History and Physical Examination for Putul Barua

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CASE STUDY 3

HISTORY AND PHYSICAL EXAMINATION

Patient Name: Putul Barua

Patient ID: 135799

Room No.: CCU-4

Date of Admission: 01/07/2013

Admitting Physician: Simon Williams, MD

Admitting Diagnoses
1. Rule out myocardial infraction
2. History of tuberculosis.
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 tuberculosis in Bangladesh 15 years ago. This has prompted the concern of whether his treatment for tuberculosis was adequate or whether there is another cause for his hemoptysis. The duration of his tuberculosis 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 tuberculosis has been raised. Ancillary history was given by the patient’s wife, Nupur, with the patient translating for her from the Hindu language.

PAST HISTORY: Tuberculosis in the past. Embolectomy at Hillcrest last year.

SOCIAL HISTORY: Married with 2 daughters. Patient has been in the USA for 10 years. Patient has no recent history of smoking. He smoked in the past,

(Continued)
HISTORY AND PHYSICAL EXAMINATION

Patient Name: Putul Barua
Patient ID: 135799
Date of Admission: 01/07/2013
Page 2

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...
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