HISTORY & PHYSICAL REPORT

Patient Name: Putul Barua

Patient ID: 135799

Room Number: CCU-4

Date of Admission: 01:07/...

Admitting Physician: Simon Williams. MD. Pulmonology 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

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 or
tuberculosis in bang aces years ago
This has prompted the concern whether his treatment for tuberculosis.
was adequate or whether there is another cause for his hemoptysis. The duration of his imbecilities
treatment was innocently adequate.
according to his wife. out 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 significant elevated at To. nonetheless. because of the cavitary lesions that arc scene in the right
and left upper lobes. the possibility of
tuberculosis has been raised. Ancillary history was given by the patient's white 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 USA for 10 years. Patient has
no recent history of smoking: he smoked in the past. the amount is unclear. fie 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 an MVA.
in Bangladesh.
(continued)

HISTORY & PHYSICAL REPORT

Patient Name: Put Bama

Patient Id: 135700

Date Of Admission: 01/07/...

Page 2

REVIEW SYSTEMS: Negative other than as stated in Hill.

PHYSICAL EXAMINATION: VITAL SIGNS are WNL. Apparently, he has had no chills, night sweats,
or fevers. Generalized malaise and the lack of energy have been the main concerns. HEART: Regular rate
and rhythm with ST and S2. No $3 or $4 is heard at this time. LUNGS:
Bilateral rhonchi. No significant camphoric sounds are noted.
ABDOMEN: Soft. nontender. No hepatosplenomegaly or masses are detected. RECTALEXAM: restate
smooth and firm. No stool is.

DIAGNOSIS: Hemoptysis with history of tuberculosis.

PLAN: Have reviewed the chest x-rays available here and agree with the finding of bleb formation in the
right and left upper lobes. Even though 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 for his bleeding.
have discussed this matter with the patient and his wife. Have told.
them that there is the possibly of observing the condition Dy X-rays and repeated tests 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 consent to bronchoscopy. We will arrange for the patient to have a
bronchoscopy done. He is oft Coumadin. We will recheck the prothrombin time and INK tomorrow.
Depending upon those results, we will proceed with Bronchoscopy and Further evaluation.

Simon Williams, MD, Pulmonology

SM: hs
D: 01/08/
T: 01/08/.