case 1 A 22-year-old male porter from South Africa was admitted to hospital after being found by his landlord with confusion. On arrival at the hospital his Glasgow Coma Score was 13. He was apyrexial, with a blood glucose of 5.4mmol/L, pulse rate 60 beats/min and regular, and blood pressure 114/58mmHg. Heart sounds were normal and his chest was clear. He was noted to be jaundiced. Asterixis was present. There were no focal neurological signs. There were no spider naevi, muscle wasting, or gynaecomastia. His only medical history was pulmonary tuberculosis 6 months earlier, diagnosed by pleural biopsy and pleural fluid analysis. He had last been followed up 2 months previously and was well at that time. He had completed 2 months of rifampicin, isoniazid, pyrazinamide and ethambutol, followed by rifampicin and isoniazid alone. There was no record of any other medications or over the counter preparations. There was no known alcohol or drug history. HIV testing had been negative. *Investigations showed* ● Hb 15.2g/dL, WCC 9.1 x 109/L, platelets 173 x 109/L ● Na 135mmol/L, K 3.7mmol/L, urea 2.8mmol/L, creatinine 78µmol/L ● Bilirubin 357µmol/L, ALT 1307 IU/L, ALP 436 IU/L, albumin 32g/L ● Prothrombin time 53.8 sec. *Questions* 1a) What is the clinical syndrome illustrated by this case? 1b) Give a differential diagnosis for the cause of (a). 1c) What blood tests would you request? 1d) What radiological tests would you request? 1e) What is the management? 1f) What is the most likely cause in this patient and why? What is the mechanism of injury? 1g) How might this problem have been prevented?
