History and Physical Examination Putul Barua Essay

613 Words 3 Pages
HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD

Patient Name: Putul Barua

Patient ID: 135799 Age: 42 Sex: M

Room No.: CCU4

Date of Admission: 01/07/----

Admitting Physician: DR. Simon Williams, MD

Chief Complaint: Tightness in the chest, shortness of breath, fast heart rate.

ADMITTING DIAGNOSIS
1) Rule out myocardial infarction
2) History of TB
3) Hemoptysis
4) Status post embolectomy

HISTORY OF PRESENT ILLNESS: Mr. Barua is a 42 year old 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 resent onset of hemoptysis. He was treated for
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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 rates 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 non tender. No hepatosplenomegaly masses are detected. RECTAL EXAM: Prostate smooth and firm. No stool is present for Hemoccult test.

DIAGNOSIS: Hemoptysis with history of TB.

PLAN: I have reviewed the chest x-rays available here and agreed with the finding of bleb formation in the right and left upper lobes. Despite the fact that the patient has had an high INR, because of his history of TB 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

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HISTORY AND PHYSICAL EXAMINATION or EMERGENCY DEPARTMENT TREATMENT RECORD

Patient Name: Putul Barua
Patient ID: 135799
Date of Admission: 01/07/----
Page 3

observing the condition by x-rays and repeated test 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 consider bronchoscopy. We will

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