Introduction: Many patients present to the emergency department (ED) with nonspecific, acute-on-chronic complaints. It requires a thorough diagnostic approach and broad differential diagnosis to determine whether there is serious, undiagnosed pathology.

Case Presentation: A 60-year-old female presented to the ED for gradually worsening bilateral lower extremity swelling with associated abdominal distension, ascites, diarrhea, vomiting, and weight loss.

Discussion: This case takes the reader through the evaluation of a patient with acute-on-chronic complaints who presented in a decompensated state.