CHIEF COMPLAINT: Chest pain

PRESENT ILLNESS: The patient is a 75-year-old
Russian speaking male with a past medical history significant
for coronary artery disease, status post myocardial
infarction in [**2143**], status post percutaneous transluminal
coronary angioplasty and stent to the LAD and left circumflex
in [**2152-10-21**] in [**Location (un) **] who presents with worsening
and more frequent episodes of chest pain.

MEDICAL HISTORY: 1.  Coronary artery disease.  The patient has had multiple
cardiac catheterizations with the most recent one being done
in [**Location (un) **] in [**2152-10-21**] at which time a stent was
placed in the LAD and left circumflex.  His most recent
catheter done at [**Hospital6 256**] prior
to this admission was in [**2151-4-22**].  That catheter showed
a 20% lesion in the left main, 50% in the LAD, 50% in the
left circumflex, previously placed stent which was deemed to
be hemodynamically insignificant and a 75% right coronal
artery lesion.  Most recent stress MIBI done in [**2151-4-22**]
showed ischemia in the inferolateral region.
2.  Benign prostatic hypertrophy
3.  Hypertension
4.  Hypercholesterolemia
5.  History of pancreatitis during his admission in [**Location (un) **]
for his cardiac catheterization
6.  Status post pacer placement in [**2148-12-22**] for sick
sinus syndrome which was upgraded in [**2152-12-22**] for
lead upgrades and generator change.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: VITAL SIGNS:  The patient was afebrile.  Blood pressure
117/78, heart rate of 52, respiratory rate 18, saturating
97%.
GENERAL:  The patient is alert and oriented x3 in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT:  Pupils equal, round and
reactive to light.  Extraocular movements intact.  There was
no jugular venous distention.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm, no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended.  There was no
hepatosplenomegaly.  There were normoactive bowel sounds.
EXTREMITIES:  Without cyanosis, clubbing or edema.  The PT
pulses were 2+ bilaterally.

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is originally from [**Country 532**].  He
has lived in the United States for approximately six years.
He speaks limited English.  He drinks occasional alcohol.  He
denies tobacco.  He is married.  He has one son who lives
nearby as well as a daughter who is a nurse [**First Name8 (NamePattern2) **] [**Name (NI) **].
Acute myocardial infarction of other anterior wall, initial episode of care,Other complications due to other vascular device, implant, and graft,Iatrogenic cerebrovascular infarction or hemorrhage,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Thrombocytopenia, unspecified,Coronary atherosclerosis of native coronary artery,Hemiplegia, unspecified, affecting unspecified side,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
AMI anterior wall, init,Comp-oth vasc dev/graft,Iatrogen CV infarc/hmrhg,Crbl emblsm w infrct,Food/vomit pneumonitis,Thrombocytopenia NOS,Crnry athrscl natve vssl,Unsp hemiplga unspf side,Abn react-cardiac cath
Admission Date:  [**2153-4-27**]       Discharge Date:  [**2153-5-10**]

Date of Birth:   [**2078-4-14**]       Sex:  M

Service:  [**Hospital1 **]

CHIEF COMPLAINT:  Chest pain

HISTORY OF PRESENT ILLNESS:  The patient is a 75-year-old
Russian speaking male with a past medical history significant
for coronary artery disease, status post myocardial
infarction in [**2143**], status post percutaneous transluminal
coronary angioplasty and stent to the LAD and left circumflex
in [**2152-10-21**] in [**Location (un) **] who presents with worsening
and more frequent episodes of chest pain.

The patient notes daily angina at rest, as well as when
exerting himself which is substernal in location without
radiation.  There was no associated nausea, vomiting,
diaphoresis or shortness of breath.  Prior to the day of
admission, the daily chest pain was responsive to 3 to 10
sublingual nitroglycerin per day, but over the last 24 hours
his chest pain has been refractory to nitroglycerin and so he
decided to come in.  Of note, the patient was seen by his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15490**], in clinic
approximately one weeks prior to admission where the increase
in his angina had been noted.  There was a plan for an
outpatient ETT and possible catheter pending those results.

REVIEW OF SYSTEMS:  Negative for any orthopnea or paroxysmal
nocturnal dyspnea.  There were no fevers or chills, nausea,
vomiting or diarrhea.  The patient denied any abdominal pain.

In the Emergency Room, the patient was afebrile and had
stable vital signs.  His electrocardiogram showed no acute
changes.  His chest pain was not responsive to three
sublingual nitroglycerin, but it completely resolved with 2
mg of morphine.

PAST MEDICAL HISTORY:
1.  Coronary artery disease.  The patient has had multiple
cardiac catheterizations with the most recent one being done
in [**Location (un) **] in [**2152-10-21**] at which time a stent was
placed in the LAD and left circumflex.  His most recent
catheter done at [**Hospital6 256**] prior
to this admission was in [**2151-4-22**].  That catheter showed
a 20% lesion in the left main, 50% in the LAD, 50% in the
left circumflex, previously placed stent which was deemed to
be hemodynamically insignificant and a 75% right coronal
artery lesion.  Most recent stress MIBI done in [**2151-4-22**]
showed ischemia in the inferolateral region.
2.  Benign prostatic hypertrophy
3.  Hypertension
4.  Hypercholesterolemia
5.  History of pancreatitis during his admission in [**Location (un) **]
for his cardiac catheterization
6.  Status post pacer placement in [**2148-12-22**] for sick
sinus syndrome which was upgraded in [**2152-12-22**] for
lead upgrades and generator change.

ADMISSION MEDICATIONS:
1.  Aspirin 325 mg po q day
2.  Lipitor 40 mg po q day
3.  Prevacid 30 mg po q day
4.  Prinivil 5 mg po q day
5.  Toprol XL 25 mg po q day

ALLERGIES:  The patient has no known drug allergies.

SOCIAL HISTORY:  The patient is originally from [**Country 532**].  He
has lived in the United States for approximately six years.
He speaks limited English.  He drinks occasional alcohol.  He
denies tobacco.  He is married.  He has one son who lives
nearby as well as a daughter who is a nurse [**First Name8 (NamePattern2) **] [**Name (NI) **].

PHYSICAL EXAM:
VITAL SIGNS:  The patient was afebrile.  Blood pressure
117/78, heart rate of 52, respiratory rate 18, saturating
97%.
GENERAL:  The patient is alert and oriented x3 in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT:  Pupils equal, round and
reactive to light.  Extraocular movements intact.  There was
no jugular venous distention.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm, no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended.  There was no
hepatosplenomegaly.  There were normoactive bowel sounds.
EXTREMITIES:  Without cyanosis, clubbing or edema.  The PT
pulses were 2+ bilaterally.

ADMISSION LABS:  White count of 7.2, hematocrit of 47.3, MCV
of 88, platelets of 173, PT of 12.4, INR 1.1, PTT of 25.
Sodium of 144, potassium of 4.0, chloride of 110, bicarbonate
of 24, BUN of 19, creatinine of 1.0, glucose of 113, CK of
130, MB of 3, troponin less than 0.3.  Electrocardiogram -
most recent cholesterol in [**2153-4-21**] showed total
cholesterol of 169, LDL of 102, HDL of 48.  Electrocardiogram
showed normal sinus rhythm at 51 beats per minute with normal
axis and normal intervals, except for slight prolongation of
the QRS at 124 milliseconds.  There were no acute ST or T
wave changes.

HOSPITAL COURSE:  In summary, the patient is a 75-year-old
male with significant coronary artery disease who is admitted
for worsening chest pain.  There was concern for possible in
stent restenosis given the patient's recent cardiac
catheterization in [**2152-10-21**].  The patient was
admitted for rule out myocardial infarction.

1.  CARDIOVASCULAR:  The patient was admitted as already
stated and his cardiac enzymes were cycled.  Over the first
24 hours, the patient's CKs remained flat at 130 to 125 to
156, however the MB fraction went from3 to 6 to 9.
Initially, it was unclear whether the patient did have
unstable angina or not given that his enzymes were not
positive and his initial troponin was less than 0.3 despite
over one day of chest pain at home unresponsive to
nitroglycerin.  In addition, there was a confounding lab
discovery of acute pancreatitis and it was felt that this may
explain the patient's pain as well.  A repeat troponin on the
second hospital day came back positive at 4.4.  At that time,
cardiology was consulted for cardiac catheterization given
the fact that the evidence was now showing the patient was
having unstable angina.

Cardiology saw the patient in the morning and recommended
that the patient undergo cardiac catheterization that same
day.  However, the patient refused this procedure and wanted
to wait.  The urgency was stressed with the patient, but he
still refused the procedure.  He was started on an Integrilin
drip, as well as nitroglycerin and heparin drip.  He was
continued on his beta blocker and ACE inhibitor.  The hope
was that his family could convince him to undergo cardiac
catheterization and the medications would help protect
against further cardiac damage.  The patient was chest pain
free with the above interventions, however his platelets
dropped after being on the Integrilin drip for 24 hours and
therefore the Integrilin had to be discontinued.

The importance of cardiac catheterization was again stressed
with the patient and his daughter was [**Name (NI) 653**] and he
finally agreed to go to cardiac catheterization.  He was
scheduled to on Monday morning, the fourth hospital day and
he was stable until Monday morning.  However, prior to being
transported for catheter, he then developed severe [**8-30**]
substernal chest pain and was rushed to catheterization
emergently.  At catheterization, he was found to have 100%
restenosis of his LAD stent, as well as 99% occlusion of the
tube.

He also had 40% proximal in stent stenosis in the left
circumflex artery as well as 50% distal occlusion in the left
circumflex.  He also had 70% calcified mid RCA lesion at 60%,
posterolateral RCA lesion.  The LAD was restented with good
results.  However, the patient did suffer an acute anterior
myocardial infarction prior to catheterization with his CK
peaking at 1334.  His electrocardiogram evolved with eventual
development of Qs in leads V2 through V6.

After cardiac catheterization, the patient was scheduled to
return to the general medical floor, but suffered recurrent
chest pain in the recovery suite.  Therefore, he was rushed
back into catheter for a re-look.  There were no significant
changes during the re-look procedure and no additional
interventions were made.  The patient was then transferred to
the CCU for closer monitoring given his unstable nature and
large anterior myocardial infarction.

The patient initially did well after his cardiac
catheterization, however did have intermittent chest pain
with no electrocardiogram changes.  However, two days after
cardiac catheterization the patient was found to be
unresponsive to voice, tactile or noxious stimuli.  An
emergent head CT was performed (an MRI could not be performed
given the patient's pacemaker as well as recent stent
placement) and it showed no evidence of a bleed, but possible
new stroke in the thalamic region.

From a cardiac standpoint, the patient has been stable
following his catheterization.  His blood pressure
medications were held for a period given his acute stroke,
but has since been restarted at low doses.  His blood
pressure goal at this point is around a systolic of 120.  He
had an echocardiogram performed after his cardiac
catheterization and acute myocardial infarction and his
ejection fraction was found to be down to only 25%.  There
was severe depression of overall left ventricular systolic
function.  There was severe global hypokinesis with some
preservation of the basal wall motion.  This was new compared
with prior echocardiogram.  There was no evidence of left
ventricular thrombus.

Given the patient's new depressed ejection fraction, he was
started on a low dose of Lasix to prevent congestive heart
failure.  He was on 20 mg po q day.  However, on the day of
this discharge summary this has been held as the patient
appears to be getting too dry with this dose.  He likely will
need to be on a lesser dose, possibly 20 mg po q o day.

The patient is on Plavix 75 mg for one month given his stent
placement.  He is also to continue on aspirin 325 mg q day.

2.  NEUROLOGIC:  As already stated, the patient suffered an
acute stroke on [**2153-5-2**].  The stroke was felt to be
most likely embolic in origin possibly from plaque that had
been dislodged during the cardiac catheterization.
Neurologic exam immediately after the event showed the
patient to have no eye opening.  He was spontaneously
breathing with a normal pattern.  There was no blink to
threat.  The right pupil was 6 mm and fixed.  The left pupils
was 1 mm and could not be assessed for reactivity given how
small it was.  There was sluggish response to the doll's
maneuver, but the patient was able to cross midline
bilaterally.  There was no facial asymmetry to grimace.  The
patient withdrew both arms to nail bed pressure and lifted
them off the bed briefly with at least antigravity power to
the deltoids.  He withdrew his left leg and pulled his heel
back all the way to the buttocks.  His right leg was
externally rotated and withdrew a few inches.  His plantar
responses were noted to be flexor initially.

As already stated, his blood pressure was initially run
higher or attempted to be run higher at greater than 140 by
holding his blood pressure medications.  Despite holding his
blood pressure medications however, his blood pressure was
never above the 120 to 130 range.  He was started on
Coumadin, both given his low ejection fraction as well as to
help prevent against future cerebral events.  He was
continued on heparin as a bridge.  His exam was followed
closely.

At the time of this discharge summary, the patient has
improved in regards to his neurologic status.  Most recent
neurologic exam performed with an interpreter shows the
patient to be somnolent, but arousable to loud stimuli.  He
will open his eyes intermittently on the left.  He follows
some simple commands such as sticking out his tongue or
showing two fingers or wiggling his toes.  He can answer
simple questions.  However, his speech was noted to be
severely dysarthric.  He is noted to have a left hemiparesis,
including face, arms and legs.  He also has frontal release
signs consistent with possible underlying dementia.

At the time of this discharge summary, we are repeating a
head CT to evaluate extent of the stroke and we are starting
low dose methylphenidate at 5 mg to see if this will help
with the patient's attention and arousability.  The neurology
team feels that the patient has a good prognosis given his
degree of recovery in only a few days.  At the time of this
discharge summary, the patient's blood pressure has been
allowed to be lower, given that it has been approximately one
week since the event.

3.  PULMONARY:  The patient was noted to have developed a
pneumonia during the time of his stroke.  It was felt to be
likely secondary to aspiration.  He was started on Levaquin
and Flagyl and on [**5-10**] he was on day 9 of 14.  He is
still having thick secretions, but is improving overall.  He
is requiring only 2 liters of oxygen at this point and has
been on room air during the day saturating 95% requiring
oxygen only at night.

4.  GASTROINTESTINAL:  An nasogastric tube was placed for
tube feeds, given that the patient was not able to feed
himself.  Gastrointestinal was consulted for possible PEG
placement given that this will likely be a long term need for
the patient.  They did not feel comfortable placing a PEG
given that the patient cannot be taken off Plavix for 30 days
given his high risk for restenosis.  A pediatric nasogastric
tube was placed on [**5-9**] in interventional radiology.
The issue with the nasogastric tube is that the patient
continues to grab at it when his hands are unrestrained.  At
the time of this discharge summary, we are going to attempt
mittens to see if this will prevent the patient from pulling
out the tube.

In addition, we will see if interventional radiology would be
willing to put in the PEG despite having Plavix on board.  If
there was no way to place a PEG, then this would have to be
done when his course of Plavix is finished.

5.  HEME:  The patient had [**Last Name **] problem in regards to his
hematocrit.  His platelets, which had dropped when he was on
the 2B3A have recovered.  His most recent hematocrit was 41.9
with most platelets of 246.  His Coumadin is currently being
held given the possibility of invasive procedures.  He is
being heparinized.

6.  FLUIDS, ELECTROLYTES AND NUTRITION:  The patient is on
ProMod with fiber at 75 cc an hour with 200 cc free water
boluses 4x daily.

DISCHARGE CONDITION:  Fair

DISCHARGE MEDICATIONS:
1.  Captopril 6.25 mg po tid, holding for systolic blood
pressure less than 110
2.  Levaquin 500 mg per nasogastric tube 24 hours, day 9 of
14
3.  Flagyl 500 mg per nasogastric tube tid, day 9 of 14
4.  Ritalin 5 mg po q a.m.
5.  Metoprolol 12.5 mg po bid, holding for systolic pressure
less than 110 and heart rate less tan 55.
6.  Tylenol prn
7.  Lipitor 40 mg po q day
8.  Plavix 75 mg po q day for 30 days stated on [**4-30**]
9.  Senna two tablets q hs
10. Prevacid 30 mg po q day
11. Colace 100 mg [**Hospital1 **]
12. Coumadin dose to be determined with an INR goal of 2 to 3
13. Heparin sliding scale
14. Aspirin 325 glioblastoma multiforme po q day, currently
on hold for possible PEG placement.  It has been on hold
since [**5-8**].
15. Lasix 20 mg po q od

DISCHARGE DIAGNOSES:
1.  Coronary artery disease, status post acute myocardial
infarction
2.  LAD, in stent restenosis status post new stent placement
in the LAD on [**4-30**]
3.  Hypercholesterolemia
4   Aspiration pneumonia
5.  Acute cerebrovascular accident to the right thalamus




                            [**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.  [**MD Number(1) 3475**]

Dictated By:[**Last Name (NamePattern1) 6859**]
MEDQUIST36

D:  [**2153-5-10**]  11:46
T:  [**2153-5-10**]  11:41
JOB#:  [**Job Number 47275**]


Name:  [**Known lastname 15086**], [**Known firstname 15087**]                     Unit No:  [**Numeric Identifier 15088**]

Admission Date:  [**2153-4-27**]     Discharge Date:  [**2153-5-11**]

Date of Birth:   [**2078-4-14**]     Sex:  M

Service:  .

ADDENDUM:

1.  Genitourinary:  On the day prior to discharge, the
patient developed hematuria and passage of clots without a
Foley catheter in place.  His PTT at the time was 87 (goal
was 60 to 100).  A three-way Foley catheter was placed with
one liter of urine immediately draining.  Urology saw the
patient.

The patient has a questionable history of a bladder mass
which was resected in [**2142**] (noted in an Operative Note but no
pathology specimens available), by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2143**].  He
also had a transurethral resection of the prostate at that
time.  He also has a history of bladder calculi (uric acid)
and hematuria in [**2147**] with negative cytology at that time.

Urology irrigated the bladder and there were no further clots
present.  He was not placed on continuous irrigation.  He was
noted to have one liter of urine in the bladder so is likely
retaining urine, (although last void is not known as the
patient is incontinent).  The hematuria is likely due to
either previous irritation of Foley catheter, recurrent
stones, or recurrent tumor.  Urology recommends outpatient
abdominal/pelvic CT scan and cystoscopy when the patient is
stable from a neurologic/cardiac standpoint.

He should keep the Foley catheter in place for at least one
week (given the question of retention), with then close
monitoring of urine output and post-void residuals.  A
heparin sliding scale was adjusted to a goal PTT of 60 to 80.
His hematocrit has remained stable despite the bleeding.

2.  Gastrointestinal:  The patient has been found to have
occult blood positive stools.  He had polyps removed in [**2150**]
and his primary care physician had planned on scheduling an
outpatient colonoscopy this year.  He can have this done when
he is stabilized from a neurologic/cardiac standpoint.

He will continue with the pediatric NG tube until his Plavix
can be discontinued on [**2153-5-30**], and he will have a PEG
placed at that time if he is still not taking anything by
mouth.  He appears to be tolerating the pediatric NG tube at
this time.

3.  Neurologic:  His repeat head CT scan done on [**2153-5-10**], showed bilateral thalamic foci with new attenuation
lesions in the right occipital lobe.  The old right thalamic
lesion is slightly larger than in the previous CT scan.
Neurology feels this is evolution of his previous stroke.
There has been no new events.  He will continue with
neurologic rehabilitation as well as aspirin, Coumadin for
secondary prevention.  He will continue on Ritalin at 5 mg
p.o. q. day.  He will follow-up with Neurology after his
discharge from rehabilitation.

DISCHARGE MEDICATIONS:   Same as in original summary with the
following exceptions.
1.  Restart aspirin now on the day of discharge as he is not
going to have any further invasive procedures.
2.  Restart Coumadin in one to two days if this hematuria
stabilizes with the goal INR of 2.0 to 3.0.



                          DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-929

Dictated By:[**Dictator Info **]

MEDQUIST36

D:  [**2153-5-11**]  14:07
T:  [**2153-5-14**]  15:16
JOB#:  [**Job Number **]
{'Acute myocardial infarction of other anterior wall, initial episode of care,Other complications due to other vascular device, implant, and graft,Iatrogenic cerebrovascular infarction or hemorrhage,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Thrombocytopenia, unspecified,Coronary atherosclerosis of native coronary artery,Hemiplegia, unspecified, affecting unspecified side,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: Chest pain

PRESENT ILLNESS: The patient is a 75-year-old
Russian speaking male with a past medical history significant
for coronary artery disease, status post myocardial
infarction in [**2143**], status post percutaneous transluminal
coronary angioplasty and stent to the LAD and left circumflex
in [**2152-10-21**] in [**Location (un) **] who presents with worsening
and more frequent episodes of chest pain.

MEDICAL HISTORY: 1.  Coronary artery disease.  The patient has had multiple
cardiac catheterizations with the most recent one being done
in [**Location (un) **] in [**2152-10-21**] at which time a stent was
placed in the LAD and left circumflex.  His most recent
catheter done at [**Hospital6 256**] prior
to this admission was in [**2151-4-22**].  That catheter showed
a 20% lesion in the left main, 50% in the LAD, 50% in the
left circumflex, previously placed stent which was deemed to
be hemodynamically insignificant and a 75% right coronal
artery lesion.  Most recent stress MIBI done in [**2151-4-22**]
showed ischemia in the inferolateral region.
2.  Benign prostatic hypertrophy
3.  Hypertension
4.  Hypercholesterolemia
5.  History of pancreatitis during his admission in [**Location (un) **]
for his cardiac catheterization
6.  Status post pacer placement in [**2148-12-22**] for sick
sinus syndrome which was upgraded in [**2152-12-22**] for
lead upgrades and generator change.

MEDICATION ON ADMISSION: 

ALLERGIES: The patient has no known drug allergies.

PHYSICAL EXAM: VITAL SIGNS:  The patient was afebrile.  Blood pressure
117/78, heart rate of 52, respiratory rate 18, saturating
97%.
GENERAL:  The patient is alert and oriented x3 in no acute
distress.
HEAD, EARS, EYES, NOSE AND THROAT:  Pupils equal, round and
reactive to light.  Extraocular movements intact.  There was
no jugular venous distention.
LUNGS:  Clear to auscultation bilaterally.
HEART:  Regular rate and rhythm, no murmurs, rubs or gallops.
ABDOMEN:  Soft, nontender, nondistended.  There was no
hepatosplenomegaly.  There were normoactive bowel sounds.
EXTREMITIES:  Without cyanosis, clubbing or edema.  The PT
pulses were 2+ bilaterally.

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is originally from [**Country 532**].  He
has lived in the United States for approximately six years.
He speaks limited English.  He drinks occasional alcohol.  He
denies tobacco.  He is married.  He has one son who lives
nearby as well as a daughter who is a nurse [**First Name8 (NamePattern2) **] [**Name (NI) **]. 

### Response:
{'Acute myocardial infarction of other anterior wall, initial episode of care,Other complications due to other vascular device, implant, and graft,Iatrogenic cerebrovascular infarction or hemorrhage,Cerebral embolism with cerebral infarction,Pneumonitis due to inhalation of food or vomitus,Thrombocytopenia, unspecified,Coronary atherosclerosis of native coronary artery,Hemiplegia, unspecified, affecting unspecified side,Cardiac catheterization as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
