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 Persistent low mood with anhedonia, and the commonest condition underlying self-harm. A single ingestion at a known time three hours ago in a well patient raises it.
2. Personality disorder Repeated self-harm as a means of managing intolerable distress, in a pattern going back years. A single ingestion at a known time three hours ago in a well patient describes it.
3. Adjustment disorder A time-limited reaction to an identifiable stressor, and it is a diagnosis made in retrospect rather than in the department. A single ingestion at a known time three hours ago in a well patient makes it plausible.
4. Bipolar affective disorder (including mania/hypomania) A history of elevated mood as well as depression, and it changes the treatment entirely because an antidepressant alone can precipitate a switch. A single ingestion at a known time three hours ago in a well patient makes the history essential.
5. Self-harm correct Correct. Deliberate ingestion of a quantity she knew to be dangerous. Regret afterwards does not reclassify it, and it does not reduce what she is owed here.

The point: Every episode of self-harm gets a psychosocial assessment, whatever the medical severity and whatever the apparent intent. Do not use risk stratification tools to decide who gets assessed or who goes home, because they predict poorly and NICE advises against it. Ask about suicidal intent directly; it does not plant the idea. The strongest predictors of a completed suicide are a previous attempt, male sex, older age, isolation, a violent method and continued intent. Paracetamol overdose is treated on the nomogram at four hours, or immediately without waiting where the ingestion is staggered, the timing is unknown, or the patient presents late. Someone refusing treatment who lacks capacity can be treated in their best interests; capacity is assessed and documented rather than assumed from the fact of the overdose.

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 Required after every episode. It is the intervention as much as the assessment, and it should not be skipped because the injury was minor. A single ingestion at a known time three hours ago in a well patient makes it mandatory.
2. Electrocardiogram Essential in tricyclic overdose, where a QRS above 100 ms predicts seizures and above 160 ms predicts arrhythmia. A single ingestion at a known time three hours ago in a well patient makes it necessary.
3. Clotting screen, liver function and creatinine The markers of paracetamol-induced liver injury, and the INR is the most useful of them for prognosis. A single ingestion at a known time three hours ago in a well patient makes it the right set.
4. Paracetamol level at 4 hours post-ingestion correct Correct. A single ingestion at a known time is exactly the situation the nomogram was built for. A level at three hours cannot be plotted, so the sample waits one more hour.
5. Salicylate level Checked alongside paracetamol where the ingestion is unclear or mixed, because the two are frequently taken together. A single ingestion at a known time three hours ago in a well patient makes it worth adding.

The point: Every episode of self-harm gets a psychosocial assessment, whatever the medical severity and whatever the apparent intent. Do not use risk stratification tools to decide who gets assessed or who goes home, because they predict poorly and NICE advises against it. Ask about suicidal intent directly; it does not plant the idea. The strongest predictors of a completed suicide are a previous attempt, male sex, older age, isolation, a violent method and continued intent. Paracetamol overdose is treated on the nomogram at four hours, or immediately without waiting where the ingestion is staggered, the timing is unknown, or the patient presents late. Someone refusing treatment who lacks capacity can be treated in their best interests; capacity is assessed and documented rather than assumed from the fact of the overdose.

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. Discuss with the liver unit For a rising INR, acidosis, encephalopathy or a creatinine that will not settle after paracetamol. The King's College criteria decide transplantation. A single ingestion at a known time three hours ago in a well patient makes it necessary.
2. Start acetylcysteine immediately without waiting for a level For a staggered overdose, an unknown time of ingestion, or a presentation beyond eight hours. Waiting for a number that cannot be interpreted wastes the window. A single ingestion at a known time three hours ago in a well patient demands it.
3. Treat in their best interests under the Mental Capacity Act Where the patient lacks capacity to refuse life-saving treatment, after assessment and documentation. A single ingestion at a known time three hours ago in a well patient makes it lawful.
4. Acetylcysteine guided by the treatment nomogram correct Correct. Plot the four hour level and treat if it sits above the line. She is well now, which tells you nothing, because paracetamol toxicity is silent for the first day or two.
5. Discharge with a safety plan and crisis team contact For a patient assessed as safe, with named contacts, means restriction and a follow-up appointment. A single ingestion at a known time three hours ago in a well patient makes it reasonable.

The point: Every episode of self-harm gets a psychosocial assessment, whatever the medical severity and whatever the apparent intent. Do not use risk stratification tools to decide who gets assessed or who goes home, because they predict poorly and NICE advises against it. Ask about suicidal intent directly; it does not plant the idea. The strongest predictors of a completed suicide are a previous attempt, male sex, older age, isolation, a violent method and continued intent. Paracetamol overdose is treated on the nomogram at four hours, or immediately without waiting where the ingestion is staggered, the timing is unknown, or the patient presents late. Someone refusing treatment who lacks capacity can be treated in their best interests; capacity is assessed and documented rather than assumed from the fact of the overdose.

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