Thu11November0627PM 8

A 49-year-old male patient with chronic liver disease and known liver cirrhosis secondary to alcohol abuse, is admitted through the Emergency department. He is confused and has suffered with an altered sleep pattern for the past forty eight hours.

On examination the Glasgow coma scale is 13 (E2, V5, M6). He is apyrexial. His abdominal examination reveals a soft abdomen with no obvious ascites. There are stigmata of chronic liver disease.

Blood tests are as follows:

Hb 135 g/L

WCC 7 ×109/L

Platelets 128 ×109/L

Na 131 mmol/L

K 3.6 mmol/L

Creatinine 49 µmol/L

Urea 4 mmol/L

Magnesium 0.81 mmol/L

Serum ammonia is within normal limits.

How would you proceed to manage this patient?

(Please select 1 option)

Lactulose

CT brain Correct

IV fluids

Rifaximin

Lumbar puncture

Explanation

The question here leads the reader to believe there may be a hepatic encephalopathy present. However, the serum ammonia is within normal limits. The abdomen is also soft and non-tender, and inflammatory markers are low, thus excluding spontaneous bacterial peritonitis as a source of altered GCS.

So, despite the history, there is now a man with an altered conscious level and no obvious cause. A CT head is entirely appropriate and must be performed first line in order to exclude an acute intracranial abnormality. You should have a low threshold to image the brain in a confused patient, even with a background of alcohol or toxin abuse; it is safer to exclude intracranial abnormality before treating for a presumed diagnosis.

Answer Statistics

1

25%

2

66%

3

6%

4

4%

5

1%

Times answered: 290