General Investigations

1. Urine Dipstick:  It is a simple and cheap procedure that will be strongly positive for protein in nephrotic syndrome. If so, a 24 hour urine collection for protein should be undertaken; more than 3.5gm is indicative of nephrotic syndrome.

2. Complete Blood Count: Raised white cell count may indicate an infective etiology but a differential white count is more specific.

3. Urea and Electrolytes: Elevated urea and creatinine may indicate a renal etiology; however , it may also be a component of hepatorenal syndrome, which is renal impairment secondary to liver failure.

4. LFT’s : May be deranged in the presence of liver disease. The serum albumin will be able to indicate hypoalbuminaemia but the underlying cause must still be sought.

5. Chest X-ray: Findings suggestive of cardiac failure are cardiomegaly, upper venous diversion of blood, the presence of Kerley B lines, pulmonary edema and pleural effusion. Occasionally the presence of carcinoma may be suggested by a mass in the lung.

6. Ultrasound Abdomen: In addition to confirming the presence of ascites ultrasound will detect any intra abdominal masses that are not palpable on clinical examination. It may also indicate the presence of fatty deposits in the liver in the presence of cirrhosis. Dilated collateral veins may be visualized in conditions that cause obstruction of the venous outflow of the liver, including cirrhosis and Budd-Chiari syndrome.

7. Abdominal Paracentesis: Aspiration of the ascitic fluid is very useful to help determine the underlying cause. A sample should be sent to microbiology  clinical chemistry and pathology.

Ascitic fluid Examinations

Appearance

Chylous The milky white appearance of chylous ascites is due to obstruction of the lymphatic ducts.

Bile stained is suggestive of bile peritonitis

Haemorrhagic can occur in malignancy, trauma and tuberculosis.

Straw-coloured is the usual appearance with most other causes.

Biochemistry

Protein: The ascitic protein levels are often used to classifly the ascites as a transudate or an exudate; however this may not always be reliable. A transudate would be ascitic fluid with the protein concentration of less than 25 gm/l in the sample or 11 gm/l lower than the serum protein level, while an exudate is the opposite.

Amylase: is usually elevated in pancreatic ascites

Glucose: is low in bacterial infections

Triglyceride: it is elevated in chyl;ous ascites and may indicate obstruction of drainage of the thoracic duct.

Billirubin: it is elevated in bile ascites

Microbiology

Gram and Ziehl-Neelsen staining with cultures may be positive with a bacterial etiology.

Cytology

Neutrophilia is suggestive of a bacterial peritonitis, while tuberculous peritonitis usually results in a lymphocytosis. Malignant cells may be identified and a primary source may be possible located.

Specific Investigations

1. Echocardiography: It will reveal most of the cardiac causes. Cardiac failure will manifest as poorly contractile ventricle with a reduced ejection fraction. A pericardial effusion is visible as an echo free space between the left ventricle and the pericardium.

2. Liver biopsy: will be able to confirm and may be able to ascertain the underlying cause of liver cirrhosis.

3. Renal Biopsy: reveals the underlying cause of nephrotic syndrome.

4. Portal venography: will be indicated if obstruction to the venous outflow of the liver is suspected and can be used to confirm  Budd-Chiari syndrome and veno occlusive disease.

Causes

Hepatic 

• Cirrhosis
• Hepatic tumors

Malignant Disease

• Carcinomatosis
• Abdominal/pelvis tumors that may be primary or secondary
• Pseudomyxoma peretonei
• Primary mesothelioma

Cardiac

• Cardiac failure
• Constrictive pericarditits
• Tricuspid incompetence

Renal

• Nephrotic syndrome

Peritonitis

• Tuberculosis
• Spontaneous bacterial

Venous obstruction

• Budd-Chiari syndrome
• Veno-occlusive disease
• Hepatic portal vein obstruction
• Inferior vena cave obstruction

Gastrointestinal

• Malabsorption
• Pancreatitis
• Bile ascites

Clinical History

1. Does the patient have >1 type of headache?

2. Time:When did the headache start? New or recently changed headache calls for especially careful assessment. How often do they happen? Do they have any patteren( e.g constant,episodic,daily). How long do they last? Why is the patient coming to the doctor now?

3. Character: Nature and quality, site and spread of the pain. Associated symptoms e.g nausea/vomiting, visual disturbance, photophobia, neurological symptoms.

4. Cause: Ask about predisposing and /or trigger factors; aggrravating snd /or relieving factors; family history of similar headaches.

5. Response:Details of medication used (type, dose, frequency, timing). What does the pateint do? e.g can the patient continue work?

6. Health between attacks: Do the headaches go completely or does the patient feel unwell between attacks?

7. Anxieties and concerens of the patient

Physical Examination

In acute seveer headache, examine for purpuric skin rash. In all cases check BP, brief neurological examination including fundi, visual acuity and gait, palpation of temporal regions/ sinuses for tenderness and examination of neck. In young children measure head circumference and plot on centile chart.

Red Flags To Take Immediate Action

• New unexpected headache
• Thunderclap headache
• Aura for first time and using combined oral contraceptives
• New onset age > 50 yrs or < 10 yrs
• New onset in a patient with a history of HIV or cancer
• Headache with atypical aura ( > 1 hr with or witput motor weakness)
• Progressive headache worsening over weeks
• Associated postural change