Of Hepatic Encephalopathy

He is a frequent ward resident, another admission just after a discharge two days ago. The reason: alcoholic liver cirrhosis so bad he has intractable ascites, permanent jaundice, and so malnourished he could be mistaken for a 15-year old had not for his hot-temper and know-it-all attitude.
"Let's do a basic physical examination," I said after completing history taking. He was admitted the week before my rotation in General Medicine starts, so another interview is essential even though it may be pergatory for him.
"Another PE?" He asked, not pleased.
"Yup, I promise it'll be quick."
Several nights later he developed stomach ache. From my daily conversations with him he seem to blame the pain to my abdominal percussion and palpation. He became colder and reluctant in replying questions and was irritable to all staff.
"He's not talking to me anymore. I guess he blames me for the pain," I told my PGY senior.Patient is uncooperative and refused to be examined due to sleepiness - I wrote in his progress note on Thursday evening.
Friday dawns on us an illness more severe than anger. He became stuporous, drowsy, and disoriented. Hepatic encephalopathy - accummulation of toxic substance supposed to be metabolized by the liver to affect cognitive processes, was impressed. His liver functions are so decompensated as little as a constipation flares up the syndrome. Patients are typically disoriented, detached, and solemn. We didn't identify the tremor or asterixis in the early stages, only his not heeding us we presume as snobbishness and blame.
After increased laxative use and enema he recovered to his usual self. My Saturday round with him was functional but not pleasant - he doesn't smile (who would if you're almost losing your liver?), and was depressed because his family is absent for 2 days.
They are the most challenging cases in medicine - their illness inflicted upon themselves by alcohol or substance abuse, their thinking we could cure them simply with a pill, and the disappointment when the truth isn't so. I didn't learn how to handle such cases, not yet at least for this week. But I learned how sometimes our patient's littlest reactions may be a prodrome of some more serious disorder.