IM 1
TheOne - 10-27-06 14:35

A 53 year old-man is brought to the emergency department by a friend. The friend reports that
the patient has "liver disease" and has been drinking heavily lately and has not taken his
medications. He has gotten progressively more confused over the past few days. On
examination, the man is afebrile, his blood pressure is 120/70 mm Hg and his pulse is
100/min. He has no obvious signs of trauma but has some old, well-healed lacerations on his
forehead. He has deep scleral icterus and his skin is jaundiced. His lungs are clear. and
cardiac examination is normal, but he has a distended abdomen with shifting dullness. He is
alert to person only and his neurological examination is remarkable for the inability to perform
finger-to-nose touching and heel-to-shin maneuvers. There are involuntary jerking motions of
his hands when he extends his arms, dorsiflexes his wrists and spreads his fingers. Laboratory
studies show:

Sodium..............................125 mEq/L
Potassium..............................3.1 mEq/L
Bicarbonate..............................18 mEq/L
Urea nitrogen............................25 mg/dL
Creatinine..............................1.2 mg/dL
Aspartate aminotransferase.......230 U/L
Alanine aminotransferase..........310 U/L
Prothrombin time......................14.8 seconds
Alkaline phosphatase................75 U/mL
Leukocyte count.......................6,400/mm3
Hematocrit..............................35%
Blood alcohol level....................2100 mg

Which of the following is the most likely diagnosis?

A. Acute hyponatremia
B. Ascending cholangitis
C. Hepatic encephalopathy
D. Metabolic acidosis
E. Subdural hematoma