CHIEF COMPLAINT: slurred speech, left sided weakness

PRESENT ILLNESS: 64F with hx Multiple Sclerosis with chronic foley catheter, PVD,
diplegia of lower extremities, presenting with abrupt change in
mental status noted by staff at nursing home around 9am,
including increased slurred speech, L sided weakness today as
well as episode of emesis en route by EMS.  Patient had received
AM meds at nursing home, at which time she was noted to be at
baseline blood pressure and mental status.  Soon afterwards, she
complained to another staff member that she was hot and wanted a
drink; when nurse returned with a drink, she was more lethargic
with elevated BP 180/90. In the ambulance, patient was noted to
not be withdrawing to pain on the left side.

MEDICAL HISTORY: Multiple Sclerosis -- about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
   - wheelchair at baseline, lives in nursing home
   - has no use of her lower extremities, sometimes spastic
movements
UTI
Chronic Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-26**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C Diff
Hx of Sacral [**Name (NI) **]
LE spasticity
Hx of jaw pain -- ?TMJ, improved on Tegretol

MEDICATION ON ADMISSION: Simvastatin 20mg at bedtime
Tegretol XR 100mg - 3 tabs [**Hospital1 **] ;
Carbamazepine 1000mg daily at 12 noon
cyclobenzaprine 10mg [**Hospital1 **]
baclofen 5mg [**Hospital1 **]
Copaxone 20mg/ml  20mg daily
OsCal 500  1250mg daily
alendronate 70mg weekly
citalopram 40mg daily
Aricept 10mg at bedtime
trazodone 25mg QHS
cranberry supplements 2 tabs [**Hospital1 **]
Norvasc 5mg daily
aspirin 81mg daily
albuterol nebs daily in AM and prn
ipratroprium nebs daily in AM and prn
acetaminophen 650mg Q6H prn
vitamin E 400u daily
senna 8.6mg x2tabs at bedtime
multivitamin daily
potassium chloride 20meq daily
fleet enema MWF evenings
docusate 100mg [**Hospital1 **]
oyster [**Doctor First Name **] 500mg daily
Flovent HFA 110mg 2x daily
.
Allergies:   Zosyn/Ceftriaxone --> bad rash while on both of
these medications, unclear which is the offender

ALLERGIES: Zosyn / ceftriaxone

PHYSICAL EXAM: Admission
Vitals: T: 100.4 BP: 127/56 P: 77 R: 18 O2: 100% on FiO2 100% AC

FAMILY HISTORY: No family members with Multiple Sclerosis.

SOCIAL HISTORY: Lives in nursing home for last 3.5 [**Name (NI) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Wheelchair at baseline, dependent for transfers
and some of ADLs.  Has no use of lower extremities at baseline.
Tobacco: started at age 20, quit about 15yrs ago
ETOH: social, occasional, per husband
[**Name (NI) 3264**]: none
Urinary tract infection, site not specified,Toxic encephalopathy,Bacteremia,Paraplegia,Vomiting alone,Hypoxemia,Multiple sclerosis,Wheelchair dependence,Physical restraints status,Chronic airway obstruction, not elsewhere classified,Dysthymic disorder,Osteoporosis, unspecified,Neurogenic bladder NOS,Peripheral vascular disease, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Other speech disturbance,Pure hypercholesterolemia,Phlebitis and thrombophlebitis of superficial veins of upper extremities
Urin tract infection NOS,Toxic encephalopathy,Bacteremia,Paraplegia NOS,Vomiting alone,Hypoxemia,Multiple sclerosis,Wheelchair dependence,Physical restrain status,Chr airway obstruct NEC,Dysthymic disorder,Osteoporosis NOS,Neurogenic bladder NOS,Periph vascular dis NOS,Athscl extrm ntv art NOS,Speech disturbance NEC,Pure hypercholesterolem,Phlbts sprfc vn up extrm
Admission Date:  [**2118-3-28**]              Discharge Date:   [**2118-3-31**]

Date of Birth:  [**2053-11-10**]             Sex:   F

Service: MEDICINE

Allergies:
Zosyn / ceftriaxone

Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
slurred speech, left sided weakness

Major Surgical or Invasive Procedure:
endotracheal intubation and removal

History of Present Illness:
64F with hx Multiple Sclerosis with chronic foley catheter, PVD,
diplegia of lower extremities, presenting with abrupt change in
mental status noted by staff at nursing home around 9am,
including increased slurred speech, L sided weakness today as
well as episode of emesis en route by EMS.  Patient had received
AM meds at nursing home, at which time she was noted to be at
baseline blood pressure and mental status.  Soon afterwards, she
complained to another staff member that she was hot and wanted a
drink; when nurse returned with a drink, she was more lethargic
with elevated BP 180/90. In the ambulance, patient was noted to
not be withdrawing to pain on the left side.

Of note, per nursing home staff, patient's foley [**Last Name (un) **] has been
changed about 3 times since [**2118-3-24**] because it has either fallen
our or was noted to have increased urine sediment.

In the ED, initial vs were: 101.9 92 152/72 16 100% 4L NC. Both
eyes were deviated downwards, and patient was not following any
commands.  She was agitated and had another episode of emesis in
the ED in setting of altered mental status.  [**Name8 (MD) **] RN note, she
was noted to be 83% on ?room air, presenting with some
difficulty breathing. Patient was intubated for airway
protection with etomidate and succynlcholine, pretreated with
lidocaine 100mg x1 IV.  ETT was initially placed in Right
Mainstem Bronchus, pulled back about 4-5cm with bilateral breath
sounds noted on exam.  She dropped BPs initially on propofol, so
she was switched to midazolam and fentanyl for sedation.
Patient was previously DNR/DNI, but husband revoked this and
made her Full Code in the ED.  Code Stroke was called in the ED
at 12:45pm.  CTA and CT-perfusion unremarkable.  On Neurology
team exam post intubation, patient was moving all extremities.
She was noted to have significant UTI and was given a dose of IV
ciprofloxacin 500mg x1. Given fever and hx of UTIs, Neurology
team suspects that symptoms were secondary to UTI rather than a
central neurologic process.  Vitals in ED prior to ICU transfer
were as follows: 65  127/62  100% on AC FiO2 100%  RR 15  PEEP
5.

On arrival to the MICU, patient was intubated and sedated,
appearing comfortable, unable to provide further history.

Past Medical History:
Multiple Sclerosis -- about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
   - wheelchair at baseline, lives in nursing home
   - has no use of her lower extremities, sometimes spastic
movements
UTI
Chronic Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-26**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C Diff
Hx of Sacral [**Name (NI) **]
LE spasticity
Hx of jaw pain -- ?TMJ, improved on Tegretol

Social History:
Lives in nursing home for last 3.5 [**Name (NI) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Wheelchair at baseline, dependent for transfers
and some of ADLs.  Has no use of lower extremities at baseline.
Tobacco: started at age 20, quit about 15yrs ago
ETOH: social, occasional, per husband
[**Name (NI) 3264**]: none

Family History:
No family members with Multiple Sclerosis.

Physical Exam:
Admission
Vitals: T: 100.4 BP: 127/56 P: 77 R: 18 O2: 100% on FiO2 100% AC

General: intubated and sedated, no acute distress
HEENT: Sclera anicteric, pupils 1.5mm equal, sluggish, dry mm,
cannot visualize oropharynx with ETT in place
Neck: supple, JVP not elevated
Lungs: Clear to auscultation laterally, no wheezes, rales, but
soft upper airway sounds audible diffusely
CV: Regular rate and rhythm
Abdomen:  mildly distended, no grimace to palpation, bowel
sounds present, no rebound tenderness or guarding
GU: foley catheter in place
Ext: warm, well perfused, pulses, no peripheral edema

Pertinent Results:
[**2118-3-28**] 09:42PM   TYPE-ART PO2-148* PCO2-45 PH-7.35 TOTAL
CO2-26 BASE XS-0
[**2118-3-28**] 04:12PM   LACTATE-4.1*
[**2118-3-28**] 09:42PM   LACTATE-0.6
[**2118-3-28**] 04:04PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
[**2118-3-28**] 04:04PM URINE  RBC->182* WBC-83* BACTERIA-NONE
YEAST-NONE EPI-<1
[**2118-3-28**] 02:00PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-300
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-LG
[**2118-3-28**] 02:00PM URINE  RBC-92* WBC-60* BACTERIA-MANY YEAST-NONE
EPI-0
[**2118-3-28**] 12:50PM   GLUCOSE-129* UREA N-16 CREAT-0.7 SODIUM-140
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-17
[**2118-3-28**] 12:50PM   CK(CPK)-56
[**2118-3-28**] 12:50PM   CK-MB-1 cTropnT-<0.01
[**2118-3-28**] 12:50PM   WBC-10.2 RBC-4.21 HGB-14.1 HCT-38.6 MCV-92
MCH-33.4* MCHC-36.4* RDW-14.2
[**2118-3-30**] 06:25AM BLOOD WBC-4.9 RBC-3.66* Hgb-11.7* Hct-35.3*
MCV-96 MCH-31.9 MCHC-33.1 RDW-14.1 Plt Ct-172
[**2118-3-30**] 06:25AM BLOOD Glucose-77 UreaN-9 Creat-0.6 Na-141 K-3.6
Cl-107 HCO3-25 AnGap-13
[**2118-3-30**] 06:25AM BLOOD ALT-19 AST-18 AlkPhos-104 TotBili-0.3
[**2118-3-31**] 07:40AM BLOOD Phos-1.6*
[**2118-3-28**] 09:42PM BLOOD Lactate-0.6

[**2118-3-28**] 4:04 pm URINE     Site: CATHETER
                            **FINAL REPORT [**2118-3-29**]**
   URINE CULTURE (Final [**2118-3-29**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
      CONTAMINATION.

[**2118-3-28**] 4:17 pm BLOOD CULTURE
   Blood Culture, Routine (Preliminary):
      ESCHERICHIA COLI.    FINAL SENSITIVITIES.
         WARNING! This isolate is an extended-spectrum
beta-lactamase
         (ESBL) producer and should be considered resistant to
all
         penicillins, cephalosporins, and aztreonam. Consider
Infectious
         Disease consultation for serious infections caused by
         ESBL-producing species.
         Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].
                              SENSITIVITIES: MIC expressed in
MCG/ML
      _________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------  =>32 R
AMPICILLIN/SULBACTAM--  =>32 R
CEFAZOLIN-------------  =>64 R
CEFEPIME--------------   <=1 R
CEFTAZIDIME-----------       R
CEFTRIAXONE-----------       R
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----    16 S
TOBRAMYCIN------------  =>16 R
TRIMETHOPRIM/SULFA----  =>16 R

   Anaerobic Bottle Gram Stain (Final [**2118-3-29**]):
      Reported to and read back by DR. [**Last Name (STitle) **]. HEDGE ON [**2118-3-29**] AT
0635.
      GRAM NEGATIVE ROD(S).

[**2118-3-29**] 10:45 am BLOOD CULTURE  x 2  Source: Venipuncture.
   Blood Culture, Routine (Pending):

[**2118-3-30**]: ct abdomen/pelvis with contrast
IMPRESSION:
1. No evidence of intra-abdominal source for the patient's
bacteremia.
2. Essentially normal abdomen and pelvic CT.


Brief Hospital Course:
64F with hx of Multiple Sclerosis, chronic indwelling foley,
presenting with altered mental status, including slurred speech
and temporary left-sided weakness, found to have UTI, hypoxia,
intubated after emesis x2 in setting of altered mental status.

Altered Mental Status, urinary tract infection based on + u/a
but culture with mixed colonization, e coli bacteremia:

Patient was noted to have altered mental status in addition to
new Left-sided arm weakness and worsening of baseline slurred
speech on presentation to EMS and in ED.  On Neurology
examination post-intubation, patient was moving both upper
extremities spontaneously, and CT Head and Neck Perfusion showed
no acute process.  Neurology team felt that symptoms likely
represented delirium in setting of UTI and not likely central
process.  No known stroke history. Patient does have hx of
multiple sclerosis, so UTI likely exacerbated multiple sclerosis
symptoms. Patient had negative cardiac enzymes and UTI was
treated. She was extubated on [**3-29**] without complication.  Her
mental status after extubation was at baseline.  Neurologic
symptoms improved with treatment of infection.

E coli bacteremia: Blood cultures grew E coli so Meropenem was
added to Cipro morning of [**3-29**].  Ciprofloxacin had been started
in the ED. Surveillance blood cultures were sent.  Surveillance
cultures negative, E coli grew from +BCx and was ESBL.  She will
require an additional 11 DAYS OF MEROPENEM FOR A TOTAL 14 DAY
COURSE, LAST DAY OF ANTIBIOTICS SHOULD BE [**2118-4-11**].  CT of the
abdomen / pelvis done to search for other cause of bacteremia
given that the u/a had mixed flora, this was negative for any
acute intraabdominal findings.  In addition LFTs were normal
making a biliary source unlikely.  Foley was replaced in ED as
the most likely source.  Lactate elevated to 4.1 in ED which
decreased to 0.6.

Hypoxia
Patient intubated in ED to protect airway due to emesis in
setting of altered mental status.  She was reportedly not having
any respiratory symptoms in the ED, though nursing report shows
O2sat of 83% prior to intubation. Patient was extubated on [**3-29**]
without complication.

Code:  Full Code (confirmed with family in ED and on arrival to
MICU)
Patient was DNR/DNI previously, but husband revoked it in the
[**Name (NI) **], [**First Name3 (LF) **] she is now Full Code. PCP was emailed with this new
status.

Communication: Husband HCP = [**Name (NI) **] [**Name (NI) **]

Medications on Admission:
Simvastatin 20mg at bedtime
Tegretol XR 100mg - 3 tabs [**Hospital1 **] ;
Carbamazepine 1000mg daily at 12 noon
cyclobenzaprine 10mg [**Hospital1 **]
baclofen 5mg [**Hospital1 **]
Copaxone 20mg/ml  20mg daily
OsCal 500  1250mg daily
alendronate 70mg weekly
citalopram 40mg daily
Aricept 10mg at bedtime
trazodone 25mg QHS
cranberry supplements 2 tabs [**Hospital1 **]
Norvasc 5mg daily
aspirin 81mg daily
albuterol nebs daily in AM and prn
ipratroprium nebs daily in AM and prn
acetaminophen 650mg Q6H prn
vitamin E 400u daily
senna 8.6mg x2tabs at bedtime
multivitamin daily
potassium chloride 20meq daily
fleet enema MWF evenings
docusate 100mg [**Hospital1 **]
oyster [**Doctor First Name **] 500mg daily
Flovent HFA 110mg 2x daily
.
Allergies:   Zosyn/Ceftriaxone --> bad rash while on both of
these medications, unclear which is the offender

Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
2. carbamazepine 100 mg Tablet Extended Release 12 hr Sig: Three
(3) Tablet Extended Release 12 hr PO BID (2 times a day).
3. carbamazepine 200 mg Tablet Sig: Five (5) Tablet PO once a
day: at noon.
4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. baclofen 10 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).

6. Copaxone 20 mg Kit Sig: Twenty (20) mg Subcutaneous once a
day.
7. Os-Cal 500 + D  Oral
8. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.

9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

10. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime.
12. cranberry  Oral
13. Norvasc 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation once a day: qam and
prn.
16. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation once a day: qam and prn.
17. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, fever.
18. vitamin E  Oral
19. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
20. potassium chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
21. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
q mon, wed, fri.
22. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
23. Flovent HFA 110 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
24. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q6H (every 6 hours) for 11 days.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) 583**] House Rehab & Nursing Center

Discharge Diagnosis:
Primary Diagnosis:
E coli bacteremia
Urinary tract infection


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
You were admitted to the hospital with a severe blood stream
infection which was caused by a severe urinary tract infection.
You will need antibiotics IV for the next 11 days for a total 2
week course.  No other medication adjustments have been made.

Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks of your discharge
from the hospital: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 608**]
{'Urinary tract infection, site not specified,Toxic encephalopathy,Bacteremia,Paraplegia,Vomiting alone,Hypoxemia,Multiple sclerosis,Wheelchair dependence,Physical restraints status,Chronic airway obstruction, not elsewhere classified,Dysthymic disorder,Osteoporosis, unspecified,Neurogenic bladder NOS,Peripheral vascular disease, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Other speech disturbance,Pure hypercholesterolemia,Phlebitis and thrombophlebitis of superficial veins of upper extremities'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: slurred speech, left sided weakness

PRESENT ILLNESS: 64F with hx Multiple Sclerosis with chronic foley catheter, PVD,
diplegia of lower extremities, presenting with abrupt change in
mental status noted by staff at nursing home around 9am,
including increased slurred speech, L sided weakness today as
well as episode of emesis en route by EMS.  Patient had received
AM meds at nursing home, at which time she was noted to be at
baseline blood pressure and mental status.  Soon afterwards, she
complained to another staff member that she was hot and wanted a
drink; when nurse returned with a drink, she was more lethargic
with elevated BP 180/90. In the ambulance, patient was noted to
not be withdrawing to pain on the left side.

MEDICAL HISTORY: Multiple Sclerosis -- about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
   - wheelchair at baseline, lives in nursing home
   - has no use of her lower extremities, sometimes spastic
movements
UTI
Chronic Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-26**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C Diff
Hx of Sacral [**Name (NI) **]
LE spasticity
Hx of jaw pain -- ?TMJ, improved on Tegretol

MEDICATION ON ADMISSION: Simvastatin 20mg at bedtime
Tegretol XR 100mg - 3 tabs [**Hospital1 **] ;
Carbamazepine 1000mg daily at 12 noon
cyclobenzaprine 10mg [**Hospital1 **]
baclofen 5mg [**Hospital1 **]
Copaxone 20mg/ml  20mg daily
OsCal 500  1250mg daily
alendronate 70mg weekly
citalopram 40mg daily
Aricept 10mg at bedtime
trazodone 25mg QHS
cranberry supplements 2 tabs [**Hospital1 **]
Norvasc 5mg daily
aspirin 81mg daily
albuterol nebs daily in AM and prn
ipratroprium nebs daily in AM and prn
acetaminophen 650mg Q6H prn
vitamin E 400u daily
senna 8.6mg x2tabs at bedtime
multivitamin daily
potassium chloride 20meq daily
fleet enema MWF evenings
docusate 100mg [**Hospital1 **]
oyster [**Doctor First Name **] 500mg daily
Flovent HFA 110mg 2x daily
.
Allergies:   Zosyn/Ceftriaxone --> bad rash while on both of
these medications, unclear which is the offender

ALLERGIES: Zosyn / ceftriaxone

PHYSICAL EXAM: Admission
Vitals: T: 100.4 BP: 127/56 P: 77 R: 18 O2: 100% on FiO2 100% AC

FAMILY HISTORY: No family members with Multiple Sclerosis.

SOCIAL HISTORY: Lives in nursing home for last 3.5 [**Name (NI) 1686**].  Husband is HCP, lives
with one of their daughters.  [**Name (NI) **] daughter married and lives
in the area.  Wheelchair at baseline, dependent for transfers
and some of ADLs.  Has no use of lower extremities at baseline.
Tobacco: started at age 20, quit about 15yrs ago
ETOH: social, occasional, per husband
[**Name (NI) 3264**]: none 

### Response:
{'Urinary tract infection, site not specified,Toxic encephalopathy,Bacteremia,Paraplegia,Vomiting alone,Hypoxemia,Multiple sclerosis,Wheelchair dependence,Physical restraints status,Chronic airway obstruction, not elsewhere classified,Dysthymic disorder,Osteoporosis, unspecified,Neurogenic bladder NOS,Peripheral vascular disease, unspecified,Atherosclerosis of native arteries of the extremities, unspecified,Other speech disturbance,Pure hypercholesterolemia,Phlebitis and thrombophlebitis of superficial veins of upper extremities'}
