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. (continue) 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 of diabetes, heart disease, or cancer. Mother died of stroke. Father was killed in a MVA in Bangladesh. REVIEW OF SYSTEMS: Negative other than as stated in HPI. PHYSICAL EXAMINATION: VITAL SIGNS: 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 rates and rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: bilateral rhonchi. No significant amphoric sounds are noted. ABDOMEN: soft non tender. No hepatosplenomegaly masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for Hemoccult test. DIAGNOSIS: Hemoptysis with history of TB. PLAN: I have reviewed the chest x-rays available here and agreed with the finding of bleb formation in the right and left upper lobes.
Despite the fact that the patient has had an high INR, because of his history of TB and hemoptysis I believe obtaining sputum for TB is very very important. We should rule out any other endobronchial lesion as the cause for his bleeding. I have discussed this matter with the patient and his wife. I have told them that there is the possibility of (continue) HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Putul Barua Patient ID: 135799 Date of Admission: 01/07/—- Page 3 bserving the condition by x-rays and repeated test 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 consider bronchoscopy. We will arrange for the patient to have the bronchoscopy done. He is of Coumadin. We will recheck the prothrombin time and INR tomorrow. Depending upon those results, we will proceed with bronchoscopy and further evaluation. _________________________ DR. Simon Williams, MD SW :ab D: 09/21/—- T: 09/21/—- C: J. K. McClain, MD, Cardiology