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You are the new FY1 working on the Acute Medical Unit at your local hospital. Ray Diology is a 28 year old man who was admitted after being found collapsed at home. He is now alert and medically stable. He was found with five empty boxes of paracetamol. He has had no previous medical problems.

Please take a medical history from Ray and perform the appropriate examination. Ensure that you assess the impact of this overdose on Ray’s medical wellbeing.

You are Ray Diology, a 28 year old man who is feeling really low at the moment. You are in hospital because you took a lot of paracetamol tablets, since you wanted to end you own life. You immediately regretted the decision, however, and are grateful that the attempt was not successful.

HPC: You took the tablets because you feel that you do not have anything to live for any more. You broke up with your long time partner last week: you had been together for four years and it ended in a big falling out. You haven’t got a job, and don’t really have any friends to distract you from the events of this week. You think you took somewhere between seventy and one hundred tablets. You didn’t leave a note – you wouldn’t have known who to write to – and you didn’t plan the attempt in advance. This is the first such attempt you have made and you called an ambulance soon after taking the tablets. You had had one bottle of cider prior to taking the tablets, but normally you drink around 6 cans of lager per night. You only took paracetamol, you didn’t take any other tablets, since this was a random decision which you didn’t plan. Since you were brought into hospital, you have felt much better. You do not remember passing out at home: the last thing you remember is calling the ambulance. You spent around two to three hours vomiting, before that settled. You have had a small amount of tummy pain, mostly on your right hand side. It doesn’t move anywhere, and is about 5/10. You haven’t opened your bowels since it happened, but your waterworks have been a little unusual. You’ve noticed your urine has become a bit darker than it is normally. You haven’t noticed any unusual bleeding or bruising. No one has told you that you look particularly yellow, and your tummy isn’t particularly bloated.

ICE: You feel surprisingly fine considering what happened. You consider yourself to have had a lucky escape, and are now motivated to go home and rebuild your life. For that reason, you are very keen to be discharged as soon as possible. You know that you have a drip running at the moment, but because you feel well, you can’t understand why you shouldn’t be able to go home.

PMH: You have never had any previous medical problems. You broke your ankle earlier in the year, and as a result had a drawer-full of paracetamol in your room left over from that experience. When you were younger, you once went to your GP to talk about feeling low, following a poor exam result, however you feel that he turned you away without listening to your worries. Since then, you have been put off talking about your feelings, especially with professionals.

SH: You live alone in a one bedroom flat in the city. You aren’t employed at the moment, and haven’t spoken to your family in a while. You drink around six cans of lager per night.

The student should undertake a medical history of Ray’s paracetamol overdose. Good candidates would screen briefly for risk of future overdose, however an assessment of the impact of this overdose on Ray’s medical health should be the focus.

An example of a differential diagnosis would include: My differential diagnosis would include a pharmaceutical cause: specifically, paracetamol overdose. It does not obviously appear to have caused hepatic failure from the end of the bed, however I would need to investigate further for this using the appropriate criteria. This is likely secondary to this patient’s low mood and I feel that he has a low risk for repeating a suicide attempt, as he describes this attempt as ‘impulsive’.

Example discussion questions: - How would you investigate this patient on admission? - How do you manage a paracetamol overdose? - Do you know any criteria for assessing the severity of a paracetamol overdose? - What are the possible complications of paracetamol overdose.