CHIEF COMPLAINT: transfer from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for dysarthria

PRESENT ILLNESS: 69 yo F with hx of stroke ([**2161**]), CAD/HTN/CHF EF35% with BiV
pacer, transfered from OSH for dysarthria and left hand numbness
and weakness.

MEDICAL HISTORY: - Multiple cavernomas likely rpresenting an inherited syndrome
given that both sons have multiple cavernomas. One son tested
negative for CCM [**1-8**]. Seizure during pregnancy in [**2154**] (thought
to be a manifestation of eclampsia). In [**2177**] she was diagnosed
with cavernomas after right sided weakness. Last MRI brain was
in [**2191**].
- Cardiac arrest ([**Holiday 944**] [**2191**]) s/p BiV pacer
- CHF EF 35%
- CAD
- Paroxysmal Afib (none currently) - cannot be on
anticoagulation/antiplatelets given her cavernomas
- hypothyroidism

MEDICATION ON ADMISSION: Levothyroxine 75mcg daily
Diovan 80mg daily
Kcl 20 meq daily
Spirinolactone 25mg daily
Crestor 2.5mg daily
fish oil one tablet per day
Multivitamin one tablet daily
Calcium 600 + Vitamin D [**Hospital1 **]
Glucosamine 1,500mg daily
Bromolein 2,000 qdu daily

ALLERGIES: Latex / Penicillins

PHYSICAL EXAM: Admission Physical Examination:
VS Afebrile, 124/92 68 12 96%RA
GEN: NAD, pleasant
HEENT: MMM, OP clear
CV: RRR S1S2
Lungs: CTA b/l including bibasilar bases
Abd: soft, nt, nd,
Ext: warm, wp

FAMILY HISTORY: - both sons have cavernomas and one was operated on ([**Hospital1 2025**] and
[**Hospital1 756**])

SOCIAL HISTORY: lives with husband, retired, currently going to rehab
twice/three
times per week, no alcohol, no cigarettes, no illicits
Intracerebral hemorrhage,Hemangioma of intracranial structures,Atrial fibrillation,Dysarthria,Abnormality of gait,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ,Personal history of sudden cardiac arrest
Intracerebral hemorrhage,Hemangioma intracranial,Atrial fibrillation,Dysarthria,Abnormality of gait,Crnry athrscl natve vssl,Hypertension NOS,Hypothyroidism NOS,Status cardiac pacemaker,Hx sudden cardiac arrest
Admission Date:  [**2193-5-6**]              Discharge Date:   [**2193-5-8**]

Date of Birth:  [**2123-11-17**]             Sex:   F

Service: NEUROLOGY

Allergies:
Latex / Penicillins

Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
transfer from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for dysarthria


Major Surgical or Invasive Procedure:
None


History of Present Illness:
69 yo F with hx of stroke ([**2161**]), CAD/HTN/CHF EF35% with BiV
pacer, transfered from OSH for dysarthria and left hand numbness
and weakness.

(Following History is obtained from sparcely documented OSH
transfer notes, patient own report and husband.)

Patient was first diagnosed with cavernomas around the time of
her 1st pregnancy. She had a seizure which prompted further
workup (she has not had a seizure in 40 years). Since that time,
she has had several new cavernomas appear. Her first stroke was
in [**2177**] apparently she was left with deficits including Right
sided (arm/leg) weakness and dysarthria. MRI brain was performed
at
[**Hospital1 2025**]. At that time she was
told that she had multiple cavernomas. These have been followed
by Dr. [**Last Name (STitle) 83712**] at [**Hospital 36653**] clinic. Her last MRI was in [**2191**]
prior
to her cardiac pacer. Her last neuro appointment was in [**Month (only) **]
[**2193**].

More recently her medical problems have surrounded her cardiac
issues. She has had long-standing HTN as well as a cardiac
arrest
on [**Holiday 944**] [**2191**] with CHF EF35% and biV pacer placed. She also
has a history of paroxysmal afib but NOT anticoagulated given
the
brain cavernomas.

Her difficulty with dysarthria started 2 years ago around the
time of her new dentures. Since that time her dysarthria has
gradually worsened. Her neurologist suggested she begin
outpatient speech rehab which she has been doing for more than 1
year. The husband and patient both think her speech is now worse
than it has ever been but clearly state that there has not been
an abrupt change at any point (including the last few weeks).

Her difficulties with walking followed her stroke in [**2161**] and
were worsened by the cardiac issues. She is involved in
intensive
outpatient cardiac rehab.

On [**2193-5-6**], she presented to rehab and told the staff about a
fall she had experienced 1 week prior with resultant pain on her
right side. The fall was secondary to tripping on the home
carpet
and was not associated with presyncope, vertigo or other
symptoms. She remembers the whole event.

However, given her pain, worsened walking and speech
difficulties
she was sent to the ED. At [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], a neurology consult led
to a head CT which showed the known cavernomas with several
areas
of bleeding and a possible new thalamic stroke. Despite the
unknown timeline and fact that the patient was actually getting
better over the last week or so they recommended urgent transfer
to [**Hospital1 2025**] neurosurgery and then [**Hospital1 18**] neurosurgery who refused the
transfer. They then called Neurology at [**Hospital1 18**].

The patient denies recent fever, cold, dysuria, other symptoms
of
infection. She did have a couple episodes of diarrhea 3 weeks
prior.

She does endorse mild left hand numbness (novacaine) which has
since dissipated.

Additional history:

Patient is a 69-year-old woman hx of multiple cavernomas who was
was transferred from [**Hospital3 26615**] Hospital due to dysarthria and
concern for a new left thalamic subacute cavernoma bleed.

She reports slowly progressive dysarthria over the past two
years. She has also had increasing difficulty with walking,
requiring a cane six weeks ago. On [**2193-4-29**] she tripped at
home and fell on her right side. Since then, she noted increased
difficulty walking and has been using a walker. She denies focal
weakness of the arms or legs. She has occasional numbness of her
fingertips but no other numbness or paresthesias. Her dysarthria
seems slightly worse. She is not having trouble swallowing. No
acute changes in her vision.

She was seen at cardiac rehab on [**5-6**]. Staff was concerned that
she had increased dysarthria and referred her to [**Hospital3 26615**]
Hospital. First CT scan at noon at [**Hospital3 26615**] showed a new
hyperintensity in the anterolateral left thalamus with a
surrounding hypodensity (that was not seen on prior MRI brain in
[**2191**]). There was also a new 2mm hyperintensity in the medial
left
occipital lobe (not seen on the MRI brain in [**2191**]). Chronic
cavernomas were seen in the right basal ganglia (measuring 3.5mm
diameter), right posterior frontal, left frontal anterior lobe,
and left medial thalamus. Calcifications were seen in both
vertebrals and also the supraclinoid segments of the bilateral
ICA. Repeat CT brain at 7pm at [**Hospital3 26615**] did not show any
interval change. She was then transferred to [**Hospital1 18**] Neurology
Service in the ICU.

Additional PMH: She had a seizure during her pregnancy in [**2154**]
that possibly related to eclampsia. In [**2177**] she had an episode
of
right arm and leg weakness, and dysarthria. She had gait
difficulty. She underwent MRI brain at [**Hospital1 2025**] which showed at least
one cavernoma (more details are not available now). Her last MRI
brain was done at [**Hospital3 26615**] Hospital in [**2191-4-7**] (prior to
receiving a pacemaker). Her Neurologist is Dr. [**Last Name (STitle) 110514**]
[**Name (STitle) 83712**], who is at the [**Hospital3 **]. Her phone number is
([**Telephone/Fax (1) 110515**]). Both of her sons have cavernomas. Her son [**Name (NI) 1151**]
[**Name (NI) **] tested negative for the CCM1,CCM2, and CCM3 gene
mutations.
He is the only member of the family who underwent the gene
mutation testing. She has a right cataract. Left knee
replacement.

Past Medical History:
- Multiple cavernomas likely rpresenting an inherited syndrome
given that both sons have multiple cavernomas. One son tested
negative for CCM [**1-8**]. Seizure during pregnancy in [**2154**] (thought
to be a manifestation of eclampsia). In [**2177**] she was diagnosed
with cavernomas after right sided weakness. Last MRI brain was
in [**2191**].
- Cardiac arrest ([**Holiday 944**] [**2191**]) s/p BiV pacer
- CHF EF 35%
- CAD
- Paroxysmal Afib (none currently) - cannot be on
anticoagulation/antiplatelets given her cavernomas
- hypothyroidism


Social History:
lives with husband, retired, currently going to rehab
twice/three
times per week, no alcohol, no cigarettes, no illicits


Family History:
- both sons have cavernomas and one was operated on ([**Hospital1 2025**] and
[**Hospital1 756**])


Physical Exam:
Admission Physical Examination:
VS Afebrile, 124/92 68 12 96%RA
GEN: NAD, pleasant
HEENT: MMM, OP clear
CV: RRR S1S2
Lungs: CTA b/l including bibasilar bases
Abd: soft, nt, nd,
Ext: warm, wp

Neuro exam:

Mental status: Alert, oriented X3, DOW backward fast without
errors, memory of recent events intact, speech fluent without
paraphasic errors, comprehension full, speech dysarthric and
slowed, difficulty repeat "hungry hippopotamus", "[**Name Prefix (Prefixes) **]-[**Last Name (Prefixes) **]-la",
"ga-ga-ga", "pa-pa-pa"
No neglect, no difficulty with confrontational naming of stroke
card, difficulty [**Location (un) 1131**] because of significant dysarthria, no
deficits when writing

Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6 to 3mm and brisk.  VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  5    5   4+  5   4  5  5  5   5    5  5     5     5   5
R  5    5   5   5   5  5  5  5   4    4+ 5     5     5   5

-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  3  3    3    3   2
Plantar response was extensor bilaterally (although strong
withdrawal).

-Coordination: No intention tremor, mild dysdiadochokinesia
noted
b/l Mild dysmetria on FNF on the RIGHT.

-Gait: defered
.
Discharge physical examination:
Inattention, significant dysarthria, mild right facial weakness
with reflex asymmetry on the right with right extensor plantar
and clumsier movement in the right hand. Patient did not use her
cane properly, had en-bloc turning with unstable gait although
this would certainly have been helped by the approprate use of
her cane.


Pertinent Results:
Laboratory investigations:
Admission labs:
[**2193-5-7**] 12:54AM BLOOD WBC-7.2 RBC-4.11* Hgb-13.5 Hct-40.4
MCV-98 MCH-33.0* MCHC-33.5 RDW-12.6 Plt Ct-211
[**2193-5-7**] 12:54AM BLOOD PT-11.7 PTT-32.3 INR(PT)-1.1
[**2193-5-7**] 12:54AM BLOOD Glucose-106* UreaN-17 Creat-0.8 Na-138
K-4.0 Cl-101 HCO3-28 AnGap-13
[**2193-5-7**] 12:54AM BLOOD ALT-17 AST-23 LD(LDH)-194 CK(CPK)-61
AlkPhos-91 TotBili-0.6
[**2193-5-7**] 12:54AM BLOOD Albumin-4.4 Calcium-9.5 Phos-3.3 Mg-1.9
Cholest-183
.
Other pertinent labs:
[**2193-5-7**] 12:54AM BLOOD CK-MB-2 cTropnT-<0.01
[**2193-5-7**] 12:54AM BLOOD Albumin-4.4 Calcium-9.5 Phos-3.3 Mg-1.9
Cholest-183
[**2193-5-7**] 12:54AM BLOOD Triglyc-53 HDL-82 CHOL/HD-2.2
LDLcalc-9005/01/12 04:47AM BLOOD %HbA1c-5.5 eAG-111
.
Discharge labs:
[**2193-5-8**] 04:40AM BLOOD WBC-6.6 RBC-4.11* Hgb-13.6 Hct-40.8
MCV-99* MCH-33.0* MCHC-33.3 RDW-12.9 Plt Ct-198
[**2193-5-8**] 04:40AM BLOOD Glucose-100 UreaN-16 Creat-0.9 Na-135
K-4.3 Cl-96 HCO3-30 AnGap-13
[**2193-5-8**] 04:40AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.0
.
.
Urine:
[**2193-5-7**] 01:46AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2193-5-7**] 01:46AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-MOD
[**2193-5-7**] 01:46AM URINE RBC-<1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-<1
.
.
Microbiology:
[**2193-5-7**] 1:46 am URINE      Source: CVS.

                            **FINAL REPORT [**2193-5-8**]**

   URINE CULTURE (Final [**2193-5-8**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.
.
.
Radiology:
OSH CT head [**2193-5-6**] 12:26
Prlim read:
a new hyperintensity in the anterolateral left thalamus with a
surrounding hypodensity (that was not seen on prior MRI brain in
[**2191**]). There was also a new 2mm hyperintensity in the medial
left
occipital lobe (not seen on the MRI brain in [**2191**]). Chronic
cavernomas were seen in the right basal ganglia (measuring 3.5mm
diameter), right posterior frontal, left frontal anterior lobe,
and left medial thalamus. Calcifications were seen in both
vertebrals and also the supraclinoid segments of the bilateral
ICA.

OSH CT head [**2193-5-6**] 19:20
Prelim read:
No interval change.
.
CHEST (PORTABLE AP) Study Date of [**2193-5-7**] 5:52 AM
FINDINGS: As compared to the previous radiograph, the appearance
of the chest
radiograph is unchanged. On the single view, a left pectoral
pacemaker with
normal course of the wires is noted. The lung volumes are
normal. There is
moderate cardiomegaly and tortuosity of the thoracic aorta but
no evidence of
acute lung disease such as pulmonary edema or pneumonia. No
pneumothorax. No
pleural effusions.
.
.
Cardiology:
ECG Study Date of [**2193-5-7**]  1:21:04 AM


Sinus rhythm. Atrial sensing with ventricular pacing. The paced
beats are
unusual and may indicate fusion beats versus biventricular
pacing or could
be variant. No previous tracing available for comparison.
Clinical
correlation is suggested.
TRACING #1


Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
66 0 108 432/442 0 83 53
.
ECG Study Date of [**2193-5-7**]  7:52:42 AM


No significant change compared to tracing #1.
TRACING #2


Read by: [**Last Name (LF) **],[**First Name3 (LF) **] J.

  Intervals Axes
Rate PR QRS QT/QTc P QRS T
65 126 102 430/438 75 94 69

Brief Hospital Course:
69 yo RHF with HTN, long history of miltiple cavernomas s/p
operation with FH of sons both having multiple cavernomas (1 son
tested and negative for CCM [**1-8**]), CHF s/p cardiac arrest s/p
PPM, who presented on [**2193-5-6**] with gradually worsened
dysarthria. Patient had fallen 1 week prior to admission and
family had noted a subacute declne in mobility. Neurological
examination revealed inattention, significant dysarthria, mild
right facial weakness with reflex asymmetry on the right with
right extensor plantar and clumsier movement in the right hand.
Patient was admitted under the stroke srvice from [**2193-5-6**] to
[**2193-5-8**].

OSH CT head at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] revealed multiple cavernomas with a
new hyperintensity in the anterolateral left thalamus with a
surrounding hypodensity (that was not seen on prior MRI brain in
[**2191**]). There was also a new 2mm hyperintensity in the medial
left occipital lobe (not seen on the MRI brain in [**2191**]). Given
her history and the imaging results, it seems likely that the
anterolateral left thalamic cavernoma and the medial left
occipital lobe cavernoma are subacute to chronic lesions.
Chronic cavernomas were seen in the right basal ganglia
(measuring 3.5mm diameter), right posterior frontal, left
frontal anterior lobe, and left medial thalamus. Calcifications
were seen in both vertebrals and also the supraclinoid segments
of the bilateral ICA. Repeat CT brain at [**Hospital3 26615**] did not
show any interval change.

Patient was monitored on telemetry and stroke risk factors were
assessed and CEs were <0.01, HbA1c 5.5% and FLP revealed Chol
183 TGCs 53 HDL 82 LDL 90. UA was unremarkable. CXR revealed
moderate cardiomegaly and tortuosity of the thoracic aorta but
no evidence of acute lung disease.

She was initially admitted to the ICU on [**2193-5-6**] under the
stroke service for close monitoring and she was continued on her
home medications. She was transferred to the stroke neurology
floor the next day on [**2193-5-7**] without incident.

The etiology of her worse dysarthria is likely due to hemorrhage
of her thalamic cavernoma which likely also involves the
internal capsule, superimposed on her chronic dysarthria.

Symptoms were stable although patient did not use her cane
properly, had en-bloc turning with unstable gait although this
would certainly have been helped by the approprate use of her
cane. Patient was assessed bt PT/OT and deemed to benefit from
rehab and was transferred to rehab on [**2193-5-8**]. She has a
neurology follow-up appointment with her outpatient neurologist.
No changes were made to her medications.

Medications on Admission:
Levothyroxine 75mcg daily
Diovan 80mg daily
Kcl 20 meq daily
Spirinolactone 25mg daily
Crestor 2.5mg daily
fish oil one tablet per day
Multivitamin one tablet daily
Calcium 600 + Vitamin D [**Hospital1 **]
Glucosamine 1,500mg daily
Bromolein 2,000 qdu daily


Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. rosuvastatin 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
6. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever.
8. Fish Oil  Oral
9. Glucosamine 750 mg Tablet Sig: Two (2) Tablet PO once a day.

10. bromolein  Sig: One (1)   once a day.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
Primary diagnoses:
- New hemorrhage into cavernomas in the left thalamus and likely
left occipital lobe
- History of multiple cavernomas with evidence of prior bleeding
likely representing an inherited phenomenon


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Neurologic: Inattention, significant dysarthria, mild right
facial weakness with reflex asymmetry on the right with right
extensor plantar and clumsier movement in the right hand.
Patient did not use her cane properly, had en-bloc turning with
unstable gait although this would certainly have been helped by
the approprate use of her cane.


Discharge Instructions:
It was a pleasure taking care of you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented with
worsening slurred speech. CT scans at the outside hospital
revealed your known multiple cavernomas and a small area of new
hemorrhage on the left side of your brain called the thalamus.
This is likely due to bleeding of one of your cavernomas and
accounts for your worsening slurred speech. Your blood pressure
is controlled and there is no other intervntion that can be done
at this time regarding your cavernomas. You were assessed by
physical therapy and deemed to benefit from rehab. We have
arranged neurology follow-up with your outpatient neurologist.
.
Medication changes:
We made no changes to your medications

Followup Instructions:
Please see your PCP on discharge from rehab.

We have also arranged the neurology follow-up with your
outpatient neurologist:

Department: NEUROLOGY [**Hospital3 **]
When: MONDAY [**2193-7-1**] at 1 PM
With: DR [**Last Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 110516**]
{'Intracerebral hemorrhage,Hemangioma of intracranial structures,Atrial fibrillation,Dysarthria,Abnormality of gait,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ,Personal history of sudden cardiac arrest'}


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: transfer from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for dysarthria

PRESENT ILLNESS: 69 yo F with hx of stroke ([**2161**]), CAD/HTN/CHF EF35% with BiV
pacer, transfered from OSH for dysarthria and left hand numbness
and weakness.

MEDICAL HISTORY: - Multiple cavernomas likely rpresenting an inherited syndrome
given that both sons have multiple cavernomas. One son tested
negative for CCM [**1-8**]. Seizure during pregnancy in [**2154**] (thought
to be a manifestation of eclampsia). In [**2177**] she was diagnosed
with cavernomas after right sided weakness. Last MRI brain was
in [**2191**].
- Cardiac arrest ([**Holiday 944**] [**2191**]) s/p BiV pacer
- CHF EF 35%
- CAD
- Paroxysmal Afib (none currently) - cannot be on
anticoagulation/antiplatelets given her cavernomas
- hypothyroidism

MEDICATION ON ADMISSION: Levothyroxine 75mcg daily
Diovan 80mg daily
Kcl 20 meq daily
Spirinolactone 25mg daily
Crestor 2.5mg daily
fish oil one tablet per day
Multivitamin one tablet daily
Calcium 600 + Vitamin D [**Hospital1 **]
Glucosamine 1,500mg daily
Bromolein 2,000 qdu daily

ALLERGIES: Latex / Penicillins

PHYSICAL EXAM: Admission Physical Examination:
VS Afebrile, 124/92 68 12 96%RA
GEN: NAD, pleasant
HEENT: MMM, OP clear
CV: RRR S1S2
Lungs: CTA b/l including bibasilar bases
Abd: soft, nt, nd,
Ext: warm, wp

FAMILY HISTORY: - both sons have cavernomas and one was operated on ([**Hospital1 2025**] and
[**Hospital1 756**])

SOCIAL HISTORY: lives with husband, retired, currently going to rehab
twice/three
times per week, no alcohol, no cigarettes, no illicits 

### Response:
{'Intracerebral hemorrhage,Hemangioma of intracranial structures,Atrial fibrillation,Dysarthria,Abnormality of gait,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Unspecified acquired hypothyroidism,Cardiac pacemaker in situ,Personal history of sudden cardiac arrest'}
