History and Physical for Putul Barua
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
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
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
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