A 45-Year-Old Man Is Brought to the Emergency Department by His

question 643

Multiple Choice

A 45-year-old man is brought to the emergency department by his wife due to progressive lethargy, confusion, and abdominal pain.  He has had no hematemesis, melena, or hematochezia.  The patient has a history of alcoholic cirrhosis.  He had a variceal hemorrhage 2 months ago and has been treated previously for hepatic encephalopathy.  The patient takes nadolol, furosemide, spironolactone, and lactulose at home.  There have been no changes in his dietary intake, and he has not used any over-the-counter medicines or herbal supplements.  He still occasionally drinks alcohol but does not use tobacco or illicit drugs.  Temperature is 38 C (100.4 F) , blood pressure is 104/60 mm Hg, and pulse is 96/min.  The patient is cachectic and somnolent, and he wakes up with painful stimuli.  He has a flapping tremor of both hands, and the speech is slurred and incomprehensible.  Mucous membranes are dry, and he has scleral icterus.  Several spider angiomata are present on the upper torso.  The lungs are clear to auscultation, and heart sounds are normal with no murmur.  The abdomen is distended and tense with large abdominal wall collaterals.  There is a fluid wave and diffuse tenderness but no rebound tenderness.  Bowel sounds are decreased.  Stool occult blood is negative.  Laboratory results are as follows:

A diagnostic paracentesis is performed, and the ascitic fluid results are as follows:
Which of the following is the best next step in management of this patient?

• A)Additional rifaximin and close observation
• B)Intravenous 3% sodium chloride infusion
• C)Intravenous antibiotics and albumin
• D)Therapeutic (large-volume) paracentesis
• E)Transjugular intrahepatic portosystemic shunt

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Definitions:

Living Will

A legal document addressed to a patient’s family and healthcare providers stating what type of treatment the patient wishes or does not wish to receive if terminally ill, unconscious, or permanently comatose; sometimes called an advance directive.

Americans with Disabilities Act

A civil rights law enacted in 1990 in the United States that prohibits discrimination against individuals with disabilities in all areas of public life.

Health Care

The diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental impairments in humans, delivered by health professionals.

American Medical Association

A professional organization for physicians in the United States aimed at promoting the art and science of medicine and improving public health.