Ascites 101

  Real Case and Fake ID 💯 

S – Situation

• Patient: 76-year-old male

• Chief Complaint: Abdominal pain ×1 day (now resolved)

• Status: Admitted from ED for further management of abdominal pain, ascites, and possible colitis.

B – Background

• Past Medical History:

  • Atrial fibrillation on Eliquis

  • HFpEF

  • Tachy/Brady syndrome s/p dual lead PPM

  • Mitral valve repair, tricuspid valve repair

  • Presumed COPD

  • Gastric cancer s/p total gastrectomy

  • Chronic anemia

  • Left femoral hernia s/p repair

  • Severe malnutrition, bowel obstruction (2022), C. difficile colitis, PUD, hypertension, prostate enlargement, tobacco use disorder in remission, history of pneumonia, chest pain, and SOB

• Past Surgical History: Appendectomy, gastrectomy, gastrostomy tube placement (2015), hernia repairs (umbilical and femoral), colonoscopy, EGD

• Allergies:

  • Dilaudid – anaphylaxis, respiratory distress

  • Morphine – behavioral reaction (“makes him crazy”)

  • Penicillins – rash (tolerates cephalosporins)

• Social History: Former smoker (60 pack-years, cigars and cigarettes), no alcohol or drug use, lives with daughter.

• Family History: Sister with diabetes; sister with bone cancer.

A – Assessment

• History of Present Illness:

  • Patient Spanish-speaking, HOH, refused interpreter. Limited history obtained.

  • Reported diffuse abdominal pain beginning yesterday, improved on arrival.

  • Denied nausea, vomiting, diarrhea, constipation, chest pain, SOB.

  • Daughter reports no other symptoms until abdominal pain this morning.

• ED Findings:

  • Vitals: Afebrile, HR 80, RR 18, BP 147/75, SpO₂ 96% RA

  • Labs:

    • K 3.1, glucose 336, ALP 124

    • Troponin T 18 → 20 → 26 (flat trend)

    • Hgb 10.4 → 9.0

    • UA: 2+ leukocytes, 7 WBC/HPF, glucose 4+

  • Imaging:

    • CT A/P: Mild rectosigmoid wall thickening/edema (possible colitis), moderate ascites, small R pleural effusion, anasarca, prostatomegaly

    • CXR: No acute findings

  • EKG: AFib, V-paced, PVCs, unchanged from prior

• Hospital Course / Current Exam:

  • Vitals: Stable (T max 99°F, HR 62, BP 124/65, SpO₂ 95%)

  • Exam: No abdominal tenderness or distension, lungs clear, CV regular, no edema, alert.

  • Labs (most recent): Hgb 9.0, WBC 5.8, ANC 4.37; electrolytes stable after repletion; glucose variable (79–336).

  • Code status: Full code (patient previously signed DNR but daughter requests full code currently).

• Problem List:

  1. Abdominal pain, resolved – CT suggests possible colitis, but no diarrhea or tenderness.

  2. Moderate ascites – unclear etiology: CHF vs malignant (given gastric cancer history).

  3. Mild troponin elevation – flat, EKG unchanged, denies chest pain.

  4. Hypokalemia – K 3.1, being repleted.

  5. Chronic conditions – AFib (on Eliquis), HFpEF, COPD, chronic anemia, gastric cancer history.

R – Recommendation

• Diagnostics / Consults:

  • Consult procedure team for diagnostic/therapeutic paracentesis; send cytology.

  • Consider GI consult.

• Medications / Management:

  • Continue home regimen: Eliquis 2.5 mg BID, Cardizem 120 mg daily, Bumex 2 mg daily, Metoprolol 50 mg daily, Jardiance 10 mg daily.

  • Tylenol PRN for pain.

  • Replete electrolytes as needed.

• Monitoring:

  • Monitor troponin, cardiac telemetry.

  • Trend Hgb given chronic anemia and recent drop (10.4 → 9.0).

  • Watch for signs of infection/colitis.

• Supportive Care:

  • Diet: Cardiac.

  • DVT prophylaxis: Eliquis.

  • Code: Full Code per family request