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.
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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
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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD 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. CHIEF COMPLAINT Tightness in the chest‚ shortness of breath‚ fast heart rate. HISTORY OF PRESENT ILLNESS
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DEATH SUMMARY Patient Name: Putul Barua Patient ID: 135799 Room No.: CCU-4 Date of Admission: 01/07/2011 Date Deceased: 01/15/2011 00:41:00 Admitting physician: Simon William‚ MD‚ Pulmonology Consultations: J.K. Mc Clain‚ MD‚ Cariology Trevor Jordan‚ Nephrology This 42 year old gentleman was admitted on 1-7 and expired on jan 15. He was admitted with progressive tachycardia‚ hemoptysis‚ and dyspnea. Please see his admission history and physical exam for details
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History and Physical Examination Critical Care Unit Treatment Record Patient Name: Putul Barua Patient ID: 135799 Room No.: CCU4 Date of Admission: 01/07/2012 Admitting/Attending Physician: Simon Williams‚ MD‚ Pulmonary Thoracic Surgery 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
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OPERATIVE REPORT Patient Name: Putul Barua Hospital No.: 135799 Room No.: CCU-4 Date of Surgery: 01/08/2010 Admitting Physician: Joshua Steven Gatlin‚ MD Surgeon: Joshua Steven Gatlin‚ MD Preoperative Diagnosis: Recent onset hemoptysis. History of tuberculosis. Postoperative Diagnosis: No tuberculosis lesion seen. Procedure: Bronchoscopy indications. Mr. Barua requires bronchoscopy because of recent onset hemoptysis in a remote history of tuberculosis. PROCEURE: Patient was routinely pre-medicated
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HISTORY AND PHYSICAL EXAMINATION Patient Name: Deanna Martinez ID No.: 117232 Room No.: 425 Date of Admission: 05/26/2013 Admitting Physician: Sheila Goodman‚ MD Admitting Diagnosis: Questionable herniated disk Chief Complain: Low back pain‚ right leg pain. HISTORY OF PRESENT ILLNESS: This 40-year-old Latin female presents with complaints of low back and right leg pain. She said that she hurt her back in a motor vehicle accident three years ago and she has had a history of intermittent
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[pic] HISTORY AND PHYSICAL EXAMINATION (H&P) Patient Name: Brenda Seggerman Hospital No.: N/A Room No.: N/A Date of Admission: 03/27/- - - - Admitting Physician: Alex Mcclure‚ MD Admitting Diagnosis: Ectopic Pregnancy HISTORY OF PRESENT ILLNESS: The patient states that she has been having vaginal bleeding more like spotting over the past month. The patient denies the chance of pregnancy‚ although the patient states that she
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Death Summary Patient Name: Putul Barua Hospital No.: 135799 Room No.: CCU4 Admitted: 01/07/2009 Deceased: 01/15/2009 0041 hrs BRIEF HISTORY: This 42-year-old gentleman was admitted on January 7th and died on January 15th. He was admitted with progressive cardiac palpitation‚ hemoptysis‚ and dyspnea. Please see his admission history and physical exam for details. HOSPITAL COURSE: Mr. Barua’s hospital course was characterized by a progressively downhill course. He was initially hospitalized
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HILLCREST MEDICAL CENTER HISTORY AND PHYSICAL EXAMINATION Patient Name: Emma Parker Hospital No.: 11259 Room No.: 444 Date of Admission: 09/25/2010 Admitting Physician: Sherman Loyd‚ M.D. Admitting Diagnosis: Acute intertrochanteric fracture of right hip. The history below was obtained from the patient and physical examination was performed with her stated verbal understanding and consent. She was alert oriented x3 with reasonable thought content she understood questions
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