Schizophrenia Case Study Essay

A 54-year-old man is brought to the Eemergency Ddepartment by an ambulance because he has been vomiting large amounts of fresh blood. He The patient admits to drinking three six-packs of beer and a pint of vodka on a regular basis for years. This is the second time he has presented with this symptom. Last week, he was admitted in to the same hospital for the same complaint. An endoscopy was performed, which revealed esophageal varices. Banding was done and he was discharged yesterday with no post-operative complications. He suddenly began vomiting blood today in the afternoon. He denies any trauma, eating, or taking any medication prior to the current episode. His physical examination is remarkable for hepatosplenomegaly and shifting dullness with a fluid wave on percussion of the abdomen. He has palpable

tortuous veins arising from his umbilicus. The patient is considered for portal-systemic shunt. Which set of symptoms could be a complication of the procedure?
A. Aphasia, hemiparesis, facial droop, and hemisensory deficits
B. Dizziness, dry mouth, increased appetite, and congested conjunctiva
C. Fever, seizures, headache, and neck stiffness.
D. Gait disturbances, urinary incontinence, and changes in cognitive function
E. Lethargy, changes in personality, inappropriate behavior, and slurred speech.

Answer

Choice "E" is the best answer. This patient has alcoholic cirrhosis and is experiencing rebleeding from his esophageal varices after undergoing banding. Consequently, the next step in management is a transjugular intrahepatic portosystemic shunt (TIPS) placement, which would reduce the portal vein pressure by diverting blood from the portal to systemic circulation. Hepatic encephalopathy is the most common complication from the TIPS procedure. It occurs due to the shunting of neurotoxic substances, such as ammonia, past the liver to the brain. Its symptomatology may be classified by the West Haven classification system:
• Grade 0 - Minimal hepatic encephalopathy (also known as CHE and previously known as subclinical hepatic encephalopathy); lack of detectable changes in personality or behavior; minimal changes in memory, concentration, intellectual function, and coordination; asterixis is absent.
• Grade 1 - Trivial lack of awareness; shortened attention span; impaired addition or subtraction; hypersomnia, insomnia, or inversion of sleep pattern; euphoria, depression, or irritability; mild confusion; slowing of ability to perform mental tasks
• Grade 2 - Lethargy or apathy; disorientation; inappropriate behavior; slurred speech; obvious asterixis; drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time
• Grade 3 -– Somnolent, but can be aroused; unable to perform mental tasks; disorientation about time and place; marked confusion; amnesia; occasional fits of rage; present, but incomprehensible speech
• Grade 4 -– Coma, with or without response to painful stimuli .

Choice "A" is not the best answer. These symptoms are typical of a cerebrovascular accident/stroke. They are not present in hepatic encephalopathy.

Choice "B" is not the best answer. These are adverse effects of the drug cannabis. They are not symptoms of hepatic encephalopathy.

Choice "C" is not the best answer. These are symptoms of meningitis. They are not symptoms of hepatic encephalopathy.

Choice "D" is not the best answer. These symptoms are part of the classic triad of normal pressure hydrocephalus: gait abnormality, urinary incontinence, and dementia. They are not symptoms of hepatic

encephalopathy.