In July 2022, A 47-year-old male patient was admitted to the General Medicine unit in a tertiary care hospital with complaints of Yellowish discoloration of skin, abdominal distension, disturbed sleep cycle, severe dyspnea, diminished urine output, and swelling on both legs for 3 days.

His symptoms started a week before his admission and they gradually progressed in nature. The patient was a known case of chronic liver disease, diabetes mellitus, and hypertension.  He was nonadherent to his medication schedule. His past medication were Tab. Amlodipine 5mg BD, T. Metformin 500mg BD, Tab. Udiliv 300mg OD.

The patient was a non-smoker chronic alcoholic for the past 30 years. He takes a mixed diet. The patient had been hospitalized for the same condition twice before. On examination, the patient was conscious and oriented, history of pedal edema on both legs, Patient also had ascites, anasarca, and icterus positive. There was no history of lymphadenopathy and clubbing. His blood pressure level was 150/100 mmHg and his pulse rate was 100 beats per minute.

On systematic examination distended abdomen was observed with mild ascites and dilated veins. On cardiovascular examination normal S1 and S2 sounds were present. No murmurs were observed. On observing his laboratory parameters, his complete blood showed low hemoglobin levels i.e., 8.1 mg/dL, and low platelet levels of 1.25 lakhs/cu.mm, SGOT levels were 140 IU/L, SGPT 65 IU/L, and all the other parameters were observed to be normal. Other investigations like USG abdomen were done and the impression showed chronic liver parenchymal disease with mild splenomegaly, and mild to moderate ascites. Exfoliative cytology test for malignancy was observed to be negative. Ascitic fluid examination showed High SAAG ascites.

The patient was treated with Inj. Furosemide 20mg IV BD, Tab. Spironolactone 25mg OD, Inj. Ranitidine 1 ampule, Tab. Propranolol 25mg BD, T. Alprazolam 0.25mg HS, and Multivitamin tablets as supplements.

Salt-restricted diet and high protein intake were advised to the patient. Large volume paracentesis (2lit) was extracted. Intravenous albumin replacement (100 mL 20% albumin for every 2.5 L drained) was  given at the time of paracentesis to reduce the risk of precipitating hepatorenal syndrome. Tab. Ciprofloxacin 500mg BD, Tab. Metronidazole 400mg TID was added to the medication chart to provide antibiotic cover. The input and output chart of the patient was monitored throughout his hospital stay. The patient’s condition improved and the symptoms subsided. He was also counselled on quitting alcoholism and complications were explained. The patient was diagnosed with