65 year old female ,occasionally alcoholic and smoker as well, daily wage labourer by occupation who shed her sweat everyday to meet her daily requirements,  presented to us with complaints of

                     generalised swelling of body since 3 months
                     Dyspnoea since 2 months
                     Pain in the left knee since 10 days.

     All her story began an year back when she developed jaundice then as any layman would do ,she went to a local RMP who prescribed her herbal medications and her yellowish discolouration subsided with it, then later on
     3 months from now she started noticing distention of her abdomen which was gradually progressing which made her worrisome and then  progressed to her  lower limbs and then on developed generalised swelling of her whole body , pitting type
     since 2months complaints of dyspnoea which was initially grade 2 ,later on her dyspnoe started interfering with her routine activity  and progressed to grade 3 associated with palpitations
     Had no complaints of chest pain,orthopnea,paroxysmal nocturnal dyspnoea,cough,

On examination : Thin built ,malnourished,pallor present,anasarca  present
                            PR 100bpm,BP 120/80mm of Hg, afebrile,RR 31 cycles/min,JVP was visible.

 CVS  :                          on inspection: jugular pulse visible ,trachea appears to be slightly deviated to                                                                right, apex beat visible ,no scars or sinuses noted.


                                      on palpation: consistent with the inspectory findings,apical impulse shited to
                                                            down and out ,parasternal heave present.

                                     on auscultation: MITRAL AREA          -S1 ,S2 heard,murmur present
                                                               TRICUSPID AREA      - S1 ,S2 heard,murmur present
                                                               PULMONARY AREA -S1 S2 heard
                                                               AORTIC AREA            -S1 S2 heard

   ABDOMEN EXAMINATION:

   On inspection :  Diffuse distention of abdomen with flank fullness with umbilicus everted ,all quadrants moving equally with respiration ,no engorged veins or scars noted.
   On palpation :  Non tender,
   On percussion : Fluid thrill present
   On ausculatation: bowel sounds present ,no murmur or thrill noted.

  OTHER SYSTEMS: NAD

PROVISIONAL DIAGNOSIS: 1) Ascitis under evaluation {secondary to ?? heart failure ??chronic                                                                                                     liver disease}
On Evaluation:

Heamoglobin  and serum protein were on lower side.

 
USG abdomen showed massive ascitis with bilateral RPD changes ,increased echotexture of liver with irregular margins  with cholelithiasis

 Ascitic fluid analysis showed high SAAG and low protein.

 

Started her on preload and afterload reducing agents and she is well responding to it.
                       Advised for fluid and salt restriction.
                      Thiamine injections.
Patient is complaining of fever on and off.

Temperature recording during the hospital stay

                   
DIAGNOSIS AFTER WORK UP:  Mixed Ascitis possibly due to  Dilated cardiomyopathy ,liver                                                                 failure

POINTS OF DISCUSSION:

1) what could be the cause of ascitis ?
2) How reliable is  the ascitic analysis workup in a patient with ascitis?
3) If it is a mixed ascitis ,which is predominant and how can we further evaluate it?