HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD
Patient Name: Putul Barua
Patient ID: 135799
Room No.: CCU 4
Date of Admission/Date of Arrival: 01/07/2012
Admitting/Attending Physician: Simon Williams, MD
Admitting Diagnosis: 1. Rule out myocardial infarction. 2. History of TB 3. Hemoptysis. 4. Status post embolectomy.
Chief Complaint: Tightness in the chest, shortness of breath, fast heart rate.
HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42 year-old gentleman from Bangladesh who presents with chest tightness, shortness of breath, and tachycardia. Dr. J. K. McClain of cardiology is evaluating his heart condition. The patient has had the recent onset of hemoptysis. He was treated for TB in Bangladesh 15 years ago. This has prompted the concern of whether his treatment for TB was adequate or whether there is another cause for his hemoptysis. The duration of his TB treatment was apparently adequate, according to his wife, but no records are available. In addition, the patient had thrombosis of the axillary artery treated last year at Hillcrest. He had an embolectomy and has been on Coumadin since. INR is significantly elevated at 16. Nonetheless, because of the cavitary lesions that are seen in the right and left upper lobes, the possibility of TB has been raised. Ancillary history was given by the patient’s wife, Nupur, with the patient translating for her from a Hindi language.
PAST HISTORY: TB in the past. Embolectomy at Hillcrest last year.
SOCIAL HISTORY: Married with two daughters. Patient has been in the USA for 10 years. Patient has no recent history of smoking. He smoked in the past, but the amount is unclear. He is a restaurant manager for the Marriott hotel chain.
FAMILY HISTORY: No known family history of diabetes, heart disease, or cancer. Mother died of a stroke. Father was killed in an MVA in Bangladesh.
REVIEW OF SYSTEMS: Negative other than...
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