CHIEF COMPLAINT: shortness of breath

PRESENT ILLNESS: The patient is a 82 yo male with hx of CHF (EF 55% 3+MR), afib,
DMII, and recent MRSA PNA who presents with dyspnea. Pt has
multiple recent hospitalizations the most significant of which
was [**Date range (3) 15221**] during which he suffered an SDH which was
surgically evacuated, liver failure from dilantin toxicity, ARF
due to CHF and pneumonia treated with a course of levofloxacin.
He was readmitted [**Date range (1) 15222**] for mental status changes and
hypoxia requiring intubation for airway protection. BNP was in
the 30,000's and he was found to have a RML infiltrate on CT and
MRSA in his sputum and treated with a 10 day course of
vancomycin which he completed on [**2119-5-27**]. He was also breifly
hospitalized [**Date range (1) 15223**] for apneic episodes at rehab with confusion
thought to be due to [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations secondary to CHF
exacerbation. He represented to the ED yesterday with confusion
and found to have hypokalemia, ARF, and FS of 60 with mental
status improved with correction of these disturbances. CXR was
read as clear by ED staff but final read showed new left sided
effusion and bilateral infiltrates concerning for CHF but head
CT was unchanged.
He now presents from rehab after being started on levofloxacin
since [**6-16**] for fever and suspected UTI and PNA . In the ED he
was found to be hypoxic suspectedly due to CHF with concomitant
PNA. He was given a dose of lasix 40mg IV with vancomycin and
started on BIPAP since the patient was DNR/DNI and appeared to
have difficult work of breathing with hypercarbia on ABG despite
normal O2 sats on 4L NC.

MEDICAL HISTORY: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia
12. ?progressive dementia

MEDICATION ON ADMISSION: Protonix 40 mg daily
ferrous sulfate 325 mg daily
furosemide 40 mg daily
Keppra 250 mg twice daily
Celexa 10 mg daily
vitamin C 250 mg daily
levothyroxine 25 mcg daily
lisinopril 5 mg daily
glyburide 2.5 mg daily
potassium chloride 20 mg once Monday, Wednesday, Friday
metoprolol 50 mg twice daily
RISS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
T 99.8 HR 85 BP 135/55 RR 30 O2 sat 95% 4L NC
HEENT-PERRL, MM dry, elevated JVP to ear but pt breathing
forcefully, no ant or post cerv LAD
Hrt-RRR nS1 soft S2 [**2-27**] SM at apex, [**2-27**] diastolic murmur at LUSB

FAMILY HISTORY: no Alzhemer's or Parkinson's

SOCIAL HISTORY: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).
Rheumatic heart failure (congestive),Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Hypopotassemia,Unspecified pleural effusion,Chronic kidney disease, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asbestosis,Abdominal aneurysm without mention of rupture,Gout, unspecified,Unspecified essential hypertension,Esophageal reflux,Mitral valve insufficiency and aortic valve insufficiency,Anemia of other chronic disease,Unspecified acquired hypothyroidism
Rheumatic heart failure,Food/vomit pneumonitis,Acute kidney failure NOS,Hypopotassemia,Pleural effusion NOS,Chronic kidney dis NOS,Atrial fibrillation,DMII wo cmp nt st uncntr,Asbestosis,Abdom aortic aneurysm,Gout NOS,Hypertension NOS,Esophageal reflux,Mitral/aortic val insuff,Anemia-other chronic dis,Hypothyroidism NOS
Admission Date:  [**2119-6-18**]              Discharge Date:   [**2119-6-23**]


Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
shortness of breath

Major Surgical or Invasive Procedure:
none


History of Present Illness:
The patient is a 82 yo male with hx of CHF (EF 55% 3+MR), afib,
DMII, and recent MRSA PNA who presents with dyspnea. Pt has
multiple recent hospitalizations the most significant of which
was [**Date range (3) 15221**] during which he suffered an SDH which was
surgically evacuated, liver failure from dilantin toxicity, ARF
due to CHF and pneumonia treated with a course of levofloxacin.
He was readmitted [**Date range (1) 15222**] for mental status changes and
hypoxia requiring intubation for airway protection. BNP was in
the 30,000's and he was found to have a RML infiltrate on CT and
MRSA in his sputum and treated with a 10 day course of
vancomycin which he completed on [**2119-5-27**]. He was also breifly
hospitalized [**Date range (1) 15223**] for apneic episodes at rehab with confusion
thought to be due to [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations secondary to CHF
exacerbation. He represented to the ED yesterday with confusion
and found to have hypokalemia, ARF, and FS of 60 with mental
status improved with correction of these disturbances. CXR was
read as clear by ED staff but final read showed new left sided
effusion and bilateral infiltrates concerning for CHF but head
CT was unchanged.
He now presents from rehab after being started on levofloxacin
since [**6-16**] for fever and suspected UTI and PNA . In the ED he
was found to be hypoxic suspectedly due to CHF with concomitant
PNA. He was given a dose of lasix 40mg IV with vancomycin and
started on BIPAP since the patient was DNR/DNI and appeared to
have difficult work of breathing with hypercarbia on ABG despite
normal O2 sats on 4L NC.


Past Medical History:
1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia
12. ?progressive dementia

Social History:
Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards).


Family History:
no Alzhemer's or Parkinson's

Physical Exam:
Admission:
T 99.8 HR 85 BP 135/55 RR 30 O2 sat 95% 4L NC
HEENT-PERRL, MM dry, elevated JVP to ear but pt breathing
forcefully, no ant or post cerv LAD
Hrt-RRR nS1 soft S2 [**2-27**] SM at apex, [**2-27**] diastolic murmur at LUSB

Lungs-bronchial BS at left lung base and dullness to percussion
at bases bilat, no crackles, mild diffuse end expiratory wheeze

Abdomen-soft NT, ND, no organomeg, NABS
Extrem-2+ rad and dp pulses, 2+ pitting edema
Neuro-noncompliant with exam, moving all extrem well, arousable
but agitated and appropriate
Skin-left forearm abrasion 1/2cm


Pertinent Results:
Admission labs:

[**2119-6-17**] 05:45PM BLOOD WBC-4.9 RBC-3.55* Hgb-10.2* Hct-30.8*
MCV-87 MCH-28.8 MCHC-33.2 RDW-17.9* Plt Ct-150
[**2119-6-17**] 05:45PM BLOOD Neuts-50.8 Lymphs-40.1 Monos-7.6 Eos-1.3
Baso-0.3
[**2119-6-17**] 05:45PM BLOOD Hypochr-1+ Anisocy-1+ Microcy-1+
[**2119-6-17**] 05:45PM BLOOD PT-14.3* PTT-26.2 INR(PT)-1.3*
[**2119-6-17**] 05:45PM BLOOD Glucose-79 UreaN-27* Creat-1.5* Na-145
K-3.1* Cl-102 HCO3-33* AnGap-13
[**2119-6-17**] 05:45PM BLOOD ALT-14 AST-21 CK(CPK)-37* AlkPhos-70
Amylase-47 TotBili-0.8
[**2119-6-17**] 05:53PM BLOOD Lactate-1.8

Other labs:

[**2119-6-17**] 06:11PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2119-6-17**] 06:11PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2119-6-17**] 06:11PM URINE RBC-0 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-<1
[**2119-6-17**] 05:45PM BLOOD cTropnT-0.04*
[**2119-6-18**] 03:10PM BLOOD CK-MB-NotDone cTropnT-0.04*
[**2119-6-17**] 05:45PM BLOOD Lipase-22
[**2119-6-19**] 05:30AM BLOOD %HbA1c-5.1 [Hgb]-DONE [A1c]-DONE
[**2119-6-19**] 05:30AM BLOOD TSH-1.9
[**2119-6-18**] 04:41PM BLOOD Type-ART Rates-/30 pO2-81* pCO2-50*
pH-7.45 calHCO3-36* Base XS-8 Intubat-NOT INTUBA
[**2119-6-19**] 08:06AM BLOOD Type-ART Temp-37.3 pO2-106* pCO2-53*
pH-7.43 calHCO3-36* Base XS-8 Intubat-NOT INTUBA
[**2119-6-18**] 03:34PM BLOOD Lactate-2.1*
[**2119-6-19**] 08:06AM BLOOD Lactate-1.2
[**2119-6-19**] 02:39PM PLEURAL WBC-60* RBC-1295* Polys-3* Lymphs-62*
Monos-28* Eos-2* Meso-1* Macro-4*
[**2119-6-19**] 02:39PM PLEURAL TotProt-2.2 LD(LDH)-105
[**2119-6-19**] Pleural fluid show no maligant cells

Discharge Labs:

[**2119-6-23**] 06:15AM BLOOD WBC-6.3 RBC-3.49* Hgb-10.3* Hct-29.8*
MCV-86 MCH-29.6 MCHC-34.6 RDW-17.0* Plt Ct-147*
[**2119-6-23**] 06:15AM BLOOD Glucose-94 UreaN-23* Creat-1.2 Na-139
K-3.6 Cl-98 HCO3-31 AnGap-14
[**2119-6-23**] 06:15AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9

Echocardiogram ([**2119-6-19**]) The left atrium is moderately dilated.
The right atrium is markedly dilated.  There is mild symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal.  The aortic root is mildly dilated. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Mild to moderate ([**12-26**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. At least
moderate(2+) mitral regurgitation is seen (view suboptimal). The
mitral regurgitation jet is eccentric. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.  Compared with the prior study (images reviewed) of
[**2119-4-3**], there is no
significant change.

Radiology

CXR ([**2119-6-19**]) -bilat effusion worse on left, patchy opacity in
RLL but no clear focal infiltrate


Brief Hospital Course:
The patient is 82 yo male with hx of CHF (EF 55% 3+MR), afib,
DMII, and recent MRSA PNA who presents with dyspnea. His
hospital course on this admission is as follows:

1. Confusion-Appears to be a delirium with waxing and [**Doctor Last Name 688**]
mental status due to acute illness. We treated his agitation
with zyprexa prn and it completely cleared with diuresis,
improvement in potassium levels and better glucose control.

2. Fever-He had a positive UA at rehab but repeat UA and culture
were negative. There was no clear infiltrate on CXR although he
was presumed to be at risk for aspiration PNA with altered
mental status along with hypoxia. He had been recently treated
with vancomycin for PNA and levofloxacin for UTI along with
watery diarrhea raised concern for Cdiff colitis since he has a
known history of colitis on sulfasalazine in past. He was
initially broadly covered with Vancomycin for recent MRSA PNA,
levofloxacin to cover aspiration PNA with flagyl for C.
difficile. He was never febrile while in hospital with no
elevated WBC or for left shift so antibiotics except for flagyl
was stopped on HD2. Flagyl was then stopped on HD3 after Cdiff
toxin assay was negative x3.

3. Hypoxia-Pt was thought to be at risk for aspiration PNA as
above. Bilateral effusions with LE edema and elevated JVP raised
concern for CHF. Wheeze on exam was likely cardiac wheeze. ECG
showed no acute changes suggestive ischemia or infarct with CE
stable for >24 since his ED visit on the day prior to admission.
Pt had known chronic hypercarbia which were thought to be
related to effusions causing hypoventilation. He required bipap
intermittently over the first night of admission and was
diuresed approximately 2-3 liters over the first 48 hours of
hospitalization. Repeat TTE showed now change in ventricular
function. Left sided thoracentesis was performed due to risk of
parapneumonic effusion and 2L were removed and found to be
transudative and no evidence of malignant cells.  We initially
held on his ACE-I due to ARF and afterload reduced with Imdur
and hyralazine.  Once patient's condition was stabilized, and
transferred from the MICU to the medicine floor, we d/c his
hydralazine, and started him on lisinopril 5mg PO, which is his
home dose.  In additon, we weaned him gradually off supplemental
O2 to up 90% on 2L at the time of the discharge, which is his
baseline.

4. Hypokalemia-Due to poor PO intake and diuresis. Mental status
had been poor in past in the setting of hypokalemia. Initially,
we replete him aggressively and required >120mEq of KCL per day
to maintain serum potassium levels >3.6, then daily potassium
check and supplement as needed. As he was total body potassium
depleted he will likely need standing KCl supplementation with
close monitoring at rehab.

5. Subdural hematoma-Remained stable on head CT from ED visit on
the day prior to admission. His MS continued to improve with
correction of metabolic derangements so no repeat head CT was
performed. We continued Keppra for seizure prophylaxis.

6. AAA-ascending; measured >5cm in [**11-27**] & pt refused surgical
intervention at that time although no hypotension or back pain
to suggest dissection at this time.

7. Acute on CRI-Likely due to CHF and poor perfusion. Creatinine
returned to baseline after he was adequately diuresed.

8. Paroxysmal Afib- We continue metoprolol for rate control
despite acute CHF exacerbation as he needs longer ventricular
filling times due to valvular dysfunction. We did not initiate
anticoagulation with warfarin given recent subdural hematoma and
h/o frequent falls.

9. DM2-Given his recent weight loss we suspected that his
hyupoglycemia was due to loss of insulin resistence and
continued glyburide use. He remained hypoglycemic during the
first 48 hours of hospitaliztion with FS in the 60's requiring
multiple amps of D50. His hemaglobin A1c was 5.1 suggesting no
insulin resistance so glybride should be held indefinitely.

10. Anemia-iron studies were most c/w chronic dz (ferritin 86).
Hct remained stable. We continued ferrous sulfate.

11. Hypothyroidism-He was clinically euthyroid. We continued
synthroid and rechecked TSH which was found to be WNL.

12. Depression-remained stable. Continue celexa.

13. Communication-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (daughter) [**Telephone/Fax (5) 15224**]

14. Nutrition and Diet-on low salt, cardiac, diabetic and renal
diet.

15. Activity-Assist out of bed, PT consults

16. Code- Full code which was reversed by the patient from
DNI/DNR during this admission, but needs to be addressed
further.

Medications on Admission:
Protonix 40 mg daily
ferrous sulfate 325 mg daily
furosemide 40 mg daily
Keppra 250 mg twice daily
Celexa 10 mg daily
vitamin C 250 mg daily
levothyroxine 25 mcg daily
lisinopril 5 mg daily
glyburide 2.5 mg daily
potassium chloride 20 mg once Monday, Wednesday, Friday
metoprolol 50 mg twice daily
RISS


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
7. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).


Discharge Disposition:
Extended Care

Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - [**Location (un) **]

Discharge Diagnosis:
Primary diagnosis:
CHF excerbation
pneumonia

Secondary Diagnosis:
2 + mitral regurgitation and significant AR [**3-30**]
Atrial fibrillation-off coumadin due to liver coagulopathy and
falls
Ascending aortic aneurysm (not interested in surgery)
Type 2 diabetes
Gout
Hypertension
GERD
chronic renal insufficiency
h/o Asbestosis
Recent B12 and Fe def. anemia
Subdural hematoma s/p evacuation in [**2119-4-12**]
recent MRSA peumonia ([**4-29**])


Discharge Condition:
Patient is discharged in good condition, experiencing no
symptoms of shortness of breath, chest pain, dizziness, O2 sat
up 90% on 2L, which is his baseline.


Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2L

If you experience any chest pain, shortness of breath,
dizziness, or other concerning symptoms, please seek medical
attention immediately

Followup Instructions:
Please follow up with your primary care doctor: Dr [**Last Name (STitle) 3649**]
([**Telephone/Fax (1) 3070**]) within one week of discharge, in addition to the
following appointments.

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2119-7-3**] 4:30


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

Completed by:[**2119-6-23**]
{'Rheumatic heart failure (congestive),Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Hypopotassemia,Unspecified pleural effusion,Chronic kidney disease, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asbestosis,Abdominal aneurysm without mention of rupture,Gout, unspecified,Unspecified essential hypertension,Esophageal reflux,Mitral valve insufficiency and aortic valve insufficiency,Anemia of other chronic disease,Unspecified acquired hypothyroidism'}


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: shortness of breath

PRESENT ILLNESS: The patient is a 82 yo male with hx of CHF (EF 55% 3+MR), afib,
DMII, and recent MRSA PNA who presents with dyspnea. Pt has
multiple recent hospitalizations the most significant of which
was [**Date range (3) 15221**] during which he suffered an SDH which was
surgically evacuated, liver failure from dilantin toxicity, ARF
due to CHF and pneumonia treated with a course of levofloxacin.
He was readmitted [**Date range (1) 15222**] for mental status changes and
hypoxia requiring intubation for airway protection. BNP was in
the 30,000's and he was found to have a RML infiltrate on CT and
MRSA in his sputum and treated with a 10 day course of
vancomycin which he completed on [**2119-5-27**]. He was also breifly
hospitalized [**Date range (1) 15223**] for apneic episodes at rehab with confusion
thought to be due to [**Last Name (un) 6055**]-[**Doctor Last Name **] respirations secondary to CHF
exacerbation. He represented to the ED yesterday with confusion
and found to have hypokalemia, ARF, and FS of 60 with mental
status improved with correction of these disturbances. CXR was
read as clear by ED staff but final read showed new left sided
effusion and bilateral infiltrates concerning for CHF but head
CT was unchanged.
He now presents from rehab after being started on levofloxacin
since [**6-16**] for fever and suspected UTI and PNA . In the ED he
was found to be hypoxic suspectedly due to CHF with concomitant
PNA. He was given a dose of lasix 40mg IV with vancomycin and
started on BIPAP since the patient was DNR/DNI and appeared to
have difficult work of breathing with hypercarbia on ABG despite
normal O2 sats on 4L NC.

MEDICAL HISTORY: 1. CHF: [**2-27**] echo: mild symm LVH, EF 55% but likely
overestimation with degree of MR
2.  3+ mitral regurgitation
3. Atrial fibrillation
4. Ascending aortic aneurysm- [**11-27**] CTA: 5.7 x 5.4 cm stable
(pt. currently not interested in surgery)
5. DM2
6. Gout
7. Inflammatory Colitis (?)on chronic sulfasalazine.  No prior
surgeries or recent flares.
8. Hypertension
9. GERD
10. h/o Asbestosis
11. Recent B12 and Fe def. anemia
12. ?progressive dementia

MEDICATION ON ADMISSION: Protonix 40 mg daily
ferrous sulfate 325 mg daily
furosemide 40 mg daily
Keppra 250 mg twice daily
Celexa 10 mg daily
vitamin C 250 mg daily
levothyroxine 25 mcg daily
lisinopril 5 mg daily
glyburide 2.5 mg daily
potassium chloride 20 mg once Monday, Wednesday, Friday
metoprolol 50 mg twice daily
RISS

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Admission:
T 99.8 HR 85 BP 135/55 RR 30 O2 sat 95% 4L NC
HEENT-PERRL, MM dry, elevated JVP to ear but pt breathing
forcefully, no ant or post cerv LAD
Hrt-RRR nS1 soft S2 [**2-27**] SM at apex, [**2-27**] diastolic murmur at LUSB

FAMILY HISTORY: no Alzhemer's or Parkinson's

SOCIAL HISTORY: Married, lives with wife, no prior [**Name (NI) **]/ETOH. Worked as a
salesman. h/o asbestosis exposure when in the service
(?shipyards). 

### Response:
{'Rheumatic heart failure (congestive),Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Hypopotassemia,Unspecified pleural effusion,Chronic kidney disease, unspecified,Atrial fibrillation,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Asbestosis,Abdominal aneurysm without mention of rupture,Gout, unspecified,Unspecified essential hypertension,Esophageal reflux,Mitral valve insufficiency and aortic valve insufficiency,Anemia of other chronic disease,Unspecified acquired hypothyroidism'}
