Collaborative Management in Acute Care
Chief Complaint
A 39-year-old male is brought to the emergency department (ED) by emergency medical
services (EMS) with confusion and decreased responsiveness
General Survey and History of Present Illness (HPI)
In the preliminary evaluation of the patient, EMS personnel are still in the ED, and where asked
about the patient’s surroundings when they arrived at the scene. They noted that he was found at
home sitting in a chair and his brother was present. He had not been incontinent and there was
no evidence that he had fallen or had a seizure. They also report that no prescription bottles
found in the home; however, there was a half –filled bottle of acetaminophen found in the
bathroom, as well as a couple bottles of over-the-counter (OTC) cold medicines. There was no
smell of alcohol but they did not look for any empty bottles. They asked the patient’s brother to
check the garbage for any empty alcohol containers. Upon entering the exam room, the AG-ACNP notes that the patient is a well-developed adult male who appears to be sleeping. He is arousable to light tactile stimulation, is oriented to person only, has slurred speech, a moderate cough, and adequate air movement with clear breath
sounds. He moves all extremities slowly but his strength is equal bilaterally in both his upper and lower extremities and his face is symmetric. Although his skin is tan, it appears jaundiced and the scleras are icteric. He has no evidence of injury to his head or upper body. Although he has been changed into a hospital gown, the ED
staff reports he has not been incontinent. His bedside monitor shows a sinus tachycardia at 105 beats per minute and a pulse oximetry reading of 96% on room air. His brother and mother arrive in the ED and are able to provide additional information related to history. The brother states, “When I talked to him this morning he was fine. I didn’t notice anything strange. We were supposed to go to the gym together after work but he didn’t show up
there and didn’t answer his phone. That concerned me because he had been having trouble at
work recently and last month his divorce was finalized. When I got to his house, I found him
just sitting in a chair in his bedroom. He couldn’t look at me, and I’m not sure he even
recognized me. He didn’t remember anything about going to the gym. He was kind of slurring
his words and when he finally looked at me his eyes looked really funny, almost yellow.” He has
not traveled out of the country recently.
Past Medical History
He has hypertension, but is not currently on any medication; he had his appendix removed as a
teenager and surgery on his left ankle after breaking it playing softball. His ankle causes him a
lot of discomfort at times, especially with changes in the weather. Family denies a history of
liver disease.
Allergies
No known drug allergies; he does have seasonal allergies.
Social History
In college he drank heavily and smoked marijuana. Since that time he rarely drinks, he has no
other illicit drug use, and he has never smoked. He currently manages a convenience store but
has had financial problems related to the business for the last year. He was married for 18 years.
Although they separated 4 years ago, it was only last year that his wife filed for divorce. The
divorce was finalized a month prior to this admission.
Medications
The family is not aware of any regular medication use; however, he is not opposed to taking
over-the-counter-medications for colds, allergies, and pain.
Review of Systems (ROS)
Because of the patient’s current mental state, a ROS is unable to be completed. However, the
family is able to contribute that he had complained that he thought he was getting a cold.
Thinking back over the last few weeks, they confirm that it seemed he was more withdrawn and
may have had some depression which they attributed to his reaction to his divorce.
Physical Examination
Vital signs:
HR 102 bpm BP 126/72 mmHg RR 18 breaths per minute Temp 99.4 F orally
Bedside monitoring: pulse oximetry 96% on 2L via nasal cannula (NC), telemetry reveals sinus
tachycardia
Constitutional: well-developed adult male, who appears his stated age, lethargic in bed
HEENT: head normocephalic and atraumatic, pupils equal, round, reactive to light and accommodation
at 2mm, sclera icteric, ears, nose, and oropharynx unremarkable with good dentition, mucous
membranes pale and slightly jaundiced, but with no evidence of bleeding
Neck: supple with no nuchal rigidity, trachea appears to be midline, no appreciable thyromegaly, no
jugular vein distension (JVD), no lymphadenopathy
Cardiovascular: normal S1S2, no murmurs, gallop or rub appreciated, peripheral pulses palpable, no
peripheral edema
Pulmonary: symmetric chest expansion, no retractions or accessory muscle use, bilateral breath sounds
clear throughout all lung fields, cough intact with no sputum production
Gastrointestinal: abdomen soft, nondistended with no organomegaly or masses palpated, patient
grimaces to palpation of right upper quadrant (RUQ) but no other evidence of abdominal tenderness,
normoactive bowel sounds
Genitourinary: Foley catheter in place and draining dark yellow urine; normal male genitalia
Integumentary: color jaundiced, warm and dry, no visible marks, lesions, or tattoos, no petechiae or
spider angiomas
Neurological: arouseable to touch, does not respond to voice, speech slurred, does not follow
commands, oriented to person only, able to elicit asterixis in feet bilaterally, reflexes present bilaterally
Diagnostic Testing Results
The comprehensive metabolic panel shows the following abnormal values:
Lab Result Normal Range
Potassium 5.2 3.5–5 mmol / L
CO2 13 22-29 mmol/L
BUN 32 7-21 mg/dL
Creatinine 2.1 0.6-1.1 mg/dL
Total bilirubin 23 0.2-1.1 mg/dL
ALT 3627 11-41 U/L
AST 5623 12-40 U/L
Alkaline phosphate 326 40-115 U/L
PT 29.8 9.6-12.5 sec
INR 3.4 1
Ammonia 106 11-51 umol/L
Lactate (venous) 12.6 0.5-2.2 mmol/L
Urinalysis Unremarkable
Note:
The rest of his electrolytes and hemogram are within normal limits.
Case Study Questions
What are the pertinent positives from the information given?,
- The patient is lethargic and unresponsive.
- The patient appears jaundiced, and the scleras are icteric.
- History of hypertension without current medication.
- Elevated liver function tests, including ALT, AST, alkaline phosphatase, total bilirubin, and PT/INR.
- Elevated ammonia and lactate levels in the blood.
- No evidence of head injury or trauma.
- Reported past history of heavy alcohol use.
- Recent divorce and financial stressors.
What are the significant negatives from the information given?,
- No incontinence.
- No evidence of falls or seizures.
- No evidence of significant physical injuries or trauma.
- No recent travel history
Based on the information presented provide 3 differential diagnosis?,
a. Acute Liver Failure: Elevated liver function tests (ALT, AST, alkaline phosphatase, total bilirubin, PT/INR) and jaundice suggest possible acute liver failure, possibly due to alcohol-related liver disease.
b. Hepatic Encephalopathy: Elevated ammonia levels and altered mental status can be indicative of hepatic encephalopathy, a complication of liver disease.
c. Gastrointestinal Bleeding: Elevated PT/INR could be associated with gastrointestinal bleeding. The patient’s history of aspirin use may contribute to this condition.
Are there any other diagnostic testing you would order? Provide a rationale to justify.,
- Abdominal ultrasound or CT scan to assess the liver and rule out structural abnormalities.
- Imaging of the brain (e.g., CT or MRI) to evaluate for any intracranial pathology.
- Comprehensive viral hepatitis panel to investigate viral causes of liver dysfunction.
- Toxicology screen to assess for possible substance use.
Formulate a diagnosis and treatment plan. Include national guidelines to support your
plan.
Preliminary Diagnosis: Acute liver failure with hepatic encephalopathy.
Treatment Plan:
- Transfer the patient to a liver transplant center or tertiary care facility for specialized management.
- Administer N-acetylcysteine (NAC) to counteract potential acetaminophen toxicity.
- Initiate lactulose therapy for hepatic encephalopathy to lower ammonia levels.
- Assess and address potential gastrointestinal bleeding.
- Continue monitoring liver function tests, ammonia levels, and coagulation profile.
- Consider psychiatric evaluation and counseling due to the recent divorce and financial stressors, as these could impact the patient’s mental state and overall health.