CHIEF COMPLAINT: 

PRESENT ILLNESS: This is an 81-year-old with no
significant past medical history who is transferred from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Hospital for anemia, melena, acute renal failure and
rule in myocardial infarction.  This is an 81-year-old with
no medical history except for tophaceous gout who was in her
usual state of excellent health until three days prior to
admission when after lunch, she laid down because she did not
feel well.  She sleeps in a different room from her husband,
with whom she lives.  When he asked her later that evening
how she was, she said she was fine.  The next day, she
continued to remain in bed.  He offered her some [**Location (un) 2452**]
juice, which she drank, but she was slowly becoming more
confused and lethargic.  On the third day, she was barely
arousable and incoherent.  He called EMS who found her to be
"incontinent of urine."  She was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital where she was lethargic, oliguric and confused.  She
had a rectal temperature of 87 degrees.  Her pulse was 80
with a systolic blood pressure of 72-135.  She was found to
be guaiac positive with a fingerstick of 38.  Her white blood
cell count was 17.1, 87% neutrophils, 14% bands, 4%
lymphocytes and 2% monocytes.  Her hematocrit was found to be
16.1.  He platelet count was 100,000.  Her Chem-7 revealed a
sodium of 148, potassium 4.8, chloride 118, bicarbonate 15,
BUN 83 and creatinine 2.5.  Her CK was 499 with an MB of 60
and an index of 12.  Her INR was 2.6.  Blood cultures times
two were negative.  A head CT was performed which showed
enlarged ventricles, but was otherwise negative.  She was
resuscitated and given two units of packed red blood cells.
She was warmed to a rectal temperature of 94 and transferred
to [**Hospital6 256**] for further care.

MEDICAL HISTORY: Tophaceous gout.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: A sibling with diabetes.

SOCIAL HISTORY: No tobacco or alcohol use.  Never visited a
doctor.  Lives with her husband in [**Name (NI) 13011**].  Does the
banking, and shopping and cooking.  Is very active at home,
taking care of her husband of the past 60 years.
Unspecified septicemia,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Gouty tophi of other sites, except ear,Acute respiratory failure,Acute and subacute necrosis of liver,Disseminated candidiasis,Defibrination syndrome
Septicemia NOS,Cholelith w ac cholecyst,Acute pancreatitis,Ac kidny fail, tubr necr,Gouty tophi site NEC,Acute respiratry failure,Acute necrosis of liver,Disseminated candidiasis,Defibrination syndrome
Admission Date:  [**2125-4-7**]     Discharge Date:  [**2125-5-4**]


Service:  [**Hospital1 **]

HISTORY OF PRESENT ILLNESS:  This is an 81-year-old with no
significant past medical history who is transferred from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Hospital for anemia, melena, acute renal failure and
rule in myocardial infarction.  This is an 81-year-old with
no medical history except for tophaceous gout who was in her
usual state of excellent health until three days prior to
admission when after lunch, she laid down because she did not
feel well.  She sleeps in a different room from her husband,
with whom she lives.  When he asked her later that evening
how she was, she said she was fine.  The next day, she
continued to remain in bed.  He offered her some [**Location (un) 2452**]
juice, which she drank, but she was slowly becoming more
confused and lethargic.  On the third day, she was barely
arousable and incoherent.  He called EMS who found her to be
"incontinent of urine."  She was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital where she was lethargic, oliguric and confused.  She
had a rectal temperature of 87 degrees.  Her pulse was 80
with a systolic blood pressure of 72-135.  She was found to
be guaiac positive with a fingerstick of 38.  Her white blood
cell count was 17.1, 87% neutrophils, 14% bands, 4%
lymphocytes and 2% monocytes.  Her hematocrit was found to be
16.1.  He platelet count was 100,000.  Her Chem-7 revealed a
sodium of 148, potassium 4.8, chloride 118, bicarbonate 15,
BUN 83 and creatinine 2.5.  Her CK was 499 with an MB of 60
and an index of 12.  Her INR was 2.6.  Blood cultures times
two were negative.  A head CT was performed which showed
enlarged ventricles, but was otherwise negative.  She was
resuscitated and given two units of packed red blood cells.
She was warmed to a rectal temperature of 94 and transferred
to [**Hospital6 256**] for further care.

On arrival, her temperature was 98 and she had a systolic
blood pressure in the low 100s.  She received more blood
products and Vitamin K and was admitted to the Medical
Intensive Care Unit.

PAST MEDICAL HISTORY:   Tophaceous gout.

MEDICATIONS:  Advil 1 tablet q.d.

ALLERGIES:  No known drug allergies.

SOCIAL HISTORY:  No tobacco or alcohol use.  Never visited a
doctor.  Lives with her husband in [**Name (NI) 13011**].  Does the
banking, and shopping and cooking.  Is very active at home,
taking care of her husband of the past 60 years.

FAMILY HISTORY:  A sibling with diabetes.

PHYSICAL EXAMINATION:  This is an ill-appearing elderly woman
who had a temperature of 98 rectally, a blood pressure of
106/50.  Pulse of 87.  Respiratory rate of 28 and an oxygen
saturation of 100% on 100% nonrebreather.  She was
normocephalic, atraumatic with a 2 mm right pupil and a 1 mm
sluggish left pupil.  She had anicteric sclera.  Her mucous
membranes were dry.  She had upper dentures and dried blood
on her upper palate above her dentures.  Her neck had no
masses.  Her chest was clear except with good air movement
except for decreased breath sounds at the right base.  Her
heart was regular in rate and rhythm with no murmurs.  Her
abdomen was moderately distended without rebound or guarding
and good bowel sounds.  Her back had no overt lesions.  She
had a fluctuant mass along her right thorax extending from
her axilla to her iliac crest without erythema.  She had
large gouty tophi and joint disease of bilateral hands and
feet.  She had 2+ anasarca.  She had 2+ bilateral radial and
dorsalis pedis pulses.  She had ischemic discoloration of her
right second finger, left second to fourth digits in all ten
toes bilaterally.  She had numerous ulcerations on her feet.
Her gout involved the small joints of her hands, as well as
both her elbows and both her knees.  On neurological exam,
she was awake and responded to voice, but did not answer
questions.  Her extraocular movements were intact and she was
moving all her extremities, as well as withdrawing to pain.

LABORATORY DATA ON ARRIVAL:  White blood cell count of 15.9,
hematocrit of 24.9, a platelet count of 117,000, INR of 2.6,
an arterial blood gas of 7.41, 28 and 114.  A negative
toxicology screen and a Chem-7 consistent with that of the
outside hospital.  Albumin is 3.1, AST of 749 with ALT of
437.  Alkaline phosphatase of 269 and a total bilirubin of
1.9.  Her TSH was 6 with a free T4 of 0.7.  Her cortisol was
55.  Amylase and lipase revealed a 123 and 405.  Her CK was
485.  It peaked at 1064 and then returned to [**Location 213**].  Her
troponin peaked at 1.4.

Electrocardiogram revealed normal sinus rhythm at 90 beats
per minute with low voltage in the limb leads.  She had
normal axis, normal intervals and no acute ST changes.

Chest x-ray showed low lung volumes and bilateral pleural
effusions, right greater than the left, with associated
collapse of her right lower lobe and right middle lobe.

Abdominal CT revealed a large right and a moderate left
pleural effusion, as well as ascites.  She also had a right
subcutaneous fluid collection.  She had a uterine fibroid.
Her bowels appeared normal as did her liver and gallbladder.
She had atrophic kidneys with scattered cysts.  She had
normal pancreas, spleen and adrenals.

HOSPITAL COURSE:  On admission to the Medical Intensive Care
Unit, she was resuscitated with two units of FFP, 1 mg of
intravenous Vitamin K, intravenous fluids and she was started
on antibiotics, mainly vancomycin, Ceftriaxone and Flagyl.
She did not require pressors at any point during her stay.
The main initial differential included TTP, although, her
coags were abnormal and she had a negative lupus
anticoagulant and anticardiolipin antibodies, so that
diagnosis was excluded.  The main concerns then were either
sepsis leading to DIC or massive gastrointestinal bleed
leading to DIC.  She spent six days in the Intensive Care
Unit where she was persistently obtunded and guaiac positive.
However, she was hemodynamically stable and was easily weaned
off all supplemental oxygen and remained with a good blood
pressure.  Multiple blood cultures were negative.  She had a
single urine culture on presentation that had 10-100,000
pansensitive E. Coli, but all subsequent urine cultures were
negative.  Her necrotic toes were cultures and grew out
polymicrobial gram positive cocci and gram negative rods.
She was given the diagnosis of sepsis of unknown etiology
with complications of DIC and multisystem organ failure,
namely acute renal failure, shock liver, acute myocardial
infarction, altered mental status and digital necrosis.  She
also had gross anasarca.

Given her altered mental status, MR of her head was performed
which revealed chronic microvascular infarct, but was
negative for anoxic brain injury or major infarct.  An lumbar
puncture was negative with normal protein and glucose and
negative cultures.  An electroencephalogram was consistent
with toxic metabolic encephalopathy.  Her B12, folate and RPR
were all normal.  Her arterial blood gases remained within
normal limits.  Her white blood cell count fell to
approximately 13.  Her INR improved with Vitamin K and FFP.
She initially had a lactate of 3.9 that dropped to 1.9.  Her
hematocrit remained stable at about 26-28.  Her platelets
remained low in the 80,000s.  Her creatinine peaked at 3.9
and then slowly dropped to approximately 1.4.  Her
bicarbonate improved from 17 to 25.  Her transaminases
returned to [**Location 213**].  Her alkaline phosphatase stabilized in
the 300-400 range.

Numerous consultations were obtained including a Cardiology
that stated that her myocardial infarction was likely in the
setting of severe anemia and sepsis.  An echocardiogram
revealed severe apical hypokinesis with decreased systolic
function and a small effusion with fiber and deposits on the
cardiac surface.  Cardiology recommended no anticoagulation
given her anemia and guaiac positive stools.  They
recommended keeping her hematocrit about 30 and the use of a
beta-blocker if she became hypertensive or tachycardic,
neither of which happened during her stay.

Hematology was also consulted regarding her coagulopathy.
They felt it was consistent with DIC and was not TTP.  They
recommended Vitamin K supplementation which improved her INR.
She did, however, have a persistently elevated PTT despite
having a negative lupus anticoagulant and anticardiolipin
antibody.

The Renal Service was consulted and diagnosed her with ATN
with muddy brown casts.  He creatinine slowly improved from a
peak of 3.9 to 1.4.  Her anasarca improved with diuresis.
She did not require hemodialysis.  A Rheumatology Consult
stated that she had chronic gout with no apparent acute flare
of any joints.  She was unable to receive colchicine or
NSAIDs due to her acute renal failure and would not have
benefited from allopurinol at that time.  Her right elbow was
causing her some discomfort and was tapped twice during her
stay.  Both times, it was negative for infectious arthritis,
but did reveal crystals suggestive of gout.

The Vascular Surgery Service was consulted and continues to
follow her throughout her stay with regard to the gangrene of
her toes.  Her lower extremities were elevated and received
wound care.  Amputations were recommended when she was
medically stable.  Her toes were never a cause of her sepsis
and never look infected.  They were debrided as necessary.
They became very well demarcated and healed nicely.

The Gastrointestinal Service was consulted.  They felt that
she most likely had pancreatitis and were uncertain what the
initial cause of her sepsis or her massive gastrointestinal
bleed was.  They recommended transfusions, following her
guaiac and no NG suction.  They stated that neither
esophagogastroduodenoscopy nor colonoscopy could be done
until six weeks after her myocardial infarction unless she
demonstrated active bleeding.  However, her hematocrit
remained stable after her initial transfusion.  After six
days in the unit, she was transferred to the floor. There was
a concern that her mental status were due to the morphine and
Ativan she was receiving because of her extreme pain during
dressing changes.  During her stay in the unit, she was
nearly constantly crying or screaming.

On the floor, she remained hypothermic with an alkaline
phosphatase of about 500.  Her white blood cell count
increased to about 26.  Her stool culture was negative for C.
difficile times three.  She was changed from Ceftriaxone to
ceftazidime and remained on broad spectrum coverage.  She
continued to have excellent saturations and blood pressures.
Her only focal sign remained abdominal pain.  An ultrasound
was unhelpful.  A second CT was obtained which showed a large
gallbladder that was not inflamed with a large gallstone.
There was no pericholecystic fluid or biliary dilatation or
obstruction.  During this time, she had been started on tube
feeds.  However, she had an episode of nausea and vomiting
with aspiration and so she was made NPO and TPN was started
via a PICC.

Due to the concern for cholecystitis, a HIDA scan was
performed which showed no uptake.  This was consistent with
acute cholecystitis and there was a potential that this could
have been the triggers setting off her sepsis.  A gallbladder
drain was placed by Interventional Radiology as General
Surgery consulted and stated that she was far too ill to
undergo surgery.  Her viral culture was negative.

In the continued search for a source of her sepsis, her
pleural effusion was tapped.  It was transudate and the
cultures were negative.  Her ascites was also tapped.  Her
serum to ascites albumin gradient was 1.1.  She had 1700
white blood cells with 60% polys and a negative Gram stain
and cultures.  At that point, she had received adequate
coverage for bacterial peritonitis with Ceftriaxone and then
ceftazidime.

After the gallbladder drain was placed.  Her white blood cell
and alkaline phosphatase started to decrease, but after a few
days, her total bilirubin, white blood cell count and
alkaline phosphatase once again started to rise for unclear
reasons.  A GGT was checked to insure that the alkaline
phosphatase was of liver source and it was very elevated.
She also had a mild lipase leak at this point from 45 to 71.
There was a concern for gallstone pancreatitis or
cholangitis.  She continued to have melena throughout this
time.   A magnetic resonance cholangiopancreatography was
performed which showed pancreatitis and no biliary
dilatation, but raised the question of a mass in the head or
uncinate process of the pancreas and also a question of duct
disruption.  As her alkaline phosphatase continued to rise,
from the 500s to the 1000s and her total bilirubin increased
to 2.2 and her lipase increased to 123, an Endoscopic
retrograde cholangiopancreatography Consult was obtained.
The endoscopic retrograde cholangiopancreatography fellow
recommended a cholangiogram as an initial first step.  This
was done injecting dye through her gallbladder drain.  This
revealed a distal common bile duct obstruction, question
stenosis versus stone with no duodenal filling and mild
dilatation of her hepatic and common bile ducts.

Also during this time, other sources of infection were being
sought and an MRI of her feet were done, which were negative
for infection.  As above, her right elbow joint was also
tapped and was negative for septic arthritis.

After the cholangiogram revealed obstruction, an endoscopic
retrograde cholangiopancreatography was performed which
revealed no pus or masses but did reveal ampullary stenosis.
A sphincterotomy was performed.  On the floor, after her
endoscopic retrograde cholangiopancreatography, she developed
post endoscopic retrograde cholangiopancreatography
pancreatitis and her lipase rose to 163.  She had increasing
abdominal tenderness and became slightly more confused.
Prior to the endoscopic retrograde cholangiopancreatography,
her mental status had greatly improved, although, she still
was not speaking, she was alert.  After the endoscopic
retrograde cholangiopancreatography, a third abdominal CT
with intravenous contrast was obtained to evaluate for
potential endoscopic retrograde cholangiopancreatography
induced perforation of the intestine or for pancreatic mass
given the question raised on the magnetic resonance
cholangiopancreatography done earlier.

Abdominal CT number three revealed pancreatitis with no
hemorrhage or significant necrosis and no pancreatic mass.
She had no signs of perforation secondary to her endoscopic
retrograde cholangiopancreatography and no bowel ischemia.
After the endoscopic retrograde cholangiopancreatography, her
total bilirubin dropped to normal, however, her alkaline
phosphatase continued to increase from the 1100s to the
1700s.  As she slowly recovered from her endoscopic
retrograde cholangiopancreatography pancreatitis, not only
did her alkaline phosphatase continue to rise, but she
developed a direct hyperbilirubinemia again.  At this point,
she began growing [**Female First Name (un) **] from her blood and her urine.  She
received 24 days of broad spectrum antibiotics at this point.
Her antibiotics were stopped and her TPN was stopped as
well.  Her PICC line was removed.  She was started on
fluconazole.  Right around this time, she developed
dysarthria and a facial droop that was unclear if it was new.
A repeat MRI with gadolinium was the same as her previous.
The repeat was done on [**5-2**] and it showed no changes from
the MRI on [**4-10**].  A repeat electroencephalogram was
normal.  Over a few days, her dysphonia improved.  She
remained on her fluconazole.  Surveillance blood cultures
were negative.  A repeat cholangiogram showed normal biliary
tree and flow.  This cholangiogram was performed as her
alkaline phosphatase  had continued to rise from the 1700s to
the [**2123**].  A repeat bile culture grew yeast.  Her white
blood cell count remained stable between 16 and 20,000
throughout this time.  She was restarted on tube feeds as her
post endoscopic retrograde cholangiopancreatography
pancreatitis was improving.  An Ophthalmology Consult was
obtained to evaluate for fungal eye disease secondary to her
candidemia.  She had no evidence of fungal eye disease.
After she developed candidemia and with her increasing
alkaline phosphatase, her creatinine bumped from 1.4 to 1.6.

Despite her positive cultures, she continued to improve in
terms of mental status, abdominal pain, and renal function.
However, since her bile culture had grown out [**Female First Name (un) **], her
gallbladder drain was removed.  After it was pulled, she had
leakage of her ascites out of the cutaneous fistula tract
that had led to her gallbladder.  The ascitic fluid was
tinged brown with concern for bile spillage into the
peritoneal cavity.  Over the afternoon after her gallbladder
drain was pulled, she demonstrated increasing abdominal
tenderness and guarding that was new.  This was discussed
with the Gastrointestinal and Radiology Services who stated
that she should be started on broad spectrum antibiotics to
cover potential secondary bacterial peritonitis, although,
she was most likely suffering from a chemical peritonitis
secondary to bile spillage.  Fluid was sent for Gram stain
culture and fungal culture.  Radiology stated that in the
presence of ascites, the site of her gallbladder drain in the
gallbladder wall was less likely to close off immediately
after the catheter was pulled, but should close with time.
They recommended supportive care through this peritonitis.
Later that evening, she was noted to be bradycardic on
telemetry.  A code was called.  She underwent PEA arrest and
was transferred to the Medical Intensive Care Unit after she
was resuscitated.




                          [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 3851**]

Dictated By:[**Name8 (MD) 1552**]

MEDQUIST36

D:  [**2125-7-25**]  20:23
T:  [**2125-7-25**]  20:23
JOB#:  [**Job Number **]


Name:  [**Known lastname 7001**], [**Known firstname 4169**]                       Unit No:  [**Numeric Identifier 7002**]

Admission Date:  [**2125-4-7**]     Discharge Date:  [**2125-5-11**]

Date of Birth:   [**2043-11-6**]     Sex:  F

Service:  MICU

Addendum to the discharge summary performed on [**2125-5-4**], but
which will also service as her final discharge summary for
her hospitalization here.

HISTORY OF PRESENT ILLNESS:  After her arrest and transferred
to the Medical Intensive Care Unit, the patient was followed
for a number of conditions.

1. With regards to Infectious Disease, the patient continued
to be covered for her high-grade candidemia.  In addition,
she was covered with broad-spectrum antibiotics to cover
other possible infectious contributions to her illness.

2. She continued to remain dependent on ventilator and could
not be successfully weaned without developing marked
respiratory distress.

3. GI.  She continued to be followed by the GI team, who
remained concerned that her elevated LFTs represented hepatic
candidiasis or a potential biliary obstruction.
Unfortunately, the patient was not stable enough to undergo
MRI examination of her abdomen, and this remained an
unanswered question.

4. Neurology.  After her arrest, the patient never regained
meaningful interactions with her caretakers or her family.
At various times she appeared very uncomfortable, and a
decision was ultimately made to focus treatment on her
comfort.

After extensive discussions with the family about her ongoing
issues and her grim prognosis, the decision was made to defer
further aggressive measures and focus care on her comfort.
In accordance with these wishes, the patient was extubated on
[**4-10**], and weaned from all antibiotics and blood pressure
supporting medicines.  Shortly thereafter, the patient
expired.

TIME OF DEATH:  1:30 am on [**2125-4-10**].

CAUSE OF DEATH:
1. Cardiac arrest.
2. Sepsis.

No autopsy was performed per the family's request.

DISCHARGE STATUS:  Deceased.

DISCHARGE DIAGNOSES:
1. Candidemia.
2. Sepsis.
3. Anemia.
4. Tachycardia.
5. Electrolyte abnormalities.
6. Hepatitis.
7. Acute cholecystitis.
8. Pancreatitis.
9. Status post pulseless electrical activity arrest.
10. Tophaceous gout.
11. Hypothyroidism.

DISCHARGE MEDICATIONS:  None.

FOLLOW-UP PLAN:  None.




                          [**First Name4 (NamePattern1) 460**] [**Last Name (NamePattern1) 461**], MD

Dictated By:[**Last Name (NamePattern1) 7003**]

MEDQUIST36

D:  [**2126-6-11**]  10:28
T:  [**2126-6-14**]  11:49
JOB#:  [**Job Number 7004**]
{'Unspecified septicemia,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Gouty tophi of other sites, except ear,Acute respiratory failure,Acute and subacute necrosis of liver,Disseminated candidiasis,Defibrination syndrome'}


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: 

PRESENT ILLNESS: This is an 81-year-old with no
significant past medical history who is transferred from [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] Hospital for anemia, melena, acute renal failure and
rule in myocardial infarction.  This is an 81-year-old with
no medical history except for tophaceous gout who was in her
usual state of excellent health until three days prior to
admission when after lunch, she laid down because she did not
feel well.  She sleeps in a different room from her husband,
with whom she lives.  When he asked her later that evening
how she was, she said she was fine.  The next day, she
continued to remain in bed.  He offered her some [**Location (un) 2452**]
juice, which she drank, but she was slowly becoming more
confused and lethargic.  On the third day, she was barely
arousable and incoherent.  He called EMS who found her to be
"incontinent of urine."  She was taken to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Hospital where she was lethargic, oliguric and confused.  She
had a rectal temperature of 87 degrees.  Her pulse was 80
with a systolic blood pressure of 72-135.  She was found to
be guaiac positive with a fingerstick of 38.  Her white blood
cell count was 17.1, 87% neutrophils, 14% bands, 4%
lymphocytes and 2% monocytes.  Her hematocrit was found to be
16.1.  He platelet count was 100,000.  Her Chem-7 revealed a
sodium of 148, potassium 4.8, chloride 118, bicarbonate 15,
BUN 83 and creatinine 2.5.  Her CK was 499 with an MB of 60
and an index of 12.  Her INR was 2.6.  Blood cultures times
two were negative.  A head CT was performed which showed
enlarged ventricles, but was otherwise negative.  She was
resuscitated and given two units of packed red blood cells.
She was warmed to a rectal temperature of 94 and transferred
to [**Hospital6 256**] for further care.

MEDICAL HISTORY: Tophaceous gout.

MEDICATION ON ADMISSION: 

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: 

FAMILY HISTORY: A sibling with diabetes.

SOCIAL HISTORY: No tobacco or alcohol use.  Never visited a
doctor.  Lives with her husband in [**Name (NI) 13011**].  Does the
banking, and shopping and cooking.  Is very active at home,
taking care of her husband of the past 60 years. 

### Response:
{'Unspecified septicemia,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute pancreatitis,Acute kidney failure with lesion of tubular necrosis,Gouty tophi of other sites, except ear,Acute respiratory failure,Acute and subacute necrosis of liver,Disseminated candidiasis,Defibrination syndrome'}
