Station - Instructions for candidate
You are an intern working in the Emergency Department of a metropolitan hospital in Perth. It is 10.30 pm.
Jun Lim, 19, arrived at 9.30 pm. The 10 pm results are on your sheet with the triage note. A relative is with him and his nurse can answer short questions.
| Ambulance and triage note | 19 M, 55 kg. Took 20 x 500 mg paracetamol (immediate release, standard supermarket pack) at 18:00 - time confirmed by sister (empty blisters, text message sent 18:05). No other tablets, no alcohol. Vomited once at home 19:30. Now nauseated, otherwise well, GCS 15. No previous overdose; low mood for two months. Sister with him; parents on the way. Voluntary; agrees to treatment. |
|---|---|
| Observations at 10 pm | HR 92 /min, BP 118/74 mmHg, RR 14 /min, SpO2 99% on room air, T 36.8 degrees C, GCS 15, glucose 5.4 mmol/L, weight 55 kg. Nurse's note: alert, tearful, abdomen soft and non-tender, no jaundice. |
Results provided:
4-hour bloods (drawn at 10 pm; tablets taken at 6 pm)
| Item | Value | Reference range |
|---|---|---|
| Serum paracetamol (4 hours after the tablets) | 1,100 micromol/L | Therapeutic 66-130 micromol/L |
| ALT | 22 units/L | <40 units/L |
| AST | 24 units/L | <40 units/L |
| Bilirubin | 8 micromol/L | <20 micromol/L |
| Albumin | 42 g/L | 35-50 g/L |
| INR | 1.0 | 0.9-1.2 |
| Creatinine | 64 micromol/L | 60-110 micromol/L |
| Urea | 4.2 mmol/L | 3.0-8.0 mmol/L |
| Sodium / potassium | 139 / 4.0 mmol/L | 135-145 / 3.5-5.0 mmol/L |
| Bicarbonate | 24 mmol/L | 22-28 mmol/L |
| Glucose | 5.4 mmol/L | 3.5-7.8 mmol/L |
| Venous gas | pH 7.39, pCO2 42 mmHg, HCO3 24 mmol/L, lactate 1.1 mmol/L | pH 7.35-7.45; lactate <2.0 |
| Ethanol | Not detected | Not detected |
| Salicylate | Not detected | Not detected |
Your tasks are to:
- Interpret the results printed on your sheet and state your findings to the examiner, including the dose he has taken per kilogram and how the 4-hour level should be interpreted.
- State your assessment and the differential considerations to the examiner.
- Outline your management plan to the examiner, including any drug with its dose, route and duration, the repeat tests you will order and when, and what must happen before he is referred on.
- The examiner will ask you two questions at the end.
- You do NOT need to take a history or examine the patient; the nurse's findings are on the sheet and the nurse can answer brief questions.
- You do NOT need to summarise your findings beyond the tasks above.
- A dose-time chart is not provided; state the line value you would use at 4 hours.
This is a 10-minute station, with 2 minutes of reading time.