CHIEF COMPLAINT: Hypoxemia

PRESENT ILLNESS: 71 year old trached and PEG'd male w/ multiple medical problems
including DM, COPD, afib, CAD s/p CABG and locally invasive
laryngopharyngeal cancer on chemo and XRT who was admitted to
[**Hospital3 417**] Hospital from [**Hospital1 1872**] rehab on [**10-12**] for
shortness of breath, chest pain and atrial fibrillation with
RVR.  During the episode his O2 sat reportedly dropped to 87%.
Prior to admission he developed neutropenic fever and was being
treated with broad spectrum antibiotics.
.
While at OSH, continued to have AF with rapid ventricular
response.  ECG showed diffuse ST depressions during RVR (rate
138).  Troponin I elevated at 65.48.  For his AF he was treated
with diltiazem drip and then converted to PO metoprolol day of
transfer.  He was not started on anticoagulation due to recent
[**Hospital1 18**] admission for hemoptysis as well as thrombocytopenia.  He
did report some chest pain during these episodes of rapid HR.
CXR revealed cardiomegaly and interstitial pulmonary changes
indicative of CHF.
.
Other notable lab values include neutropenia (ANC 700) with an
elevated BUN/Cr (57/2.2) - baseline Cr 0.9-1.0.  CXR showed a
right middle lobe pneumonia.
.
Patient was recently admitted here on [**9-20**] for hemoptysis which
was felt due to tumor mass.  He was given 1U PRBC.

MEDICAL HISTORY: Diabetes
Hypertension
Coronary Artery Disease, s/p CABG x 5
Permanent Pacemaker for sick sinus
Peripheral Vascular Disease (AAA s/p repair)
COPD
Spontaneous Pneumothorax s/p chest tube
Colon Cancer s/p resection and chemo (pt does not know details
of therapy) in approximately [**2102**]

MEDICATION ON ADMISSION: MEDICATIONS AT HOME:
Imipenem 500mg q8H
Vancomycin 1g q12h
Zofran 4mg IV PRN
Nexium 40mg PO daily
Metoclopramide 10mg QACHS
Lopressor 50mg q8H PO
RISS
Albuterol nebs
Atrovent nebulizer q6H
.
MEDICATIONS ON TRANSFER:
Ondansetron 4mg q8H PRN
Aspirin 325mg daily
Metoprolol 50mg TID
RISS
Lantus 16U qhs
Ambien 5mg qhs
Colace 100mg [**Hospital1 **]
Lorazepam 0.5mg q8h PRN
Metoclopramide 5mg QACHS
Esomeprazole 40mg daily
Heparin subq
Imipenem 250mg q8H
Ceftazidime 1000mg q24H
Vancomycin 500mg x1
Filgrastim 480mcg x1
Furosemide 20mg x1
Albuterol nebs
Ipratroprium nebs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: 97.6, BP 117/99, HR97, RR 17, O2sat 100% on trach
GEN: Cachectic male lying comfortably in bed, conversant
HEENT: NC/AT, + temporal wasting, OP clear, PERRL
NECK: trach in place, no JVD
CARDIAC: Irregular rhythm, nl s1 s3, no discernible murmur.
Heart sounds obscured by lung sounds
LUNG: Diffuse rhonchi with some wheezing.
ABDOMEN: scaphoid, PEG site erythematous, dry, healing
EXT: decreased bulk and tone, no c/c/e
NEURO: grossly intact
SKIN: erythematous with some breakdown over anterior neck

FAMILY HISTORY: Aunt with breast cancer and uncle with throat cancer.

SOCIAL HISTORY: Patient is single. He does not have any children. He reports he
has been an alcoholic for the past 45 years and had been
drinking 2 glasses wine per day up to hospitalization in [**Month (only) **].
He has a 59 pack year smoking history.
Subendocardial infarction, initial episode of care,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Acute respiratory failure,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Pneumonia, organism unspecified,Gastrostomy complication, unspecified,Tracheostomy status,Aortocoronary bypass status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Personal history of malignant neoplasm of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Malignant neoplasm of head, face, and neck,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Subendo infarct, initial,Atrial fibrillation,Chr airway obstruct NEC,Acute respiratry failure,Acute kidney failure NOS,Acute necrosis of liver,Pneumonia, organism NOS,Gastrostomy comp NOS,Tracheostomy status,Aortocoronary bypass,Cor ath unsp vsl ntv/gft,Hx of colonic malignancy,DMII wo cmp nt st uncntr,Mal neo head/face/neck,Abn react-plast surg NEC
Admission Date:  [**2107-10-14**]              Discharge Date:   [**2107-10-21**]

Date of Birth:  [**2036-4-3**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Hypoxemia

Major Surgical or Invasive Procedure:
GJ tube placement, previous G tube removed


History of Present Illness:
71 year old trached and PEG'd male w/ multiple medical problems
including DM, COPD, afib, CAD s/p CABG and locally invasive
laryngopharyngeal cancer on chemo and XRT who was admitted to
[**Hospital3 417**] Hospital from [**Hospital1 1872**] rehab on [**10-12**] for
shortness of breath, chest pain and atrial fibrillation with
RVR.  During the episode his O2 sat reportedly dropped to 87%.
Prior to admission he developed neutropenic fever and was being
treated with broad spectrum antibiotics.
.
While at OSH, continued to have AF with rapid ventricular
response.  ECG showed diffuse ST depressions during RVR (rate
138).  Troponin I elevated at 65.48.  For his AF he was treated
with diltiazem drip and then converted to PO metoprolol day of
transfer.  He was not started on anticoagulation due to recent
[**Hospital1 18**] admission for hemoptysis as well as thrombocytopenia.  He
did report some chest pain during these episodes of rapid HR.
CXR revealed cardiomegaly and interstitial pulmonary changes
indicative of CHF.
.
Other notable lab values include neutropenia (ANC 700) with an
elevated BUN/Cr (57/2.2) - baseline Cr 0.9-1.0.  CXR showed a
right middle lobe pneumonia.
.
Patient was recently admitted here on [**9-20**] for hemoptysis which
was felt due to tumor mass.  He was given 1U PRBC.

Past Medical History:
Diabetes
Hypertension
Coronary Artery Disease, s/p CABG x 5
Permanent Pacemaker for sick sinus
Peripheral Vascular Disease (AAA s/p repair)
COPD
Spontaneous Pneumothorax s/p chest tube
Colon Cancer s/p resection and chemo (pt does not know details
of therapy) in approximately [**2102**]


Social History:
Patient is single. He does not have any children. He reports he
has been an alcoholic for the past 45 years and had been
drinking 2 glasses wine per day up to hospitalization in [**Month (only) **].
He has a 59 pack year smoking history.


Family History:
Aunt with breast cancer and uncle with throat cancer.

Physical Exam:
VITALS: 97.6, BP 117/99, HR97, RR 17, O2sat 100% on trach
GEN: Cachectic male lying comfortably in bed, conversant
HEENT: NC/AT, + temporal wasting, OP clear, PERRL
NECK: trach in place, no JVD
CARDIAC: Irregular rhythm, nl s1 s3, no discernible murmur.
Heart sounds obscured by lung sounds
LUNG: Diffuse rhonchi with some wheezing.
ABDOMEN: scaphoid, PEG site erythematous, dry, healing
EXT: decreased bulk and tone, no c/c/e
NEURO: grossly intact
SKIN: erythematous with some breakdown over anterior neck

Pertinent Results:
[**2107-10-14**] 09:49PM   GLUCOSE-151* UREA N-81* CREAT-2.7* SODIUM-137
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2107-10-14**] 09:49PM   ALT(SGPT)-1014* AST(SGOT)-408* LD(LDH)-736*
CK(CPK)-80 ALK PHOS-97 TOT BILI-1.1
[**2107-10-14**] 09:49PM   CK-MB-NotDone cTropnT-4.92*
[**2107-10-14**] 09:49PM   ALBUMIN-2.5* CALCIUM-8.1* PHOSPHATE-5.1*
MAGNESIUM-2.2
[**2107-10-14**] 09:49PM   WBC-2.5* RBC-3.27* HGB-10.0* HCT-29.1* MCV-89
MCH-30.4 MCHC-34.2 RDW-17.2*
[**2107-10-14**] 09:49PM   NEUTS-80.8* BANDS-0 LYMPHS-12.7* MONOS-5.5
EOS-0.4 BASOS-0.4
[**2107-10-14**] 09:49PM   HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ BURR-1+
[**2107-10-14**] 09:49PM   PLT COUNT-49*
[**2107-10-14**] 09:49PM   PT-19.7* PTT-32.8 INR(PT)-1.9*
[**2107-10-14**] 09:49PM   GRAN CT-[**2090**]*
[**2107-10-14**] 09:48PM   HBs Ab-NEGATIVE HBc Ab-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2107-10-14**] 09:48PM   ACETMNPHN-NEG
[**2107-10-14**] 02:26PM   GLUCOSE-203* UREA N-83* CREAT-2.7* SODIUM-137
POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
[**2107-10-14**] 02:26PM   CK(CPK)-131
[**2107-10-14**] 02:26PM   CK-MB-14* MB INDX-10.7* cTropnT-6.43*
[**2107-10-14**] 02:26PM   CALCIUM-8.0* PHOSPHATE-5.5* MAGNESIUM-2.3
[**2107-10-14**] 02:26PM   PT-20.1* PTT-32.7 INR(PT)-1.9*
[**2107-10-14**] 07:47AM URINE  HOURS-RANDOM UREA N-623 CREAT-84
SODIUM-12 POTASSIUM-65
[**2107-10-14**] 04:21AM   TYPE-ART TEMP-36.8 RATES-16/1 TIDAL VOL-500
PEEP-5 O2-40 PO2-88 PCO2-33* PH-7.50* TOTAL CO2-27 BASE XS-2
-ASSIST/CON INTUBATED-INTUBATED
[**2107-10-14**] 02:50AM   GLUCOSE-105 UREA N-77* CREAT-2.7*# SODIUM-142
POTASSIUM-4.8 CHLORIDE-101 TOTAL CO2-23 ANION GAP-23*
[**2107-10-14**] 02:50AM   estGFR-Using this
[**2107-10-14**] 02:50AM   ALT(SGPT)-2522* AST(SGOT)-1552* LD(LDH)-1182*
CK(CPK)-318* ALK PHOS-111 AMYLASE-26 TOT BILI-1.5
[**2107-10-14**] 02:50AM   LIPASE-27
[**2107-10-14**] 02:50AM   CK-MB-28* MB INDX-8.8* cTropnT-10.43*
[**2107-10-14**] 02:50AM   ALBUMIN-2.8* CALCIUM-8.9 PHOSPHATE-5.6*#
MAGNESIUM-2.3 IRON-190*
[**2107-10-14**] 02:50AM   calTIBC-185* VIT B12-GREATER TH
FOLATE-GREATER TH FERRITIN-GREATER TH TRF-142*
[**2107-10-14**] 02:50AM   WBC-2.3* RBC-3.59* HGB-10.7* HCT-30.9* MCV-86
MCH-29.8 MCHC-34.6 RDW-16.8*
[**2107-10-14**] 02:50AM   PLT COUNT-46*#
[**2107-10-14**] 02:50AM   PT-20.4* PTT-31.2 INR(PT)-2.0*
[**2107-10-14**] 02:50AM   GRAN CT-1640*

Brief Hospital Course:
71M with head and neck cancer, trach/[**Hospital 73098**] transferred from an
outside hospital with atrial fibrillation with RVR, NSTEMI,
acute oliguric renal failure, and acute ischemic hepatitis.
.
# NSTEMI:
Patient has a history of CABG, and had very elevated cardiac
enzymes on admission (Trop T 65.48, CKMB 72.1). TTE during this
admission shows acute changes, EF from 55-60% on [**7-26**] to 25-30%,
severely depressed LV systolic function, severe LV global HK in
inf, post, lat walls, depressed RV systolic function, 3+MR,
2+TR. EKG shows 2 mm STD V3-V5 which is 0.[**Street Address(2) 73099**]
depression laterally from his old EKGs. CXR shows unchanged
pleural effusions and atelectasis. He was maintained on aspirin
and metoprolol. He was not started on a statin since he was
admitted with acute ischemic hepatitis, and LFTs were still
decreasing to normal levels.
.
# AFIB with rapid ventricular rate:
He was in AFIB with rapid ventricular rate, with a pacer for
sick sinus/tachy-brady, HR 100-140s, controlled on Metoprolol
and Diltiazem. He was not anticoagulated since he has head and
neck cancer and had pancytopenia from chemo and radiation.
.
# Hypoxemic respiratory failure:
Likely associated with bilateral pleural effusions, cardiac
stunning, and COPD. Patient has a trach and was kept on trach
mask for most of the day, with intermittent transition to AC and
PS ventilatory support during the night or with decreasing O2
saturation. Patient was diuresed here with lasix gtt, 5-10 mg
per hour for pleural effusions, but he was not total body fluid
overloaded. Patient has COPD and was placed on albuterol
inhalers, spiriva, and advair during admission to be continued.
.
**As a note, the patient's lasix regimen was added during this
admission, and should be titrated up as appropriate to diurese
for his bilateral pleural effusions. Currently at the standing
dose, he is running even in his fluid goals daily.
.
# Acute oliguric renal failure:
Patient's acute renal failure was prerenal in etiology and
associated with a depressed EF and/or post-ischemic ATN, not
responsive to fluid boluses. Renal US showed atrophic L kidney
unchanged since [**7-14**], no stone, no hydro, no mass. Ulytes
consistent with prerenal etiology. Renal failure gradually
resolved over admission.
.
# Acute ischemic hepatitis:
Patient had LFTs in the thousands, associated with hepatic
congestion from NSTEMI. He showed no signs of cholestasis or
obstruction. Tylenol tox screen was negative, hepatitis panel
was negative.
.
# Febrile neutropenia/pancytopenia/L piriform sinus SCC:
Patient has head and neck cancer, s/p carboplatin/taxol and XRT,
last XRT and chemo [**10-7**]. He was neutropenic for only the first
day of admission, and was afebrile throughout admission. He is
followed as an outpatient by Hem/Onc: [**First Name8 (NamePattern2) 7306**] [**Last Name (NamePattern1) **], Dr.
[**Last Name (STitle) **]. He completed a Ceftazidime/Vanco for a 7 day course for
neutropenia and coverage in case of pneumonia. He was on
neupogen until he was no longer neutropenic. All blood, urine,
sputum cultures were negative. His goal Hct was maintained at
>28, goal platelets were >30, and these goals were met
throughout admission.
.
# Hypertension:
Was unremarkable throughout admission, controlled on Metoprolol
and Diltiazem.
.
# Diabetes mellitus:
He was maintained on Lantus 16 qhs and sliding scale.

Medications on Admission:
MEDICATIONS AT HOME:
Imipenem 500mg q8H
Vancomycin 1g q12h
Zofran 4mg IV PRN
Nexium 40mg PO daily
Metoclopramide 10mg QACHS
Lopressor 50mg q8H PO
RISS
Albuterol nebs
Atrovent nebulizer q6H
.
MEDICATIONS ON TRANSFER:
Ondansetron 4mg q8H PRN
Aspirin 325mg daily
Metoprolol 50mg TID
RISS
Lantus 16U qhs
Ambien 5mg qhs
Colace 100mg [**Hospital1 **]
Lorazepam 0.5mg q8h PRN
Metoclopramide 5mg QACHS
Esomeprazole 40mg daily
Heparin subq
Imipenem 250mg q8H
Ceftazidime 1000mg q24H
Vancomycin 500mg x1
Filgrastim 480mcg x1
Furosemide 20mg x1
Albuterol nebs
Ipratroprium nebs


Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Insulin Glargine 100 unit/mL Cartridge [**Hospital1 **]: Sixteen (16)
units Subcutaneous at bedtime.
3. Insulin Regular Human 100 unit/mL Cartridge [**Hospital1 **]: One (1) dose
Injection QACHS and bedtime: Please give according to standard
insulin sliding scale.
4. Zolpidem 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime).

5. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day).
6. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
7. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000)
units Injection TID (3 times a day).
8. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs Inhalation
Q4H (every 4 hours) as needed for when on vent.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Hospital1 **]: 4-6 Puffs
Inhalation Q4H (every 4 hours) as needed for when on vent.
10. Senna 8.6 mg Tablet [**Hospital1 **]: 8.6 mg Tablets PO BID (2 times a
day).
11. Diltiazem HCl 30 mg Tablet [**Hospital1 **]: Three (3) Tablet PO QID (4
times a day).
12. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
(3 times a day).
13. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
15. Ondansetron 4 mg IV Q8H:PRN


Discharge Disposition:
Extended Care

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

Discharge Diagnosis:
Primary diagnosis: NSTEMI
Secondary diagnosis: Head and neck cancer, AFIB, COPD, Trach,
PEG


Discharge Condition:
VSS, on trach mask, comfortable and asymptomatic.


Discharge Instructions:
1. Take all medications as prescribed.
2. Return to the ER if you experience increasing shortness of
breath, difficulty of breathing, or chest pain.

Followup Instructions:
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2108-4-2**]
2:30



Completed by:[**2107-10-21**]
{'Subendocardial infarction, initial episode of care,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Acute respiratory failure,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Pneumonia, organism unspecified,Gastrostomy complication, unspecified,Tracheostomy status,Aortocoronary bypass status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Personal history of malignant neoplasm of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Malignant neoplasm of head, face, and neck,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: Hypoxemia

PRESENT ILLNESS: 71 year old trached and PEG'd male w/ multiple medical problems
including DM, COPD, afib, CAD s/p CABG and locally invasive
laryngopharyngeal cancer on chemo and XRT who was admitted to
[**Hospital3 417**] Hospital from [**Hospital1 1872**] rehab on [**10-12**] for
shortness of breath, chest pain and atrial fibrillation with
RVR.  During the episode his O2 sat reportedly dropped to 87%.
Prior to admission he developed neutropenic fever and was being
treated with broad spectrum antibiotics.
.
While at OSH, continued to have AF with rapid ventricular
response.  ECG showed diffuse ST depressions during RVR (rate
138).  Troponin I elevated at 65.48.  For his AF he was treated
with diltiazem drip and then converted to PO metoprolol day of
transfer.  He was not started on anticoagulation due to recent
[**Hospital1 18**] admission for hemoptysis as well as thrombocytopenia.  He
did report some chest pain during these episodes of rapid HR.
CXR revealed cardiomegaly and interstitial pulmonary changes
indicative of CHF.
.
Other notable lab values include neutropenia (ANC 700) with an
elevated BUN/Cr (57/2.2) - baseline Cr 0.9-1.0.  CXR showed a
right middle lobe pneumonia.
.
Patient was recently admitted here on [**9-20**] for hemoptysis which
was felt due to tumor mass.  He was given 1U PRBC.

MEDICAL HISTORY: Diabetes
Hypertension
Coronary Artery Disease, s/p CABG x 5
Permanent Pacemaker for sick sinus
Peripheral Vascular Disease (AAA s/p repair)
COPD
Spontaneous Pneumothorax s/p chest tube
Colon Cancer s/p resection and chemo (pt does not know details
of therapy) in approximately [**2102**]

MEDICATION ON ADMISSION: MEDICATIONS AT HOME:
Imipenem 500mg q8H
Vancomycin 1g q12h
Zofran 4mg IV PRN
Nexium 40mg PO daily
Metoclopramide 10mg QACHS
Lopressor 50mg q8H PO
RISS
Albuterol nebs
Atrovent nebulizer q6H
.
MEDICATIONS ON TRANSFER:
Ondansetron 4mg q8H PRN
Aspirin 325mg daily
Metoprolol 50mg TID
RISS
Lantus 16U qhs
Ambien 5mg qhs
Colace 100mg [**Hospital1 **]
Lorazepam 0.5mg q8h PRN
Metoclopramide 5mg QACHS
Esomeprazole 40mg daily
Heparin subq
Imipenem 250mg q8H
Ceftazidime 1000mg q24H
Vancomycin 500mg x1
Filgrastim 480mcg x1
Furosemide 20mg x1
Albuterol nebs
Ipratroprium nebs

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITALS: 97.6, BP 117/99, HR97, RR 17, O2sat 100% on trach
GEN: Cachectic male lying comfortably in bed, conversant
HEENT: NC/AT, + temporal wasting, OP clear, PERRL
NECK: trach in place, no JVD
CARDIAC: Irregular rhythm, nl s1 s3, no discernible murmur.
Heart sounds obscured by lung sounds
LUNG: Diffuse rhonchi with some wheezing.
ABDOMEN: scaphoid, PEG site erythematous, dry, healing
EXT: decreased bulk and tone, no c/c/e
NEURO: grossly intact
SKIN: erythematous with some breakdown over anterior neck

FAMILY HISTORY: Aunt with breast cancer and uncle with throat cancer.

SOCIAL HISTORY: Patient is single. He does not have any children. He reports he
has been an alcoholic for the past 45 years and had been
drinking 2 glasses wine per day up to hospitalization in [**Month (only) **].
He has a 59 pack year smoking history. 

### Response:
{'Subendocardial infarction, initial episode of care,Atrial fibrillation,Chronic airway obstruction, not elsewhere classified,Acute respiratory failure,Acute kidney failure, unspecified,Acute and subacute necrosis of liver,Pneumonia, organism unspecified,Gastrostomy complication, unspecified,Tracheostomy status,Aortocoronary bypass status,Coronary atherosclerosis of unspecified type of vessel, native or graft,Personal history of malignant neoplasm of large intestine,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Malignant neoplasm of head, face, and neck,Other restorative surgery causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
