History and Physical Examination Essays

History and Physical Examination Essays History and Physical Examination Essay History and Physical Examination Essay EMERGENCY DEPARTMENT TREATMENT RECORD Patient Name: Putul Barua panent ID: 135799 sex: Male Room NO. : CCU4 Date of Admission/Date of Arrival: 01107/2013 Admitting/Attending Physician: Simon Williams, MD 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 ightness, 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 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, he 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 patients wife, Nupur, with the patient translating for her from the Hindi language. PAST HISTORY Tuberculosis in the past. Embolectomy at Hillcrest last year. continued) Page 2 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 Mariette 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 SYSTEMS Negative other than as stated in HPI. PHYSICAL EXAMINATION V ital signs are 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 Sl and S2. No S3 or S4 is heard at this time. LUNGS: Bilateral bronchi. 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 with history of tuberculosis. Room No. C Page 3 PLAN I have reviewed the chest x-rays available here and agree with the findings of bleb ormation 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 of 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 ecause 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. 135799 sex: Male Patient ID: Room No. : CCU4 Date ot Admission/Date ot Arrival: O Page 4 We will recheck the prothrombin time and INR tomorrow. Depending upon those results, we will proceed with bronchoscopy and further evaluation. Simon Williams, MD Pulmonology sw:tm D: 01107/2013 -r: 01/08/2013 CC: J. K. McClain, MD Cardiology