The most appropriate diagnostic test to perform next is ultrasound of the liver and spleen. This patient has a history of nonalcoholic fatty liver disease (NAFLD) and now has abdominal distention suggestive of ascites. Her low platelet count is suggestive of portal hypertension, and liver dysfunction is supported by the slightly elevated serum bilirubin and low albumin levels. The next test should be liver imaging with a test such as ultrasound to assess for changes consistent with portal hypertension. In the United States, many cases of “cryptogenic” liver disease are likely related to advanced NAFLD.

Although this patient has risk factors for cardiac disease, she does not have other signs or symptoms suggestive of heart failure. In addition, cardiac dysfunction, unless very long-standing, would not produce splenomegaly. Therefore, echocardiography is not necessary at this time.

Liver biopsy to diagnose cirrhosis is not necessary in patients with other clear manifestations of liver dysfunction and portal hypertension, such as is seen in this patient.

Simvastatin rarely produces mild liver test abnormalities but does not cause chronic liver injury or portal hypertension. Patients with NAFLD have a high prevalence of coronary artery disease; therefore, risk-factor reduction, including the use of statins where appropriate, is advised.