Hillcrest Medical Case 3

HISTORY AND PHYSICAL
Patient Name: Patul Barua
Patient ID: 135799
Room Number: CCU4
Date of Admission: 01/07/2010
Admitting Physician: Simon Williams, MD of Pulmonalogy
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 ILLINESS: 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 weather his treatment of tuberculosis was adequate or if weather there is another cause of 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 axially 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 been given by the wife, Nupaul, with the patient translating for her from the Indie language. PAST HISTORY: Tuberculosis is the past. Embolectomy at Hillcrest last year.
SOCIAL HISTORY: Married with two daughters. Patient has been in the USA for 10 years. The patient has no recent 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 a stroke and father was killed in a MVA in Bangladesh.
REVIEW OF SYSTEMS: Negative other than as stated in HPI.
PHYSCIAL EXAMINATION: Vital signs are WNL. Apparently he has had no fever, chills or night sweats. Generalized malaise and the lack of energy has been the main concern. HEART: Regular rate a rhythm with S1 and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral bronchi. No significant euphoric sounds were noted. ABDOMEN: Soft non tender. No hepatosplenomegagaly detected. RESTAL: Prostate smooth and firm, no stool present of 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 patient has had a high INR, because of his history of hempotysis and tuberculosis I believe obtaining sputum for TB is very, very important. We should rule out any other endobronchial lesions are the cause of his bleeding. I have discussed this matter with the patient and his wife. I told them that there is a possibility of observing the condition via x-rays and repeated tested of sputum. They understand that this is an option However, they have decided because of the concern regarding of his repeating hemoptysis, they would consent to bronchoscopy. We will arrange for the patient to have a bronchoscopy done. The patient is off Coumadin. We will recheck the prothrombin time and INR tomorrow. Depending on those results we will proceed with bronchoscopy and further evaluation.

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Simon Williams, MD Pulonology

SB:xx
D:01/07/2010
T:01/07/2010

C: JK McLean, MD of Cardiology

DIAGNOSTIC IMAGING REPORT #1 Patient Name: Putul Barua
Patient ID: 135799
Room Number: CCU4
X-Ray number: 10-0460
Referring Physician: Simon William, MD from pulmanlolgy
Reason for exam: Hemoptysis
Date of exam: 01/10/2010
Procedure: CT scan of chest without contrast
FINDINGS: CT scan of the chest performed in 7mm axiel sections with no intravenous contrast enhancement. Comparison is made to previous CT scans done during admission from last year. There is previous interval resolution of the previously noted cavitary lesions in both upper lobes. However there is of chronic residual infiltrates or scaring in both upper lobes as well in the mid and lower lung fields posteriorly, heart again appears enlarged. there is evidence of mild bilateral plural thickening, no interval pulmonary parenchymal or plural based mass lesions. no mediastinal or hilar masses. no lymphanopathy or plural effusions or no significant lesions of the bony thorax. impression-significant interval improvement with evidence of interval resolution of the previously described bilateral upper lobe cavitary lesions in the lungs since his previous ct scans. there is residual chronic infiltrates caring in both upper lobes. There is also evidence of residual scaring or infiltrates in the mid and lower lung fields posteriorly . The heart in enlarged. there are no other significant findings.

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Donna Harrison, MD
NN:xx
T: 01/07/2010
D: 01/07/2010

Diagnostic Imaging Report #2
Patient Name: Putul Barua
Patient ID: 135799
Room Number: CCU4
X-Ray number: 10-0478
Referring Physician: Simon William, MD from Pulmonology
Reason for exam: Incubated
Date of Exam: 01/12/2010
Procedure: Chest x-ray, portable, adult
Portable chest findings: When compared to the chest x-ray done previously there is mild interval improvement in the pulmonary vascular congestion. There is no change in the heart size. ET tube pulmonary artery catheter and EGK leads remain in place.
IMPRESSION: Mild interval improvement in the patients bilateral lung infiltrates and the pulmonary vascular congestion.

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Donna Harrison, MD

Operative Report
Patient Name: Putul Barua
Patient ID: 135799
Room Number: CCU4
Date of surgery: 01/08/2010
Admitting Physician: Simon Williams, MD of Pulmonology
Surgeon: Simon Williams, MD of Pulmonology
Preoperative diagnosis: Recent onset hemoptysis, history of tuberculosis.
Postoperative diagnosis: No tuberculosis lesions seen.
Name of procedure: Bronchoscopy
Specimens Removed: Blood clots.
INDICATIONS: Mr. Barua requires a bronchoscopy because of recent onset hemoptysis and a remote history of tuberculosis.
PROCEDURE: Patient was routinely pre medicated with 25mg of Demmoral with 2mg of Versed were used. About 4mL of 4% Xylocaine was used during the procedure. The glottis, epiglottis, pseudocords and cords were normal. Upper trachea was normal. Lower trachea and carina were normal. A few small, scattered thrombi present were easily suctioned. The right upper lobe was observed. No endobronchial lesion were detected. The right lower lobe and right middle lobe were free of endobronchial lesions. The left side was entered the left lower and upper lobe was investigated with no endobronchial lesions were detected. We obtained no brushing because of the patients INR and the fact that he became hypoxic very quickly. We had to do the procedure very quickly and discontinue it as soon as possible. No further significant hypoxic was observed.
The lowest level of hypoxic observed was about 86%, which was immediately reversed with an increase in oxygen therapy.
DIAGNOSIS: Evidence of old hemorrhage. No new lesions seen. Recommend close follow up.

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DEATH SUMMARY
Patient Name: Patul Barua
Patient ID: 135799
Room number: CCU4
Date of Admission: 01/07/2010
Date of Death: 01/15/2010 at 00 48 hours
Admitting Physician: Simon Williams, MD of Pulonology
Consultants: J.K. McClean, MD of Cardiology. Trevor Jordan or Nephrology
This 42 year old gentleman was admitted on January 7th and expired on January 15th. He was admitted with progressive tachycardia, hemoptysis and dyspena. Please see his admission history and physical exam for details.
HOSPITAL COURSE: The patients hospital course was characterized by a progressively downhill course. He was initially hospitalized and found to be mildly hypoxic, which rapidly corrected by supplemental low flow oxygen therapy However, he gradually became more oxygen dependent on high flow oxygen, eventually requiring intubation with mechanical ventilation in order to maintain his oxygenation. He underwent a open lung biopsy in an attempt to delineate the etiology of his pulmonary situation, and this was reported as idiopathic pulmonary fibrosis and alveolitis. The specimen was sent to the Forest General pathology department for further evaluation, and they were able to give no further help concerning the etiology of the pulmonary status. An echocardiogram showed left ventricular wall motion hypokinesia and an injection fracture of approximately 35%.
Dr. J.K. McClean and other members from the cardiology department consulted on this patient. They felt like his hypoxia and breathlessness were not secondary to his cardiac status. He had supraventricular cardiac arrhythmias, including atrial fibrillation and atrial flutter. The cardiology staff utilized intravenous medications that controlled the cardiac rate, adequately resolving these cardiac issues. I managed the patients ventilator and intensive care status along with the respiratory therapy team. Unfortunately the patient developed multiple infections, hospital acquired, including Klebsiella pneumoniae infection and probable fungemia. Multiple evaluations of sputum and lungs for the presence of active pulmonary active tuberculosis were negative.
The patient developed acute renal failure, managed by Dr. Trevor Jordan and his team of nephrologists by hemodialysis. Mechanical ventilation, hemodialysis, and nasoduodenal feeding tube were completed in an attempt to provide further support however, the patient continued to deteriorate. On January 15 at 0017 hours he became asystolic and Code Blue was called. The patient underwent advanced cardiac life support with multiple medications. He failed to respond to the advanced cardiac life support and was pronounced dead at 0041 hours on January 15th. Permission for autopsy was denied.
FINAL DIAGNOSIS:
1: Etiolopathic pulmonary fibrosis with alveolitis
2: History of Tuberculosis
3: Acute renal failure
4: Hospital acquired septicemia and fungemia secondary to multiple organisms.

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Simon William, MD of Pulmonology
AZ:xx
T:1/15/2010
D:1/15/2010

Diagnostic Imaging Report #3
Patient Name: Putul Barua
Patient ID: 135799
Room Number: CCU4
X-Ray Number: 10-04-99
Referring Physician: Simon Williams, MD form Pulmonolgy.
Reason for exam: Rule out cerebral bleed.
Date of exam: 1/14/2010
PROCEDURE: CT scan of the brain without contrast.
FINDINGS: CT scan of the brain was performed in 5mm and 10mm axial sections without intravenous contrast enhancement. The ventricles are mildly dilated with mild central and cortical atrophy. There are bilateral basal ganglia calcifications. There is no mid line shift of the lateral ventricles. No evidence of hemorrhages, infarcts or cerebral edema. There is evidence of neither subarachnoid hemorrhage nor obstructive hydrocephalus.
IMPRESSION: Mild dilatation of lateral ventricles , mild central and cortical atrophy. Bilateral basal ganglia calcifications. No acute lesions or cerebral hemorrhages are identified.

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