History and Physical for Putul Barua

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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD

Patient Name: Putul Barua

Patient ID: 135799Sex: Male

Room No.: CCU4

Date of Admission/Date of Arrival: 01/07/2013

Admitting/Attending Physician: Simon Williams, MD

Admitting Diagnosis:
1.) Rule out myocardial infarction.
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. McClean 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 Hindi language.

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

(continued)
Patient Name: Putul Barua

Patient ID: 135799 Sex: Male

Room No.: CCU4

Date of Admission/Date of Arrival: 01/07/2013

Admitting/Attending Physician: Simon Williams, MD

Admitting Diagnosis:
1.) Rule out myocardial infarction.
2.) History of tuberculosis.
3.) Hemoptysis.
4.) Status post embolectomy.

Page 2

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 Mariette Hotel chain.

FAMILY HISTORY
No known family history of diabetes, heart disease, or cancer. Mother died of a stroke. Father was killed in a MVA in Bangladesh.

REVIEW OF SYSTEMS
Negative other than as stated in HPI.

PHYSICAL EXAMINATION
Vital signs are WNL. Apparently he has had no chills, night sweats, or fevers. Generalized malaise and a lack of energy have been the main concerns. HEART: Regular rate and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral bronchi. No significant amphoric sounds are noted. ABDOMEN: Soft, nontender. No hepatosplenomegaly or masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for Hemoccult test.

DIAGNOSIS
Hemoptysis with history of tuberculosis.

(continued)
Patient Name: Putul Barua

Patient ID: 135799 Sex: Male

Room No.: CCU4

Date of Admission/Date of Arrival: 01/07/2013

Admitting/Attending Physician: Simon Williams, MD

Admitting Diagnosis:
1.) Rule out myocardial infarction.
2.) History of tuberculosis.
3.) Hemoptysis.
4.) Status post embolectomy.

Page 3

PLAN
I have reviewed the chest x-rays available here and agree with the findings of bleb formation in the right and left upper lobes. Despite the fact that the patient has had a high INR, because of his history of tuberculosis and hemoptysis, I believe obtaining sputum for TB is very, very important. We should rule out any other endobronchial lesion as the cause of his bleeding.

I have discussed this matter with the patient and his wife. I have told them that there is the possibility of observing the condition via x-rays and repeated tests of his sputum. They understand that this is an option; however, they have decided that because of the concern regarding his repeated hemoptysis, they would consent to...
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