Approach to altered mental status Quiz: Ace Your Exams

A 58-year-old man is brought to the emergency department for evaluation of confusion, disorientation, and slurred speech. His partner reports that he has been increasingly forgetful over the past few weeks and has had difficulty with daily tasks. She also mentions that he has been more fatigued than usual, and his abdomen has become distended. The patient has a history of alcohol use disorder and has multiple glasses of vodka nightly. He was diagnosed with cirrhosis two years ago. He has not returned to the clinic for follow-up care or treatment. Temperature is 37.0 °C (98.6 °F), pulse is 84/min, respiratory rate is 16/min, blood pressure is 128/70 mmHg, and oxygen saturation is 97% on room air. On examination, the patient is drowsy but awakens easily. He is oriented to person only. There is a bilateral scleral icterus. Pupils are equally round and reactive to light. Spider angiomas are present across the chest. Extraocular muscles are intact and there are no abnormalities in eye movement. Asterixis is present. The abdomen is distended with a positive fluid wave. There is no tenderness to palpation. There are no focal neurologic deficits. Which of the following is the most likely diagnosis?