Liver puzzle answered

NO one gave any suggestion so far for the recent puzzle.. I am giving away the correct answers.



The liver tests did not support primary liver disease. The albumin was low but not what we would expect with cirrhosis. The other liver tests were remarkably normal.
We obtained an echocardiogram which showed severe pulmonary hypertension and pure right sided dilation and heart failure. I will followup on the pulmonary consultation. I suspect that the patient has obstructive sleep apnea, and possibly also COPD.
This patient represents a fascinating cognitive issue. He presented with ascites and anasarca. The SAAG was consistent with portal hypertension. Assuming primary liver disease was the natural error. This presentation requires further thought. His lab values were not consistent with that clinical assumption, so we reconsidered our assumptions. This reconsideration allowed us to hone in on the correct explanation.