Mr. Farley is a 57 year old male with a history of alcohol abuse who is brought to the Emergency Department (ED) by some work friends with altered mental status (AMS) and a reported seizure. He has significant ascites and jaundice to his sclera and nail beds. 

Mr. Farley is admitted to the Medical Stepdown Unit. He is confused, oriented to person only, and agitated. He keeps trying to climb out of bed and is yelling profanities at the nurses. His ammonia level results are 93 mcg/dL. He has also begun to show a fine tremor in his hands and arms. The provider is concerned he may be at risk for alcohol withdrawal in addition to experiencing hepatic encephalopathy.

Mr. Farley is placed in bilateral soft wrist restraints for his safety.  The provider orders 1 mg Ativan IV push PRN q5min for seizures, plus 2 mg Ativan IV push PRN q2h for signs of alcohol withdrawal.  The provider also orders Lactulose 20 mg PO q6h, and Thiamine IV 100 mg BID. Mr. Farley’s level of consciousness continues to diminish and you determine through a bedside swallow study that he is unable to swallow safely at this time. 

The nurse inserts a nasogastric tube (NG Tube) for administration of Lactulose 20 mg PO q6h. After 48 hours, Mr. Farley’s ammonia level has decreased to 46 mcg/dL.  He is now alert and oriented x 3, calm, and cooperative and unrestrained. He states that he can’t remember what happened or why he’s here. The last thing he remembers is going out for a steak dinner after work to celebrate a big sale and having “a few drinks”.   The provider agrees that it is safe for Mr. Farley to be discharged home.