History Taking · Advanced · Psychiatry

Overdose Assessment

Practise this PLAB 2 history taking station on Paracetamol Overdose. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the emergency department. Callum Nelson, a 28-year-old man, was brought to the ED by ambulance after taking a deliberate paracetamol overdose. He is medically stable. Please take a sensitive psychiatric history, assess risk, and discuss management and follow-up.

Background notes: PMH: Nil significant

What this station tests

  • Paracetamol level at 4 hours plotted on nomogram: determines NAC treatment
  • NAC (N-acetylcysteine) as the antidote: started if level is above treatment line
  • Psychiatric assessment alongside medical management: both are essential, neither can be omitted
  • Precipitant understanding: family rejection of sexuality is the trigger, not 'mental illness'
  • LGBTQ+ specific support services: Switchboard, Mind LGBTQ+, and involving the partner

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

Paracetamol overdose requires both medical management (NAC if indicated) and psychiatric assessment. Callum is 28, brought by ambulance after taking 32 paracetamol tablets 4 hours ago following conflict with his parents about his sexuality. He is medically stable. Open with: 'Callum, I am glad you are here and safe. I need to ask you some medical questions first, and then I want to understand what happened.'

Core approach

Medical assessment first. Time of ingestion: 4 hours ago. Number of tablets: 32 (16g, well above toxic threshold of 150mg/kg). Staggered or single ingestion? (Single, which allows use of the Rumack-Matthew nomogram.) Any co-ingestants (alcohol, other medications)? Any vomiting? Paracetamol level at 4 hours plotted on the nomogram determines whether NAC is needed (it almost certainly is at this dose).

Psychiatric assessment once medically stable. What precipitated the overdose? His parents discovered he is gay. His father said 'you are no son of mine.' He felt rejected, hopeless, and acted impulsively. This was the first attempt. Assess: did he intend to die? (Yes, in the moment.) Does he still want to die? (Less certain now, frightened by the medical consequences.) Did he tell anyone or seek help afterward? (His partner Michael called the ambulance.) Any suicide note? (No.)

Assess ongoing risk. He is frightened, no longer actively suicidal, has his partner's support, and regrets the attempt. Lower ongoing risk but needs psychiatric follow-up and support around the family rejection.

Closing and safety netting

Medical: IV NAC (N-acetylcysteine) started per protocol. Monitor LFTs, INR, renal function. If presenting before 4 hours: activated charcoal may be given (within 1 hour of ingestion is most effective). Psychiatric: liaison psychiatry assessment before discharge. Safety plan created. LGBTQ+ support services signposted (Switchboard, Mind LGBTQ+). His partner Michael should be involved in the safety plan.

Address the underlying issue: 'The rejection you experienced from your parents is devastating, and your reaction, while dangerous, is understandable. There is support available to help you through this.' Do not discharge until psychiatry has assessed. Safety net: if he takes anything else or feels unsafe, alert the nursing team immediately. Follow-up: psychiatry, GP within 1 week, LGBTQ+ support.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for paracetamol overdose. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: Ingestion details obtained (time, amount, single/staggered). Paracetamol level at 4 hours. Co-ingestants checked. Psychiatric assessment systematic. Precipitant understood.

Costs marks: Not timing ingestion. Not checking level. No psychiatric assessment.

Domain 2 (Primary focus)

Scores well: NAC started. Monitoring plan. Liaison psychiatry referral. Safety plan. LGBTQ+ support. Partner involved. Not discharging before psychiatry.

Costs marks: No NAC. No psychiatry referral. Discharging before assessment. No support signposting.

Domain 3 (Primary focus)

Scores well: Empathic about the precipitant. Acknowledging rejection without pathologising his sexuality. Involving Michael. Validating his distress while addressing the danger.

Costs marks: Pathologising his sexuality. Not involving partner. Being clinical about an emotional crisis.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Focusing only on medical or only on psychiatric: both assessments are essential for paracetamol overdose
  2. Not involving the partner: Michael called the ambulance and is his primary support, he should be part of the safety plan
  3. Not addressing the underlying precipitant: family rejection of his sexuality is the core issue, not a generic 'depression'

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How do I approach the consultation in this paracetamol overdose station?

Paracetamol overdose requires both medical management (NAC if indicated) and psychiatric assessment. Callum is 28, brought by ambulance after taking 32 paracetamol tablets 4 hours ago following conflict with his parents about his sexuality. He is medically stable.

What does a strong performance look like to the examiner in this station?

Strong performances show: Ingestion details obtained (time, amount, single/staggered). Paracetamol level at 4 hours. Co-ingestants checked. Psychiatric assessment systematic. Precipitant understood. Weak performances: Not timing ingestion. Not checking level. No psychiatric assessment.

What is the biggest pitfall in this paracetamol overdose station?

Focusing only on medical or only on psychiatric: both assessments are essential for paracetamol overdose.

How should I prepare for paracetamol overdose if I have never seen it in practice?

Structure beats experience here. Focus on nAC (N-acetylcysteine) as the antidote: started if level is above treatment line. The written guidance on this page covers the full approach, and practising the consultation aloud builds the fluency the examiner is listening for.

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