A 45-year-old male with history of hepatitis C and now cirrhosis of the liver
is brought to the emergency center by family members for acute mental status
changes. The family reports that the patient has been very disoriented and con-
fused over the last few days and has been nauseated and vomiting blood. The
family first noticed disturbances in his sleep pattern followed by alterations in
his personality and mood. On examination, he is disoriented with evidence of
icteric sclera. His abdomen is distended with a fluid wave appreciated. He has
asterixis and hyperreflexia on neurologic exam. His urine drug screen and
ethyl alcohol (EtOH) screen are both negative. A blood ammonia level was
noted to be elevated, and all other tests have been normal.
What is the most likely cause of the patient’s symptoms?
What is asterixis?
What was the likely precipitating factor of the patient’s symptoms?