Immediately after his release from the Charité, which occurred about 14 days ago, the patient noticed that the swelling of the legs and the body had come back, even though he had not returned to work. At the same time the cough and shortness of breath increased again, the sputum became more abundant, and the urine more scanty. Soon the complaints got so out of hand that he was forced to return to the clinic; this time he was moved to my ward.
The examination performed on October 22 at noon showed the following:
A man, not large, of fairly powerful build, with a panniculus low in fat and a dirty pale color to the cheeks, little redness of the lips. Elevated dorsal position. Completely conscious. Patient complains of cough, shortness of breath, and swelling of the abdomen, which is combined with a feeling of tension. The skin of the trunk has a decidedly blue tint, which is even stronger in the lower extremities. Traces of previous ulceration on the right calf. Legs quite strongly swollen, the scrotum less so.
Chest with an abnormally strong arch; the anterior wall forms an almost spherical segment between the claviculae and the sixth pair of ribs. Seen from behind, the lower half of the chest appears broader than usual. Breathing type costo-abdominal with little movement of the ribs, strong protrusion of the abdominal walls and moderate contraction of the scaleni. Percussion sound at the anterior chest wall loud, fairly deep, not tympanitic. Along the right lateral wall the sound is the same on top, but higher further down. The lower boundary of the right lung lies at the parasternal line at the height of the sixth rib, at the axillary line at the height of the eighth rib; the lower boundary of the left lung at the axillary line also at the height of the eighth rib. In the back the percussion sound on both sides is muffled in the lower third. The auscultation in front reveals on both sides rasping (vesicular) respiration with whistling, the latter especially during exhalation, in the back an exceedingly faint, undetermined noise along the lower portions, occasionally with quiet whirring, in the upper half a purely rasping respiratory sound. Frequent coughing, especially in the horizontal position and thus, as the patient maintains, more frequent at night than during the day; but the cough supposedly disappears immediately if the patient sits up. Sputum, currently not present, is said to be fairly abundant.