BEFORE A.P STATE CONSUMER DISPUTES REDRESSAL COMMISSION AT HYDERABAD
C.C.NO.87 OF 2010
Between:
Smt Zeenath Sajida W/o Syed Najmuddin Quadri
Age 56 years, Occ: Housewife, R/o H.No.11-4-375,
Manvi (PO), Raichur (Dt.) Karnataka
Complainant
A N D
1. Azam Hospital,
21-4-189, Hussaini Alam
Hyderabad, rep. by its Proprietor,
the opposite party no.2
2. Dr.Md.Yousuf Azam, Consultant
In-charge, Azam Hospital
21-4-189, Hussaini Alam
Hyderabad-02
Opposite parties
Counsel for the Complainant M/s C.Kesava Rao
Counsel for the opposite parties M/s Alvender Goud
QUORUM: SRI R.LAKSHMINARASIMHA RAO, HON’BLE MEMBER
AND
SRI THOTA ASHOK KUMAR, HON’BLE MEMBER
WEDNESDAY THE TWENTY SECOND DAY OF AUGUST
TWO THOUSAND TWELVE
Oral Order (As per Sri R.Lakshminarasimha Rao, Hon’ble Member)
***
1. The complaint is filed seeking direction to the opposite party to pay an amount of `22 ,82,565.98 ps with interest @ 18% per annum from the date of complaint and costs.
2. The averments of the complaint are that the complainant suffering from abdominal pain for about three days approached the opposite party no.1 hospital on 13.9.2008 where the second opposite party examined her and advised her to undergo laparoscopy Cholecystectomy for the complaint of inflammation of the gallbladder and accordingly in the morning on 16.9.2008 the complainant had undergone surgery and she developed pain in her abdomen at operation site on 17.9.2008 which aggravated with severe pain at her epigastric region with swelling and redness from 18.9.2008. The second opposite party informed the complainant that it is a postoperative complication and it would subside. The complainant was discharged on 19.9.2008 in the same condition with an advice that she should come back to the hospital for removal of the sutures on 22.9.2008.
3. The infection at the operated site was not diagnosed nor treated by the second opposite party though the complainant was experiencing severe pain. The second opposite party had knowledge of the complainant being diabetic and he failed to take into consideration of the symptoms of infection associated with pain, swelling and redness at the operated site . The complainant suffered from fever at 103 degrees without any medical attention until 22.9.2008. The redness and swelling surrounding the incision with pus formation and cellulites worsened because of infection. On 23.9.2008 the second opposite party removed the sutures and left the wound open.
4. The second opposite party had put the complainant on spinal anaesthesia on 23.9.2008 and had done wound excision and debridement. The treatment went on an experimental basis. In view of the worsening situation the attendants of the complainant requested the second opposite party to refer her to a higher centre. In the opposite party no.1 hospital the complainant incurred an expenditure of `50,000/-. The complainant was shifted to Yashoda Hospital Hyderabad with extensive postoperative wound infection. The complainant had undergone three series of surgeries at Yashoda Hospital on 1.10.2008, 6.10.2008 and 16.10.2008 as an inpatient from 29.9.2008 to 5.11.2008. She incurred an expenditure of Rs.8 lakh and had undergone pain and suffering from the date of operation conducted by the second opposite party. The complainant suffers impact of the operation and with scar on her abdomen on account of loss of tissue.
5. On noticing the case sheet sent to her by the second opposite party at her request, the complainant came to know that laparoscopic surgery was performed upon her by an unknown surgeon Dr.Rajasekhar Reddy. No pre-operative discussion was ever arranged by the second opposite party. The complainant developed post-operative complications during which time the surgeon was not contacted nor secured by the second opposite party to asses her condition. The second opposite party was careless in discharging the complainant. The complainant was discharged without inspecting the wound despite her complaining of pain and swelling. Had the second opposite party exercised minimum care of taking note of pain and other symptoms of the complainant prior to her discharge, the subsequent deterioration in her condition and corresponding pain and suffering including huge hospitalization and medical bills would have been averted.
6. The complainant is unable to work normally because of the repeated surgeries and functionally she is inhibited to bent forward because of the severe scarring and tightness over the abdomen.
7. The second opposite party filed counter affidavit in the shape of written version and it was filed on behalf of the first opposite party also. It is contended that the complaint is not maintainable for lack of evidence and as it is contrary to law. The complainant has no cause of action. The complainant had misrepresented the facts of the case with an oblique motive. The complainant was taken to the opposite party no.1 hospital with severe abdominal pain on 13.9.2008. The second opposite party admitted her as inpatient and subjected her to clinical investigation under information and permission from her attendants. The clinical investigations revealed that the complainant was suffering with diabetes mellitus and calculus cholicystitis i.e., inflammation of gallbladder with gallstones. She was put on antibiotics and supportive therapy and advised to undergo laparoscopy Cholecystectomy.
8. The complainant and her attendants were explained about the inherent risk involved in the surgical procedure treatment and consequential side effects thereof. The complainant and her attendant had given informed consent to carry out the laparoscopy Cholecystectomy by the second opposite party at the first opposite party hospital. Pre-surgical vitals/parameters leading to surgery were investigated and it was found that the complainant was fit to undergo surgery. As per the standard protocol and procedure, laparoscopy cholecystectomy was conducted by the opposite party no.2 along with team of medical and para medical staff who include a post graduate general surgeon Dr.Rajasekhar Reddy, laparoscopic surgical speciality Dr.Wasae Quavi anaesthetist of the opposite party no.1 hospital. After performing the cholecystectomy and confirming homeostasis, a drain was kept in view of the infection. Wound was closed after washing with betadine and normal saline. The laparoscopic procedure was successful and the complainant was shifted to ward for post-operative care. Her condition was stable, good and all her vitals were normal and she was relived of persistent problem as also misery of pain which she had undergone before the procedure was carried out.
9. During the postoperative period, the complainant was put on antibiotics and supportive therapy as per accepted standard protocol. The extensive care taken by the opposite parties no. 1 and 2 at every stage of treatment was recorded in the case sheet. The complainant had no pain in abdomen until evening of 16.9.2008. At 10 p.m. on 16.9.2008 the complainant experienced pain in abdomen. The opposite party no.2 immediately attended the complainant and provided medication to relive her from pain. During the following days of her stay at the opposite party no.1 hospital all her vitals were normal and her recovery was extensive and fast.
10. The second opposite party having satisfied in terms of the complainant’s vitals being normal, discharged her on 19.9.2008 with an advice to report at opposite party no.1 hospital on 22.9.2008 for removal of sutures. The complainant had nor protested nor disagreed with her discharge from the opposite party no.1 hospital. The redness or swelling could not be seen with naked eye without removing the dressing on the wound. The complainant had no infection nor redness or any other complaint during her stay at the opposite party no.1 hospital. She was well attended and appropriate medication was administered.
11. The second opposite party removed the sutures on 23.9.2008 and found that the wound has developed infection due to irregular intake of medicine at home by the complainant and he had taken steps to stitch abscess at the epigastric port site. After removing the sutures, the pus collection was let out and the complainant was administered with antibiotics and supportive therapy. The dressing was changed and the wound at the epigastrium was extended and converted to cruciate and infected material was removed. Pus was sent for culture and sensitivity test. Probable diagnosis of “necrotising fasciitis” was made and wound excision and debridement was made under general anaesthesia after obtaining informed consent of the complainant and her attendance. Daily dressings were changed antibiotics administered with supportive therapies and she was closely monitored and was found recovering extensively.
12. The complainant and her attendants requested the second opposite party for discharge of the complainant from the opposite party no.1 hospital for further treatment at Yashoda Hospital. The second opposite party informed them about the extensive recovery of the complainant and advised her to continue the medication at opposite partyno.1 hospital. They did not heed to the advice of the second opposite party. The complainant was discharged with a referral note to Yashoda Hospital. The condition of the complainant was stable and good at the time of discharge. The complainant left the hospital on her own accord and against the medical advice. Had she not been discharged on 29.9.2008 from the opposite partyno.1 hospital the complainant would have recovered completely, under the treatment of the second opposite party and other specialities and further strain would not have been happened.
13. The opposite party no.1 hospital is a multi-speciality hospital established in the year 1987. The second opposite party is a postgraduate general surgeon in the field of medicine and surgery. The team of doctors at the opposite party no.1 hospital are qualified specialities. Any surgical procedure carries certain inherent risks which cannot be imputed to the doctors. All due care and caution were taken in accordance with medical text and literature and standard protocol. Any surgical procedure will leave a scar on the skin which cannot tantamount to deformity or abnormality.
14. The complainant has made false claim against the opposite parties based on the fabricated documents. The matter involves adjudication of complicated questions of fact which need to be decided on evidence under trial of the parties. An expert opinion is required for the complainant to prove her claim. The complainant has exaggerated the amount incurred by her towards the expenditure. The complainant cannot attribute any negligence to the opposite parties and prayed for dismissal of the complaint.
15. The complainant has filed her affidavit and the documents Exs.A1 to A13. On the side of the opposite parties, the second opposite party has filed the affidavit and the documents Exs.B1 to B6.
16. The learned counsel for the complainant and opposite parties have filed written submissions.
17. The points for consideration are:
1) Whether there was any medical negligence on the part of the opposite parties during the course of treatment to the complainant?
2) To what relief?
18. POINT NO.1 The complainant, with complaint of abdominal pain consulted the second opposite party on 13.9.2008 at the opposite party no.1 hospital. On examination of the complainant the second opposite party diagnosed her suffering with diabetes mellitus and calculus choleysistis i.e., inflammation of gallbladder with gallstones. She was put on IV antibiotics and supportive therapy and was advised to undergo laparoscopic Cholecystectomy i.e., surgical procedure for removal of gallbladder with stones through key holes on the abdomen.
19. The complainant contends that she has not given informed consent whereas the opposite parties submit that they explained the surgical procedure, treatment and possible complications thereof. The admission record of the opposite party no.1 hospital contains at second and third pages the consent given by the complainant and her son. It is categorically mentioned in the consent sheet that the complainant had given her consent for the treatment diagnosis, examination, biopsy, transfusion, operation and anaesthesia as also she was explained the need nature procedure consequences and other details of operation and anaesthesia as also the complications, morbidity (postoperative disability and suffering) and mortality (death rate) of the operation, anaesthesia etc. It is mentioned in the consent form that the complainant was explained about the alternative methods of treatment and she was informed about the possibility of failure of operation.
20. The learned counsel for the complainant has contended that Dr.Rajasekhar Reddy who performed the operation was not known to the complainant and the complainant was not informed about his performing the operation along with the second opposite party. It is nowhere stated by the complainant that the opposite parties informed her and her attendant that team of certain doctors was going to perform operation upon her. It is not the case of the complainant that at the first instance she was given to understand that certain doctor was going to perform operation and later she came to know that Dr.Rajasekhar Reddy along with opposite party no.2 conducted the operation. At any stretch of imagination can it be said that not letting the complainant know of the name of the surgeon had led her to confusion and complications.
21. The plea of the complainant that she was not subjected to medical test prior to operation is not supported by evidence and on the contra, the case sheet indicates that her fasting blood sugar, random blood sugar levels were tested on 23.09.2008 and 24.09.2008,26.09.2008,27.09.2008,28.09.2008 and 29.09.2008. The anesthetist’s notes establish the pre-operative findings recorded by him. It also contains post-operative instructions. All relevant medical tests were conducted prior to the surgery performed upon the complainant.
22. Operation was conducted upon the complainant on 16.09.2008 by the second opposite party, Dr.Rajashekar Reddy, a post graduate general surgeon and Dr.M.A.Wasae Qavi, anesthetist. After performing cholecystectomy and conforming homeostasis the second opposite party had kept a drain in view of the infection. The doctors closed the wound and as the surgery was successful, the complainant was shifted to the ward. The condition of the complainant was noted as stable and functioning of all her vitals was normal. In the case sheet the patient’s progress and the doctor’s advice from the time the complainant was shifted to the ward after undergoing surgery till 10 P.M. on 16.09.2008 is noted as under:
16.9.2008:
5.30 A.M. (GC stable; HR-80hpm; BP-140/90; P/A-Syt; Lungs-clear, Temp.(N); sleep –good
8.30 A.M. (Pt. is in day sleep; snoring; GC stable; HR-80hpm; BP-120/80; P/A-Syt; Lungs-clear, Temp.(N);
9.30 A.M. (PR-72; Temp.(N); BP100/70; Lungs -clear)
10.40 A.M (G.C.Fair; B.P. – 100/70; P/R – 70; Temp.(N); M/L-8.5 heart/clear)
12.30 P.M. (G G.C.Fair; B.P. – 100/70; P/R – 70; Temp.(N); H/L-S1 S2 heard/clear
2.00 P.M. (had backache o/c; Temp.(N), P/R – 76; B.P. – 100/70; lungs-clear ; heart – S1 S2)
3.20 P.M. (GC fair; BP-120/80; PR-80, Lungs-clear, Drain (+)
4.30 P.M. (GC fair; Temp.(N); BP-130/80; PR-80)
6.00 P.M. ( BP-140/80; PR-80, Lungs-clear; B-S –
10.00 P.M. (C/o pain abdomen; .G.C.Fair; H.R.-74; B.P. – 110/80; lungs – clear, Temp.(N)
23. At 10 P.M. it is noted that the complainant complained of abdominal pain and her G.C. was fair, B.P. 110/80 , lungs—clear and temperature normal. Again on 17.09.2008 pain reported at operated site by the complainant is noted and antibiotics were administered. Thereafter, the complainant has not expressed any grievance till she was discharged from the first opposite party-hospital. The contention of the complainant is that though the opposite parties immediately after the operation noticed complications at the operated site, they discharged her without attending the complications as a result of which she suffered from formation of abscess around the wound site, with acute fever and as such she again approached the opposite parties on 22.09.2008 whereas the opposite parties contend that having themselves satisfied with the condition of the complainant and all her vitals being normal, they discharged her on 19.09.2008 with an advice to report to the opposite parties on 22.09.2008 for removal of sutures.
24. The complainant had not protested nor expressed any dissatisfaction of her being discharged in unfit condition. There was gap of three days from the day of her discharge from the opposite party no.1 hospital till she was admitted therein on 22.09.2008. Thus, the plea of the complainant that she was discharged in unfit condition on 19.09.2008 is devoid of any substance.
25. On 22.09.2008 the complainant reported to the opposite parties as per their advice and she was examined and found to be normal in respect of her CBP,WBC count etc., Abscess at epigastria region was noted. Stitches were removed and the wound was left open. She was diagnosed with post abscess with cellulitis. Her complaint at 5 P.M. of headache was recorded. She was put on antibiotics and dressing was done.
26. Drawing our attention to the clinical notes dated 22.09.2008 the learned counsel for the complainant has contended that despite the complainant suffering from pain and swelling over the abdomen, the opposite parties negligently discharged her from the first opposite party hospital. The clinical notes recorded on 22.09.2008 read as under:
CLINICAL NOTES: - Date 22.09.2008
Presenting complaints: - C/o Pain & swelling over the abdomen since 4 days
History of present illness: - Since 4 days she is feeling pain & swelling in the abdomen (epigasteric region) which is slowly increasing
No H/o of DM (Diabetes Mellitus) HTN
Local examination: Swelling & Redness on the epigastric region
27. The complainant contends that despite the onset of infection and pain at the epigstric region, the second opposite party discharged her from the first opposite party hospital which led to formation of abscess and infection of serious magnitude whereas the opposite parties submit that the wound had developed due to irregular intake of medicine at home and negligence of hygiene by the complainant.
28. Insofar as the condition of the complainant at the time of her discharge from the first opposite party hospital on 19.09.2008, as mentioned in the above paragraphs of the order we have not found the opposite parties negligent. The clinical notes showing the complainant suffering from pain for three days on 22.09.2008 would not by itself establish that the opposite parties had negligently discharged her on 19.09.2008 from the first opposite party hospital. The case sheet indicates her condition at the time of discharge and it is noted as follows:
19.9.2008
8.00 A.M. ( G.C. – Stable; Temp (N); B.P. – 160/100; P.R. – 84/min; H/L – S1 S2 heard/clr; B/m – Constipated; sleep – Disturbed.
29. From the date of her admission on 22.9.2008 till she was discharged from the first opposite party hospital, the complainant was administered with antibiotics and pus culture sensitivity was also done. The complainant states that her attendance discharged her on 29.9.2008 from the opposite partyno.1 hospital as her condition deteriorated and the wound spread into a dangerous dimension whereas the opposite parties contend that had the complainant been not discharged on 29.9.2008 from the opposite party no.1 hospital she could have recovered under the treatment of the second opposite party and other specialities. The treatment administered to the complainant from 22.9.2008 till 29.9.2008 is noted in the case sheet which manifest administration of Metrozyl, NS 500ml, Zone XP, Beselic, Amikacin etc. At 5 a.m. on 28.9.2008 the complainant was suffering from pain in abdomen. On 29.9.2008 the second opposite party referred the complainant at 8 a.m. to Yashoda Hospital under Dr.Mahender Reddy for management of Necrotizing fasciitis and at the time her vitals were stable.
30. The complainant was admitted to Yashoda Hospital on 29.9.2008 and she had undergone surgery on 1.10.2008, 6.10.2008 and 16.10.2008 and she was discharged therefrom on 5.11.2008. The Discharge summary of Yashoda Hospital indicates the diagnoses as “Post Cholecystectomy, fungal infection of abdominal wound, DM, HT, Hypoproteinemia plus hypoculpamania, anaemia”. The illness was referred to as subsequently developed post wound infection.
31. The opposite party no.2 after conducting pus culture and sensitivity test diagnosed the complainant with cellulitis with necrotizing fasciitis. During her stay at opposite eparty no.1 hospital, the second opposite party maintain her blood sugar within target level by administering insulin. The learned counsel for the opposite parties has referred to current diagnoses and treatment surgery edited by Gerard M Doherty wherein necrotizing fasciitis and its cause is mentioned as under.
a) Necrotizing fasciitis is caused by multiple nonclostridial bacterial pathogens. Infection usually involves a mixed microbial flora, often including microaerophilic streptococci, staphylococci, aerobic gram-negative bacteria, and anaerobes, especially peptostreptococci and bacteroides. Fasciitis usually begins in a localized area such as puncture wound, leg ulcer, or surgical wound. The infection spreads along the relatively ischemic fascial planes, leading to thrombosis of penetrating vessels. Overlying subcutaneous tissue and skin are thus devascularized.
b) Those with chronic immunosuppressive illnesses such as cancer, diabetes, and end-stage renal disease and those taking corticosteroids are increased risk.
c) Daily debridement under anesthesia may be required, since these lesions are extensive and the degree of tissue viability is often difficult to assess in the operating room. Tight fascial compartments must be decompressed. Wide-open drainage is essential and may require extensive denudation.
32. Insofar the cause for cellulitis is concerned, the opposite parties had done dressing and extended antibiotic coverage with supportive therapy and the complainant was taken up for debridement and wound excision. The diagnosis and treatment thereof cannot be found fault with, in view of the Silverberg’s principal and Practice of Surgical Pathology and Cytopathology. The author has expressed its opinion as under:
a) The classic pathogens that cause cellulitis are staphylococcus aureus and streptococcus pyogenes (group A beta-hemolytic streptococcus) The lesion is an aggressive acute inflammatory response that dissects through fascial planes.
b) Since the 1980s there have been selected strains of group A betahemolytic streptocci with markedly upregulated necrosis-inducing enzymes such as hyaluronidase that cuase a presentation hailed by the media as fles eating bacteria. These may be life threatening and are often ause for emergent surgical debridement.
c) Mixtures of anaerobic bacteria or mixtures of aerobic and anaerobic bacteria, which may result in synergistic gangrene, also produce necrotizing cellulitis/fasciitis with or without myositis particularly in persons who have other risk factors such as diabetes mellitus or severe peripheral vascular disease.
33. The treatment at Yashoda Hospital included excision and debridement of the wound and the opposite parties had drawn our attention to the pus and culture and sensitivity report which had shown positive for coagulase and negative for staphylococcus which is in confirmation with the causative organisms of necrotizing fasciitis.
34. According the Michael Maynor, Clinical Assistant Professor, Louisiana State University, School of Medicine, Necrotizing Fasciitis can occur after trauma and it is difficult to recognise it in the early stage as also morbidity and mortality would be around 70 to 80%. He has opined that:
a) Necrotizing fasciitis can occur after trauma of around foreign bodies in surgical wounds, or it can be idiopathic as in scrotal or penile necrotizing fasciitis.
Necrotizing fasciitis has also been referred to as haemolytic streptococcal gangrene, Maleney ulcer, acute dermal gangrene, hospital gangrene, suppurative fasciitis, and synergistic necrotizing cellulitis. Fournier gangrene is a form of necrotizing fasciitis that is localized to the scrotum and perineal area.
b) These infections can be difficult to recognize in their early stages, but they rapidly progress. They require aggressive treatment to combat the associated high morbidity and mortality
c) In necrotizing fasciitis, group A haemolytic streptococci and Staphyloccoccus aureus, alone or in synergism are frequently the initiating infecting bacteria.
d) The overall morbidity and mortality is 70-80%
35. The doctors at Yashoda Hospital diagnosed the complainant with fungal infection of abdominal wound. The opposite parties had also diagnosed her it with cellulitis with necrotizing fasciitis. The diagnoses made by the opposite parties and corresponding treatment administered to the complainant by the opposite parties cannot be found fault with in the absence of evidence documentary or oral. It is unfortunate that the complainant had to undergo three rounds of operation at Yashoda Hospital after she was referred to the hospital by the second opposite party at the instance of the complainant’s attendants. One can understand the misery and agony a patient has undergone due to the complications developed as a result of infection during postoperative stage of treatment. There was no negligence on the part of the opposite partyno.2.
36. The negligence on the part of the first opposite party in attending to the patient during postoperative stage at the ward before she was discharged on 22.9.2008 is manifest by the contents of case sheet on 16.9.2008 at 10 p.m. which goes to show that the complainant having complained of abdominal pain was not attended to nor administered with any type of medicine till the morning at 8 a.m. the next day. Though inaction and negligence on the part of the opposite party no.1 hospital did not contribute to the formation of abscess at the operated site near epigastric region, the negligence of the first opposite party cannot be viewed in lenient manner.
37. In Smt.Savita Garg V.the Director National Hear Institute, (2004) 8 SCC 56, the Hon’ble Supreme Court held:
“It is the common experience that when a patient goes to a private clinic, he goes by the reputation of the clinic and with the hope that proper care will be taken by the hospital authorities……….. They charge fee for the services rendered by them and they are supposed to bestow the best care.”
38. In any view of the matter, the opposite partyno.1 is guilty of negligence and deficient service in not taking care of the patient who is diabetic and hypertensive and required constant attention compared to other patients at night on 16.9.2008. In the circumstances, we are of the considered opinion that a sum of `50,000/- if awarded as compensation against the first opposite party hospital, it would meet the ends of justice.
39. In the result the complaint is partly allowed. The first opposite party is directed to pay an amount of `50,000/- towards compensation and costs of `3,000/-. The complaint against the second opposite party is dismissed. Time for compliance four weeks.
MEMBER
MEMBER
Dt.22.08.2012
KMK*
APPENDIX OF EVIDENCE
WITNESSES EXAMINED
For complainant for opposite parties
NIL NIL
EHXIBITS MARKED
For the complainants
Ex. A1 Photographs of the infected surgical wound of the Complainant
Ex. A2 Admission record of Azam Hospital for the period
13.09.08 to 19.09.08
Ex.A3 Duplicate Bill dated 19.09.2008 of Azam Hospital for Rs. 27,870/-
Ex. A4 Second Admission record from 22.09.2008 to 29.09.2008
of Azam Hospital
Ex. A5 Duplicate Bill dated 19.09.2008 of Azam Hospital for Rs. 9,125/-
Ex. A6 Azam Hospital clinical pathological bills
Ex. A7 Discharge Summary of Yashoda Hospital, Hyderabad
Ex. A8 Lab tests and various medical records of Yashoda Hospital (56 nos)
from 29-09-2008 to 05-11-2008
Ex.A9 Casualty Cash Receipt Bill of Yashoda Hospital (7nos )
from 7-11-2008 to 16-12-2008 for Rs. 1470/-
Ex.A10 Cash Bill of Yashoda Hospital (6Nos) for Rs.4205/-
Ex.A11 Medical /pharmacy bills (43 Nos) from 30-09-2008 to 08-02-2010
Ex.A12 Medicine charges (supplied by Yashoda Hospital)
2 bills for Rs.66,123/- from 29-09-2008 to 05-11-2008
Ex.A13 Yashoda Hospital Final Bill Statement for Rs.2,83,011.98/-
Opposite parties
Ex.B1 Original Admission Record, dated 13.09.2008
Ex.B2 Original Admission Record, dated 22.09.2008
Ex.B3 True Copy of Biochemistry Reports, dated
23.09.2008 to 29.09.2008
Ex.B4 True Copy of Clinical Laboratory Report, dated 24.09.2008
Ex.B5 True Copy of Hematology Report, dated 14.09.2008
Ex.B6 True Copy of Clinical Laboratory Report, dated 19.09.2008
MEMBER
MEMBER
