Woodland Memorial Hospital
225 Main Street, Anywhere AL 12345
Office: (555) 123-4567
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Putul Barua
Patient ID: 135799
Room #: CCU 4
Date of Admission: 01/07/2015
Emergency Room Physician: Simon Williams, MD
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 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 stated in HPI.
(Continued)
Woodland Memorial Hospital
225 Main Street, Anywhere AL 12345
Office: (555) 123-4567
Patient Name: Putul Barua
Patient ID: 135799
Room #: CCU 4
Date of Admission: 01/07/2015
Page 2
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 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.
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 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
SW:vw
D: 01/07/2015
T: 01/07/2015
CC: J.K. McClain, MD