She reported a medical history of hypertension, obesity, type II diabetes mellitus, depression, portal hypertension with endoscopically documented gastric and esophageal varices, hepatic encephalopathy, degenerative joint disease, and polycystic ovaries. She had undergone a total knee replacement (2 years previously), a cholecystectomy (10 years ago), and three cesarean sections. She was allergic to morphine. Her medications consisted of propranolol, insulin, venlafaxine, spironolactone, famotidine, an oral contraceptive, and multivitamins. On examination at the time of the hospital transfer, she had a BP of 100/70 mm Hg, a pulse of 84 beats/min, a respiratory rate of 28 breaths/min, and oxygen saturation of hemoglobin of 76% by pulse oximetry (which increased to 91% while she received 4 L/min nasal oxygen). The patient had produced only 50 mL urine in the preceding 24 h. She was markedly jaundiced (total bilirubin level, 3.4 mg/dL). She had small ulcers on her lips and hard palate. She had bilaterally reduced breath sounds with expiratory wheezes, basilar rales, and distant heart sounds without a gallop, murmur, or rub. She was obese and had a large nontender abdomen with obvious ascites. Her right leg was erythematous and swollen. She was oriented to person but not to time or place. She was too weak to assess motor strength. Table 1
documents her jaundice, hepatic dysfunction, and renal dysfunction, and it tracks these abnormalities through her hospital course. Imaging studies documented a large cardiac shadow that was strongly suggestive of a pericardial effusion, a pancreatic mass in the head of the pancreas, and a clotted portal vein.