مريضة تليف كبد في الجناح، أخبرتك ابنتها أنها صارت تنام كثيراً في النهار ومشوشة في الوقت. عند مد يديها للأمام ترتعش الكفان بشكل رفرفة. أمس عندها إمساك وأخذت حبة منوم. ما أكثر شيء يرتبط بحالتها؟

A client with cirrhosis is reported by her daughter to be sleeping more by day and confused about time. When she holds her hands out, they flap. Yesterday she was constipated and took a sleeping pill. What is her state most associated with?

1. Rising ammonia and early hepatic encephalopathy
2. A small stroke needing urgent thrombolysis
3. Depression from a long hospital stay
4. Low sodium from drinking a lot of water

Answer: A) Rising ammonia and early hepatic encephalopathy. Confusion, sleepiness and asterixis indicate hepatic encephalopathy, triggered by constipation, sedatives, bleeding and infection. Treat with lactulose, address the trigger and avoid sedatives.