Hillcrest Medical Case 3 H&P
HISTORY AND PHYSICAL EXAMINATION
Patient Name: Putul Barua
Patient ID: 135799 Room: CCU4 Age: 42 Sex: Male
Admitting Physician: Dr. Simon Williams, MD Pulmonology
Date of Admission: 01/07/2013
Admitting Diagnosis: 1) Rule out myocardial infarction 2) History of tuberculosis 3) hymoptesis
4) status: post embolectomy.
Chief Complaint: tightness in 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 hypomtesis. 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 hymoptesis. The duration of his tuberculosis treatment was apparently adequate, according to his wife. But, no records are available. In addition, the patient had a 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 Nupor, 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 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 Marriot 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
Patient Name: Putul Barua
Patient ID: 135799 Room: CCU4 Age: 42 Sex: Male
Admitting Physician: Dr. Simon Williams, MD Pulmonology
Date of Admission: 01/07/2013
Admitting Diagnosis: 1) Rule out myocardial infarction 2) History of tuberculosis 3) hymoptesis
4) status: post embolectomy.
Chief Complaint: tightness in 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 hypomtesis. 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 hymoptesis. The duration of his tuberculosis treatment was apparently adequate, according to his wife. But, no records are available. In addition, the patient had a 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 Nupor, 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 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 Marriot 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