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Hint
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Answer
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A paracetamol overdose is often asymptomatic in the early stages. How many hours can it typically take for symptoms to develop?
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24-72 hours
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List the symptoms of a paracetamol overdose
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Nausea
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Vomiting
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Malaise
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Abdominal/RUQ pain
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Anorexia
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Confusion / altered mental status
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What are the clinical signs of a paracetamol overdose?
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Bruising
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Jaundice
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Metabolic acidosis
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Oliguria/anuria
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Tachycardia
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Hypotension
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If the patient has hepatic necrosis, they may also exhibit additional signs:
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Hypoglycaemia
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Encephalopathy
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Asterixis (flapping hand tremour)
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Coma
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What is the treatment threshold for a paracetamol overdose, i.e. the amount of paracetamol that must have been consumed to necessitate medical intervention? (NB: answer is given as mg per kg of patient's body weight.)
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150mg/kg
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If the patient presents within ONE hour of ingestion, they are treated with...?
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Activated charcoal
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If the patient presents 1-8 hours after ingestion, how long must the doctor wait FROM THE TIME OF INGESTION to assess the paracetamol level?
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4 hours
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What is the name of the graph which is used to determine the patient's need for NAC?
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Nomogram
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What does NAC stand for?
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N-acetyl cysteine
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"If a patient with a paracetamol overdose presents to A&E two hours after ingestion, doctors will not administer treatment for another two hours, so that paracetamol levels can be assessed to determine the need for treatment." True or false?
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True
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In what circumstance can NAC be administered, even if the patient does not meet the treatment threshold?
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Evidence of hepatic injury
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"If a paracetamol level will not be available within ______ of ingestion, NAC is started immediately."
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8 hours
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What other blood tests will be performed on a patient presenting with paracetamol overdose?
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FBC
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LFTs
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U&E
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Venous blood gas (VBG)
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INR
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A patient presents with a paracetamol overdose ten hours after ingestion. Bob says a paracetamol level should be taken, and they should wait 4 hours to assess if NAC is necessary. Linda says they should take the level and give NAC immediately. Who is correct?
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Linda. The patient has presented >8 hours after ingestion, so NAC is given immediately.
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If a patient presents >24 hours after ingestion, they are given NAC IMMEDIATELY if they are j_____ or have hepatic t_______.
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jaundiced
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tenderness
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If a patient presents >24 hours after ingestion, they are given NAC if their ____ is raised, or INR is greater than _____.
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ALT
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1.3
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If a patient presents with a STAGGERED paracetamol overdose, is NAC started immediately?
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Yes
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A patient presents with a staggered overdose. Fred says they don't need to take a paracetamol level, because the overdose is staggered. Jen says they take a paracetamol level if the patient has symptoms. Oli says they take a paracetamol level 4 hours after the last ingestion of paracetamol. Anna says they take a paracetamol level upon admission. Who is right?
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Oli
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Does a paracetamol overdose raise or lower blood pH?
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Lower
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A life-threatening paracetamol overdose with a poor prognosis can have the following features: an INR greater than ___,
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3
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...a plasma creatinine greater than ___ micromol/L,
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200
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...and a blood pH less than ___.
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7.3
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What is the most common metabolic pathway for paracetamol?
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Glucuronidation
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Where does this process mainly occur?
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The liver
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What metabolic pathway processes approximately a third of total paracetamol?
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Sulfation
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The final metabolic pathway for paracetamol is n-_______ and dehydration/rearrangement. This process is ____ mediated. This pathway creates a toxic intermediate called _____.
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hydroxylation
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CYP
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NAPQI
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This toxic intermediate is detoxified by _____?
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Glutathione (GSH)
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