MRCP2-3757
A 50-year-old man presents to the Accident and Emergency department and a medical referral is requested. He reports that for the past week he has been hearing voices. He states that he cannot recognise who the voices are as they are whispering quietly but he thinks that they are making derogatory comments about him. He denies any visual hallucinations and you cannot elicit any delusional beliefs. His mood appeared euthymic.
He tells you that he has a long history of alcohol dependence lasting for 30 years drinking approximately 10 units of alcohol a day on average. He tells you that in the past he has tried to stop drinking alcohol but this has caused admission to hospital due to seizures. He is particularly worried because he has cut down on alcohol since the hallucinations because he is worried that he is going mad. He is now only drinking 2 units a day and has not drunk any alcohol for 24 hours. On one previous occasion where he abstained from alcohol, he said that he had hallucinations and had to be admitted to hospital for a few days and put on a drip and was told that he almost died.
Na+ 144 mmol/l
K+ 3.6 mmol/l
Urea 14.1 mmol/l
Creatinine 119 µmol/l
Bilirubin 36 µmol/l
ALP 199 u/l
ALT 92 u/l
γGT 271 u/l
Albumin 36 g/l
He has a family history of alcohol dependence and depression but no other psychiatric problems. His medications include Omeprazole, Vitamin B, Thiamine and Diazepam.
On examination his GCS is 15, there is no tremor or sweating Pulse 80 regular BP 138 / 74 chest clear, abdo soft non tender, no peripheral focal neurology MMSE 28/30 He is commenced on chlordiazepoxide and observed for 24 hours. His GCS remains at 15 and his repeat physical examination remains unchanged and the hallucinations are still present.
What is the most likely diagnosis?