that over-ingestion of Theraflu Nighttime has a high chance of being the preparation driving up his ALT.  We calculated his AST: ALT Ratio.  The value returned was 0.65.  This ruled out cirrhosis.  The culprit drug appears to be Acetaminophen (APAP).  Acetaminophen is hepatotoxic (kills liver cells).  As long as Buster avoids Acetaminophen in any form his liver should demonstrate Plastic Resilience (PR).  In other words his liver should heal AMB normal AST and ALT lab results.  Buster has a follow up lab schedule this year.  The Prognosis is “Good”.

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Next Steps – Prudent Actions - Request 4 Funding (R4F)

Buster’s liver issue is tied intimately with his COPD problems.  The reason Buster took Theraflu was to address his COPD during the 2018-2019 season.  Try as he may Buster cannot put smoking cigarettes behind him and move ahead.  Brand New Day (BND) is Buster’s insurer.  In 2012 BND sent Buster with a full scholarship to a crisis residential treatment program for Buster’s Substance Use Issues.  We would like BND to send him to the same or similar program on a full paid scholarship.  This time we need a program that has a proven high chance at delivering long-term smoking cessation.  While we wait Buster will avoid any Acetaminophen containing OTCs.  In preparing for the next “Cold & Flu” season Buster will carefully consider avoiding his PCP in favor of using for a second time the BND Telehealth Benefit.  We cannot share this report with our PCP or Doctor In Charge (DIC) because it would be too much for him to: Process, digest, or apply.

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CLOZE with Numbers

Prior to naming us Mentalation Solutions Group (MSG) we Did Business As (DBA) Tork Reconstruction Company (TRC).  As TRC we saved and collected up Medical Records.  We have so many Medical Records that we really can’t put together whole collections under any given theme.  As MSG we are more efficient with records management than we were using our TRC systems.  We gathered three records from Buster’s history that documented his Liver Enzyme History (LEH).  We retrieved hard copies for years: 2007, 2015, and 2017.  On all three reports Buster’s AST and ALT results are normal.  This helps us rule out one of Buster’s potentially complicating medication: Clozapine.  Buster has been on Clozapine roughly since Dr. RP Singh first started the Clozapine process in November of 2006.  About the Liver Lab Testing (LLT) for July 11, 2019 Buster’s AST was normal while his ALT was slightly high.  Using the “gihep” calculator on July 24, 2019 we calculated an AST: ALT Ratio using the 2019 results at 0.65.  This value indicates that Cirrhosis of Buster’s liver is unlikely.  We believe that at least one cause of Buster’s elevated ALT is most likely Acetaminophen (APAP).  The primary vehicle that delivered APAP is Theraflu Nighttime.  In one pack of Theraflu the box indicates that there is 650mg of APAP.  In one box of Theraflu Nighttime there are six (6) packs or doses.  Buster took way too much APAP containing preparations last “Cold & Flu” season.  For follow-up testing about Buster’s liver health, only liver enzymes are warranted.  Once again the prognosis is “Good”.

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Partners

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Table - PCP – Care - Report Header

Pertains To Buster/CDM Unilateral V Partnership

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Specification		Entry	Note
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Client		Keith “Buster” Torkelson
Practitioner		Chester D Mojica MD	CDM
Specialty		Primary Care Physician	PCP
Date of Appointment		20190725-TH	The Billy Appointment
Time of Appointment		11am
Duration of Appointment		7 minutes
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Lab(s) Associated with Appointment		20190711-TH	Quest DX patient portal MyQuest
Specific Area within Appointment		Liver Health as related to lab values	Liver Lab materials included here
Lab makes material available in time for appointment		Yes Via MyQuest	This is a 5.0 stars service
Nature of Appointment		Interim Routine Lab	IRL
Invoiced for Appointment		No	Accountability issue
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Satisfaction with this component of appointment		No	Poor bedside manner again No satisfaction survey
Insurer		Brand New Day	Medicare Advantage Plan Medi-Medi Special Needs Plan Wraparound Care
Was there an error with this component		Failing parity check between lab report and what the practitioner was observing	Doctor declares “Liver is OK”
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Last Reviewed: 20190830-F:

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List of Matrices, Tables, Figures, etc.

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Figure - Scan of Theraflu Nighttime

Results Up Front (RUF) – Key Labs From Jul 11, 2019

Results Up Front (RUF) - Lab History – 2007 & 2015 & 2017

Results Up Front (RUF) – Current Lab – 20190711-TH

Figure - Our Motivation – Applied Liver Studies

2019 – Matrix – AST: ALT Ratio

2019 – Table – Inter-lab Reference Range Comparison

Table - Elimination List – Diagnostic Rule Outs

Table – Elimination – Deepening the Picture - So What is Wrong?

Table – How did it go wrong? - Drug-induced liver injury (DILI)

2019 – Table – Drug Workup Sheet

FYI – Very Good Read – Tuning the Clinical “Eye”

Table – Further Testing Eliminations – Only One Warranted

Prognosis - 2019 – Table – Behaviors that may influence ALT levels

Table – Take Away - Key Words and Term Summary (n=14)

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In House Report Metadata

Reference report

GHlth_CCCHC_CDM_17100502_Physical_Report V2019 Practice

We changed our Level Of Rigor (LOR) this year (2019).  In years past we made an attempt to assess and share about full scope Health & Human Resources.  This full scope was centered about Brand New Day (BND) and its’ contractors.  Our PCP is a BND contractor.  On an annual cycle we published our findings in standalone and comprehensive reports.  Our comprehensive reports we centered about our product with call Christmas Report Card (CRC).  This standalone report centers about lab testing in relation to COPD.  We have new hopes about managing Buster’s COPD and his smoking cigarettes.

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Metadata - Associated Report

Global_Health_COPD_For_2019_20181107_Hope V2019

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Prescribed Assessments – Indicators of Satisfaction

Torkelson Pathology specializes in Social Pathologies.  Are methods are assessment driven.  Rather than work with clinical lab results and other clinical samples we focus and written assessments.  This report is pleasant break from written assessments.  We get to work with objective clinic evaluations such as lab results.  Two of the areas we address with written assessments are Consumer Satisfaction and Consumer Quality Of Life.  Buster’s PCP abandoned his Satisfaction Survey Program (SSP) several years ago.  If he still implemented his SSP we would have brought some of the findings in this report directly to Buster’s PCP.  With MSG’s prior satisfaction reports we made an effort to let our PCP find reports about him online.  For this report we decide to move ahead and not mention him by name so often.

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Figure - Scan Theraflu Nighttime

Drug-Induced Liver Injury (DILI)

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Theraflu Packaging and Notes

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Drug Facts

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Interest - Applied Liver Physiology and Patho-physiology

Problem(s) & Problem Resolution

Basically as you will see Buster tested high this year about one of his liver enzyme tests.  We have no records on file that indicated this had occurred before.  The suspect test is for Buster’s Alanine Aminotransferase (ALT) status in Buster’s blood.  Buster’s ALT isn’t all that high, yet his ALT was not normal at the time of the test.  We here at MSG eliminated several potential causes only to come to a tentative conclusion that it was the Theraflu Nighttime (contains hepatotoxic acetaminophen) Over-The-Counter (OTC) preparation that was suspect.  Buster took way too much Theraflu Nighttime this “Cold and Flu” season.  When we met with Dr. Chester D Mojica (CDM-PCP) he declared that the liver values “are normal”.  We had the labs on hand to show him yet he failed to give “Buster” an opening to comment.  Buster really wanted to know that until his liver heals should he quit the aspirin that CDM has and is prescribing.  Checking the literature the prognosis looks good if “Buster” avoids any preparations that contain Acetaminophen.  If we are correct Buster’s ALT levels are very likely to resolve.  His next ALT test is planned for later this year.  Now we will discuss “Liver” because Buster enjoys studying liver pathology.  Buster has a history of periodically being much sicker than he has for the first half of 2019.  It very likely he has Over Dosed (OD’d) on Acetaminophen containing preparations in seasons prior to 2018-2019.  He just did not have liver labs to bring it to our attention.

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Lab First Method (LFM)

Lab findings are objective.  MSG has a special interest in Behavioral Health. For years we promoted increases about clinical laboratory tests to support Behavioral Health (BH). Because there are so few proven lab tests about BH we use a myriad of written assessments to capture the consumer experience with Medicine and BH.  Below we share the key labs results as provided by Quest Diagnostics (QD) via their free patient portal.  This service QD calls MyQuest.

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Results Up Front (RUF) – Key Labs From Jul 11, 2019

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Results Up Front (RUF) – Labs From Jul 11, 2019

ALT Over Time – Time Series

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Special Topic – How is it Alanine Aminotransferase (ALT)?

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Results Up Front (RUF) – Liver Lab History – 2007 & 2015 & 2017

All values pertain to Keith “Buster” Torkelson

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Time Stamp	Lab	Test	Result	Ref Range
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20070302	UCI Med Cntr	AST Plasma	20 IU/L	8-40 IU/L
20070302	UCI Med Cntr	ALT Plasma	18 IU/L	0-60 IU/L
20150908	Quest DX	AST	15 U/L	10-35 U/L
20150908	Quest DX	ALT	12 U/L	9-46 U/L
20170717	Quest DX	AST	22 U/L	10-35 U/L
20170717	Quest DX	ALT	28 U/L	9-46 U/L
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Last Reviewed: 20190902-M: Interpretation: All within normal ranges

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Results Up Front (RUF) – Current Lab – 20190711-TH

All values pertain to Keith “Buster” Torkelson

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Time Stamp	DOW		Test Description	QUANT	Note Reference	Interp
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20190711	TH		AST	34 U/L	10-35 U/L	Slightly Normal
20190711	TH		ALT	52 U/L	9-46 U/L	Slightly High
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Last Reviewed: 20190902-M:

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Introduction

Special Topic - Clinical Patterns - Insurance Glossary Definition - IRMI.com

https://www.irmi.com/term/insurance-definitions/clinical-patterns

Clinical Patterns (CPs) might be defined as standardized medical procedures or routines for treating specific medical conditions.  “When clinical patterns become an accepted standard of care and are followed by physicians and hospitals, their exposure to claims alleging medical malpractice is generally reduced. However, the reverse is also true, so that when treatment deviates from an accepted clinical pattern, the exposure is increased.”

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Promises to Mentor

Back in 1987 Keith (not Buster yet) Torkelson was doing his graduate work on Trehalose as a cryo-protectant for poultry semen.  After preliminary research he determined that this endeavor would look super good on his application to Veterinary School.  In “industry” Keith’s primary mentor at the time was Doctor “Yan” Ghazikhanian.  Doctor Yan had several specialties with only one being Salmonella control efforts in commercial turkeys.  In the process of organizing and obtaining funding for his graduate research Keith was shopping for a department to oversee things.  Obvious choices were Epidemiology, Physics, Microbiology, and Masters’ of Preventative Veterinary Medicine (MPVM).  Keith, the dunderhead, picks the Pathology Department.  At this time the department chair was Dr. Donald Dungworth.  In Dr. D’s and Keith’s first meeting Dr. D instructs Keith to write a CV.  Dr. D instructed to come back with you CV and your elevator speech.  To shorten things: Dr. D accepted Keith and as such also became a mentor for Keith.  With the final acceptance interview Keith promised Dr. D to always work on refining his clinical “Eye”.  In addition Keith indicated an interest in MicroTech.  Keith was to contribute to developing Holographic Microscopes.  More recently Keith Doing Life As (DLA) Buster found this article by and from a local medical school.  Its’ title is: “Training the clinical eye and mind: using the arts to develop medical students' observational and pattern recognition skills”.  See Buster is not all that over the hill at age sixty (60).  His promise to Dr. D still matters.  We will hold off on MicroTech because it is out of scope.

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Dr. Donald "D" - One of Keith's Graduate School Mentors

At time chair of the UC Davis Pathology Department 

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In Veterinary School

We here at MSG will state (transparence) up front a Vaccine Adverse Event (VAE) complicated Keith’s career as a veterinary student.  When he could perform he did well.  Poor performance was associated with hospital stays.  Prior to returning to Orange County and attending school Keith’s GPA hovers near 3.4.  After saying goodbye to Davis in 1993 Keith attended local schools: Saddleback College, California State University @ Fullerton (CSUF), and Cypress College.  His overall Orange County GPA is 4.0.  Back to Vet School - In Fall quarter of 1992 (Actually Keith was really messed up) Keith took the required 13.40 units.  This “load” included three (3) units of Liver Physiology.  After the first year of Vet School Keith decided it was okay to earn in the B+ - A- range.  For the liver course he earned and “A-“.  Keith still used his office hours approach.  It is Buster's office hours' approach that helps us define good qualities about professionals and practitioners alike.  Before the first midterm we met with the liver professor Dr. Bruss.  He indicates to Keith that he is Mr. Liver Guy and he has high expectations for him.  When Keith went to pick up his final in person Dr. Bruss was irritated with Keith’s poor performance.  What follows is some liver stuff.

Introduction

Figure - Our Motivation – Applied Liver Studies from Fall Quarter 1992

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Applied Liver Physiology – UC Davis Veterinary Medicine Program
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What’s up with the “A-“?

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The Torkel Saga 2059 

Saturday, January 27, 2018

Veterinary Medicine – Liver Physiology – Exam Results (1992) for Keith E Torkelson, MS

http://the-torkel-saga-2059.blogspot.com/2018/01/veterinary-medicine-liver-physiology.html

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Exam Rigor

The lesson to be learned from this exam is how to convert the assigned points per question into a number of scored items.  For example a twenty (20) pointer would involve the following rigor.  Brainstorm roughly five (5) key points then embellished each with supporting information.  It is possible to over answer.  Looking back and remembering “Liver” helps Buster feel happier.  In the liver class Keith also performed his first surgery while in Vet School.  Just a side note: Lithium and surgery do not mix well.

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Process – Calculating an AST: ALT Ratio

How severe is Buster’s liver destruction?  Like we said earlier, Buster’s ALT is not all that high.  Yet to round things out we decided to calculate his AST: ALT ratio.  We found in the literature that seriously problematic (cirrhotic) livers have ratios over 100.  We calculated Buster’s ratio to be 0.65.

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2019 – Matrix – AST: ALT Ratio

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Time Stamp	DOW		Description	QUANT	Note Reference
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20190711	TH		AST	34 U/L	10-35 U/L (Quest)
20190711	TH		ALT	52 U/L	9-46 U/L (Quest)
20190724	W		AST:ALT Ratio	0.65	“gihep” calculator
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Last Reviewed: 20190726-F: U/L = Units per Liter

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FYI - “gihep” calculator

http://gihep.com/calculators/hepatology/ast-to-alt-ratio/

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FYI - [Really cool calculator – Not Used at the Time]

AST: ALT Ratio Equation Page -  MediCalculator - ScyMed

http://www.scymed.com/en/smnxpc/pcdgr339.htm

Equation Parameters – AST: ALT Ratio

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How bad is it? - What level of AST is dangerous?

“Typically the range for normal AST is reported between 10 to 40 units per liter and ALT between 7 to 56 units per liter. Mild elevations are generally considered to be 2-3 times higher than the normal range. In some conditions, these enzymes can be severely elevated, in the 1000s range.” Jan 10, 2019

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2019 – Table – Inter-lab Reference Range Comparison

 “emedicinehealth” Reference Ranges

Liver Blood Tests - High & Normal Symptoms - Causes & Results

FYI - https://www.emedicinehealth.com/liver_blood_tests/article_em.htm

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Test		Quest (U/L) Reference	“emedicinehealth” (U/L) Reference	20190711 Quest Actual
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AST		10-35	10-40	34 U/L	HITVIRR
ALT		9-46	7-56	52 U/L
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AST/ALT Ratio					“gihep” 34/52 = 0.65
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Last Reviewed: 20190724-W: HITVIRR = How is it variance in reference ranges

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AST :ALT Ratio Interpretation

http://gihep.com/calculators/hepatology/ast-to-alt-ratio/

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Table - Elimination List – Diagnostic Rule Outs

Exclusion of Other Diagnoses

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Feature		Position from HX	Note
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Alcohol Complication		None since 2012
Aspirin		Unlikely	Keep taking as prescribe by doctor
Cholesterol-lowering medications		Unlikely	Rule pending Atorvastatin
Clozapine		Unlikely	Older labs help rule out Clozapine impact
Fatty Liver		Unlikely
Cirrhosis		Unlikely	AMB Ratio
Liver metabolism competition changes		Possible	Likely
Other medicines to treat psychiatric disorders		Unlikely	Lorazepam & Lithium Older Labs help rule out both
Other OTCs with acetaminophen (APAP)		Likely	As of May 2019 cold turkey off all OTC cold – etc. remedies
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Last Reviewed: 20190831-SAT:

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Table – Elimination – Deepening the Picture - So What is Wrong?

Clinical Course - LiverTox

FYI > https://livertox.nih.gov/ClinicalCourse.html

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A careful history, focusing on

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Focus		Note
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Risk factors for viral hepatitis		No change over lifetime
Alcohol use		Not for more than 7 years
Weight gain		Insignificant
History of Autoimmune Disease		None
History of cardiac failure, shock, or septicemia		None
History of all drug intake, including time of starting and stopping prescription and nonprescription (over-the-counter) drugs and herbals within the previous 3 months		Nothing new except OTCs
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Last Reviewed: 20190726-F:

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Table – How did it go wrong? - Drug-induced liver injury (DILI)

As Measured By (AMB) – Blood Work 20190711-TH:

All information pertains to Keith “Buster” Torkelson MS

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Key Date	Chemical	Dosage	Function	Note
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20190308-F	Chlorpheniramine Maleate	UKN	Antihistamine
20190308-F	Phenylephrine Hydorchloride	UKN	Nasal decongestant
Multiple	Acetaminophen (APAP)	650 mg	Pain Reliever/fever reducer	Theraflu Nighttime
UNK	Diphenhydramine HCL	25mg	Antihistamine/cough suppressant
UKN	Phenylephrine HCL	10mg	Nasal decongestant
20190321-TH	Doxycycline Hyclate	100mg	Antibiotic
20190602-SU	Fexofenadine HCL USP	180mg	Antihistamine
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Last Reviewed: 20190726-F: UKN = Unknown

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Clinical Course - LiverTox

FYI > https://livertox.nih.gov/ClinicalCourse.html

More common causes have been ruled out (eliminated)

Substantiating Acetaminophen as a likely culprit - “In judging the likelihood of drug induced liver disease, six features are important”

2019 – Table – Drug Workup Sheet

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#	Feature		Note	Detail
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	Name of suspect drug		Acetaminophen (APAP)	Delivered with Theraflu Nighttime as well as other OTCs
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1	The onset after starting the drug		Time to onset	Very likely sometime after APAP exposure  and before the key lab test
2	The recovery after stopping the drug		Time to recovery	Pending next lab tests
3	The clinical pattern		Injury pattern and clinical phenotype
4	Exclusion of other causes of liver injury		Clozapine	Pretty much eliminated
5	Whether the drug is a known cause of liver injury			Yes APAP can injure liver
6	Response to re-exposure, whether inadvertent or intentional			Unlikely because we may never risk high levels of APAP intoxication again
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Last Reviewed: 20190830-F:

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FYI – Very Good Read – Tuning the Clinical “Eye”

Training the clinical eye and mind: using the arts to develop medical students' observational and pattern recognition skills.

https://www.ncbi.nlm.nih.gov/pubmed/16483329

Conclusion:

“The Interventions Studied Were Naturally Complementary And, Taken Together, Can Bring Greater Texture To The Process Of Teaching Clinical Medicine By Helping Us See A More Complete 'Picture' Of The Patient.”

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Operation(s) Manual Applied to CDM’s Practice

Next we want to address two separate statements made by BND core contracted doctors.  The first is Dr. Mojica’s (CDM) when choose to kill the patient-provider partnership approach.  “This is how we do it around here”.  The second is Dr. Rimal B Bera’s (RBB) statement: “This is how I choose to run my practice”.  In part he was justifying having caseloads so big the he really could not spend enough with his “Easy” clients.  We have been looking through some of Keith “Buster” Torkelson’s Vet Med learning materials.  The majority of the courses had cutting edge class notes.  Epidemiology and Behavior note sets we around 100 pages long.  Whereas, courses such neurology and microbiology lab had note sets around 500 pages.  In keeping it short we would prefer that both CDM and RBB provide us note sets on how they run their practices.  This we meet the transparency, partnership, and consumer-driven principles.

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[INSERT SCHWABE’S PRACTICE GUIDE]

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Table – Further Testing Eliminations – Only One Warranted

For Educational Purposes Only (FEPO)

Laboratory test results (and diagnoses to exclude):

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Test		Diagnosis	Change RFs
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IgM anti-HAV		Hepatitis A	No
HBsAg or IgM anti-HBc or both		Hepatitis B	No
Anti-HCV or HCV RNA or both		Hepatitis C	No
Antinuclear antibody (ANA) and globulin levels		Autoimmune hepatitis	No
Ultrasound or other radiological visualization of gallbladder and biliary system and		Gallstones Obstructive  jaundice	No
Ultrasound characterization of liver quality		Alcoholic and nonalcoholic fatty liver disease	No
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Liver Panel		To measure extent of liver repair	Decreased
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Number of these tests warranted = 1
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Last Reviewed: 20190830-F: FYI > Reference - Clinical Course - LiverTox

https://livertox.nih.gov/ClinicalCourse.html - RFs = Risk Factors

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Prognosis - 2019 – Table – Behaviors that may influence ALT levels

Special Topic - Reversibility

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#	Behavior		Application	Note
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1	Limit alcohol consumption		NA	Limited down to none 2012-2019
2	Lose weight		NA	At target weight
3	Quit smoking		Needed	Would like a SUD residential treatment program of 3 months
4	Get regular exercise		SoSo
5	Consider taking probiotic supplements to improve your digestive health		Periodic Adequate	Aside our probiotic inhaler idea
6	Eat a healthy diet		SoSo	Buster eats what is given him
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Last Reviewed: 20190724-W: NA = Not Applicable

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Rate of Healing - Reference

Liver Blood Tests - High & Normal Symptoms - Causes &Results

https://www.emedicinehealth.com/liver_blood_tests/article_em.htm

“How can I lower my ALT levels quickly?”

“The good news is that many people can lower their elevated ALT with changes in their lifestyle and exercise.”

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Summary

For the summary we here at MSG decided to list some take-away words and terms:

Table – Take Away - Key Words and Term Summary

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##	Key Term		Notes Pending
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01	Clinical Error
02	Clinical Patterns
03	Clozapine
04	Doctor In Charge
05	Drug-induced liver injury
06	Lived Experience
07	Mentor
08	MyQuest
09	Patient Portal
10	Prognosis
11	Reference Range
12	Request 4 Funding
13	Satisfaction Survey Program
14	Training the Clinical Eye and Mind
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Last Reviewed: 20190903-TU while at MHSA – MHA – Wellness Center West for Meeting

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Promotions

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One Health

A Schwabe Vision

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WorldWafers
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In Keeping with promises to Dr. Schwabe

A Keith "Buster" Torkelson Vision

OC - LINKS
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Images @ The End

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