A 25-year-old female presents with a 2-day history of nausea and upper abdominal pain. She is a previously well lady with no significant medical history. However, she has had a severe toothache for 1 week and has been taking painkillers for 1 week.

Examination reveals that she is slightly jaundiced. Her blood pressure is 80/50 mm Hg, HR 105, GCS 15. Temperature 37.5


Blood tests reveal the following results

Na

138 mmol/l

(135 – 145)

K

3.9 mmol/l

(3.5 – 5)

Cl

108 mmol/l

(97 -109)

Bicarbonate

20 mmol/l

(24-32)

Urea

2.6 mmol/l

(3 – 8)

Creat

130 micromol/l

(50 – 90)

Bilirubin

80micromol/l

(0-18)

Albumin

38 g/l

(36-48)

ALP

81 U/L

(30 – 130)

ALT

1840 U/l

(5 – 55)

AST

1220 U/l

(5 – 55)

What abnormalities do these investigations show and what are the possible causes?

The rest of the questions focussed on the management of subacute/chronic paracetamol toxicity.

Disclaimer: the viva stem above is the original CICM stem, acquired from their publicly available past papers. However, because the college do not make the rest of the viva text or marking criteria available, the rest has been confabulated. It sounds like a plausible viva and it can be used for the purpose of practice, but all should be aware that it does not represent the "true" canonical CICM viva station.