Admission Date: 1/16/2023 Discharge Date: Jan 30, 2023  PRESENTING PROBLEM: Hepatic encephalopathy   HOSPITAL COURSE: The patient is a 74-year-old female with PMH significant for hypertension, dyslipidemia, type 2 diabetes, chronic ITP on Eltrombopag, coronary artery disease, cirrhosis (07/2022) felt to be related to NASH, chronic HFpEF, recent influenza and COVID infection and a recent hospital admission from 1/6-1/10 due to SBP during which time she presented with sepsis and altered mental status.  Paracentesis showed significant peritonitis, and she was was treated with broad-spectrum cephalosporin and discharged on oral Bactrim.  The patient returned the next day to the hospital due to not feeling well and was noted to be in sepsis and started on cefepime/vancomycin.  CT abdomen/pelvis with IV contrast showed small volume ascites and possible adynamic ileus and bibasilar atelectasis.  Patient was admitted, underwent a repeat paracentesis on 01/13, consistent with SBP.  Patient was improving, but acutely became more encephalopathic on 01/15 and then subsequently transferred to this Hospital on 01/16 for Gastroenterology input.  She had a CT of her head which was negative.   Patient was admitted, consultations requested from Gastroenterology, infectious Diseases and Neurology.    Patient was initially treated with Rocephin and Flagyl, but transitioned to Rocephin alone per ID.  The patient was noted to have indeterminate C difficile toxin, but with significant diarrhea.  ID did recommend treatment, and the patient was started on oral vancomycin.  Initially this was given rectally due to altered mental status however her mental status did improve, and she was able to take this orally with improvement in her diarrhea.   Patient did undergo paracentesis which showed persistent peritonitis however number of PMNs was noted to decrease.  Patient's abdominal pain also improved.  A 3rd paracentesis was performed on 01/22 again showing increasing peritonitis.  Labs at that time also showed increasing leukocytosis.  Recommendations from ID included continuing Rocephin and restarting Flagyl. Due to persistent elevated PMN count in peritoneal fluid, repeat paracentesis was performed on 1/27 with PMN count of 972 with negative cultures. She completed 7 days of Flagyl while hospitalized and ID deferred to GI regarding SBP prophylaxis on discharge (either Bactrim or Cipro). GI recommended discharge on Cipro and patient tolerated antibiotic while hospitalized and was discharged on such. She was also continued on Lasix and Aldactone while hospitalized and repeat paracentesis order was placed on discharge with fluid studies in event fluid did not improve with diuretic titration.   After transfer, the patient was also seen by Neurology given her altered mental status.  EEG was performed which was consistent with toxic encephalopathy.  Initially an MRI was recommended, however the patient's mental status quickly improved, returned to baseline.  With her mental status returning to baseline, it was felt the patient no longer required MRI and the study was canceled. Etiology was felt secondary to toxic metabolic encephalopathy due to prior Cefepime, peritonitis, hepatic encephalopathy.    During the patient's hospitalization she also complained of severe right ear pain.  Examination was unremarkable, with normal external canal, and normal tympanic membrane.  Patient was treated with nasal saline, Flonase and decongestants for eustachian tube dysfunction.  CT sinuses was also performed showing no evidence of mastoiditis.   In regards to her diabetes, her home Actos was discontinued on discharge as propensity to lead to fluid retention and her home Jardiance was decreased to 10 mg HS. She required minimal insulin while hospitalized.    The patient was seen by PT/OT who recommended discharge to SAR.  As patient was clinically stable, with resolution of her altered mental status, resolution of her abdominal pain/peritonitis with antibiotic therapy, she was discharged to SAR on 1/30/23. She was noted to have tested positive for COVID-19 on day of discharge but was asymptomatic in this regard.