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Woman, 34, with increasing abdominal girth.

Article Excerpt
A 34-year-old woman presented to the emergency department (ED) with a three- to four-week history of increasing abdominal girth and a three-day history of fever, chills, and mild periumbilical discomfort radiating into her back.

The patient had been seen in the ED 16 days earlier for similar symptoms. At that time, her complete blood count, basic metabolic panel, and liver function tests yielded normal results. A urine pregnancy test was negative. A flat and upright abdominal x-ray series revealed no significant findings.

During the current visit, the patient mentioned loss of appetite but denied any nausea, vomiting, diarrhea, constipation, hematochezia, or genitourinary symptoms. She complained of some shortness of breath at night, secondary to her increased abdominal girth. Her past medical history was significant only for mild asthma, for which she was not currently being treated. She admitted to occasional alcohol use but denied use of tobacco or intravenous drugs.

The patient said she was a home personal care worker. She had immigrated to the United States six years earlier from Liberia, West Africa.

On physical examination, she had a temperature of 101[degrees]F. She was morbidly obese but in no acute distress. Examinations of the head, eyes, ears, nose, throat, and neck were unremarkable. Pulmonary examination revealed no respiratory distress; lungs were clear bilaterally without wheezes, rales, or rhonchi. Cardiovascular examination revealed regular rate and rhythm without murmurs, gallops, or clicks.

Gastrointestinal examination revealed marked abdominal distention with mild to moderate tenderness in the periumbilical region. The patient had a reducible umbilical hernia but no rebound tenderness, guarding, or appreciable masses. A questionable fluid wave was noted. Femoral pulses were 2+ and equal; the neurologic examination yielded normal findings.

In laboratory studies, the only findings not within normal range were hemoglobin, 11.3 g/dL; hematocrit, borderline low at 35%; urinalysis, 2+ ketones, 1+ protein; and high bacteria levels. Serum sodium and serum albumin levels were both slightly low (135 mmol/L and 3.2 g/dL, respectively). Prothrombin lime was 13.9 seconds, with an international normalized ratio of 1.39.

Abdominal ultrasound showed significant ascites, with slight gallbladder wall thickening (3.8 mm).

The gastroenterology service was consulted, and the patient was admitted. The following day, an ultrasound-guided paracentesis was performed, with...

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