Maria, a 44-year-old woman with a history of paroxysmal nocturnal hemoglobinuria (PNH) and chronic alcohol use, presents with severe abdominal pain, abdominal distention, and shortness of breath over the past week. She also reports intermittent vomiting. Physical examination reveals jaundice, a protuberant abdomen with right upper quadrant tenderness, painful hepatomegaly extending 7 cm below the costal margin, and moderate ascites. Visible dilated abdominal veins are noted when she is standing, along with bilateral pitting edema. Her vital signs show mild hypotension (BP 87/57 mmHg) and tachycardia (HR 112 bpm). Given her history of hypercoagulable conditions and physical findings, you suspect hepatic vein thrombosis (Budd-Chiari syndrome). Of the following, which is the initial test of choice in this patient to confirm the diagnosis?

A 44-year-old woman complains of severe abdominal pain and a feeling of abdominal fullness. She has been vomiting off and on for the last week. First she got abdominal pain and then the abdominal distention after two days. She gets short of breath on exertion. She has been having normal bowel movements. Her stool frequency and stool color is normal. She takes vitamin tablets and a daily oral contraceptive. Her past medical history is significant for several admissions for alcohol-related complications and paroxysmal nocturnal hemoglobinuria. Her sister had developed a deep venous thrombosis at age 48 years. Her temperature is 99 °F (37.2 °C), heart rate is 112 beats/min, blood pressure is 87/57 mm Hg, respirations are 19 breaths/min, and oxygen saturation is 96% on room air. On physical examination, she is afebrile. She has scleral icterus, otherwise eye examination is normal. She displayed shallow and rapid respirations. She has a protuberant abdomen with right upper quadrant tenderness and painful hepatic enlargement measuring 7 cm below the costal margin and a fluid wave. You can see visible dilated veins on her abdomen and back when standing. There is moderate ascites. She has 1+ pitting edema bilaterally. Rectal examination is normal. No occult blood was detected. Nervous system examination is normal. What is the most likely diagnosis in this patient?

A 56-year-old male with a history of chronic alcohol use and liver cirrhosis, presents to the clinic with worsening abdominal swelling and bilateral lower limb edema over the past two weeks. He also reports mild shortness of breath and reduced urine output. Mark denies any fever, chest pain, or gastrointestinal bleeding. Mark’s medical history includes liver cirrhosis, diagnosed two years ago due to chronic alcohol use. He stopped consuming alcohol six months ago and has no other significant health issues. On examination, Mark’s vital signs reveal mild hypotension with a blood pressure of 100/65 mmHg and a heart rate of 92 bpm. Abdominal examination shows gross ascites with a positive fluid wave, and pitting edema extends to the mid-thighs bilaterally. Signs of chronic liver disease, such as jaundice and spider angiomas, are also noted. Which diuretic is considered first-line therapy for ascites management in chronic liver cirrhosis?

A 54-year-old male with a history of chronic alcohol use and liver cirrhosis, presents to the clinic with worsening abdominal swelling and bilateral lower limb edema over the past two weeks. He also reports mild shortness of breath and reduced urine output despite being on diuretics, including spironolactone and furosemide, for the past month. He denies any fever, chest pain, or gastrointestinal bleeding. His medical history includes liver cirrhosis, diagnosed two years ago due to chronic alcohol use. His ascites has previously been managed with diuretics and occasional paracentesis. He stopped consuming alcohol six months ago and has no other significant health issues. On examination, his vital signs reveal mild hypotension with a blood pressure of 100/65 mmHg and a heart rate of 92 bpm. Abdominal examination shows gross ascites with a positive fluid wave, and pitting edema extends to the mid-thighs bilaterally. Signs of chronic liver disease, such as jaundice and spider angiomas, are also noted. Laboratory findings reveal significant hypoalbuminemia with a serum albumin level of 2.1 g/dL (normal: 3.5–5 g/dL). Total bilirubin is elevated at 3.5 mg/dL, and his INR is prolonged at 1.8, consistent with synthetic liver dysfunction. Renal function is mildly impaired with a creatinine level of 1.3 mg/dL, and serum sodium is 129 mEq/L. Mark’s urine output has decreased to 500 mL/day despite diuretic therapy. Mark is initiated on intravenous albumin infusion at 25%, administered twice weekly. What is the role of intravenous albumin infusion in managing ascites in liver cirrhosis?

Mark T., a 54-year-old male with a history of chronic alcohol use and liver cirrhosis, presents to the clinic with worsening abdominal swelling and bilateral lower limb edema over the past two weeks. He also reports mild shortness of breath and reduced urine output despite being on diuretics, including spironolactone and furosemide, for the past month. Mark denies any fever, chest pain, or gastrointestinal bleeding. Mark’s medical history includes liver cirrhosis, diagnosed two years ago due to chronic alcohol use. His ascites has previously been managed with diuretics and occasional paracentesis. He stopped consuming alcohol six months ago and has no other significant health issues. On examination, Mark’s vital signs reveal mild hypotension with a blood pressure of 100/65 mmHg and a heart rate of 92 bpm. Abdominal examination shows gross ascites with a positive fluid wave, and pitting edema extends to the mid-thighs bilaterally. Signs of chronic liver disease, such as jaundice and spider angiomas, are also noted. Laboratory findings reveal significant hypoalbuminemia with a serum albumin level of 2.1 g/dL (normal: 3.5–5 g/dL). Total bilirubin is elevated at 3.5 mg/dL, and his INR is prolonged at 1.8, consistent with synthetic liver dysfunction. Renal function is mildly impaired with a creatinine level of 1.3 mg/dL, and serum sodium is 129 mEq/L. Mark’s urine output has decreased to 500 mL/day despite diuretic therapy. How does low serum albumin in chronic liver cirrhosis impair diuretic response?

A 24 year-old male comes to your office for some laboratory tests prescribed by his infectious diseases specialist. He started on isoniazid as part of his treatment for latent tuberculosis 6 weeks ago. Patient reports he has been taking isoniazid as prescribed. He does not report any symptoms today. His physical examination is unremarkable. The laboratory test results include the following: Serum Reference Range Alanine aminotransferase (ALT) 88 U/L 10 – 40 U/L Aspartate aminotransferase (AST) 96 U/L 12 – 38 U/L Alkaline phosphatase 104 U/L 25 – 100 U/L What is the next best step in the management of this patient?