Which of the following is earliest symptom of Hepatic encephalopathy -

Hepatic encephalopathy - Defined as an alteration in mental status and cognitive function occurring in the presence of liver failure. Clinical features - Earliest symptom - Change in sleep pattern. This is followed by change in personality, irritability, and mental dullness Fuher sequelae are confusion, disorientation, stupor and Coma Physical findings include asterixis , Fetor hepaticus Earliest sign - Change in handwriting which is assesed by use of the Trail-making test , - Normal connect the-dot time - 15-30 sec - In hepatic encephalopathy patients - >30 sec TREATMENT - Hydration and correction of electrolyte imbalance The mainstay of treatment is to correct precipitating factors is use of lactulose Lactulose is a nonabsorbable disaccharide, which results in colonic acidification. Catharsis ensues, contributing to the elimination of nitrogenous products in the gut that are responsible for the development of encephalopathy. The goal of lactulose therapy is to promote 2-3 soft stools per day. Antibiotics like Rifaximin, neomycin or metronidazole can also be used Zinc supplementation Electroencephalography- Triphasic Wave pattern