Rule Out / Past cases / Hepatic encephalopathy
Rule Out case #8 · ToughHepatic encephalopathy: a six-clue practice case
Read the clues in order and name the diagnosis as early as you can. Clues move from the patient’s story to the classic findings.
Play it as a game firstGuess before each clue unlocks, then share your score.The clues
Clue 1: A 62-year-old woman is brought in by her family because she “isn’t herself.”
Clue 2: Over the past week she has been sleeping all day and awake at night.
Clue 3: She drinks heavily, was treated for a GI bleed last week, and hasn't had a bowel movement in 4 days.
Clue 4: Her belly is swollen with fluid, and when she holds her arms out with wrists bent back, her hands flap.
Clue 5: Her blood ammonia is high, and her head CT and blood sugar are normal.
Clue 6: She becomes alert again after a few days of lactulose and rifaximin.
Show the diagnosis and takeaways
What gives it away
- A failing liver can't clear ammonia and other toxins, and they affect the brain.
- Flapping of the outstretched hands (asterixis) is a classic sign.
- Lactulose and rifaximin are the mainstays; look for triggers such as bleeding, infection or constipation.
Ran as Rule Out #8 (Sunday, October 25, 2026).
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