MRCP2-2192

MRCP2-2192

A 65 year old man presents with a 9 month history of abnormal behaviors which have been noticed by his daughter. He has described seeing vivid visual hallucinations of animals in his living room which sometimes talk to him and appear very real. He believes that he is a zookeeper and is responsible for taking care of the animals although this is not true.

At times he is lucid and is fully independent but at other times he is disorientated in time and place and is unable to perform simple tasks such as preparing food and going to the shops. His daughter thinks that his mood is also lower since the onset of symptoms. He presented in A+E today because of having a second fall in two weeks.

There is no history of infective symptoms. He went to see his GP three days ago who thought that he may have a UTI and prescribed trimethoprim.

He has a history of stroke 8 years ago and hypertension and takes warfarin, amlodipine and enalapril.

Physical examination is unremarkable except for slightly increased tone on the left side compared to the right.

Bloods:

Hb 14.5 g/dl
Platelets 400 * 109/l
WBC 11.8 * 109/l

Na+ 140 mmol/l
K+ 4.4 mmol/l
Urea 5.9 mmol/l
Creatinine 80 µmol/l

Bilirubin 5 µmol/l
ALP 60 u/l
ALT 18 u/l
Calcium 2.40 mmol/l
Albumin 42 g/l

MSU (from GP from 3 days ago): Heavy growth of E.coli Sensitive to trimethoprim, nitrofurantoin, amoxicillin and co-amoxiclav

CT Brain: some generalised atrophy and periventricular white matter changes normal for age. Changes in keeping with an old left sided lacunar infarct

Mini Mental State Examination 16/30

Which medications would most appropriately treat the underlying diagnosis?