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MRCP Part 1 > Clinical Pharmacology and Therapeutics > Flashcards

Clinical Pharmacology and Therapeutics Flashcards

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1
Q

What are two side effects of dopamine receptor agonists?

A

Nausea/vomiting
Postural hypotension
Hallucinations
Daytime somnolence

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2
Q

What factors increase the risk of developing hepatotoxicity following a paracetamol overdose?

A

Patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St. John’s Wort)

Malnourished patients (ex. anorexia nervosa) or patients who have not eaten for a few days

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3
Q

List three side effects of amiodarone.

A 
Corneal microdepositis 
Hyper/hypo-thyroidism 
Pneumonitis 
Pulmonary fibrossis 
Hepatotoxicity
Photosensitivity
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4
Q

What visual disturbances does sildenafil cause?

A

Blue tinge to vision and non-arteriti anterior ischemic neuropathy

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5
Q

List two side effects of rifampicin.

A

Liver enzyme inducer
Hepatitis
Orange secretions
Flu-like symptoms

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6
Q

List two side effects of isoniazid.

A

Peripheral neuropathy
Hepatitis
Agranulocytosis
Liver enzyme inhibitor

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7
Q

List two side effects of pyrazinamide.

A

Gout
Arthralgia
Myalgia
Hepatitis

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8
Q

What visual disturbances are associated with ethambutol?

A

Optic neuritis

Restriction of visual field

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9
Q

List three drugs associated with drug-induced thrombocytopenia.

A

Quinine
Abciximab
NSAIDs
Furosemide
Antibiotics: penicillins, sulphonamides, rifampicin
Anticonvulsants: carbamazepine, valproate
Heparin

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10
Q

List three potential side effects of anticholinergics.

A 
Dry mouth 
Blurred vision 
Urinary retention 
Constipation 
Palpitations 
Tachycardia
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11
Q

What is the MOA of heparin?

A

Activates antithrombin III. Standard heparin then forms a complex that inhibits thrombin and factors Xa, IXa, Xia, and XIIa. LMWH then forms a complex that inhibits factor Xa.

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12
Q

What are criteria for liver transplantation following a paracetamol overdose?

A

Arterial pH <7.3 24 hours after ingestion

OR

all of the following: prothrombin time > 100 seconds, creatinine > 300 micromol/L, and grade III or IV encephalopathy

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13
Q

How is a beta-blocker overdose managed?

A

If bradycardic, then atropine. If resistent, glucagon may be used.

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14
Q

List three side effects of tamoxifen.

A

Menstrual disturbance: vaginal bleeding, amenorrhea

Hot flushes

VTE

Endometrial cancer

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15
Q

List notable inducers of the cytochrome P450 system.

A 
Antiepileptics: phenytoin, carbamazepine 
Barbiturates: phenobarbitone 
Rifampicin 
St. John's Wort 
Chronic alcohol intake 
Griseofulvin 
Smoking
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16
Q

List notable inhibitors of the cytochrome P450 system.

A 
Antibiotics: ciprofloaxacin, erythromycin 
Isoniazid 
Cimetidine, omeprazole 
Amiodarone 
Allopurinol
Imidazoles: ketoconazole, fluconazole 
SSRIs: fluoxetine, sertraline 
Ritonavir 
Sodium valproate
Acute alcohol intake 
Quinupristin
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17
Q

What is the management of cocaine toxicity?

A

Benzodiazepines
If chest pain, add glyceryl trinitrate.
If hypertension, add sodium nitroprusside.

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18
Q

What are features of organophosphate insecticide poisoning?

A 
Salivation
Lacrimation 
Urinartion 
Defecation/diarrhea 
Cardiovascular: hypotension, bradycardia 
Small pupils 
Muscle fasciculation

DUMBBELSS - diarrhea, urination, miosis, bronchospasm, bradycardia, emesis, lacrimation, sweating, salivation

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19
Q

What is the management of organophosphate insectide poisoning?

A

Atropine - reverses muscarinic effects and crosses BBB

Pralidoxime - reactives AChE and has both muscarinic and nicotinic effects, cannot cross the BBB

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20
Q

What is the notable side effect of anthracyclines (doxorubicin, daunorubicin)?

A

Cardiotoxicity

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21
Q

What is the notable side effect of bleomycin?

A

Interstitial pulmonary fibrosis

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22
Q

What is the notable side effect of cisplatin?

A

Mg wasting

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23
Q

What is the most notable side effect of cyclophosphamide?

A

Hemorrhagic cystitis

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24
Q

What is the notable side effect of vincristine?

A

Peripheral neuropathy, SIADH, hyponatremia

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25
What are common drugs that cause nephrogenic DI?
Demeocycline, lithium, amphotericin, glibenclamide
26
How is a CCB overdose managed?
IV insulin
27
How is a diethylene glycol overdose managed?
Fomepizole or ethanol (inhibit alcohol dehydrogenase) | Hemodialysis if severe
28
What is the management of lithium toxicity?
If mild, symptomatic and volume resuscitation with normal saline. If severe, hemodialysis.
29
How is an aspirin overdose managed?
Multdose activated charcoal. Consider hemodialysis and IV sodium bicarbonate if severe.
30
What medications are contraindicated with sildenafil?
Nitric oxide or nitrous vasodilators
31
What are the features of lead poisoning?
``` Abdominal pain Basophilic stippling of RBCs Anemia Motor peripheral neuropathy Interstitial nephritis Gingival markings (Burton's lines, blue) Lead lines on long bones ```
32
What is the management of tricyclic poisoning?
IV sodium bicarbonate
33
What are the signs and symptoms of digoxin toxicity?
Anorexia, nausea, xanthopsia, bradyarrythmia
34
What are the signs of paracetamol overdose?
Nausea, vomiting | Right subcostal pain - may lead to encephalopathy, hypoglycemia, hemorrhage, cerebral edema, death
35
What are the features of aspirin overdose?
Hyperventilation, tinnitus, deafness, vasodilation, sweating, coma
36
What are the features of tricyclic antidepressant overdose?
Dry mouth, seizures, coma, cardiac conduction defects and arrythmias, hypothermia, hypotension, hyperreflexia, respiratory failure, dilated pupils, urinary retention, metabolic acidosis, delirium
37
What are the features of SSRI overdose?
Nausea, vomiting, agitation, tremor, nystagmus, drowsiness, sinus tachycardia, convulsons Serotoning syndrome Hyperthermia, rhabdomyolysis, renal failure, and coagulation deficiences
38
What are the features of beta blocker overdose?
Lightheadness, syncope, bradycardia, hypotension, precipitation/exacerbation of heart failure
39
What are the features of CCB overdose?
Nausea, vomiting, agitation, confusion, dizziness, hyperglycemia, coma Dihydropyridine CCB: peripheral vasodilation, hypotension Verapamil/diltiazem: arrythmias including complete heart block and asystole
40
What is the management of aspirin poisoning?
Activated charcoal can be givin within one hour of ingesting the overdose IV sodium bicarbonate may be given (check K concentration prior) Hemodialysis for severe poisoning
41
What is the management of aspirin poisoning?
Activated charcoal can be givin within one hour of ingesting the overdose IV sodium bicarbonate may be given (check K concentration prior) Hemodialysis for severe poisoning
42
What is the management of paracetamol overdose?
Staggered: give NAC immediately Single: measure paracetamol levels 4 hours after ingestion to determine if NAC needs to be given
43
What is the management of TCA overdose?
Supportive measures Activated charcoal if given within 1 hour of overdose IV sodium bicarbonate IV lorazepam or diazepam for convulsions or sedation
44
What is the management of SSRI overdose?
Supportive | Activated charcoal within one hour of ingestion
45
What is the management of beta-blocker overdose?
Activated charcoal can be considered if the patient presents within 1 hour of ingestion IV glucagon/severe cases can use IV insulin and glucose IV sodium bicarbonate for correction of metabolic acidosis IV atropine for bradycardia
46
What is the management of CCB overdose?
Consider activated charcoal if the patient presents within 1 hour of overdose Calcium chlorie or calcium gluconate Atropine for bradycardia Severe cases: IV insulin and glucose infusion
47
What are the features of iron overdose?
Nausea, vomiting, diarrhoea, abdominal pain, haematemesis, and rectal bleeding. Hypotension and hepatocellular necrosis can occur later. If severe poisoning: coma and shock.
48
What are the features of lithium toxicity?
Initially, apathy and restlessness followed by vomiting, diarrhoea, ataxia, tremor, weakness, dysarthria, and muscle twitching. If severe poisoning: electrolyte imbalance, dehydration, convulsions, renal failure, hypotension and coma. ``` Features of toxicity coarse tremor (a fine tremor is seen in therapeutic levels) hyperreflexia acute confusion polyuria seizure coma ```
49
What is the management of iron salt poisoning?
Desferrioxamine mesilate (chelation)
50
What is the management of lithium poisoning?
Supportive | Hemodialysis if severe
51
What are the features of theophylline toxicity?
Severe vomiting, restlessness, agitation, dilated pupils, hyperglycaemia and tachycardia. More serious effects include haematemesis, seizures and arrhythmias (supraventricular and ventricular). Hypokalaemia can develop quickly.
52
What is the management of theophylline overdose?
Repeated doses of activated charcoal Ondansetron, IV potassium chloride, and IV lorazepam/diazepam as needed
53
What are the features of benzodiazepine overdose?
Drowsiness, dysarthria, ataxia, and nystagmus. Respiratory depression and coma can also occur.
54
What is the management of benzodiazepine overdose?
Activated charcoal within 1 hour of ingesting Flumazenil
55
What are the features of phenothiazine overdose?
Sinus tachycardia, arrhythmias, hypothermia, hypotension, reduced consciousness and respiratory depression. Dystonic reactions may be seen with therapeutic doses. Seizures in severe cases.
56
What is the management of a phenothiazine overdose?
Treat dystonic reactions with procyclidine hydrochloride or diazepam
57
What are the features of amphetamine overdose?
Initially excessive activity, wakefulness, hallucinations, paranoia and hypertension. Later there may be convulsions, hyperthermia, exhaustion and coma.
58
What is the management of amphetamine overdose?
Diazepam/lorazepam
59
What are the features of cocaine overdose?
Agitation, hypertension, tachycardia, dilated pupils, hallucinations, hyperthermia, hypertonia and hyperreflexia and cardiac effects such as chest pain, arrhythmias, myocardial infarction. Ischemic colitis, metabolic acidosis, rhabdomyolysis
60
What is the management of cocaine overdose?
IV diazepam
61
What are the features of opioid overdose?
Drowsiness, coma, respiratory depression, pinpoint pupils
62
What is the management of opiate overdose?
Naloxone hydrochloride
63
What are the features of ecstasy overdose?
Delirium, coma, hyperthermia, rhabdomyolysis, acute renal failure, acute hepatitis, disseminated intravascular coagulation, adult respiratory distress syndrome, hyperreflexia, hypotension and intracerebral haemorrhage; hyponatraemia, convulsions, ventricular arrhythmias, delirium, coma
64
What is the management of ecstasy overdose?
Supportive Diazepam Danrtrolene for hyperthermia
65
What is the treatment of methemoglobinemia?
Methylthioninium chloride | Methylene blue
66
What is the management of cyanide poisoning?
Dicobalt edetate
67
What is the management of ethylene glycol and methanol poisoning?
Fomepizole If needed, ethanol
68
What is the management of carbon monoxide poisoning?
High flow oxygen
69
What are the common agents causing anticholinergic poisoning?
Antihistamines, tricyclic antidepressants, carbamazepine, phenothiazines.
70
What are the features of anticholinergic poisoning?
Tachycardia, hyperthermia, dilated pupils, warm and dry skin, urinary retention, agitation.
71
What are the common agents causing cholinergic poisoning?
Carbamates, organophosphates insecticines, some mushrooms.
72
What are the features of cholinergic poisoning?
Salivation, lacrimation, urination, diarrhoea, bronchorrhoea, bronchospasm, bradycardia, vomiting
73
What are the common agents causing hallucinogenic poisoning?
Amphetamines, cocaine, MDMA
74
What are the features of hallucinogenic poisoning?
Hallucinations, panic, seizures, hypertension, tachycardia, tachypnoea
75
What are the common agents causing opioid poisoning?
Morphine, codeine, methadone
76
What are the features of opioid poisoning?
Hypoventilation, hypotension, miosis, sedation, bradycardia.
77
What are common agents causing sedative/hypnotic poisoning?
Anticonvulsants, benzodiazepines, ethanol
78
What are the features of sedative/hypnotic poisoning?
Ataxia, blurred vision, sedation, hallucinations, slurred speech, nystagmus
79
What are the common features of sympathomimetic poisoning?
Amphetamines, cocaine, MDMA
80
What are the features of sympathomimetic poisoning?
Tachycardia, hypertension, mydriasis, agitation, seizures, hyperthermia, sweating
81
What are some potential side effects of corticosteroids?
``` Increased appetite potentially leading to weight gain Acne Thinned skin that bruises easily Increased risk of infections Mood changes, mood swings, and depression Diabetes High blood pressure Osteoporosis Withdrawal ```
82
How are corticosteroids stopped?
Gradual dose reduction alongside adrenal tests
83
What bone protection is offered alongside steroid treatment?
Oral bisphosphonates - alendondronic acid, risedronate sodium
84
What is the recommended dose and strength of adrenaline in anaphylaxis?
0.5ml in 1:1,000 IM
85
What is the recommended dose and strength of adrenaline in cardiac arrest?
10ml 1:10,000 IV or 1ml 1:1,000 IV
86
What is the management of accidental local injection of adrenaline?
Loca infiltration of phentolamine
87
What are methods to improve alcohol abstinence?
Disulfram | Acamprosate
88
Which classes of antibiotics inhibit cell wall formation?
Peptidoglycan cross-linking: penicillins, cephalosporins, carbopenams Peptidoglycan synthesis: glycopeptides
89
Which classes of antibiotics inhibit protein synthesis?
50s subunit: macrolides, chloramphenicol, clindamycin, linezolid, streptogrammins 30s subunit: aminoglycosides, tetracyclines
90
Which class of antibiotic inhibits DNA synthesis?
Quinolones
91
Which class of antibiotics damage DNA?
Metronidazole
92
Which classes of antibiotics inhibit folic acid formation?
Sulphonamides | Trimethoprim
93
Which class of antibiotic inhibits RNA synthesis?
Rifampicin
94
What is the MOA of aspirin?
Blocks COX-1 and COX-2, blocking thromboxane A2 formation
95
What are the features of carbon monoxide toxicity?
``` Headache (most common) Nausea and vomiting Vertigo Confusion Subjective weakness Severe toxicity: pink skin and mucosae, hyperpyrexia, arrythmias, extrapyramidal features, coma, death High carboxyhemoglobin levels Bilateral globus pallidus lesions ```
96
What is the management of carbon monoxide poisoning?
100% high flow oxygen via non-rebreather mask | Consider hyperbaric oxygen
97
What is the MOA of ciclosporin and tacrolimus?
Inhibits calcineurin, reducing IL-2 release
98
What are side-effects of ciclosporin?
``` Nephrotoxicity Hepatotoxicity Fluid retention Hypertension Hyperkalemia Hypertrichosis Gingival hyperplasia Tremor Impaired glucose tolerance Hyperlipidemia Increased susceptibility to severe infection ```
99
What is the management of cocaine toxicity?
Benzodiazepines
100
What is the MOA of cyanide poisoning?
Inhibition of enzyme cytochrome c oxidase, resulting in cessation of the mitochondrial electron transfer chain
101
What is the presentation of cyanide poisoning?
'classical' features: brick-red skin, smell of bitter almonds lactic acidosis with arteriovenous oxygen difference acute: hypoxia, hypotension, headache, confusion chronic: ataxia, peripheral neuropathy, dermatitis
102
What is the management of cyanide poisoning?
supportive measures: 100% oxygen definitive: hydroxocobalamin (intravenously), also combination of amyl nitrite (inhaled), sodium nitrite (intravenously), and sodium thiosulfate (intravenously)
103
What are the features of digoxin toxicity?
generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision arrhythmias (e.g. AV block, bradycardia) gynaecomastia
104
What is the management of digoxin toxicity?
Digibind correct arrhythmias monitor potassium
105
List three drugs that cause agranulocytosis.
Antithyroid drugs - carbimazole, propylthiouracil Antipsychotics - atypical antipsychotics (CLOZAPINE) Antiepileptics - carbamazepine Antibiotics - penicillin, chloramphenicol, co-trimoxazole Antidepressant - mirtazapine Cytotoxic drugs - methotrexate
106
List two drugs that commonly cause urticaria.
aspirin penicillins NSAIDs opiates
107
List three drugs that impair glucose tolerance
``` thiazides, furosemide (less common) steroids tacrolimus, ciclosporin interferon-alpha nicotinic acid antipsychotics ```
108
List three drugs that cause thrombocytopenia.
quinine abciximab NSAIDs diuretics: furosemide antibiotics: penicillins, sulphonamides, rifampicin anticonvulsants: carbamazepine, valproate heparin
109
List three drugs that cause urinary retention.
tricyclic antidepressants e.g. amitriptyline anticholinergics e.g. antipsychotics, antihistamines opioids NSAIDs disopyramide
110
List three drugs that cause lung fibrosis.
amiodarone cytotoxic agents: busulphan, bleomycin anti-rheumatoid drugs: methotrexate, sulfasalazine nitrofurantoin ergot-derived dopamine receptor agonists (bromocriptine, cabergoline, pergolide)
111
List three drugs that cause ocular problems
Cataracts - steroids Corneal opacities - amiodarone, indomethacin Optic neuritis - ethambutol, amiodarone, metronidazole Retinopathy - chloroquine, quinine Sildenafil - blue discoloration, non-arteritic anterior ischemic neuropathy
112
List three drugs that cause photosensitivity.
``` thiazides tetracyclines, sulphonamides, ciprofloxacin amiodarone NSAIDs e.g. piroxicam psoralens sulphonylureas ```
113
When are gentamicin levels monitored?
Peak (1 hour after administration) Trough (just before next dose)
114
What drugs can be cleared with hemodialysis?
``` Barbiturate Lithium Alcohol (inc methanol, ethylene glycol) Salicylates Theophyllines (charcoal haemoperfusion is preferable) ```
115
Against what do antibodies form in heparin-induced thrombocytopenia?
Complexes of platelet factor 4 and heparin
116
What antibiotics are contraindicated with statins?
Macrolides (erythromycin, clarithromycin, azithromycin) Increased risk of myopathy and rhabdomyolysis
116
What antibiotics are contraindicated with statins?
Macrolides (erythromycin, clarithromycin, azithromycin) Increased risk of myopathy and rhabdomyolysis
117
What is the MOA of metformin?
acts by activation of the AMP-activated protein kinase (AMPK) increases insulin sensitivity decreases hepatic gluconeogenesis may also reduce gastrointestinal absorption of carbohydrates
118
What are the common side effects of metformin?
GI upset - nausea, anorexia, diarrhea Reduced B12 absorption Lactic acidosis
119
How is metformin started?
metformin should be titrated up slowly to reduce the incidence of gastrointestinal side-effects if patients develop unacceptable side-effects then modified-release metformin should be considered
120
What is the management of methanol poisoning?
fomepizole (competitive inhibitor of alcohol dehydrogenase) or ethanol haemodialysis cofactor therapy with folinic acid to reduce ophthalmological complications
121
What is the target of infliximab?
Anti-TNF
122
What is the target of rituximab?
anti-CD20
123
What is the target of cetuximab?
Epidermal growth factor receptor antagonist
124
What is the target of trastuzumab?
HER2/neu receptor antagonist
125
What is the target of alemtuzumab?
anti-CD52
126
What is the target of abciximab?
Glycoprotein IIb/IIIa receptor antagonist
127
What is the target of OKT3?
anti-CD3
128
What is the only depolarizing NMJ blocker?
Suxamethonium
129
What are the three non-depolarizing NMJ blockers?
Atracurium Vecuronium Pancuronium
130
How are non-depolarizing NMJ blockers reversed?
Neostigmine
131
What is the management for salicylate poisoning?
urinary alkalinization with IV bicarbonate | haemodialysis
132
What is the management of a benzodiazepine overdose?
Flumazenil
133
What is the management of warfarin overdose?
Vitamin K | Prothrombin complex
134
What is the management of a heparin overdose?
Protamine sulphate
135
What do phase I and phase II drug reactions involve?
Phase I - oxidation, reduction, hydrolysis Phase II - conjugation
136
What is the MOA of amiloride?
blocks the epithelial sodium channel in the distal convoluted tubule
137
What is the MOA of spironolactone?
acts in the cortical collecting duct
138
List two drugs that may exacerbate heart failure.
``` thiazolidinediones verapamil NSAIDs glucocorticoids class I antiarrythmics - flecainide ```
139
What drugs should be avoided in renal failure?
antibiotics: tetracycline, nitrofurantoin NSAIDs lithium metformin
140
List three drugs to avoid in pregnancy.
``` tetracyclines aminoglycosides sulphonamides and trimethoprim quinolones: the BNF advises to avoid due to arthropathy in some animal studies ACE inhibitors, angiotensin II receptor antagonists statins warfarin sulfonylureas retinoids (including topical) cytotoxic agents anti-epileptics ```
141
What is the MOA of quinolones?
inhibit topoisomerase II (DNA gyrase) and topoisomerase IV
142
What are the ADRs of quinolones?
lower seizure threshold tendon damage/rupture cartilage damage QT prolongation
143
What are the contraindications of quinolones?
Pregnancy Breastfeeding G6PD
144
What are the features of serotonin syndrome?
Neuromuscular excitation - hyperreflexia, myoclonus, rigidity Autonomic nervous system excitation - hyperthermia, sweating Altered mental state - confusion
145
What is the management of serotonin syndrome?
Supportive Benzodiazepines more severe cases are managed using serotonin antagonists such as cyproheptadine and chlorpromazine
146
What are common side effects of CCBs?
• Headache • Flushing • Ankle oedema Verapamil also commonly causes constipation
147
What are common side effects of beta-blockers?
• Bronchospasm (especially in asthmatics) • Fatigue • Cold peripheries • Sleep disturbances
148
What are common side effects of nitrates?
• Headache • Postural hypotension • Tachycardia
149
What are common side effects of nicorandil?
• Headache • Flushing • Anal ulceration
150
What are common side effects of sulfonylureas?
Hypoglycaemic episodes Increased appetite and weight gain Syndrome of inappropriate ADH secretion Liver dysfunction (cholestatic)
151
What are common side effects of glitazones?
Weight gain Fluid retention Liver dysfunction Fractures
152
What is a common side effect of gliptins?
Pancreatitis
153
What are the ADRs of tamoxifen?
menstrual disturbance: vaginal bleeding, amenorrhoea hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects venous thromboembolism endometrial cancer
154
How does the COCP affect cancer risk?
reduced risk of ovarian, endometrial - this effect may last for several decades after cessation increased risk of breast and cervical cancer
155
When should ciclosporin levels be checked?
Trough levels immediately before dose
156
When should lithium levels be checked?
12 hours post-dose
157
When should digoxin levels be checked?
At least 6 hours post dose
158
When should phenytoin levels be checked?
Trough levels immediately before dose
159
What is the management of TCA overdose?
IV bicarbonate Arrythmia management (do not give drugs like quinidine, flecainide, amiodarone) IV lipid emulsion
159
What is the management of TCA overdose?
IV bicarbonate Arrythmia management (do not give drugs like quinidine, flecainide, amiodarone) IV lipid emulsion
160
What are the features of methanol poisoning?
Mydriasis, optic disc hyperemia, confusion, stupor, coma, bradycardia, bradypnea, hypotension, hyporeflexia Metabolic acidosis with a high anion gap High osmolar gap
161
What are the features of ethylene glycol poisoning?
Acute renal failure - flank pain, oliguria Hypocalcemia Tetany Metabolic acidosis with a high anion gap High osmolar gap
162
What are the features of mercury poisoning?
Neurotoxic symptoms - anxiety, irritability, depression, memory deficits, numbness, tremors
163
What are the features of acute arsenic poisoning?
GI symptoms - abdominal pain, nausea, vomiting, diarrhea Garlic like breath odor CNS symptoms - drowsiness, confusion, delirium Cardiac symptoms - prolonged QT interval
164
What are features of chronic arsenic poisoning?
Occupational - vineyard work Increased risk of tumors - lung cancer, SCC, liver angiosarcoma Mees line
165
What is the management of arsenic poisoning?
Children - succimer | Adults - dimercaprol
166
What is the management of lead poisoning?
Children - succimer | Adults - dimercaprol or EDTA
167
What is the management of mercury poisoning?
Children - succimer | Adults - dimercaprol
168
What are the features of methemoglobinemia?
Cyanosis, dyspnea, confusion, drowsiness, seizures, coma, death Chocolate brown blood High methemoglobinemia

MRCP Part 1 (2 decks)

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