History and Physical Examination Putul Barua

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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD

Patient Name: Putul Barua

Patient ID: 135799 Age: 42 Sex: M

Room No.: CCU4

Date of Admission: 01/07/----

Admitting Physician: DR. Simon Williams, MD

Chief Complaint: Tightness in the chest, shortness of breath, fast heart rate.

ADMITTING DIAGNOSIS
1) Rule out myocardial infarction
2) History of TB
3) Hemoptysis
4) Status post embolectomy

HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42 year old 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 resent 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 auxiliary artery treated last year at Hill Crest. 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 patients wife Nepor, with the patient translating for her from the Hindu language.

PAST HISTORY: TB in the past. Embolectomy at Hill Crest last year.

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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD

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

SOCIAL HISTORY: Married with 2 daughters. Patient has been in the USA for 10 years. Patient has no resent history of smoking he smoked in the past, but the amount is unclear. He is a restaurant manager for the Marriot hotel chain.

FAMILY HISTORY: No known family history...
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