Young malay male: history to be recorded (please add to his history if any of you have examined him earlier when he was more co-operative enough to give a better history)

General physical examination
      Pt appears cachexic, poorly built, poorly nourished and shows effort intolerance on moving. He has a tendency to sleep on the left side. He talks in full sentences.
 
There is no pallor, cyanosis, clubbing, but conj looks muddy.
 
Systemic examination:
      Bp 126/64 mmhg
      Pr 144/min
      SpO2 93%
 
Systemic examination:
      CVS
             S1 & s2 heard
             Increased JVP
 
Resp examination:
      Crepts on left middle & lower lobe
      No wheeze
 
Local examination:
      Chest and Abdominal
 
Inspection:
      Tachpnoiec ( >25/min)
      Gross distension
      Skin shinny 
      Umbilicus everted
      Scar present- midline extending 4 inches above umbilicus
      Muscle wasting not commendable
 
 
 
 
Palpation:
      Decreased chest expansion on lower lobe of right side
      Unable to feel for organomegaly as pt feels pain on deep palpation
      Pain present on right iliac and right lumbar
     
Percussion
      Chest is resonant in all areas except in the lower back of right side of chest
      Resonant traube��s space
 
Auscultation:
      Crepitation on the lower end of right lobe of lung
      Bowel sounds are heard
 
Provisional diagnosis:
      Fluid overload ascites
      Right pleural effusion
      Congestive cardiac failure
      Chronic liver disease ( Hep C )
      Thallasemia major
 
Management:
Plan:
      Branula to be inserted
      I/O chart
      O2- nasal prongs
      Peritoneal tap
      Pleural tap
      FBC, BUSE, coagulation profile
      LFT, creatinine
      Keep SpO2
      ESR
      Sputum C&S
      Blood transfusion
      ECHO
     
     
 
Investigation results:
 
Urea and electrolyte
      Sodium 114 ( 135-145 mmol/l)
      Chloride 86 (98-108 mmol/l)
 
Coagulation profile:
      Prothrombin time-15.6 sec (9-12.4)
 
WBC-18.7* 10-3 ( 4-11)
RBC-2.6 * 10-6( 4.5-6.5)
Hb- 7.1 g/dl ( 13-18)
Platelet- 566* 10-3 (150-400)
 
Sputum negative
Pleural tap negative
Peritoneal tap negative
Blood C&S negative
Body fluid biochemistry
      Protein- body fluid 29.30 g/l
      Cloudy
 
Iron profile
      TIBC-205 micro grams/dl  ( 244-400 ratio)
 
ECHO
      Good LV function EF-58%
      LV- mildly dilated
      No valvular defect
      No vegetations seen intra cardiac