Mental health for PLAB 1

A 19 year old woman is brought to the emergency department three hours after taking 30 paracetamol tablets in one go, following the end of a relationship. She feels well and has no symptoms. She says she now regrets it and wants to go home. She is fully alert and orientated and understands what she is being told. What is the SINGLE most likely diagnosis?

1. Depression Low mood that will not lift, with no joy in things, and it is the most common condition behind self-harm. But a single dose taken at a known time three hours ago in a patient who feels well does not point to it.
2. Personality disorder Self-harm used again and again as a way to cope with feelings that feel unbearable, in a pattern going back years. Here, a single dose taken at a known time three hours ago in a patient who feels well points elsewhere.
3. Adjustment disorder A short-lived reaction to a clear stressful event, and it is a diagnosis made looking back rather than in the emergency department on the day. It does not fit a single dose taken at a known time three hours ago in a patient who feels well.
4. Bipolar affective disorder A history of periods of high mood as well as low mood, and it changes the treatment completely, because an antidepressant on its own can trigger a switch to high mood. That does not match a single dose taken at a known time three hours ago in a patient who feels well.
5. Self-harm correct Correct. A deliberate dose she knew was dangerous. Regretting it afterwards does not change what this was, and it does not reduce what she is owed in terms of care.

The point: Every episode of self-harm gets a mental health and social assessment (psychosocial assessment), whatever the injury looks like and whatever the person's reason seems to be. Do not use risk-scoring tools to decide who gets assessed or who goes home; they predict poorly, and NICE advises against using them that way. Ask directly whether someone wants to die; asking does not put the idea in their head. The strongest warning signs for a completed suicide are a previous attempt, being male, older age, being alone, a violent method, and still wanting to die. Paracetamol overdose is treated using the treatment chart (nomogram) at four hours, or treated right away without waiting where the tablets were taken over time, the timing is unknown, or the patient comes in late. Someone who refuses treatment and lacks the mental capacity to make that choice can be treated in their best interests; capacity is checked and written down, not assumed to be missing just because someone has overdosed.

Source: NICE NG225 — Self-harm: assessment, management and preventing recurrence NICE · tier 1, national regulator or guidance

A 19 year old woman is brought to the emergency department three hours after taking 30 paracetamol tablets in one go, following the end of a relationship. She feels well and has no symptoms. She says she now regrets it and wants to go home. She is fully alert and orientated and understands what she is being told. What is the SINGLE most appropriate initial investigation?

1. Psychosocial assessment by a mental health practitioner Needed after every episode. It is part of the treatment as much as it is an assessment, and it should not be skipped because the injury looks small. But a single dose taken at a known time three hours ago in a patient who feels well does not point to it.
2. Electrocardiogram Needed in tricyclic overdose, where a widened QRS (heart tracing) above 100 ms points to a risk of fits and above 160 ms to a risk of a dangerous heart rhythm. That does not match a single dose taken at a known time three hours ago in a patient who feels well.
3. Clotting screen, liver function and creatinine The tests that show paracetamol-caused liver damage, and the clotting test (INR) is the most useful one for telling how things are likely to go. Here, a single dose taken at a known time three hours ago in a patient who feels well points elsewhere.
4. Paracetamol level at 4 hours post-ingestion correct Correct. A single dose at a known time is exactly the case the treatment chart (nomogram) was built for. A level at three hours cannot be plotted, so the blood sample waits one more hour.
5. Salicylate level Checked alongside paracetamol where what was taken is unclear or mixed, because the two are often taken together. It does not fit a single dose taken at a known time three hours ago in a patient who feels well.

The point: Every episode of self-harm gets a mental health and social assessment (psychosocial assessment), whatever the injury looks like and whatever the person's reason seems to be. Do not use risk-scoring tools to decide who gets assessed or who goes home; they predict poorly, and NICE advises against using them that way. Ask directly whether someone wants to die; asking does not put the idea in their head. The strongest warning signs for a completed suicide are a previous attempt, being male, older age, being alone, a violent method, and still wanting to die. Paracetamol overdose is treated using the treatment chart (nomogram) at four hours, or treated right away without waiting where the tablets were taken over time, the timing is unknown, or the patient comes in late. Someone who refuses treatment and lacks the mental capacity to make that choice can be treated in their best interests; capacity is checked and written down, not assumed to be missing just because someone has overdosed.

Source: NICE NG225 — Self-harm: assessment, management and preventing recurrence NICE · tier 1, national regulator or guidance

A 19 year old woman is brought to the emergency department three hours after taking 30 paracetamol tablets in one go, following the end of a relationship. She feels well and has no symptoms. She says she now regrets it and wants to go home. She is fully alert and orientated and understands what she is being told. What is the SINGLE most appropriate immediate management?

1. Admit under the Mental Health Act Where the wish to die continues, the patient refuses to stay, and the risk cannot be managed any other way. But a single dose taken at a known time three hours ago in a patient who feels well does not point to it.
2. Discuss with the liver unit For a rising clotting test (INR), acid build-up in the blood, confusion from liver failure, or a creatinine that will not settle after paracetamol. The King's College criteria decide whether a liver transplant is needed. That does not match a single dose taken at a known time three hours ago in a patient who feels well.
3. Treat in their best interests under the Mental Capacity Act Where the patient lacks the capacity to refuse life-saving treatment, after this has been checked and written down. It does not fit a single dose taken at a known time three hours ago in a patient who feels well.
4. Acetylcysteine guided by the treatment nomogram correct Correct. Plot the four-hour level and treat if it sits above the line. Feeling well now tells you nothing, because paracetamol harm to the liver stays silent for the first day or two.
5. Activated charcoal within one hour For a recent large amount taken, in a patient who is awake enough to protect their own airway. Here, a single dose taken at a known time three hours ago in a patient who feels well points elsewhere.

The point: Every episode of self-harm gets a mental health and social assessment (psychosocial assessment), whatever the injury looks like and whatever the person's reason seems to be. Do not use risk-scoring tools to decide who gets assessed or who goes home; they predict poorly, and NICE advises against using them that way. Ask directly whether someone wants to die; asking does not put the idea in their head. The strongest warning signs for a completed suicide are a previous attempt, being male, older age, being alone, a violent method, and still wanting to die. Paracetamol overdose is treated using the treatment chart (nomogram) at four hours, or treated right away without waiting where the tablets were taken over time, the timing is unknown, or the patient comes in late. Someone who refuses treatment and lacks the mental capacity to make that choice can be treated in their best interests; capacity is checked and written down, not assumed to be missing just because someone has overdosed.

Source: NICE NG225 — Self-harm: assessment, management and preventing recurrence NICE · tier 1, national regulator or guidance