Case Study on Putul Barua
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 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 fifteen 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 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. None the less, 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 U.S.A. for ten 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 a MVA in Bangladesh.
Review of
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 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 fifteen 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 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. None the less, 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 U.S.A. for ten 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 a MVA in Bangladesh.
Review of