HISTORY AND PHYSICAL EXAMINATION_______________________
Patient Name: Putul Barua
Patient ID: 135799
Room No.: CCU-4
Date of Admission: 01/07/---Admitting Physician: Simon Williams, MD, Pulmonology
Admitting Diagnoses
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. McClain 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.
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
(Continued)
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HISTORY AND PHYSICAL EXAMINATION
Patient Name: Putul Barua
Patient ID: 135799
Date of Admission: 01/07/---Page 2
the past, but the amount is unclear. He is a restaurant manager for the
Marriott Hotel chain.
FAMILY HISTORY: No known family history of diabetes, heart disease, or
cancer. Mother died of a stroke. Father was killed in an 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 rhonchi. 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.
PLAN: I have reviewed the chest x-rays available here and agree with the
finding 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 for 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
(Continued)
©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part,
except for use as permitted in a license distributed with a certain product or service or otherwise on a passwordprotected website for classroom use.
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Putul Barua
Patient ID: 135799
Date of Admission: 01/07/---Page 3
repeated hemoptysis, they would consent to bronchoscopy. We will arrange
for the patient to have a bronchoscopy done. He is off Coumadin. We will
recheck the prothrombin time and INR tomorrow. Depending upon those
results, we will proceed with bronchoscopy and further evaluation.
______________________________
Simon Williams, MD, Pulmonology
SW:xx
D:01/07/---T:01/07/---C: J. K. McClain, MD, Cardiology
©2011 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part,
except for use as permitted in a license distributed with a certain product or service or otherwise on a passwordprotected website for classroom use.