Question

Carl Vinson, a 65-year-old Caucasian man, was admitted today with increased shortness of breath, fatigue, and decreased level of consciousness. Mr. Vinson has a history of liver disease, most likely related to a long history of alcohol use. Upon arrival to the unit, he is somnolent and responds only to shouting and shaking. Upon arousal, he is only able to state his first name. His wife accompanies him to the unit, and describes that he has become increasingly restless over the last 3 days, and she is concerned for his safety. Additionally, he has not eaten or taken in any fluids in 24 hours. (Learning Objectives 2, 3, and 6)

 a. Correlate the patient’s presenting clinical manifestations to hepatic encephalopathy.

 b. The physician orders a STAT ammonia level, along with a CBC and complete chemistry panel. The ammonia result is elevated. What is your interpretation?

 c. The physician orders Mr. Vinson to receive lactulose (Cephulac) orally. What is the rationale for this medication?

 d. Mrs. Vinson asks why her husband must decrease intake of protein. How will you respond to her question?

Answer 1

ANSWER

6.a) Clinical manifestations of the patient

          * Shortness of breath.

          * Fatigue.

      * Decreased level of consciousness.

      * Somnolent.

      * Low response level.

      * Restlessness.

          * Anorexia.

* Clinical manifestations of patient with hepatic encephalopathy.

         * Changes in conscious level.

         * Motor disturbances.

         * Anorexia.

         * Disturbed sleep pattern.

         * Restlessness.

         * Asterixis (flapping tremor of the hands).

         * Fetor hepaticus.(A characterstic breath odor like acetone,freshy mowed grass

            seen in hepatic encephalopathy).

* When correlating clinical manifestations of the admitted patient and manifestations

   commonly seen in hepatic encephalopathy it shows increase chances for this patient

   has hepatic encephalopathy.

b) Elevated ammonia level indicate patient has hepatic encephalopathy because

   increased ammonia is the main etiological factor for development of hepatic

   encephalopathy.

* Ammonia is a toxic product which formed during digestion of proteins and ingestion of

    ammonium salts usually removed by the action of liver but in the case liver failure this

    process will not happen which result in elevated ammonia level in the body.

* Liver failure associated portal hypertension result in shunting of blood from the portal

     venous system to systemic circulation so excess ammonia reaches into the brain

    from liver through systemic circulation leads to hepatic encephalopathy.

c) Administration of drug Cephulac help to reduce serum ammonia level in the body

    so this drug is used for medical management of hepatic encephalopathy.

d) This patient should decrease intake of protein because

         * Elevated level of ammonia is the reason for developing hepatic encephalopathy

           in a patient with liver failure.

         * Ammonia is toxic product which formed during digestion of protein so intake of

           protein result in elevated level of ammonia in the blood which aggrevate hepatic

           encephalopathy.