Alcohol-related brain injury and Korsakoff — structured clinical viva

Working diagnosis. Probable Wernicke encephalopathy (malnutrition risk + oculomotor + cerebellar + altered mental state — Caine met) with evolving or concurrent Korsakoff-range amnestic features (confabulation, orientation failure). May coexist with alcohol withdrawal. This is not first-label Alzheimer disease.^[1][4][5]

Immediate action. Stop under-treatment with low-dose oral-only thiamine for suspected WE. Start high-dose parenteral thiamine multi-day now (EFNS-style 200 mg IV TDS teaching; many protocols use higher ~500 mg IV TDS for established WE), replete Mg, manage withdrawal if present. Do not wait for MRI.^[2][3]

Imaging. MRI can support (mammillary bodies, medial thalami, periaqueductal grey) but is adjunctive; normal imaging does not exclude early WE.^[2][6]

Capacity. Dense amnesia/confabulation likely impairs retention and use of information for a tenancy agreement — formal capacity assessment, collateral, least-restrictive supports; delay binding decisions until stable and supported.^[4][7]

Long-term. Abstinence, step-down oral thiamine while risk persists, neuropsychology, cognitive rehab, ARBD/supported living pathway, family education.^[4][5][7]