Ok, so that was a fairly brief history to work at!  but it has produced some interesting differential – not all haematological which is useful!

The patient gives you the following history:

He has been generally unwell/lethargic for the past 2 weeks.  He has noted swelling of his lower limbs right>left.  He denies weight loss but thinks he may have put on some weight and feels his abdomen is very bloated.  The pain is generalised throughout the abdomen, and he describes this as a discomfort/aching pain, which has been present for the past 24 hours.  However he describes a feeling of fullness which has been present for the past few days.  Over the past twenty four hours he has had difficulty passing urine, although he has not been able to drink significant volumes due to nausea and vomiting.  He has noted that his urine is very concentrated.

From the end of the bed you note he is quite pale and clammy.

On examination, he has significant peripheral oedema and ascites.  You suspect there is a fullness in the right iliac fossa.  Heart sounds are normal, and on auscultation of the chest you find a few bibasal crepitations.

Bp 84/45, HR 113, RR 18, SATS 94% on RA, apyrexial

How do you respond?  what investigations do you organise? any further questions you wish to ask? any further examination needed? Who would you wish to contact?