Vale

Yes.

Hi, friends.

I'm glad to be back.

I'm Vale.

I am an IMG from Peru, Lima, and I'm starting neurology residency soon.

So I'm just working on that.

That's what's new to me.

How about you, Mukund?

I think of two problems here.

First, the subacute volume overload and then the acute abdominal pain.

I'll approach them separately and then think how can we connect them.

I love how Amol approached the abdominal distension and now we have confirmation that there's ascites.

But also we see fluid in the lungs, which raises the question, is this fluid coming from the liver or from the heart?

The fact that the abdominal distension was the chief concern in this patient rather than dyspnea or orthopnea makes me more concerned that this is a primary abdominal process.

However, an examine would be helpful to look for jugular venous distension or the hepatojugular reflex.

Also, finding hepatomegaly would indicate hepatic congestion, would be a point towards the heart, in comparison to finding a small cirrhotic liver, which would be a point towards the liver.

When we look at the labs, we have some clues.

The albumin is a little low, the bilirubin and the INR are mildly elevated, and interpreting the platelets is hard, because if we are thinking that this is ascites secondary to portal hypertension, cirrhosis is the most common cause of portal hypertension.

However, not all causes of portal hypertension are cirrhosis-related.

Our patient totally has JAK2-positive thrombocytosis, which is a myeloproliferative neoplasm, meaning there's an abnormal production of blood cell lines.