PORTAL-SYSTEMIC ENCEPHALOPATHY

1. CHIEF COMPLAINT
•Portal-systemic encephalopathy

2. HPI

3. ROS

4. SYMPTOMS
•Fatigue
•Somnolence
•Episodic confusion

5. HISTORY
•FAMILY HISTORY
•SOCIAL HISTORY
•PAST MEDICAL HISTORY
•SURGICAL HISTORY
•CHRONIC CONDITIONS

6. ALLERGIES

7. PHYSICAL EXAMINATION
•Difficulty with memory
•Mild confusion
•Agitation
•Irritability
•Restlessness
•Sleeping during the day and remaining awake at night
•Tremor
•Incoordination
•Constructional apraxia
•Slowing of mentation and speech
•Difficulty with orientation to time
•Irregular flapping tremor
•Dysarthria
•Ataxia
•Hypoactive deep-tendon reflexes
•Gynecomastia
•Testicular atrophy
•Palmar erythema
 •Spider nevi
•Splenomegaly
•Caput medusae
•Ascites
•Peripheral edema
•Shrunken liver
•Kayser-Fleischer rings
•Bronzed skin
•Arthropathy
•Xanthelasma

8. SPECIFIC DATA LIKE GRADING ETC

•Subclinical portosystemic encephalopathy
•Grade 1 portosystemic encephalopathy
•Grade 2 portosystemic encephalopathy
•Grade 3 portosystemic encephalopathy
•Grade 4 portosystemic encephalopathy

9. TESTS TO BE ORDERED
•Serum calcium
•Serum ammonia
•Serum glucose
•Serum albumin
•Serum aspartate aminotransferase
•Serum alanine aminotransferase
•Serum bilirubin
•Complete blood cell (CBC) count
•Blood and urine screen for drugs
•Blood alcohol level
•Serum electrolytes
•Serum transaminases
•Prothrombin time
•Computed tomography scan of the head
•Magnetic resonance imaging
•Psychometric testing
•Electroencephalography

10. ASSESSMENT /PLAN

Surgical Care
•Orthotopic liver transplantation (OLT)

11. EDUCATION
Nutritional therapy
•Vegetable protein–based diets that exclude meat are
relatively high in BCAAs and low in aromatic amino acid
content.

Activity
•Patients need adequate rest, and their goal should be to
sleep at least 8 hours at night. Strenuous activity should be
avoided, but regular mild exercise is distinctly advantageous
for maintaining bone mass and cardiovascular conditioning in
anticipation of the long wait for a donor organ attendant with
orthotopic liver transplantation.

12. MEDICATION
•Lactulose
•Lactitol
•Neomycin
•Metronidazole
•Rifaximin
•Ornithine
•Aspartate
•Sodium benzoate
•Zinc gluconate.
•Flumazenil
•Levodopa
•Bromocriptine

13. FOLLOW-UP