CHIEF COMPLAINT: hypotension

PRESENT ILLNESS: Ms. [**Known lastname 23333**] is a [**Age over 90 **] year old woman with history of coronary
artery disease presented on [**5-22**] with anorexia, emesis x 2,
right-sided abdominal pain, malaise, and fatigue. She was noted
to have a mildly elevated white count of 13.6K. She had a RUQ
ultrasound in the ED which demonstrated moderate amount of
sludge with few shadowing stones in the gall bladder. A
presumptive diagnosis of acute cholecystitis was made, and she
was admitted to the surgical service. She was started on
ciprofloxacin and metronidazole. She was seen by GI (Dr.
[**Last Name (STitle) 15831**] during the admission, who recommended conservative
management and consideration of elective cholecystectomy as an
outpatient. Her blood pressures on [**5-23**] ranged 110-147/53-82,
and on [**5-24**] ranged 132-180/73-91. She had increased RUQ pain the
morning of [**5-24**], and then triggered the night of [**5-24**] for
tachycardia to the 140's and hypoxia to 80% on room air. Cardiac
enzymes were checked, and the first set was elevated (troponin
0.11, CK at that time 82). Second set was elevated as well (T
0.22, CK 103). Cardiology was consulted. Of note, she was
consented for laparascopic cholecystectomy this morning. The
morning of admission, she again triggered for hypotension
(80/46), heart rate 56. She was given her usual dose of
metoprolol (12.5mg) this morning. On arrival to the [**Hospital Unit Name 153**], she is
confused, tachypneic, and pale appearing. No further review of
systems was obtained from the patient. Per the family, she had
been complaining of back pain

MEDICAL HISTORY: - Hypercholesterolemia
- Coronary artery disease
- Asthma
- Osteoarthritis

MEDICATION ON ADMISSION: Medications on transfer from ICU:
- Heparin 5000 units SC TID
- Hydrocodone-Acetaminophen [**1-7**] Tab PO Q6H:PRN
- Acetaminophen 1000mg PO Q6H:PRN
- Metoprolol Tartrate 12.5 mg PO BID
- Albuterol Inhaler [**1-7**] PUFF IH Q4H:PRN SOB/cough/wheeze
- Metronidazole (FLagyl) 500 mg IV Q8H
- Aspirin 81 mg PO DAILY
- Morphine Sulfate 1 mg IV Q2H:PRN breakthrough pain
- Atorvastatin 10 mg PO DAILY
- Omeprazole 20 mg PO DAILY
- Citalopram Hydrobromide 20 mg PO DAILY
- Ciprofloxacin 200 mg IV Q12H
- Donepezil 5 mg PO HS
- Docusate Sodium 100 mg PO BID
- Trazodone 50 mg PO HS
- Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]

ALLERGIES: Zoloft

PHYSICAL EXAM: Discharge PE

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No tobacco, EtOH. Daughter is [**Hospital1 93429**], has two other
daughters.
Streptococcal septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Septic shock,Subendocardial infarction, initial episode of care,Endocarditis, valve unspecified, unspecified cause,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute on chronic systolic heart failure,Severe sepsis,Hypovolemia,Coronary atherosclerosis of native coronary artery
Streptococcal septicemia,Acute respiratry failure,Acute kidney failure NOS,Septic shock,Subendo infarct, initial,Endocarditis NOS,Cholelith w ac cholecyst,Ac on chr syst hrt fail,Severe sepsis,Hypovolemia,Crnry athrscl natve vssl
Admission Date:  [**2163-5-23**]              Discharge Date:   [**2163-5-31**]


Service: MEDICINE

Allergies:
Zoloft

Attending:[**First Name3 (LF) 358**]
Chief Complaint:
hypotension

Major Surgical or Invasive Procedure:
intubation/extubation
bronchoscopy
PICC placement


History of Present Illness:
Ms. [**Known lastname 23333**] is a [**Age over 90 **] year old woman with history of coronary
artery disease presented on [**5-22**] with anorexia, emesis x 2,
right-sided abdominal pain, malaise, and fatigue. She was noted
to have a mildly elevated white count of 13.6K. She had a RUQ
ultrasound in the ED which demonstrated moderate amount of
sludge with few shadowing stones in the gall bladder. A
presumptive diagnosis of acute cholecystitis was made, and she
was admitted to the surgical service. She was started on
ciprofloxacin and metronidazole. She was seen by GI (Dr.
[**Last Name (STitle) 15831**] during the admission, who recommended conservative
management and consideration of elective cholecystectomy as an
outpatient. Her blood pressures on [**5-23**] ranged 110-147/53-82,
and on [**5-24**] ranged 132-180/73-91. She had increased RUQ pain the
morning of [**5-24**], and then triggered the night of [**5-24**] for
tachycardia to the 140's and hypoxia to 80% on room air. Cardiac
enzymes were checked, and the first set was elevated (troponin
0.11, CK at that time 82). Second set was elevated as well (T
0.22, CK 103). Cardiology was consulted. Of note, she was
consented for laparascopic cholecystectomy this morning. The
morning of admission, she again triggered for hypotension
(80/46), heart rate 56. She was given her usual dose of
metoprolol (12.5mg) this morning. On arrival to the [**Hospital Unit Name 153**], she is
confused, tachypneic, and pale appearing. No further review of
systems was obtained from the patient. Per the family, she had
been complaining of back pain


She had been admitted twice within the past year for
choledocholithiasis ([**8-/2162**] with two 8-10mm stones in CBD,
sphincterotomy/stent but no stone extractions; [**11/2162**] stone
extraction and stent removed).




Past Medical History:
- Hypercholesterolemia
- Coronary artery disease
- Asthma
- Osteoarthritis

Social History:
No tobacco, EtOH. Daughter is [**Hospital1 93429**], has two other
daughters.

Family History:
non-contributory

Physical Exam:
Discharge PE

General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Endotracheal tube
Lymphatic: Cervical WNL
Cardiovascular: RRR, no murmers appreciated
Resp: CTAB
Abdominal: Soft, Non-tender, Bowel sounds present
Skin:  Stage 1 decubitis ulcer
Neurologic: not oriented to city, place, month; sleepy but
arousable and conversant, responds to questions


Pertinent Results:
Admission labs:
[**2163-5-22**] 05:20PM   WBC-13.8*# RBC-4.33 HGB-13.1 HCT-38.2 MCV-88
MCH-30.3 MCHC-34.4 RDW-13.3
[**2163-5-22**] 05:20PM   NEUTS-87.7* LYMPHS-7.6* MONOS-4.0 EOS-0.5
BASOS-0.1
[**2163-5-22**] 05:20PM   ALT(SGPT)-17 AST(SGOT)-31 ALK PHOS-97 TOT
BILI-1.4
[**2163-5-22**] 05:20PM   GLUCOSE-133* UREA N-23* CREAT-1.0 SODIUM-141
POTASSIUM-4.5 CHLORIDE-102 TOTAL CO2-27 ANION GAP-17

Discharge labs:
WBC-8.8 RBC-3.05* Hgb-9.2* Hct-29.1* MCV-96 MCH-30.2 MCHC-31.7
RDW-13.9 Plt Ct-249
Glucose-89 UreaN-20 Creat-1.1 Na-141 K-4.1 Cl-107 HCO3-27
AnGap-11

CT abdomen [**5-26**]:

1. Evidence of acute cholecystitis, with progression of
inflammation since
[**5-22**]. There is increased distention, wall thickening and
stranding, and at least one intraluminal stone is seen. No
intra- or extra-hepatic biliary ductal dilatation.

2. An intraluminal oval rounded hypodense structure is seen near
the junction of the second and third portions of the duodenum,
previously hyperdense on a contrast-enhanced study (and
therefore possibly enhancing). The structure appears quite
hyperdense on the prior exam of [**5-22**]. The etiology is unclear.


There is no upstream duodenal dilation to suggest obstruction.
The
differential diagnosis includes atypical food particles/debris
(if not truly enhancing), polyp (if enhancing) and
neuroendocrine tumor is not excluded.

3. Small bilateral pleural effusions and associated atelectasis.


4. Circumscribed fluid attenuation structure in the right hilar
region as
described, likely representing a pericardial cyst.

TTE [**5-26**]:
The left atrium is dilated. Left ventricular wall thicknesses
and cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with moderate to severe
hypokinesis of the mid to distal inferior wall, inferolateral
wall and apex. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.

IMPRESSION: Moderate regional left ventricular systolic
dysfunction. Diastolic dysfunction. Mild aortic and moderate
mitral regurgitation. Moderate pulmonary artery systolic
hypertension. A pericardial cyst is not seen on this study.

MICROBIOLOGY
[**2163-5-24**] 9:35 pm BLOOD CULTURE
Blood Culture, Routine (Final [**2163-5-29**]):
      STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP.    FINAL
SENSITIVITIES.
         Sensitivity testing performed by Sensititre.
         CLINDAMYCIN <=0.12 MCG/ML.
      GRAM POSITIVE RODS.    UNABLE TO FURTHER IDENTIFY.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
                             |
CLINDAMYCIN-----------       S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------  0.06 S
VANCOMYCIN------------   <=1 S

   Aerobic Bottle Gram Stain (Final [**2163-5-26**]):
      GRAM POSITIVE COCCI IN CHAINS.
      REPORTED BY PHONE TO DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2163-5-26**] @ 3:00 PM.

   Anaerobic Bottle Gram Stain (Final [**2163-5-26**]):
      REPORTED BY PHONE TO DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ [**2154**],
[**2163-5-26**].
      GRAM POSITIVE ROD(S) CONSISTENT WITH CORYNEBACTERIUM AND

                           PROPIONIBACTERIUM SPECIES.

[**5-26**] and [**5-27**] blood cultures: no growth to date


Brief Hospital Course:
[**Age over 90 **]yF with significant cardiac history admitted with ?
cholecystitis, transferred to [**Hospital Unit Name 153**] for hypotension, hypoxia,
elevated white count.

#) Cholecystitis: Ms. [**Known lastname 23333**] has a history of
choledocholothiasis, and she had 2 ERCP procedures in [**2162**] with
no complications. She presented on [**5-22**] with symptoms of
anorexia, vomiting, R-sided abdominal pain, and CT scan and U/S
reports concerning for acute cholecystitis. She was admitted to
surgery, started on cipro/flagyl, and monitored with serial
exams as her functional status and comorbidities did not make
her a good candidate for surgery.  In the setting of her sepsis
(see below), surgery continued to opt for medical management and
her coverage was broadened to include vancomycin and zosyn
(started [**5-25**]).  Vancomycin was discontinued when the bacteremia
pathogen was identified (Strep milleri). Over the course of her
hospitalization, Ms. [**Known lastname 23333**] improved clinically with her
abdominal pain resolving and improving LFTs. She was discharged
with instructions to continue broad coverage for GI pathogens
with zosyn for 2 weeks, followed by a course of penicillin G
(renally dosed).

#) Sepsis: Ms. [**Known lastname 23333**] was triggered on [**5-24**] for increasing
temperature to 99.5, tachycardic to 140s, and increased O2
requirement, as well as hypotenstion.,  She was found to be
bacteremic with positive cultures growing Gram positive Strep
milleri. She had a CT torso to evaluate for source of infection,
which showed worsening cholecystitis. Her urine was clear at
that time. She was intubated and stabilized in the ICU, and was
transferred to the floor with all blood cultures from [**5-27**] being
negative at time of discharge.

Ms. [**Known lastname 23333**] also underwent an echocardiogram to evaluate for
endocarditis in the setting of bactermia. She was found to have
a thickend mitral valve leaflet. It was decided that she would
not be a good candidate for further imaging with
trans-esophageal echocardiogram, so she will be treated for a
6-week course of antibiotics for presumed endocarditis based on
TTE.

#) Respiratory failure: Ms. [**Known lastname 23333**] required intubation
secondary to respiratoy failure in the setting of sepsis and
NSTEMI. She had a clear x-ray.  She was gently diuresed, FiO2
and PEEP were downtitrated, she was given albuterol/ipratropium
MDIs for history of asthma.  She was easily extubated and
rapidly weaned down to minimal oxygen. Since being on the floor,
she has remained >95% on 2L nasal cannula and continues to
breath comfortably.

#) NSTEMI:  Ms. [**Known lastname 23333**] suffered NSTEMI while septic secondary
to increased demand.  Troponin peaked at .91, CK at 211.  Echo
showed moderate regional left ventricular systolic dysfunction,
diastolic dysfunction, mild aortic and moderate mitral
regurgitation. Moderate pulmonary artery systolic hypertension.
Cardiology evaluated her and recommended 3 days of heparin gtt
([**Date range (1) 83455**]).  She was continued on statin, ASA, and B blocker
with no plans for catheterization.

Given her depressed EF, ACEI was recommended once her BP was
able to tolerate an additional antihypertensive. She was
discharged with plans to add ACE-inhibitor when she can tolerate
and to increase statin to goal of 80mg as tolerated.

#) Anuria/acute renal failure: Creatinine peaked at 1.8 in the
setting of sepsis/hypovolemia.  Her creatinine improved with
fluid resuscitation and treatment of infection to 1.1 at time of
discharge.

#) Back pain: While on the floor, Ms. [**Known lastname 23333**] reported back
pain but was unable to localize location, did not have point
tenderness, and no neurologic deficits. This was most likely
musculoskeletal, so we treated with lidocaine patch and standing
Tylenol.  The posibility of epidural abscess from bacterial
seeding was discussed, but unlikely given exam findings.  MRI
should be considered for further evaluation if she has
hemodynamic decline or develops neurologic deficits.  Her
current planned treatment with 6 weeks of targeted antibiotics
would be appropriate for discitis/osteomyelitis as well.
Furthermore, she is a poor surgical candidate and we would
likely be managed conservatively. We were also concerned that
this pain was recurring in the setting of cholecystitis, but we
were treating with antibiotics and already determined that she
was a poor candidate for surgical intervention.

This new pain regimen was initiated on [**5-31**] so it will be
important to monitor for effectiveness on discharge.

She was discharged to [**Hospital **] [**Hospital **] rehab center in [**Location (un) 701**].

Medications on Admission:
Medications on transfer from ICU:
- Heparin 5000 units SC TID
- Hydrocodone-Acetaminophen [**1-7**] Tab PO Q6H:PRN
- Acetaminophen 1000mg PO Q6H:PRN
- Metoprolol Tartrate 12.5 mg PO BID
- Albuterol Inhaler [**1-7**] PUFF IH Q4H:PRN SOB/cough/wheeze
- Metronidazole (FLagyl) 500 mg IV Q8H
- Aspirin 81 mg PO DAILY
- Morphine Sulfate 1 mg IV Q2H:PRN breakthrough pain
- Atorvastatin 10 mg PO DAILY
- Omeprazole 20 mg PO DAILY
- Citalopram Hydrobromide 20 mg PO DAILY
- Ciprofloxacin 200 mg IV Q12H
- Donepezil 5 mg PO HS
- Docusate Sodium 100 mg PO BID
- Trazodone 50 mg PO HS
- Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]


Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.

2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
[**1-7**]  Inhalation twice a day as needed for shortness of breath or
wheezing.
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).

5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q8H (every 8 hours) for 8 days: end date
[**2163-6-8**].
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
9. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itching.
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
11. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAY ().
12. Docusate Sodium 50 mg/5 mL Liquid Sig: [**1-7**]  PO BID (2 times
a day).
13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
16. Penicillin G Pot in Dextrose 2,000,000 unit/50 mL Piggyback
Sig: One (1)  Intravenous every four (4) hours for 4 weeks:
first dose [**6-9**] after finishing Zosyn, last dose [**2163-7-7**].
17. Morphine 15 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain: breakthrough pain only, hold for
sedation, RR<10 or confusion.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
1. Cholecystitis

Secondary diagnosis
2. NSTEMI
3. Sepsis/Strep milleri bacteremia
4. Acute Renal Failure


Discharge Condition:
stable, breathing comfortably on 2L/NC, sleepy but arousable and
conversant


Discharge Instructions:
You were admitted to the hospital for cholecystitis (infection
of the gall bladder), and this was complicated by a blood
infection. Likely because of this infection, you had low blood
pressures and difficulty breathing. You required intubation in
the ICU, but you recovered with antibiotics, you were extubated,
and you were transferred to the floor.

Because of your extensive infection, you were too ill to have
surgery to remove your gall bladder.  You may consider
discussing this surgery with a surgeon when you are well and off
antibiotics.

Also because of your infection and low blood pressues, you
experienced a small heart attack while you were in the hospital.


We also saw evidence of possible infection in your heart valves.
This was probably from the infection in your blood. Because of
the infection of your valves, you will need antibiotic treatment
for 6 weeks.

Please take all medications as prescribed.  The following
changes were made to your medication regimen:
1) We started you on antibiotics. Please take Zosyn IV as
prescribed until WEDNESDAY [**6-8**]. After that, please take
Penicillin as prescribed for 4 weeks.
2) We discontinued your trazadone because you were very sleepy.
3) We started Tylenol and lidocaine patch for your pain.
4) We discontinued your Lasix because your blood pressure was
low.

If you develop worsening shortness of breath, difficlty
breathing, low blood pressures with systolic <90, fevers >101
degrees, or any other concerning symptoms, please seek medical
attention immediately.

Followup Instructions:
Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) **], 1
week after being discharged from rehab. You can call
[**Telephone/Fax (1) 61899**] to schedule an appointment.

Please keep the following scheduled appointment:
Provider: [**Name10 (NameIs) 28909**],[**Name11 (NameIs) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB)
Date/Time:[**2163-7-22**] 2:15



Completed by:[**2163-5-31**]
{'Streptococcal septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Septic shock,Subendocardial infarction, initial episode of care,Endocarditis, valve unspecified, unspecified cause,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute on chronic systolic heart failure,Severe sepsis,Hypovolemia,Coronary atherosclerosis of native coronary artery'}


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: hypotension

PRESENT ILLNESS: Ms. [**Known lastname 23333**] is a [**Age over 90 **] year old woman with history of coronary
artery disease presented on [**5-22**] with anorexia, emesis x 2,
right-sided abdominal pain, malaise, and fatigue. She was noted
to have a mildly elevated white count of 13.6K. She had a RUQ
ultrasound in the ED which demonstrated moderate amount of
sludge with few shadowing stones in the gall bladder. A
presumptive diagnosis of acute cholecystitis was made, and she
was admitted to the surgical service. She was started on
ciprofloxacin and metronidazole. She was seen by GI (Dr.
[**Last Name (STitle) 15831**] during the admission, who recommended conservative
management and consideration of elective cholecystectomy as an
outpatient. Her blood pressures on [**5-23**] ranged 110-147/53-82,
and on [**5-24**] ranged 132-180/73-91. She had increased RUQ pain the
morning of [**5-24**], and then triggered the night of [**5-24**] for
tachycardia to the 140's and hypoxia to 80% on room air. Cardiac
enzymes were checked, and the first set was elevated (troponin
0.11, CK at that time 82). Second set was elevated as well (T
0.22, CK 103). Cardiology was consulted. Of note, she was
consented for laparascopic cholecystectomy this morning. The
morning of admission, she again triggered for hypotension
(80/46), heart rate 56. She was given her usual dose of
metoprolol (12.5mg) this morning. On arrival to the [**Hospital Unit Name 153**], she is
confused, tachypneic, and pale appearing. No further review of
systems was obtained from the patient. Per the family, she had
been complaining of back pain

MEDICAL HISTORY: - Hypercholesterolemia
- Coronary artery disease
- Asthma
- Osteoarthritis

MEDICATION ON ADMISSION: Medications on transfer from ICU:
- Heparin 5000 units SC TID
- Hydrocodone-Acetaminophen [**1-7**] Tab PO Q6H:PRN
- Acetaminophen 1000mg PO Q6H:PRN
- Metoprolol Tartrate 12.5 mg PO BID
- Albuterol Inhaler [**1-7**] PUFF IH Q4H:PRN SOB/cough/wheeze
- Metronidazole (FLagyl) 500 mg IV Q8H
- Aspirin 81 mg PO DAILY
- Morphine Sulfate 1 mg IV Q2H:PRN breakthrough pain
- Atorvastatin 10 mg PO DAILY
- Omeprazole 20 mg PO DAILY
- Citalopram Hydrobromide 20 mg PO DAILY
- Ciprofloxacin 200 mg IV Q12H
- Donepezil 5 mg PO HS
- Docusate Sodium 100 mg PO BID
- Trazodone 50 mg PO HS
- Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]

ALLERGIES: Zoloft

PHYSICAL EXAM: Discharge PE

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: No tobacco, EtOH. Daughter is [**Hospital1 93429**], has two other
daughters. 

### Response:
{'Streptococcal septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Septic shock,Subendocardial infarction, initial episode of care,Endocarditis, valve unspecified, unspecified cause,Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute on chronic systolic heart failure,Severe sepsis,Hypovolemia,Coronary atherosclerosis of native coronary artery'}
