CHIEF COMPLAINT: Shortness of breath

PRESENT ILLNESS: 73 year old woman with hx of ESRD on HD, diastolic CHF, PVD s/p
bilateral lower leg amputations, and atrial fibrillation
presenting with shortness of breath.  She was recently
discharged from [**Hospital1 18**] on [**2163-5-14**] following an admission for
hypertensive urgency complicated by hypoxia due to pulmonary
edema.  During that admission, she was placed on CPAP, had blood
pressure control with a nitroglycerin gtt initally and had extra
HD/UF sessions.  There was no clear etiology to the
decompensation as she had no clear cardiac ischemic event nor
missed HD session.  She was discharged to resume her usual MWF
dialysis sessions.
.
On Saturday night she first noted shortness of breath when she
was trying to sleep.  She stated that everytime that she would
try to lay flat she would get more short of breath. She denied
chest pain, cough, or diaphoresis.  She had no
fevers/chills/sweats prior to coming to the hosptial. She stated
that before coming into the hospital that she noted her heart
was racing.
.
In the ED, her initial vital signs were T not recorded HR 113 BP
230/112 38 100%NRB.  She was started on a nitroglycerin gtt. She
was started on CPAP. She received lasix 100 mg x1 to which she
urinated ~80cc.  She received 1 dose of ceftriaxone and was
prescribed 1 dose of levofloxacin.

MEDICAL HISTORY: - Diastolic CHF with LVOT obstruction at rest
- Chronic 2L NC at night
- Hypertension
- Diabetes
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- GERD
- Hypercholesterolemia
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Paroxysmal atrial flutter, s/p failed ablation with subsequent
a. fib
- Peptic ulcer disease
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
- Diastolic Congestive Heart Failure

MEDICATION ON ADMISSION: Aspirin 325 mg Tablet DAILY
Simvastatin 80 mg DAILY
Sevelamer HCl 800 mg TID W/MEALS
Ranitidine HCl 150 mg [**Hospital1 **]
Metoprolol Tartrate 100 mg [**Hospital1 **]
Lisinopril 30 mg DAILY
Irbesartan 150 mg daily
Diltiazem HCl SR 120 mg DAILY
Nephro-caps daily
Warfarin 2 mg PO 2X/WEEK (MO,FR)
Warfarin 3 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA).
NPH 4 units [**Hospital1 **].
BRIMONIDINE 0.15 % Drops - 1 Drops(s) in the right eye DAILY
LATANOPROST  0.005 % Drops - 1 Drops(s) in the right eye HS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 96  78  163/80  23 100% 5L
GEN: NAD
HEENT: AT, NC, PERRLA, arcus senilus, EOMI, no conjunctival
injection, anicteric, OP clear, MMM, Neck supple, no LAD, no
carotid bruits
CV: RRR, nl s1, s2, 3/6 systolic murmur at apex
PULM: crackles [**12-23**] way up from base, dullness at bases
ABD: soft, NT, ND, + BS, no HSM
EXT: bilateral BKA w/o evidence of skin breakdown. no femoral
bruits. biphasic thrill in AV graft to left arm
NEURO: alert & orientedx3, CN II-XII grossly intact, [**4-25**]
strength throughout upper extremities. No sensory deficits to
light touch appreciated. No asterixis
PSYCH: appropriate affect

FAMILY HISTORY: Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.

SOCIAL HISTORY: Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.
Congestive heart failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Mitral valve disorders,Peripheral vascular disease, unspecified,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Long-term (current) use of anticoagulants,Below knee amputation status,Esophageal reflux,Pure hypercholesterolemia,Tobacco use disorder,Family history of ischemic heart disease,Family history of diabetes mellitus
CHF NOS,DMII renl nt st uncntrld,End stage renal disease,Hyp kid NOS w cr kid V,Obs chr bronc w(ac) exac,Pneumonia, organism NOS,Mitral valve disorder,Periph vascular dis NOS,Sec hyperparathyrd-renal,Atrial fibrillation,Long-term use anticoagul,Status amput below knee,Esophageal reflux,Pure hypercholesterolem,Tobacco use disorder,Fam hx-ischem heart dis,Fam hx-diabetes mellitus
Admission Date:  [**2163-5-30**]              Discharge Date:   [**2163-6-2**]

Date of Birth:  [**2090-1-9**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 30201**]
Chief Complaint:
Shortness of breath

Major Surgical or Invasive Procedure:
None

History of Present Illness:
73 year old woman with hx of ESRD on HD, diastolic CHF, PVD s/p
bilateral lower leg amputations, and atrial fibrillation
presenting with shortness of breath.  She was recently
discharged from [**Hospital1 18**] on [**2163-5-14**] following an admission for
hypertensive urgency complicated by hypoxia due to pulmonary
edema.  During that admission, she was placed on CPAP, had blood
pressure control with a nitroglycerin gtt initally and had extra
HD/UF sessions.  There was no clear etiology to the
decompensation as she had no clear cardiac ischemic event nor
missed HD session.  She was discharged to resume her usual MWF
dialysis sessions.
.
On Saturday night she first noted shortness of breath when she
was trying to sleep.  She stated that everytime that she would
try to lay flat she would get more short of breath. She denied
chest pain, cough, or diaphoresis.  She had no
fevers/chills/sweats prior to coming to the hosptial. She stated
that before coming into the hospital that she noted her heart
was racing.
.
In the ED, her initial vital signs were T not recorded HR 113 BP
230/112 38 100%NRB.  She was started on a nitroglycerin gtt. She
was started on CPAP. She received lasix 100 mg x1 to which she
urinated ~80cc.  She received 1 dose of ceftriaxone and was
prescribed 1 dose of levofloxacin.


Past Medical History:
- Diastolic CHF with LVOT obstruction at rest
- Chronic 2L NC at night
- Hypertension
- Diabetes
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- GERD
- Hypercholesterolemia
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Paroxysmal atrial flutter, s/p failed ablation with subsequent
a. fib
- Peptic ulcer disease
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
- Diastolic Congestive Heart Failure

Social History:
Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker.


Family History:
Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.


Physical Exam:
VS: 96  78  163/80  23 100% 5L
GEN: NAD
HEENT: AT, NC, PERRLA, arcus senilus, EOMI, no conjunctival
injection, anicteric, OP clear, MMM, Neck supple, no LAD, no
carotid bruits
CV: RRR, nl s1, s2, 3/6 systolic murmur at apex
PULM: crackles [**12-23**] way up from base, dullness at bases
ABD: soft, NT, ND, + BS, no HSM
EXT: bilateral BKA w/o evidence of skin breakdown. no femoral
bruits. biphasic thrill in AV graft to left arm
NEURO: alert & orientedx3, CN II-XII grossly intact, [**4-25**]
strength throughout upper extremities. No sensory deficits to
light touch appreciated. No asterixis
PSYCH: appropriate affect

Pertinent Results:
EKG [**2163-5-30**]:Sinus rhythm. Left ventricular hypertrophy with ST-T
wave changes. Left atrial abnormality. Compared to the previous
tracing of [**2163-5-13**] the ST-T wave changes are more prominent and
may represent superimposed inferolateral ischemic process.
Followup and clinical correlation are suggested.
.
Renal U/S [**5-31**]: IMPRESSION: No solid renal masses identified.
Echogenic kidneys consistent with chronic renal disease and
multiple bilateral small simple renal cysts.
.
CXR: Cardiac silhouette is difficult to assess as there are
dense fluffy bilateral perihilar consolidations, obscuring the
heart borders. Pulmonary vascularity is increased, with
cephalization. There are small bilateral pleural effusions,
right greater than left. There is no pneumothorax.
.
[**2163-3-24**] TTE - The left atrium is moderately dilated. There is
severe symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Left ventricular systolic
function is hyperdynamic (EF>75%). There is a mild resting left
ventricular outflow tract obstruction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are moderately thickened. There is severe mitral annular
calcification. There is moderate functional mitral stenosis
(mean gradient 9 mmHg) due to mitral annular calcification.
Trivial mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is a small pericardial
effusion.
IMPRESSION: Severe symmetric LVH with a small cavity and
hyperdynamic systolic function. Minimal resting LVOT
obstruction. Moderate functional mitral stenosis. Moderate
pulmonary hypertension.
.
Microbiology:Sputum
[**2163-5-31**] 8:46 am SPUTUM      Source: Expectorated.

   GRAM STAIN (Final [**2163-5-31**]):
      >25 PMNs and <10 epithelial cells/100X field.
      2+   (1-5 per 1000X FIELD):   BUDDING YEAST.
      3+  (5-10 per 1000X FIELD):   MULTIPLE ORGANISMS
CONSISTENT WITH
                                    OROPHARYNGEAL FLORA.

   RESPIRATORY CULTURE (Preliminary):


Brief Hospital Course:
73 year old woman with hx of diastolic CHF, DM2, ESRD on HD
presenting with acute hypoxia and hypertensive urgency
.
# Hypoxia: Given her hx of severe dCHF, difficulty removing
fluid at HD due to LVOT obstruction, pulmonary edema on
presentation CXR, hypoxia appeared most consistent with
diastolic CHF exacerbation.  As she was hypertensive to the 200s
systolic and reported palpitations prior to admission, both htn
and perhaps a.fib with RVR caused worsening of her pulmonary
edema on presentation.  Although she had leukocytosis, she was
without fever, cough, sputum production to suggest underlying
pulmonary infection.  She does have hyperinflated lungs on CXR
and was mildly bronchospastic on admission, so she was started
on azithromycin, spireva, and albuterol nebs.  Cardiac enzymes
x3 showed flat troponin at 0.04-0.05 and negative MBI so as not
to suggest ischemic event.  As she has no PFTs in our system,
she should follow up for outpatient PFTs.  Additionally, as she
is on 2L O2 via nasal cannula at night (prescribed by outside
MD), she should have outpatient sleep study.
.
# Leukocytosis:  All cell lines were up on presentation however
this was pre HD/UF so unlikely due entirely to
hemoconcentration.  She was, however, without fever and no clear
source of infection.  CXR showed pulmonary edema and small
effusions without clear evidence of infiltrate and she was
without cough and fever.  UA was negative for infection.  She
had no GI symptoms to suggest as possible infective source.  As
she was initially mildly bronchospastic on exam, she was started
on azithromycin x 5 day course.
.
# ? COPD:  No formal diagnosis, however lungs markedly
hyperinflated on CXR and with significant pack year history of
tobacco use with continued use (although less so).  There was
initially some concern for COPD contributing to her hypoxia
given mild bronchospasm on presentation.  She was started on
spireva and albuterol nebs as well as azithromycin and her exam
improved markedly.  She should follow up for outpatient PFTs.
.
# Erythrocytosis:  Previous baseline hct high 20s-low 30s.  She
presented with hct 51-->43.  Last HD/UF session was 3 days PTA
so seemed unlikely all hemoconcentration; she did report poor PO
however.  She has not been receiving epogen at HD session per
renal as her hgb has been > goal.  Renal U/S was negative for
mass suggestive of erythropoietin producing mass.  An epo level
was sent.
.
# End-stage renal disease: She was continued on her home phos
binder and nephrocaps and was continued on HD qMWF as per her
normal schedule.
.
# Atrial fibrillation: She remained in NSR while in house and
INR was therapeutic on presentation. She was supratherapeutic on
day of discharge. Thus, she was advised not to take her dose of
coumadin on [**6-1**]. She was continued on metoprolol and coumadin.
.
# HTN:  She was briefly on nitro gtt upon arrival to the ICU
given SBPs in the 200s.  She was, however, quickly titrated off
and post HD, SBPs were stable in the 120-140s range on
metoprolol alone. Upon transfer to the medical floor pt's home
regimen of BB, CCB, [**Last Name (un) **], ACEI were restarted with good effect
(BP's 120's-140's). She will go home on this regimen.
.
# Diabetes mellitus type 2 with complication of nephropathy:
She was continued on her home dose NPH with sliding scale
coverage.
.
# Hypercholesterolemia:  She was continued on her outpatient
dose simvastatin.
.
# GERD:  She was continued on outpatient ranitidine.

Medications on Admission:
Aspirin 325 mg Tablet DAILY
Simvastatin 80 mg DAILY
Sevelamer HCl 800 mg TID W/MEALS
Ranitidine HCl 150 mg [**Hospital1 **]
Metoprolol Tartrate 100 mg [**Hospital1 **]
Lisinopril 30 mg DAILY
Irbesartan 150 mg daily
Diltiazem HCl SR 120 mg DAILY
Nephro-caps daily
Warfarin 2 mg PO 2X/WEEK (MO,FR)
Warfarin 3 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA).
NPH 4 units [**Hospital1 **].
BRIMONIDINE 0.15 % Drops - 1 Drops(s) in the right eye DAILY
LATANOPROST  0.005 % Drops - 1 Drops(s) in the right eye HS


Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: dose on [**6-1**] held.
Disp:*30 Tablet(s)* Refills:*2*
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*qs Cap(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days.
Disp:*2 Tablet(s)* Refills:*0*
8. Lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4)
units Subcutaneous twice a day: to be taken QAM and Qdinner.
10. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 inhaler* Refills:*2*
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.

13. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
14. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO daily ().
15. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 86**] [**Location (un) 269**]

Discharge Diagnosis:
Major:
COPD flare
HTN urgency
ESRD on HD
.
Minor:
DM
afib
HTN
hyperlipidemia


Discharge Condition:
stable


Discharge Instructions:
You were admitted with shortness of breath and high blood
pressure. For this you were admitted to the ICU and placed on
non-invasive ventilation and a nitro drip. You were given a
session of dialysis for which your breathing and blood pressure
improved. You were restarted on your home regimen of blood
pressure meds with good effect.
.
If you develop fevers, chills, increasing shortness of breath,
chest pain, weight gain >3lbs, or any other concerning symptom,
please contact your doctor or go to the emergency room.
.
Please take your medications as prescribed and follow up with
the appointments below.
.
You should also continue your already arranged hemodialysis
session on M/W/F. You should also resume having your INR checked
for proper coumadin dosing as you were at dialysis sessions.


Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2163-7-14**] 12:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2163-8-29**]
11:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2163-12-7**]
1:40
{'Congestive heart failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Mitral valve disorders,Peripheral vascular disease, unspecified,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Long-term (current) use of anticoagulants,Below knee amputation status,Esophageal reflux,Pure hypercholesterolemia,Tobacco use disorder,Family history of ischemic heart disease,Family history of diabetes mellitus'}


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: Shortness of breath

PRESENT ILLNESS: 73 year old woman with hx of ESRD on HD, diastolic CHF, PVD s/p
bilateral lower leg amputations, and atrial fibrillation
presenting with shortness of breath.  She was recently
discharged from [**Hospital1 18**] on [**2163-5-14**] following an admission for
hypertensive urgency complicated by hypoxia due to pulmonary
edema.  During that admission, she was placed on CPAP, had blood
pressure control with a nitroglycerin gtt initally and had extra
HD/UF sessions.  There was no clear etiology to the
decompensation as she had no clear cardiac ischemic event nor
missed HD session.  She was discharged to resume her usual MWF
dialysis sessions.
.
On Saturday night she first noted shortness of breath when she
was trying to sleep.  She stated that everytime that she would
try to lay flat she would get more short of breath. She denied
chest pain, cough, or diaphoresis.  She had no
fevers/chills/sweats prior to coming to the hosptial. She stated
that before coming into the hospital that she noted her heart
was racing.
.
In the ED, her initial vital signs were T not recorded HR 113 BP
230/112 38 100%NRB.  She was started on a nitroglycerin gtt. She
was started on CPAP. She received lasix 100 mg x1 to which she
urinated ~80cc.  She received 1 dose of ceftriaxone and was
prescribed 1 dose of levofloxacin.

MEDICAL HISTORY: - Diastolic CHF with LVOT obstruction at rest
- Chronic 2L NC at night
- Hypertension
- Diabetes
- Peripheral vascular disease status post bilateral knee
amputations in [**2146**] (L) and [**2157**] (R)
- GERD
- Hypercholesterolemia
- ESRD on hemodialysis M,W,F. Receives dialysis at [**Location (un) **]
hemodialysis center in [**Location (un) **].
- Paroxysmal atrial flutter, s/p failed ablation with subsequent
a. fib
- Peptic ulcer disease
- Hypertrophic obstructive cardiomyopathy
- Mild mitral stenosis (MVA 1.5-2.0 cm2)
- Secondary Hyperparathyroidism
- Diastolic Congestive Heart Failure

MEDICATION ON ADMISSION: Aspirin 325 mg Tablet DAILY
Simvastatin 80 mg DAILY
Sevelamer HCl 800 mg TID W/MEALS
Ranitidine HCl 150 mg [**Hospital1 **]
Metoprolol Tartrate 100 mg [**Hospital1 **]
Lisinopril 30 mg DAILY
Irbesartan 150 mg daily
Diltiazem HCl SR 120 mg DAILY
Nephro-caps daily
Warfarin 2 mg PO 2X/WEEK (MO,FR)
Warfarin 3 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,TH,SA).
NPH 4 units [**Hospital1 **].
BRIMONIDINE 0.15 % Drops - 1 Drops(s) in the right eye DAILY
LATANOPROST  0.005 % Drops - 1 Drops(s) in the right eye HS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 96  78  163/80  23 100% 5L
GEN: NAD
HEENT: AT, NC, PERRLA, arcus senilus, EOMI, no conjunctival
injection, anicteric, OP clear, MMM, Neck supple, no LAD, no
carotid bruits
CV: RRR, nl s1, s2, 3/6 systolic murmur at apex
PULM: crackles [**12-23**] way up from base, dullness at bases
ABD: soft, NT, ND, + BS, no HSM
EXT: bilateral BKA w/o evidence of skin breakdown. no femoral
bruits. biphasic thrill in AV graft to left arm
NEURO: alert & orientedx3, CN II-XII grossly intact, [**4-25**]
strength throughout upper extremities. No sensory deficits to
light touch appreciated. No asterixis
PSYCH: appropriate affect

FAMILY HISTORY: Her father died in his 90s and mother at the age of 102. Patient
unable to specify cause of death. She has one living sister and
6 sisters and one brother who passed away. Her family history is
significant for coronary artery disease, cancer, and diabetes.

SOCIAL HISTORY: Social history is significant for the presence of current
tobacco use (1 pack per week), and [**12-22**] PPD x 50 years. There is
no history of alcohol abuse. Lives in [**Hospital3 **] facility
and uses a mobile wheelchair or a walker. 

### Response:
{'Congestive heart failure, unspecified,Diabetes with renal manifestations, type II or unspecified type, not stated as uncontrolled,End stage renal disease,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage V or end stage renal disease,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Mitral valve disorders,Peripheral vascular disease, unspecified,Secondary hyperparathyroidism (of renal origin),Atrial fibrillation,Long-term (current) use of anticoagulants,Below knee amputation status,Esophageal reflux,Pure hypercholesterolemia,Tobacco use disorder,Family history of ischemic heart disease,Family history of diabetes mellitus'}
