CHIEF COMPLAINT: confusion

PRESENT ILLNESS: History obtained from [**Name (NI) **], pt's father and records from [**Hospital 28941**]. Patient is a poor historian.
.
Mr. [**Known lastname **] is a 35 year old right handed man with a history of
hypertension and gout, who was in a GSOGH until 4 days ptp when
he developed rhinorrhea, fevers to 102, L foot pain (which the
patient attributed to gout), decreased appetite and po intake x
3-4 days.  (Pt usually has a v good appetite). No sore throat or
cough. His parents thought that he had the flu.  He treated his
sx with otc meds including tylenol. Parents do not report
diarrhea but OSH ED notes do, nausea or emesis. On the morning
PTP he reported strange dreams - being a pitcher in baseball
game and strange comments "I've got to rest up and go to spring
training with the Red Sox" but pt is not a baseball fan. "He
also couldn't put a sentence together and was lethargic". He had
one episode of incontinence of stool on the day prior to
presentation. Reported L shoulder pain x 2 days with difficulty
lifting it, but no headache, vomiting, or stiff neck.  He was
confused -along with comments liste above he also had a change
in personality such that he was distant, much less tallkative
than at baseline the morning ptp per his parents, with whom he
lives, and was so weak that he could not come down the stairs of
his house.  They didn't notice any particular focal weakness of
arms or legs but they had to give him step by step commands to
move each extremity in order to enable him to come down the
stairs. His parents called EMS and he was brought to [**Hospital3 **].
His vitals on presentation were: 121/70, HR = 68->111, RR = 18
and T = 99  -> 101 with O2 sat = 99% on RA. ECG demonstrated
sinus tachycardia in the 120's, as well as LVH.  His K was 2.0.
He had an LP there that revealed (in tube 3) 170 WBC (91 PMNs 2
Lymph, 7 Mono), 18 RBC, Prot 52, and Gluc 81. Gram stain was
negative.  Serum glucose at the time was 162.  HSV PCR, Lyme ab
and VDRL was sent on the CSF. Other notable labs included wbc of
13 with 87% PMNs and 3.4 lymphs, sodium of 125, K of 2.6, BUN of
28, and Cr of 1.6.  Lyme antibodies were sent as well and are
pending.  He had a head CT there that revealed areas of
hypodensity in the right frontal lobe and in both thalami.
Prior to transfer to [**Hospital1 18**], he was given acyclovir 800 mg,
ceftriaxone, and potassium.
In the ED he was given given vancomycin 1 g, Hydrocortisone 500
mg, Acyclovir 800 mg IV, Lorazepam 2mg IV prior to MRI
.
He has no history of recent travel, no ill contacts, and no
known
history of tick bites.  He has no known history of
immunosupression.
.
ROS per father Mr. [**Known lastname **]
[**Last Name (Titles) **] night sweats or recent weight loss or gain. Denied headache,
sinus tenderness, denied cough, shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, + constipation, no abdominal pain. No dysuria. + L
shoulder pain x 2 days- new never complained of shoulder paiin
previously. Grimaces when I touch base of R toe which is red and
erythematous- first noticed 1 day ptp by father. + rash on L
hand x 2days and rash on ankles x 1 day. No h/o recent trauma,
falls, seizures or headaches.

MEDICAL HISTORY: Hypertension
Gout- first episode 1 year ago - joint not tapped per patient
s/p R arm surgery after injury sustained during opening the day
in [**2139**]

MEDICATION ON ADMISSION: Atenolol 25 mg daily started 6-8 months ago
Tylenol prn for HA
No recent NSAID or abx use.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS Tm = 103.4 in ED Tc=99.8, P = 69-112, BP = 113-150s/40-80s
117/58 RR O2Sat = 90% on RA, 95% on 4L.
GENERAL: Young, ill appearing male, with rapid shallow
breathing.
HEENT: NC/AT, PERRL, EOMI without nystagmus, + injected sclerae
without scleral icterus noted, dry MM, no lesions noted in OP
Neck: supple- no mengismus, no JVD
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: tachy, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 1. "I'm in [**Hospital1 189**]. I'm in
[**Hospital1 3597**] NH"  "I haven't the faintest idea why I am at the [**Hospital1 **]"
-cranial nerves: II, III, IV, VI, X1, XII intact
-motor: normal bulk and tone throughout. No abnormal movements
noted. Strenght difficult to assess since pt could not obey
commands consistently.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor,
-DTRs: 2+ biceps, triceps, brachioradialis, 3+ R patellar and 2+
L patellar reflexes. Plantar response was flexor bilaterally.

FAMILY HISTORY: Father had TIA's in his 50's.  No migraines, seizures, learning
problems.
One brother aged 41 in good health. No nieces or nephews.

SOCIAL HISTORY: Lives with his parents in [**Location (un) 7661**] (lives with them due to
convenience-per parents at baseline is independently
functioning).  Employed in cellular phone sales- manager of cell
phone store x 6-8months- employed at the same company for 4
years.  Occasional cigar q week, 1-2 beers q months at most, per
friends no recreational drug use, including no IV drug use. Not
married without children. Last travel was to [**State 108**] in
[**Month (only) **]/[**2160-3-12**].  Since then in MA/[**Location (un) 5131**]. Does not spend
much time outdoors.  Practices archery in the backyard. Meets
with a group of friends who play board games q week. Completed
high school. Has taken classes at a local community college. No
pets. Aunt next door with a cat but does not visit her
regularly.
Acute and subacute bacterial endocarditis,Staphylococcal septicemia, unspecified,Other causes of encephalitis and encephalomyelitis,Pyogenic arthritis, forearm,Alkalosis,Thrombocytopenia, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Gout, unspecified,Unspecified essential hypertension
Ac/subac bact endocard,Staphylcocc septicem NOS,Enceph & encephlalo NEC,Pyogen arthritis-forearm,Alkalosis,Thrombocytopenia NOS,Mth sus Stph aur els/NOS,Gout NOS,Hypertension NOS
Admission Date:  [**2161-3-9**]              Discharge Date:   [**2161-3-17**]

Date of Birth:  [**2126-1-28**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
confusion

Major Surgical or Invasive Procedure:
left wrist aspiration
Trans-esophageal echocardiogram
PICC line placement


History of Present Illness:
History obtained from [**Name (NI) **], pt's father and records from [**Hospital 28941**]. Patient is a poor historian.
.
Mr. [**Known lastname **] is a 35 year old right handed man with a history of
hypertension and gout, who was in a GSOGH until 4 days ptp when
he developed rhinorrhea, fevers to 102, L foot pain (which the
patient attributed to gout), decreased appetite and po intake x
3-4 days.  (Pt usually has a v good appetite). No sore throat or
cough. His parents thought that he had the flu.  He treated his
sx with otc meds including tylenol. Parents do not report
diarrhea but OSH ED notes do, nausea or emesis. On the morning
PTP he reported strange dreams - being a pitcher in baseball
game and strange comments "I've got to rest up and go to spring
training with the Red Sox" but pt is not a baseball fan. "He
also couldn't put a sentence together and was lethargic". He had
one episode of incontinence of stool on the day prior to
presentation. Reported L shoulder pain x 2 days with difficulty
lifting it, but no headache, vomiting, or stiff neck.  He was
confused -along with comments liste above he also had a change
in personality such that he was distant, much less tallkative
than at baseline the morning ptp per his parents, with whom he
lives, and was so weak that he could not come down the stairs of
his house.  They didn't notice any particular focal weakness of
arms or legs but they had to give him step by step commands to
move each extremity in order to enable him to come down the
stairs. His parents called EMS and he was brought to [**Hospital3 **].
His vitals on presentation were: 121/70, HR = 68->111, RR = 18
and T = 99  -> 101 with O2 sat = 99% on RA. ECG demonstrated
sinus tachycardia in the 120's, as well as LVH.  His K was 2.0.
He had an LP there that revealed (in tube 3) 170 WBC (91 PMNs 2
Lymph, 7 Mono), 18 RBC, Prot 52, and Gluc 81. Gram stain was
negative.  Serum glucose at the time was 162.  HSV PCR, Lyme ab
and VDRL was sent on the CSF. Other notable labs included wbc of
13 with 87% PMNs and 3.4 lymphs, sodium of 125, K of 2.6, BUN of
28, and Cr of 1.6.  Lyme antibodies were sent as well and are
pending.  He had a head CT there that revealed areas of
hypodensity in the right frontal lobe and in both thalami.
Prior to transfer to [**Hospital1 18**], he was given acyclovir 800 mg,
ceftriaxone, and potassium.
In the ED he was given given vancomycin 1 g, Hydrocortisone 500
mg, Acyclovir 800 mg IV, Lorazepam 2mg IV prior to MRI
.
He has no history of recent travel, no ill contacts, and no
known
history of tick bites.  He has no known history of
immunosupression.
.
ROS per father Mr. [**Known lastname **]
[**Last Name (Titles) **] night sweats or recent weight loss or gain. Denied headache,
sinus tenderness, denied cough, shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, + constipation, no abdominal pain. No dysuria. + L
shoulder pain x 2 days- new never complained of shoulder paiin
previously. Grimaces when I touch base of R toe which is red and
erythematous- first noticed 1 day ptp by father. + rash on L
hand x 2days and rash on ankles x 1 day. No h/o recent trauma,
falls, seizures or headaches.

Past Medical History:
Hypertension
Gout- first episode 1 year ago - joint not tapped per patient
s/p R arm surgery after injury sustained during opening the day
in [**2139**]


Social History:
Lives with his parents in [**Location (un) 7661**] (lives with them due to
convenience-per parents at baseline is independently
functioning).  Employed in cellular phone sales- manager of cell
phone store x 6-8months- employed at the same company for 4
years.  Occasional cigar q week, 1-2 beers q months at most, per
friends no recreational drug use, including no IV drug use. Not
married without children. Last travel was to [**State 108**] in
[**Month (only) **]/[**2160-3-12**].  Since then in MA/[**Location (un) 5131**]. Does not spend
much time outdoors.  Practices archery in the backyard. Meets
with a group of friends who play board games q week. Completed
high school. Has taken classes at a local community college. No
pets. Aunt next door with a cat but does not visit her
regularly.

Family History:
Father had TIA's in his 50's.  No migraines, seizures, learning
problems.
One brother aged 41 in good health. No nieces or nephews.

Physical Exam:
VS Tm = 103.4 in ED Tc=99.8, P = 69-112, BP = 113-150s/40-80s
117/58 RR O2Sat = 90% on RA, 95% on 4L.
GENERAL: Young, ill appearing male, with rapid shallow
breathing.
HEENT: NC/AT, PERRL, EOMI without nystagmus, + injected sclerae
without scleral icterus noted, dry MM, no lesions noted in OP
Neck: supple- no mengismus, no JVD
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: tachy, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 1. "I'm in [**Hospital1 189**]. I'm in
[**Hospital1 3597**] NH"  "I haven't the faintest idea why I am at the [**Hospital1 **]"
-cranial nerves: II, III, IV, VI, X1, XII intact
-motor: normal bulk and tone throughout. No abnormal movements
noted. Strenght difficult to assess since pt could not obey
commands consistently.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor,
-DTRs: 2+ biceps, triceps, brachioradialis, 3+ R patellar and 2+
L patellar reflexes. Plantar response was flexor bilaterally.

Pertinent Results:
[**2161-3-9**] 05:00PM   WBC-14.8* RBC-4.56* HGB-13.3* HCT-38.2*
MCV-84 MCH-29.1 MCHC-34.7 RDW-14.6
[**2161-3-9**] 05:00PM   NEUTS-83* BANDS-3 LYMPHS-4* MONOS-10 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2161-3-9**] 05:00PM   PLT SMR-LOW PLT COUNT-105* LPLT-1+
[**2161-3-9**] 05:00PM   PT-14.5* PTT-27.3 INR(PT)-1.3*
[**2161-3-9**] 05:00PM   FIBRINOGE-936*
[**2161-3-9**] 05:00PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2161-3-9**] 05:00PM   GLUCOSE-129* UREA N-28* CREAT-1.3*
SODIUM-130* POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-22 ANION GAP-16
[**2161-3-9**] 05:00PM   ALT(SGPT)-69* AST(SGOT)-89* ALK PHOS-123* TOT
BILI-1.1
[**2161-3-9**] 05:00PM   ALBUMIN-3.1* CALCIUM-7.7* PHOSPHATE-1.8*
MAGNESIUM-2.3
[**2161-3-9**] 05:56PM   LACTATE-1.5
.


Brief Hospital Course:
35 y.o. male with htn, gout p/w altered mental status, fever,
diarrhea, uri sx x 6 days now found to have MSSA bacteremia with
MV vegetation.

MSSA endocarditis: The patient developed septic emboli to the
brain, liver and joits.  He had altered mental status and
neurology was consulted.  His liver enzymes were elevated but
trended down during his hospital stay.  The patient also had
swollen joints and had an aspiration of his left wrist done by
orthopedics but did not require a washout in the OR.  A repeat
TEE was performed which showed resolution of the vegitation but
persistent regurgitation.  The patient was treated with
nafcillin and gentamycin but the gentamycin was discontinued.
ID was consulted to assist with medical managment.  An MRI spine
was done but did not reveal osteomyleitis or abscess.  Serial
blood cultures were negative.  A PICC line was placed and the
patient was discharged on IV nafcillin.

# Altered Mental Status probably secondary to septic emboli to
brain.  Neurology was consulted and followed the patient during
the hospital course.  The patient's mental status and strength
improved during the hospital course.  PT worked with the patient
and cleared him for home discharge.

Medications on Admission:
Atenolol 25 mg daily started 6-8 months ago
Tylenol prn for HA
No recent NSAID or abx use.

Discharge Medications:
1. Outpatient Lab Work
Please have a complete blood count (CBC), BUN, creatinine and
liver function tests (LFT's) drawn weekly.  Please fax the
results to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) **].
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: One (1) 2 grams
Intravenous Q4H (every 4 hours) for 6 weeks.
Disp:*qs * Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 511**] Home Therapies

Discharge Diagnosis:
MSSA Endocarditis with septic emboli


Discharge Condition:
Stable, afebrile, improved mental status


Discharge Instructions:
You were diagnosed with endocarditis with septic emboli.  You
ahve been and will be treated with antibiotics for a long
course.

Rest, drink plenty of fluids, take all medications as
prescribed.

Call your primary care provider or return to the emergency
department for any of the following:
Fever >101.4, chills, chest pain, shortness of breath, new
weakness or changes in sensation, inability to control bowel or
bladder, seizures, worsening joint pain or swelling, nausea,
vomiting, diarrhea, abdominal pain, changes in mental status or
other concerning symptoms.

Please keep your PICC line clean and dry.  If the PICC line
begins to come out, please call your primary care provider, [**Name10 (NameIs) **]
infectious disease physician or return to the emergency
department.

We changed your medications while you were in the hospital.  We
discontinued the atenolol and started lisinopril for your
hypertension.  Please see your primary care provider in the next
two weeks for any further adjustments in your medications.

Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2161-3-30**] 4:00

Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2161-4-20**] 10:30

Follow up with your primary care provider Dr [**Last Name (STitle) **] in two weeks.
{'Acute and subacute bacterial endocarditis,Staphylococcal septicemia, unspecified,Other causes of encephalitis and encephalomyelitis,Pyogenic arthritis, forearm,Alkalosis,Thrombocytopenia, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Gout, unspecified,Unspecified essential hypertension'}


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: confusion

PRESENT ILLNESS: History obtained from [**Name (NI) **], pt's father and records from [**Hospital 28941**]. Patient is a poor historian.
.
Mr. [**Known lastname **] is a 35 year old right handed man with a history of
hypertension and gout, who was in a GSOGH until 4 days ptp when
he developed rhinorrhea, fevers to 102, L foot pain (which the
patient attributed to gout), decreased appetite and po intake x
3-4 days.  (Pt usually has a v good appetite). No sore throat or
cough. His parents thought that he had the flu.  He treated his
sx with otc meds including tylenol. Parents do not report
diarrhea but OSH ED notes do, nausea or emesis. On the morning
PTP he reported strange dreams - being a pitcher in baseball
game and strange comments "I've got to rest up and go to spring
training with the Red Sox" but pt is not a baseball fan. "He
also couldn't put a sentence together and was lethargic". He had
one episode of incontinence of stool on the day prior to
presentation. Reported L shoulder pain x 2 days with difficulty
lifting it, but no headache, vomiting, or stiff neck.  He was
confused -along with comments liste above he also had a change
in personality such that he was distant, much less tallkative
than at baseline the morning ptp per his parents, with whom he
lives, and was so weak that he could not come down the stairs of
his house.  They didn't notice any particular focal weakness of
arms or legs but they had to give him step by step commands to
move each extremity in order to enable him to come down the
stairs. His parents called EMS and he was brought to [**Hospital3 **].
His vitals on presentation were: 121/70, HR = 68->111, RR = 18
and T = 99  -> 101 with O2 sat = 99% on RA. ECG demonstrated
sinus tachycardia in the 120's, as well as LVH.  His K was 2.0.
He had an LP there that revealed (in tube 3) 170 WBC (91 PMNs 2
Lymph, 7 Mono), 18 RBC, Prot 52, and Gluc 81. Gram stain was
negative.  Serum glucose at the time was 162.  HSV PCR, Lyme ab
and VDRL was sent on the CSF. Other notable labs included wbc of
13 with 87% PMNs and 3.4 lymphs, sodium of 125, K of 2.6, BUN of
28, and Cr of 1.6.  Lyme antibodies were sent as well and are
pending.  He had a head CT there that revealed areas of
hypodensity in the right frontal lobe and in both thalami.
Prior to transfer to [**Hospital1 18**], he was given acyclovir 800 mg,
ceftriaxone, and potassium.
In the ED he was given given vancomycin 1 g, Hydrocortisone 500
mg, Acyclovir 800 mg IV, Lorazepam 2mg IV prior to MRI
.
He has no history of recent travel, no ill contacts, and no
known
history of tick bites.  He has no known history of
immunosupression.
.
ROS per father Mr. [**Known lastname **]
[**Last Name (Titles) **] night sweats or recent weight loss or gain. Denied headache,
sinus tenderness, denied cough, shortness of breath. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
diarrhea, + constipation, no abdominal pain. No dysuria. + L
shoulder pain x 2 days- new never complained of shoulder paiin
previously. Grimaces when I touch base of R toe which is red and
erythematous- first noticed 1 day ptp by father. + rash on L
hand x 2days and rash on ankles x 1 day. No h/o recent trauma,
falls, seizures or headaches.

MEDICAL HISTORY: Hypertension
Gout- first episode 1 year ago - joint not tapped per patient
s/p R arm surgery after injury sustained during opening the day
in [**2139**]

MEDICATION ON ADMISSION: Atenolol 25 mg daily started 6-8 months ago
Tylenol prn for HA
No recent NSAID or abx use.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS Tm = 103.4 in ED Tc=99.8, P = 69-112, BP = 113-150s/40-80s
117/58 RR O2Sat = 90% on RA, 95% on 4L.
GENERAL: Young, ill appearing male, with rapid shallow
breathing.
HEENT: NC/AT, PERRL, EOMI without nystagmus, + injected sclerae
without scleral icterus noted, dry MM, no lesions noted in OP
Neck: supple- no mengismus, no JVD
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: tachy, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 1. "I'm in [**Hospital1 189**]. I'm in
[**Hospital1 3597**] NH"  "I haven't the faintest idea why I am at the [**Hospital1 **]"
-cranial nerves: II, III, IV, VI, X1, XII intact
-motor: normal bulk and tone throughout. No abnormal movements
noted. Strenght difficult to assess since pt could not obey
commands consistently.
-sensory: No deficits to light touch throughout.
-cerebellar: No nystagmus, dysarthria, intention or action
tremor,
-DTRs: 2+ biceps, triceps, brachioradialis, 3+ R patellar and 2+
L patellar reflexes. Plantar response was flexor bilaterally.

FAMILY HISTORY: Father had TIA's in his 50's.  No migraines, seizures, learning
problems.
One brother aged 41 in good health. No nieces or nephews.

SOCIAL HISTORY: Lives with his parents in [**Location (un) 7661**] (lives with them due to
convenience-per parents at baseline is independently
functioning).  Employed in cellular phone sales- manager of cell
phone store x 6-8months- employed at the same company for 4
years.  Occasional cigar q week, 1-2 beers q months at most, per
friends no recreational drug use, including no IV drug use. Not
married without children. Last travel was to [**State 108**] in
[**Month (only) **]/[**2160-3-12**].  Since then in MA/[**Location (un) 5131**]. Does not spend
much time outdoors.  Practices archery in the backyard. Meets
with a group of friends who play board games q week. Completed
high school. Has taken classes at a local community college. No
pets. Aunt next door with a cat but does not visit her
regularly. 

### Response:
{'Acute and subacute bacterial endocarditis,Staphylococcal septicemia, unspecified,Other causes of encephalitis and encephalomyelitis,Pyogenic arthritis, forearm,Alkalosis,Thrombocytopenia, unspecified,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Gout, unspecified,Unspecified essential hypertension'}
