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MODULE 3

 PRACTICE OF PHARMACY
 COMPOUNDING & DISPENSING
PHARMACY
 CLINICAL & HOSPITAL PHARMACY
 PHARMACEUTICAL CALCULATIONS
PRACTICE OF PHARMACY

I. Clinical Pharmacy Concepts General Clinical Pharmacy Functions:


 Providing drug information to physician & other health professionals
II. Clinical Pharmacy Service  Medication history taking
III. Hospital Pharmacy  Medication profile preparation
IV. Bioethics  Drug therapy monitoring
V. Clinical Laboratory Test  Patient education & medication
 Counseling
VI. Therapeutics  Disease screening, monitoring & maintenance care for patients with
VII. Complementary & Alternative Medicine chronic diseases
 Participation in the management of emergency medical care
I. Clinical Pharmacy Concepts  Health information source for the public
A. Introduction  Drug use review & patient care audits
Clinical Pharmacy  branch of pharmacy where the pharmacist  In-service education for physicians, nurses & other health
provides patients care that optimizes the use of professionals
medications & promotes health, wellness &  Specialized functions & services (ASHP 1983)
disease prevention B. Prescription
 a practice in which the pharmacy utilizes his  a written order for medication issued by a licensed physician,
professional judgment in the application of dentist, veterinarian, or only licensed medical practitioner.
pharmaceutical sciences to foster the safe & Parts of Prescription:
appropriate use of drugs, in or by patients, while
working w/ members of the health care team
(Francke 1969)
 health science specialty whose responsibility is to
assure the safe & appropriate use of drugs in
patients through the application of specialized
knowledge & functions in patient care
 patient-oriented
Clinical Pharmacist:
☛ Interact with the health care team (MD, RN, RPh, PT, RT)
☛ Interview & assess the patient information:
Dugs being taken, food & drug allergies
☛ Design & implement a therapeutic plan
☛ Make Therapeutic recommendation:
Adverse Drug Reaction
Drug Interaction
☛ Monitor Patient’s Response to therapy
☛ Provide drug information

Pharmaceutical Care  is the responsible provision of drug therapy


for the purpose of achieving definite
outcomes that improves a patient’s QOL 1. Name & Address of the Patient
(quality of life) 2. Date when Prescription was written
 a patient-centered practice in which the 3. Superscription  Rx sign; “RECIPE” meaning “take thou”
practitioner assumes responsibility for a  forms the beginning of a direct order from the
patient’s drug-related needs & is held prescriber to the compounder
accountable for this commitment (Cipolle 4. Inscription  list of ingredients & their respective quantities
1998) 5. Subscription  direction to the pharmacist
Major functions of Pharmaceutical Care: 6. Transcription  direction to the patient
 Identifying potential & actual drug-related problems 7. Name, Address, PTR number of the prescriber
 Resolving actual drug-related problems Incorrect Prescription (DOH AO no. 62)
 Preventing potential drug-related problems Features:
Expected Outcomes of Pharmaceutical Care: Erroneous
 Cure a disease BN preceded GN: (Lipitor®) Atorvastatin -Fill
 Elimination or reduction of patient’s symptoms GN is parenthesis: (Atorvastatin) Lipitor® -Keep
 Arresting or slowing the disease process BN is not in parenthesis: Atorvastatin Lipitor® -Report to nearest DOH
 Preventing disease & symptoms Violative
GN is not written -Fill
Knowledge & Skills Required in Clinical Pharmacy BN is written, GN is not written legibly -Keep
Knowledge  disease, drug therapy, non-drug therapy, laboratory, terms that hinder Generic Dispensing -Report to nearest DOH
& diagnostic testing -Ask the Px to return to
Skills  communication, patient monitoring, physical assessment, prescriber to get the
drug information provision, therapeutic planning proper Rx
Impossible
Only GN is written (not legible) -Fill
GN does not correspond to the BN -Keep
Both GN & BN are written, but not legible -Report to nearest DOH
-Ask the Px to return
C. Evidence-base Medicine (EBM)
”the conscientious, explicit & judicious use of current best F. Pharmacoepidiomolgy Study Design
evidence in making decisions about the care of the individual Pharmacoepidiomology  study of use & effects of drugs in a
patient. It means integrating individual clinical expertise with large population
the best available external clinical evidence from systematic 1. Case Report or Series
research” about a single case or a series of related cases
EBM Integrated Components 2. Cross-sectional Study
Clinical Expertise  Clinician’s Cumulated Experience Education &  Prevalence Studies
clinical Skills observational prevalence study ⇉ prevalence of disease &
Patient Values  Personal & Unique Concerns, Expectations, & risk factors
Values
Best Evidence  Clinically Relevant Research with sound survey the population at single point in time
methodology (Sackett D, 2002) Example: Prevalence of colon cancer
Hierarchy of Evidence: & high fat diet in a certain population
 Systematic Reviews more colon cancer & high fat diet in US vs
 Randomized Clinical Trials less colon cancer & low fat in Japan
 Non-Randomized clinical Trials 3. Case-control Study
 Observational Studies Retrospective Study
 Expert Opinions observational study
Drug Information Sources: samples chosen base on presence (cases)
Primary Source Provide the most Journal articles or absence (controls) of disease
current information (Journal of Pharmacy & information recollected about risk factors
Pharmacology, New England
Journal of Medicine) Example: People with lung cancer & people with lung cancer
Secondary Source For quick & Abstacting & indexing Services & see who smoke more
selective screening (Index Medicus, clinArt, Advantage: Inexpensive
of the primary DrugDex) Disadvantage: Recall Bias
literature
4. Cohort Study
Tertiary Sources Provide easy & Textbook’s
convenient access; (Harrison’s Principles of Prospective or retrospective follow-up Study
information may be Internal Medicine, Applied observational Study
outdated therapeutics) samples chosen based on presence or absence of risk factors
D. Drug Development subjects followed over time for development of disease
Drug Discovery & Screening (~2 yrs) Example: Smoker & Nonsmokers
discovery of the lead compounds from biologic products then see who develops lung cancer
screening for activity
chemical design
Advantage: Less recall bias
synthesis & characterization Disadvantages: Time-consuming, Expensive
Pre-clinical Studies 5. Randomized Controlled Clinical Trial
tested on animals Gold Standard -assessing effects of drugs
efficacy, safety, toxicity, mechanism (PK/ PD) Experimental Study Design-intervention
Investigational New Drug compares two or more treatments/ intervention to placebo
Clinical Trials( 4-5 years)  tested on humans Randomization =each subject has an equal & known
Phase I: Screening for Safety probability of being assigned to a certain
initial assessment of safety, tolerance, PK & PD group
healthy human volunteers (20-100)  single side =refers to the assignment of intervention in a
Phase II: Establishing the Test Protocol study
initial assessment in the target population
decreases/ reduces bias
IIa  identification of doses
IIb  assess & efficacy
eliminates comfounding factors
well-controlled narrowly-defined population (100-300) extraneous variables that may interfere
double-blinded randomized clinical trials w/ the result
Phase III: Final Testing Random Sampling  is done so that a representative
confirmation of doses portion of the population can be
expanded tolerability profile taken
more varied population (100-3000) Blinding:
multicenter multisite
 Single patient does not know the group assignment
double-blind RCT
benefit-risk ration
 Double  patient & physician do not know
New Drug Application  Triple  patient, physician, & pharmacist do not know
Marketing Blinded Study  neither the study subject nor the study
Phase IV: Post Marketing staff is aware
wider population Placebo controlled  “hidden blank”
detect previously unknown AE & DI w/ inclusion & exclusion criteria
different formulation, dosage, duration of therapy Disadvantage: Expensive, time-consuming,
Patent-usually last for 20 years Ethical Considerations (cannot compare new
when Patent Expires  Generic Counterparts, treatment to placebo if
become available there is a standard of care)
Phases of Product Development: 6. Cross-over Study  comparing treatments in w/c participants are
Pre-clinical Stage Animal Studies switched to the other
Phase 1 Assess safety in healthy human volunteers
Phase 2 Evaluate effectiveness of a drugs in patients with
disease or condition
Phase 3 Large-scale multicenter clinical studies
(hundreds to thousands)
Phase 4 Post-marketing studies
II. Clinical Pharmacy Services

A. Patient Record/ Database B. Medication Order Review


1. Medical History Medication Orders  prescription in the hospital or institutional setting
General Patient Information Drug Related Problems:
name, age, sex, residence, date, & time of admission ☛ unnecessary drug therapy
Chief Complaint (CC)  reason for seeking medical care ☛ wrong drug
History of Present Illness (HPI)  narrative that describes the ☛ wrong patient
patients current medical ☛ dose too high, too low
problem ☛ ADR & DI
Past Medical History (PMH)  brief description of current & ☛ need for additional drug therapy
previous medical condition that
☛ inappropriate compliance (patient, prescriber)
may or may not be related to
the present illness
C. Pharmacoeconomics Studies
Personal, Social History, Lifestyle
comparing value of drug or therapy w/ another
diet
1. Cost of Illness (COI)  measure the costs attribute to a specific disease
use of Tobacco: Pack year= ppd x years  Direct Medical Costs
 alcohol (drinking habits)  related to the therapy
 illicit drugs (drug, insulin, syringe, glucostrips)
 marital status  Indirect Medical Costs
 sexual history  not related to the therapy
Family Medical history (FMH)  medical history of the (fare, loss in productivity)
patient’s first degree relative Direct non-medical Costs
Medication History  salary of the health care professional
current & past medication 2. Cost Benefit Analysis (CBA)  identify & measure all the costs in
 OTC drug use providing treatment & comparing w/ the
 ADR benefits that result
 compliance  𝐵𝑒𝑛𝑒𝑓𝑖𝑡 − 𝑡𝑜 − 𝑐𝑜𝑠𝑡 =
𝐵𝑒𝑛𝑒𝑓𝑖𝑡
Obstetrics & Gynecologic History 𝐶𝑜𝑠𝑡𝑠

Obstetrics score: GxPx (EPAL) 3. Cost Minimization Analysis (CMA)  compare two or more treatment
G2P2 (2002) w/ the same therapeutic outcome
 look for the treatment w/ the
 details of past pregnancy
lowest possible cost
present pregnancy
menstrual history  Example: Branded & Generic Cost
Immunization History 4. Cost Utility Analysis (CUA)  assess the perceived, mental, physical,&
vaccines received general functioning of the patient
 data received  integrates patient preferences & health
Developmental History related QOF
 developmental milestone  measures the consequences in terms of
Review of System (ROS) the quality adjusted life year (QALY)
Patient’s complaints not included in the HPI gained
2. Physical Exam findings QALY  physical, social & emotional
3. Present Working Impression: Preliminary Diagnosis aspect a patient’s well
4. Laboratory Summary being
Hema: CBC  chronic disease  meaintenance
Coagulator: PT, aPIT  integrates patient preference in the
ABG result health related DOL
Blood Chem: BUN, Crea, Na, K, Cl, Ca Ex: ACEi vs ARBs
Urinalysis result 5. Cost Effectiveness Analysis (CEA)  compare treatment alternatives w/
Gramstain/ Culture sensitivity cost measured & treatment
ECG result: *ECG  Gold standard for detecting heart outcomes expressed in terms of
conditions involving irregularities in therapeutic objectives
electrical conduction & rhythm  compares fro the intervention w/
Imaging: Xray, MRI, CT scan the greatest therapeutic outcome
5. Patient’s Problem List summarizing the benefits &
☛Potential & Actual Problem resources
☛Intervention Example:
☛Status Drug A Drug B
6. Drug Therapy Plan 5 𝑚𝑚𝐻𝑔 10
<
☛Drug Prescribed $10 $10
☛Indication 𝑐𝑜𝑠𝑡
☛Compliance  𝐶𝑜𝑠𝑡 − 𝑡𝑜 − 𝑒𝑓𝑓𝑒𝑐𝑡𝑖𝑣𝑒 𝑟𝑎𝑡𝑖𝑜𝑛 = 𝑡𝑕𝑒𝑟𝑎𝑝𝑒𝑢𝑡𝑖𝑐 𝑒𝑓𝑓𝑒𝑐𝑡
(𝑖𝑛 𝑚𝑒𝑎𝑠𝑢𝑟𝑎𝑏𝑙𝑒 𝑢𝑛𝑖𝑡𝑠 )
7. Pharmacist’s Care Plan
ICER (Incremental Cost-Effectiveness Ratio)
Example:
Cost Outcome
Health care need Control of HTN
COI Currency ($) 
Pharmacotherapeutic Goal Decrease BP
Recommendation, Intervention Losartan CBA “ Currency ($)
Monitoring Parameter BP CMA “ No comparison
desired endpoint 120/80 CUA “ Utility (QC applied in unit)
 frequency of monitoring everyday CEA “ Therapeutic Objectives
D. Adverse Drug Reaction
E. Drug Incompatibilities
F. Drug Utilization Review (DUR)
 an authorized, structured & continuing program that Clinical Pharmacokinetics  study of the time course of the ADME of
reviews, analyzes & interpret patterns of drug usage in a drugs & their corresponding
given health care delivery system against pre-determined pharmacological response
standards Application:
Prospective DUR (before dispensing)  used to review medication Time to maximal response
profiles to assess the Need for a loading dose
appropriateness of Dosage alteration
prescription Choosing a formulation
Retrospective DUR (after dispensing)  used to review, analyze, Drugs requiring TDM
interpret, patterns of drug Intensity of pharmacologic effect is proportional to the drug
usage concentration at the site of action
Drugs have an established therapeutic plasma range
Relationship between plasma drug concentration & clinical effect is
G. Drug Information Sources better than the relationship between drug dose & its effect
1. Primary  provides most current information Drug toxicity & disease presentation are difficult to distinguish from
 written by researcher clinical assessment alone
 journal articles Therapeutic Range  the range of drug concentration within which the
2. Secondary  for quick & selective screening of primary literature drug exhibits maximum efficacy & minimum
 abstract indices toxicity in the majority of patients
3. Tertiary  provide easy & convenient access Commonly monitored Drugs:
 textbooks Aminoglycoside: Gentamicin
 may be out dated Tobramycin
Netilmicin
Amiacin
H.Drug Monitoring Vancomycin
1. Therapeutic Drug Monitoring  encompasses the measurement of Cardioactie Agents: Digoxin
serum drug levels & the application Procainamide
of clinical pharmacokinetics to Lidocaine
improve patient care. Disopyramide
 determination of plasma Flecainide
concentration of drugs to adjust
therapy
 optimizes individual drug therapy Therapeutic Guidelines
 maintain the drug concentration in provide clear & concise, independent & evidence-based
the blood recommendations about patient management that have been
Trough Level  lowest drug level in developed.
the body  Objectives of TGS:
Peak Level  highest drug level To reduce chance of error by establishing standard protocol
timing of blood collection is crucial for how care is carried out
(just before the next dose

obtain trough levels) 2. Criteria- monitored Antibiotics
Uses: Direct relationship between drug concentration &  optimizes antibiotic therapy
therapeutic effect  prevent drug resistance
Drugs w/ established therapeutic range Meropenem,
Drugs w/ no active metabolites or irreversible Doripenem,
actions Fluconazole,
Effect cannot be assessed quantitatively by clinical Azithromycin,
assessment Pineracillin- Lazobactam,
Inter-individual variability in plasma drug Cefepime (4g),
concentration Ceflobipirole (5g)
𝐓𝐃
low therapeutic index(<2)=
𝐄𝐃
(narrow ther. )
Anticipated Drug Interaction Pharmacokinetic Studies  pre-clinical studies that determine the
Replacement Treatment new drug’s absorptive, distributive,
When non-compliance is suspected metabolic, & excretory pathways
Pharmacologic Studies  pre-clinical studies that determine the
action of new drug in animals to
Drug Therapeutic Levels estimate the magnitude of its intended
Digoxin 0.5 – 2mg/mL therapeutic effect
Toxicologic Studies  pre-clinical studies in animals that
Aminoglycoside Genta  1- 10 mg/L
determine the relative safety in humans &
Amikacin  4- 12 mg/L
monitor parameters that will be used in
Phenytoin 10-20 mg/mL
clinical trials
MTX – Methotrexate >5 mmol/L
(required Folinic Acid)
Theophylline 5- 20 mg/L
Antiarrhythmics Lidocaine, Amiodarone,
1- 25 mg/L
I. Patient Medication Counseling Stages in Patient Counselling:
According to ASHP: provision of oral & written information about drugs I. Medication Information Transfer
& other health-related information to a patient or his/her II. Medication Information Exchange
representatives during dispensing process or hospital stays III. Medication Education
Scope: Name of Medication (GN, BN, classification) IV. Medication Counseling
 techniques of self-monitoring
use, benefit actions Various strategies & techniques are in place for use in
onset of action counseling & educating patients.
The effective domain of learning process involves the
 potential drug interaction
formation of attitudes such as:
route, dosage form & storage - Feelings
contraindication - Beliefs
 direction for use - Perceptions
 relationship w/ lab or x-ray procedure - Emotions
- Appreciations
actions in case of missed dose The Behavioral domain of learning process involves:
refill process - Actions
 disposal of drugs & devices - Decision making
Precaution - Physical abilities
Any other relevant health information unique to an Forms of Nonverbal Communications
individual patient -speech related (e.g. timing & pauses)
Side & adverse effects -non-verbal behavior (e.g. posture & position, eye
Questions: contact, proximity to other person, etc)
Close -use of body
-aspects of personal appearance (e.g. clothing &
 narrow hairstyle, smell, etc)
 used when a direct answer is needed -symbols
 answerable by “yes” or “no” -sign language
-written word
 chronic use  choppy interview
-use of media
  quality & quantity of information
  opportunity to develop rapport w/ the patient Elements of Communication Process:
Open - FeedBack
- Barriers
 wide-ranging - Sender
 not directly answerable by “yes” or “no”
 chronic use  lengthy interview Proxemics  involves the structure & use of space
  quality & quantity of information important in patient counselling
Kinesis  involves the manner of using the parts of the
 can develop rapport, assess disposition of the patient
body during communication w/ the patient
Leading or Loaded
 usually closed Counseling  define by British Association of Counselling,
 contain their own answer  a skilled & principled use of relationships to
facilitate self-knowledge, emotional
 imply judgment on the patient
acceptance & growth, & the optimal
 not fruitful development of personal resource
 must be avoided Empathy  the ability to see the world from the point of
Double or Multiple view of another person, through their frame of
 presents the patient w/ two or more inquiries at the same reference, through their conceptual & emotional
spectacles
time
 traps the patient in a barriage of questions Drug Education Approach by Pharmacists involves:
 patient gets confused, irritated -Counseling
-Assessment
Communication Skills:
-Reinforcement
Attending & active listening skills Empathic Responding Skills -Evaluation
Stop talking Reflecting  concentrating on the
Get rid of distractions emotional meaning J. Pharmaceutical Care Plan
React to the ideas, Paraphrasing  conveying the 1. Assessment  a review of the medical conditions & symptoms to
(Not to the person) essence of what determine the need for drug therapy
Read non-verbal messages was said 2. Plan  a decision of an appropriate drug therapy based on the
 Listen to how something is said Focusing  getting back to the assessment of the patient
Provide feedback to clarify any topic of conversation 3. Monitoring  a review of the outcomes of drug therapy (goals &
message endpoints) to determine if the patient is obtaining the
Interviewing Skills Influencing Skills desired outcomes
Ask open questions Give relevant advice
Ask closed questions Make good suggestions K. Others
 Check if the patient has Share correct information 1. Selection of Drug Therapy
understood or requires more Summarize main points of 2. Interdisciplinary Rounds –MD, RN, RPh,
information information given other health care professionals
Avoid suggesting during data- Emphasize key points with “This is
gathering phase important…” Preventive Model:
Primary Level of Prevention
Provide a balance of questions Supplement spoken word with
is concerned to prevent onset of disease, & reduce incidence
Do not jump into conclusion written instruction Secondary Level of Prevention
 Keep goals of the conversation  Give reasons for key advice is concerned to prevent development of existing disease,
in mind Check for accuracy of patient’s minimize its severity, reverse its progress, & reduce prevalence
Avoid shifting from one topic to understanding  Tertiary Level of Prevention
 is concerned to prevent deterioration, relapse & complications,
another until one is finished Give definite, concrete, explicit
promote rehabilitation, & help adjustment to terminal conditions
 Maintain objectivity instruction
III. Hospital Pharmacy
A. Hospital (d) Bed Capacity
 is an organized structure which pools together all the health Under 50 beds
professionals, the diagnostic & therapeutic facilities, equipment & 50 -99
supplies & the physical facilities into a coordinated system for 100 -199
delivering health care to the public 200 -299
 form: consists of the physical make up & quantitative nature of its 300 -399
services 400 -499
 purpose/mission: a community institution & instrument of society 500 & over
 functions: -Patient care (pay or charity) (e) Levels of Services
-Education –patient & professional 1. Primary – primary medical use
-Research –advancement of medical knowledge against – for providing find contact, emergency care &
disease hospitalization in simple cases
-Public Health –reduce incidence of illness, improve 2. Secondary – primary level w/ surgical care or specialization
general health & wellness – expertise of physician w/ not less than 6 months
Florence Nightingale  nursing service training
Jonathan Roberts  Father of Hospital Pharmacy  Departmentalized
(1) Classifications: 3. Tertiary – secondary level w/ sub specialization
(a) Types of service – teaching hospital
General  patient w/ any type of illness Tertiary Level 1  for cases requiring sophisticated
 at least 6-bed capacity for patients to the admitted for diagnostic
at least 24 hours Tertiary Level 2  has training & research capabilities
 ensure health & safety, not crowded provides residency training programs
 identifiable government authority delegates a CEO Tertiary Level 3  w/ teaching, training & research functions
(chief executive officers) Tertiary Level 4  expensive & sophisticated diagnostic
 organized medical staff (may include dentist) Provincial  provides tertiary level 1 hospital care
 each patient is assigned to a staff member Regional  provides tertiary level 2 hospital care
 services: Nursing Medical Center  provides tertiary level 3 hospital care
Medical Record District  front-line hospital; providing 2 medical care
Pharmacy
Laboratory & diagnostic (2) Organization & Administration:
Dietary Governing Authority
Operating room  CEO
Special  address special condition  President
 w/ specialized clinical services  Hospital
 Example: San Lanzaro = infectious cases  Director
Heart Center = cardiovascular Departments
NICI = renal & neurologic cases professional care = pharmacy, nursing, laboratory, etc
Long Term Health Care Facility  w/ organized medical staff administrative = business management, accounting,
 continuous nursing services cafeteria, housekeeping, engineering
 medical care to individuals Health Maintenance Organization (HMO)
needing long-term healthcare private or public
(chronic illness), convalescent provide comprehensive or total health care services to
patient individuals enrolled on a per capita basis
Resident Treatment Facility  safe & hygienic arrangement for  includes emergences, in-patient & ambulatory care,
the resident patients prescription & preventive medical staff
 regular & emergency health Supporting Services:
services & supportive services 1. Nursing Service  nursing care
Integrated Health Care  hospitals merged w/ other hospitals & 2. Dietary Service  procurement, panning & preparation of food
other patient care services like home for the patient & hospital staff
health care, long term care & wellness 3. Central Supply Service  supplies sterile linen, OR packs & other
facilities medical surgical supplies
Clinic  facility or area where ambulatory patients are seen for 4. Medical Record Service  serve as basis for planning &
special study, appointments & treatment by a group of continuity of patient care
physicians practicing together, & where the patients is  provide data for use in research
not confined in a hospital education
(b) Length of stay: serve as basis for review & evaluation
☛Short-term  < 30 days of the care rendered to the patient
☛Long-term   30 days 5. Blood Bank  generally under the supervision of a licensed
(c) Ownership: physician who has a basic interest in hematology
Governmental  federal, state, regional, provincial, city, 6. Pathology  cytological & gross anatomical analysis
municipal  clinical laboratories
Non-governmental  Non-profit: Church operated 7. Radiology  diagnostic & therapeutic application of radiant
Profit oriented: Individual energy
Partnership 8. Anesthesia  anesthesia care
Corporation 9. Medical Social Service  very important liaison between the
represent the interest of the hospital & the patient & his
owners community
 profit is legally shared among
the owners
Medical Staff B. Hospital Pharmacy Department
Constituents Hospital Pharmacy  institutional pharmacy
Main Types:  the practice of pharmacy in a hospital setting
1. Open Staff  one in which certain physicians, other including its organizationally related facilities or
than those on the attending or active services
medical staff, are allowed to use the 1. Hospital Pharmacy Department
private room facilities, providing they  department or division of the hospital wherein the procurement,
comply with all rules & regulations of the storage, compounding, manufacturing, packaging, controlling,
institution. These physicians are termed assaying, dispensing, distribution, & monitoring of medications
members of the “Courtesy Medical Staff” through drug-therapy management for hospitalized &
2. Closed Staff  one in which all professional services, ambulatory patients are performed by legally qualified,
private & charity are only provided & professionally competent pharmacists
controlled by the “Attending” or “Active  headed by a department head: Chief Pharmacist
Medical Staff” reports directly to the hospital director
 preferred for teaching hospital administer & implement to the hospital director
attending or active medical staff of the pharmacy, subject to the director’s
-selection of practitioners approval
Specific Types:
1. Honorary  been active Hospital Director
 consists of former staff members, retired or
emeritus, & of other practitioners whom the
medical staff chooses to honor Chief Pharmacist
 consists of practitioners who are eligible for executive & administrative duties
staff membership & given privileges o admit
occasional patients
2. Consulting  recognized specialists who passed the
Professional & Educations & Research &
specialty boards Clinical Services Technical Services Supplies Services
 consists of practioners of recognized
professional ability who are not members
of the preceding categories of staff Pharmacists’ Duties/Responsibilities:
membership Ambulatory Pharmacists’ Dispensing
 consultant to other medical staff Responsibilities Patient Care
3. Active/ Attending  concerned w/ direct patient care & (out-patient) General Responsibilities
counseling Central Pharmacists’
Dispensing
 responsible for the delivery of the Responsibilities
Patient Care
pre-ponderance of medical service (in-patient)
within the hospital
 most involved in the organizational & Pharmacist Responsibilities:
administrative duties pertaining to Ambulatory Pharmacists’ Responsibilities
the medical staff (a) Dispensing Area
 residents, fellows 1. Ensures that established policies & procedures are followed
4. Associate  junior or less experience 2. Checks for accuracy in the work of supportive personnel
 interns, clinical clerks 3. Ensures that food techniques are used in extemporaneous
 consists of individuals who are being compounding
considered for advancement to the active 4. Provides for adequate record keeping & billing:
medical staff patient- medication record, investigation- drug records,
 appointed & assigned to the various services outpatient billing, reports, prescription files
in the same manner as are members of the 5. Maintains professional competence
active medical staff 6. Ensured that new personnel are trained properly in the policies &
5. Courtesy  attend to private patient procedures of the ambulatory pharmacy
 but are not members of the active medical 7. Coordinates the activities of the area with the available staff to
staff make the best possible use of personnel & resources
9. Keeps the ambulatory pharmacy area neat & orderly at all times
 consists of practitioners who are eligible for
staff membership, who are given privileges to (b) Patient Care Area
admit an occasional patient to the hospital 1. Inspects the medication areas on the nursing unit periodically to
ensure an adequate supply of stock drugs & their proper storage
 may neither vote nor hold office in the medical
2. Identifies drugs brought into the clinic by patients
staff organization
3. Obtains patient medication histories & communicates all
6. Resident  receiving specialized clinical training in a
pertinent information to the physician
hospital, usually after completing an
4. Assists in drug-product & entity selection
internship
5. Assists the physician in selecting dosage regimens & schedules
6. Monitors patient’s Total Drug therapy for effectiveness/
ineffectiveness, side effects, toxicities, allergic drug reactions,
drug interactions, & appropriate therapeutic outcomes
7. Counsels patients on the proper use of their medication
8. Prepares medication for IV administration
9. Provides medication &/or supplies for patient home care
Central Pharmacists’ Responsibilities
(a) Dispensing Area
1. Ensures that established policies & procedures are followed  Divisions:
2. Checks for accuracy of dose prepared: a) IV admixture ~Administrative Services
1. Plan & coordinate departmental activities
b) unit dose 2. Develop Policies
3. Provides for proper drug control: 3. Schedule Personnel & Provide Supervision
a) Ensures that drugs are stored & dispensed properly 4. Coordinate Administrative needs of the Pharmacy &
b) Ensures that all drug laws are followed Therapeutics Committee
5. Supervise departmental office staff
4. Ensures that food techniques are used in compounding IV
~Education & Training
admixtures & extemporaneous preparations 1. Coordinate programs of undergraduate & graduate
5. Provides for proper record keeping & billing: pharmacy students
a) patient- medication record, 2. Participate in hospital wide educational programs involving
b) extemporaneous compounding records nurses, doctors, etc
3. Train newly employed pharmacy department personnel
c) IV admixture records & billing ~Pharmaceutical Research
d) Investigation- drug records 1. Develop new formulations of drugs especially dosage forms
e) reports not commercially available & of research drugs
6. Maintains professional competence, particularly in knowledge of 2. Improve formulations of existing products
drug stability & incompatibilities 3. Cooperate w/ the medical research staff on projects
involving drugs
7. Ensured that new personnel are trained properly in the policies & ~In-patient Services
procedures of the dispensing area 1. Provide medications for all in-patients of the hospital on a
8. Coordinates the activities of the area with the available staff to 24-hour per day basis
make the best possible use of personnel & resources 2. Inspection & control of drugs on all treatment areas
9. Keeps the dispensing area neat & orderly 3. Cooperate w/ medical drug research
~Out-patient Services
10. Communicates w/ all pharmacy staff regarding new 1. Compound & dispense out-patient prescriptions
developments in the area & assists in employee evaluations 2. Inspect & control all clinic & emergency service medication
11. Provides drug information as necessary to the pharmacy, stations
medical, & nursing staffs 3. Maintains Prescription records
4. Provide drug consultation services to staff medical students
12. Coordinates the over-all pharmaceutical need of the patient-care ~ Drug Information Services
areas with dispensing area 1. Provide drug information on drugs & drug therapy to
(b) Patient-Care Area doctors, nurses, medical & nursing students & the house
Supervision of Drug Administration: staff
1. Reviews & interprets each unit dose & IV admixture medication 2. Maintain the drug information center
3. Prepare the hospital’s pharmacy newsletter
order to ensure that it is entered accurately into the unit dose or 4. Maintain literature files
IV admixture system ~Departmental Services
2. Confirms periodically that administered doses are noted correctly 1. Control & dispense IV fluids
on the patient’s chart 2. Control & dispense controlled substances
3. Coordinate & control all drug delivery & distribution systems
3. Ensures that records from administered narcotics are kept
~Purchasing & Inventory Control
correctly & that the physician is informed of all automatic stop 1. Maintain drug inventory control
orders 2. Purchase all drugs
4. Ensures that proper drug administration, techniques are used 3. Receive, store & distribute drugs
5. Acts as liaison between the pharmacist & the nursing & medical 4. Interview medical service representatives
~Central Supply Services
staffs 1. Develop & coordinate distribution of medical supplies &
6. Communicates with nurses & physicians concerning irrigating fluids
medication0administration problems ~Assay & Quality Control
7. Periodically inspects the medication areas on the nursing units to 1. Performs analyses on products manufactured & purchased
ensure that adequate levels of floor stock drugs & supplies are 2. Develop & revise assay procedures
3. Assist research division in special formulations
maintained ~ Manufacturing & Packaging
8. Ensures that drugs & supplies are procures from the dispensing 1. Manufacture wide variety of items in common use at the
area as required hospital
9. Ensures that the other supportive services performed by the 2. Operate an overall drug packaging & prepackaging
program
department of pharmacy are carried out correctly
3. Undertake program in product development
10. Coordinates all pharmacy services on the nursing- unit level 4. Maintain a unit dose program
11. Ensures that the medication area is neat & orderly ~Sterile Products
12. Ensures that proper security is maintained in the medication area 1. Produce small volume parenterals
to prevent pilferage 2. Manufacture sterile ophthalmologics, irrigating solutions,
etc
(c) Direct Patient-Care 3. Prepare aseptic dilution of lyophylizal & other unstable
1. Identifies drugs brought into the hospital by patients sterile injections for administration of patients
2. Obtains patient medication histories & communicates all pertinent ~Radiopharmaceutical Services
information to the physician 1. Centralize the procurement, storage & dispensing of
radioisotopes used in clinical practice
3. Assists in drug-product & entity selection
~IV Admixture
4. Assists the physician in selecting dosage regimens & schedules, 1. Centralize the preparation of IB solution admixture
then assigns drug-administration times for these schedules 2. Review each IV admixture for physic-chemical
5. Monitors patient’s Total Drug therapy for effectiveness/ incompatibilities
ineffectiveness, side effects, toxicities, allergic drug reactions,
drug interactions, & appropriate therapeutic outcomes
6. Counsels patients on:
a) medications to be self-administered in the hospital
b) discharge medications
7. Participates in cardiopulmonary emergencies by:
a) procuring & preparing needed drugs
b) charting all medications given
c) performing cardiopulmonary resuscitation, if necessary
2. PTC (Pharmacy & Therapeutic Committee) 3. Formulary
 evaluates the clinical use of drugs  is a continually revised compilation of pharmaceuticals (plus
 oversees policies & procedure related to medication use important auxiliary information) that reflects the current
 manage the formulary system
clinical judgment of the medical staff
 is an advisory group of the medical staff which serves as the
organizational line of communication between the medical  includes, but is not limited to:
staff and pharmacy department. -list of medication & medication-related devices
 is composed of physicians, pharmacists and other health -policies
professionals elected with the guidance of the medical -auxiliary drug information
staff. -decision support tool
-organizational guidelines
Objectives: To achieve optimal patient care & safety through
rational drug therapy.  Formulary Drugs  agents whose place in therapy is well-
Primary Purposes: established
 Policy Development/ Advisory Non-formulary  not well established
 The committee recommends the adoption of, or Why create a Formulary?
assists in the formulation of, broad professional The need for hospital formularies becomes increasingly great
policies regarding evaluation, selection and because of:
therapeutic use of drugs in hospitals. (1) the increasing number of new drugs being marketed,
 Educational (2) the increasing influence of biased advertising and
The committee recommends or assists in the unscientific “scientific” drug literature,
formulation of programs assigned to meet the needs (3) the increasing complexity of untoward effects of the newer
of the professional staff (physicians, nurses, more potent drugs,
pharmacists and other health care practitioners) for (4) the highly competitive marketing practices of the
complete current knowledge on matters related to pharmaceutical industry; and
drugs and drug use. (5) the public's interest in seeing that the health professions
Organization and Operation of PTC are continuously providing the best possible care at the
a) The PTC should be composed of at least three physicians, a lowest possible cost.
pharmacist and representatives of the nursing staff. PNDF (Philippine National Drug Formulary)
Committee members are appointed by a governing unit or PART I – General Information (Information on hospital policies
elected officials of the organized medical staff. The hospital and procedures concerning drugs)
administrator or his/her representative should be an ex –
PART II – Drug products listings
officio member of the committee.
b) A chairman from among the three physician representatives  the heart of the formulary and consists one or
should be appointed. A pharmacist usually is designated as more descriptive entries for each formulary
secretary. item plus one or more indexes to facilitate the
c) The committee should meet regularly at least six times per use of the formulary
year, and when necessary.  (Essential Drugs)
d) The committee should invite to its meeting persons within or -Core List
outside the hospital who can contribute specialized or unique -Complementary List
knowledge, skills and judgments. PART III – Special Information
e) An agenda and supplementary materials (including minutes of Essential Drug List  refers to those drugs, which cure the vast
the previous meeting) should be prepared by the secretary majority of illness
and submitted to the committee members in sufficient time
before the meeting for them to properly review the material.
Core List  is a list of drugs that meets the health care needs of the
f) Minutes of the committee meetings should be prepared by the majority of the population.
secretary and maintained in the permanent records of the Complementary List  is a list of alternative drugs used when there
hospital. is no response to the core essential drug or
g) Recommendations of the committee shall be presented to the
when there is hypersensitivity reaction to
medical staff or its appropriate committee for adoption or
recommendation. the core essential drug or
h) Liaison with other hospital committee concerned with drug use Policy a define course or method of action to guide
(e.g. infection control, medical audit) shall be maintained.  framework for action
Functions and Scope of PTC Procedure  series of steps followed in a regular definite sequence
a) To serve in an evaluative, educational, and advisory capacity
Essential Drug  available at all times in adequate amounts &
to the medical staff and organizational administration in all
matters pertaining to the use of drugs. appropriate dosage forms
b) To develop a formulary of drugs accepted for use in the Drug Donations  Tax deductible
organization and provide for its constant revision.  Once they are received by a country,
c) To establish programs and procedures that help ensure safe they cannot be returned to donors
and effective drug therapy.
Elements of the PNDF:
d) To establish programs and procedures that help ensure cost –
-Tailored Procurement
effective drug therapy.
- Quality Assurance
e) To establish or plan suitable educational programs for the
- Self reliance
organization's professional staff on matters related to drug
- People Empowerment
use.
- Rational Drug Use
f) To participate in quality assurance activities related to
distribution, administration, and use of medications.
g) To monitor and evaluate ADRs in the health – care setting Methods for Quantifying Drug Requirements:
and to make appropriate recommendations to prevent their Morbidity  data of standard treatment guideline & cases of
occurrence illnesses
h) To initiate or direct (or both) drug use evaluation program and Mortality  data of certain population died form specific disease
studies, review the results of such activities, and make Consumption  data on inventory records, lead times & drug cost
appropriate recommendations to optimize drug use. Service Level  estimating budget need based on utilization
i) To advise the pharmacy department in the implementation of
effective drug distribution and control procedures. Mortality & Morbidity  is the most useful indicator of the health status of
j) To disseminate information on its actions and approved a community
recommendations to all organizational health – care staff.
k)
Trend  involves long term movement of data
Standard Treatment Guidelines Season  involves short term but regular variations in data
 systematically developed statements that assist physicians on Cycle  acts in wavelike variation
clinical decisions which concern drugs among others.
Perpetual  inventory review done anytime
 Ex: GINA (Global Initiative for Asthma)
Effectiveness  associated w/ prompt achievement of the objectives given
JNC (Joint Nation Counsel –for HTN)
Efficiency  resources needed to achieve the objective are considered in
compare to what was actually done
Formulary System C. Drug Delivery System (DDS)
is a method whereby the medical staff of an institution, working  system by which the pharmacy department makes drugs
through the PTC evaluates, appraises and selects from among available at the nursing unit.
the numerous available drug entities and drug products those Drug Distribution System
that are considered most useful in patient care. refers to a system that has as its purpose the selection,
 process by which the medical staff & PTC choose the drugs to acquisition, control, storage, dispensing, delivery, preparation, &
administration of drug products in health care institutions in
include in the formulary
response to the order of an authorized prescriber
Evidence-based evaluation  backed-up by researchers The pharmacy department makes drugs available at the nursing
Drug reviews unit for patient use usually in one of four ways
new drug monographs  drugs newly approved by FDA 1. Complete Floor stock System
addenda to original monographs  new additional for drugs in large quantities (bulk) & standard
containers
information  free or charged
expected review  drug w/out therapeutic alternatives maintained on the nursing unit
significant new safety concern about drug 2. Individualized prescription order system
strategies for managing medication use 3. Combination of 1 & 2
4. Unit Dose DDS
☛Generic Substitution
standard of practice; most accepted
Generic Drug  same active ingredients, strength,  pharmacist prepares every dose of the
concentration, dosage form, route medication
of administration as the drug  either Centralized (in the pharmacy)
products originally prescribed Decentralized (at the nursing unit level)
☛Therapeutic Substitution  Major Elements of a Distribution System:
Therapeutic Alternative  different active - Storage
ingredient, same - Delivery
pharmacologic class, - Information System
similar therapeutic 1. Floor-stock System  used in small hospitals where pharmacists
effect are not available to dispense individual doses
must be done under the authorization of the for patients.
prescriber (therapeutic interchange) 2 Classes:
☛Guided-use Strategies (a) Free floor stock  consists of a predetermined list of
medications that are available on every
restricted = formulary drugs that can only be
nursing unit of the hospital for use at
prescribed by a specific group of
no specific charge to the patient
prescribers, designated by PTC
Non-charge Floor Stock  refers to the drugs placed on
☛CPG  clinical practice guidelines
the nursing station for use of
☛Off-label Use  use of drugs for indication no all patients on that area.
specifically approved by the FDA
 considers Quantity used,
☛Research Pharmaceuticals Cost, Frequency of Use, in
investigational drugs = commercially available selecting drugs.
nonformulary drugs that (b) Charge floor stock  is medication available at each
are temporarily made nursing unit of the hospital & for
available to particular which a charge is made to the
physicians for evaluation patient
for inclusion into the Advantages:
formulary (a) ready availability of the required drugs
☛DURs (Drug Utilization Reviews) (b) elimination of drug returns
(c) reduction in number of drug order transcriptions for the
pharmacy
Purchasing & Inventory Control (d) reduction in the number of pharmacy personnel needed
- Turnover rate: Disadvantages:
𝑐𝑜𝑠𝑡 𝑜𝑓 𝑔𝑜𝑜𝑑 𝑠𝑜𝑙𝑑 (a) possible increase in medication errors due to elimination
𝑒𝑣𝑒𝑟𝑎𝑔𝑒 𝑜𝑓 𝑏𝑒𝑔𝑖𝑛𝑛𝑖𝑛𝑔 & 𝑒𝑛𝑑𝑖𝑛𝑔 𝑖𝑛𝑣𝑒𝑛𝑡𝑜𝑟𝑦 order review
(b) increased drug inventory on the pavilion
-Low turnover causes:
(c) greater opportunity for pilferage
1. duplication of stocks (d) increased hazards associated with drug deterioration
2. large purchases of slow moving items (e) possible lack of proper storage facilities on the ward
3. dead inventory (f) Greater In Loads Are Made Upon The Nurses Time
-High turnover causes: 2. Individual Prescription Order System  used predominantly in
1. small volume purchasing small hospitals where a
-Satisfactory turnover rate: 4 times a year pharmacist is not on the
premises all the time
Dispensing Advantages:
-In-patient Dispensing (a) reduced manpower requirements
(b) individualized service
1. Use of charge plate  use of a plastic or metal card prepared (c) all medications directly reviewed by the pharmacists
on patient’s admission (d) provides interaction of pharmacist, doctor, nurse & patient
2. Envelope system  used to dispense drugs to the nursing (e) provides closer control of inventory
station & at the same time is also used as Disadvantages:
(a) possible delay in obtaining required medication
a charge ticket (b) increase in cost to the patient
3. Drug basket method  used by a hospital for stocking non- 3. Combination of 1 & 2  use the individual drug order system as
charge floor stocks drugs & related the primary means of dispensing but also
products on the nursing station utilize a limited floor stock;
4. Mobile dispensing unit  utilizes a specially constructed  most commonly used, incorporates unit-
stainless steel truck dose dispensing as well.
5. Mechanical Dispensing  Ex: Brewer System
4. Unit Dose Dispensing  the pharmacist prepares every dose of NCCMERP: “any preventable even that may cause or lead to
medication ready for administration inappropriate medication use or patient harm while the
Advantages: medication is under the control of the health care
(a) improved pharmaceutical services 24 hours a day & patients professional patient or consumer”
are charged only those doses which are administered to National Coordinating Council for Medication Error Reporting & Prevention
them
(b) all doses are prepared in the pharmacy giving nurses more ASHP terms:
time for direct patient care Potential Error  is a mistake in prescribing, dispensing or planned
(c) allows checking or interpreting of the doctor’s original order medication administration that is detected &
thus reducing medication error corrected through intervention before actual
(d) eliminates excessive duplication of orders & paper works at
the nursing station & pharmacy medication administration
(e) eliminates credit Prescribing Error  incorrect selection of dose, dosage form,
(f) IV preparation & reconstitution done at the pharmacy quantity, route of administration or instruction
(g) more efficient utilization of professional & non-professional for use
personnel
(h) reduced revenue loss
 illegible prescription
(i) conserves space in nursing units by eliminating bulky floor Omission Error  failure to administer an ordered dose before next
stocks schedule dose
(j) eliminates pilferage & drug waste Wrong Time Error  administration of medication outside the
(k) extend pharmacy control & coverage throughout the hospital
interval
(l) improved communication of medication orders & delivery
systems Unauthorized Drug Error  administration of medicine not
(m) ward work as drug consultants & help provide the team authorized by legitimate prescriber
effort needed for better patient care Improper Dose Error  administration of a dose greater or less than
Major Forms of Unit Dose System: the ordered amount
(1) Centralized  most common & probably the most cost- Wrong Dosage-Form Error  administration of different dosage
efficient form
orders are interpreted & almost all drug doses
are picked & placed in the patient drawers of Wrong Drug Preparation Error  drug incorrectly formulated or
the medication carts in a central pharmacy manipulated
(2) Decentralized  have one or more satellite pharmacies Wrong Administration Technique Error  inappropriate procedure
scattered throughout the hospital form Deteriorated Drug Error  administration of expired drugs
which most of the single unit doses are
Monitoring Error  failure to review the prescribed regimen &
distributed
routine packaging of medication is usually assess patient response
carried out Compliance Error  inappropriate patient behaviour
complex drug delivery control other medication error  error that does not fall into above
(3)Systems Combining 1&2  some distribution activities are categories
performed in the patient-care
areas while the rest are Categories Level
performed centrally (NCC MERP) (ASHP)
(4) Partial  some unit dose systems are only partially No Error Occurred (Potential Error) A 0
Error did not reach the patient B
complete due to special circumstances of
Reach the patient but no harm C 1
certain hospitals 2 -(no change in
Drugs for the Emergency Box Reach the patient w/ harm vital signs)
D
Aminophylline (above pH 8) Mannitol Injection (required monitor –vital signs) 3 -(w/ a change
in vital signs)
Amphetamine Nalorphine HCl
Temporary Harm E
Amyl nitrite inhalation Neostigmine methylsulfate Hospitalization, additional drug therapy
Atropine Sulfate Norepinephrine Injection F 4
(treatment w/ another drug)
Caffeine sodium benzoate Pentobarbital Permanent Harm G 5
Calcium Gluconate Pentylenetetrazol injection Patient requiring life saving intervention H
Death (Fatal Error) I 6
Chloroprophenpyrimadine Phenobarbital
maleate
Minimum Standards for Pharmacies as Provided by ASHP:
Digoxin Phenylephrine -Leadership & Practice Management
Diphenylhydantoin sodium Phytonadione injection -Research
Epinephrine HCl Picrotoxin injection -Drug Information
-Optical Medical Therapy
Heparin Procaine Amide -Medication Distribution
Hydrocortisone Protamine Sulfate -Facilities Equipment & information resources
Isoproterenol Saline Injection
Magnesium sulphate Sodium molar lactate solution Adverse Drug Events:
injection (A) Patient Factors
Metaraminol bitartrate Water for Injection Adverse Drug Reactions
Patient’s Reactions to the Drug
Unit Dose  administered to a specified patient at one time (B)Drug Factors
Unit Dose Package  contains one discrete pharmaceutical Drug-Drug Interactions
dosage form Drug-Food Interactions
Unit Dose Drugs  refers to drugs stocked on the nursing Drug-Disease Interactions
station at all times & are billed to patient Other Incompatibilities
after administration
Patient Prescription System  wherein all drugs are retained in the Drug Interactions  one drug are altered by the effects of another
pharmacy until the order is received, & then a Pharmacodynamic Interactions  one drug alter the effect of another
multiple dose supply is dispensed to the nursing by acting at the same site of action
unit labelled for use by a specific patient Pharmacokinetic Interactions  alters ADME of another drug
Therapeutic Failure  suboptimal response to drug therapy
D. Medication Errors
E. Compounding
1. IV Fluids & Admixtures 2. Total Parenteral Nutrition (TPN)
IV Fluids  functions as a means for fluid replacement, electrolyte  IV administration of calories, nitrogen & other nutrients in
balance restoration & supplementary nutrition, & as sufficient quantities to achieve tissue synthesis & growth
through blood vessels
vehicles for administration of other drug substances & in
has been designed to serve as a nutritional infusion providing
TPN essential amino acids, carbohydrates, and electrolytes for
Large Volume Parenterals: 100-1000mL patients incapable of ingesting, digesting, or absorbing food
Small Volume Parenterals: 25-50mL substances given by mouth.
a. Colloid Solution  contain large proteins or similarly sized originally, the term Hyperalimentation was used to describe the
procedure
molecules (macromolecules)
 high calorie, low volume  hypertonic
 increase intravascular volume (plasma amount of constituents, vary based on patients needs
expander) Dudrick developed the technique for administering fluids for PN
 short term use, may dehydrate cell by way of the subclavian vein into the superior vena
 Examples: Plasma Protein Fraction cava where the solution is diluted rapidly by the large
volume of blood available, thus minimizing the
-(for bleeding patient) hypertonicity
Albumin PN is indicated for patients who are unable to ingest food due
Dextran to carcinoma or extensive burns & patients who refuse to
Hetastarch eat, as in the case of depressed geriatrics or young
b. Crystalloid Solution  contain electrolytes patients suffering form anorexia nervosa & surgical patients
who should not be fed orally
mainstay IV therapy Normal Caloric Requirement: 2500 cal/day for adults
*PNSS  plain Normal Saline Solution BEE (Basal Energy Expenditure)
isotonic, 0.9% NaCl about 300mOsm/L -Harris-Benedict Equation
to replace water & sodium Indications:
-patient cannot obtained nutrition by oral means
*D5W  Dextrose 5% in Distilled Water for Injection -severely malnourished
isotonic about 300mOsm/L -critical illness that precludes oral or enteral nutrition
 becomes hypotonic upon infusion, due to NPO =nil per os (“nothing orally”)
the metabolism of glucose -unavailable or malfunctioning gastrointestinal tract
-renal & hepatic failure
caloric agent -burn patients
*D5NSS  Dextrose 5% in Normal Saline Solution daily IV Electrolyte Requirements:
hypertonic  about 600mOsm/L -Na 1-2 mmol/L
becomes isotonic upon infusion, due to -K 1-2 mmol/L
-Cl 1-2 mmol/L
the metabolism of dextrose
-Mg 0.1-0.2 mmol/L
 not very damaging to the cells -Ca 0.1-0.15 mmol/L
 caloric agent -PO4 0.5-0.7 mmol/L
*D2.5O0.45NSS  isotonic  hypotonic TPN routes:
 caloric agent Central Peripheral
Access Large Vein Peripheral Vein
*PRS  Plain Ringers Solution
SVC= Superior Vena
hypotonic Cava through the
Na, K, Ca, Cl subclavian vein
used to keep veins open for infusion Dilution Rapidly Slow
Cellular Damage Less Higher (painful)
*PLRS  Plain Lactated Ringers Solution
Catherter Sepsis High Low
 Ringer’s Solution + Na Lactate Catheter Occlusion High Low
 approximates extracellular fluid Dextrose >10% <10%
 alkalinizing effect Concentration (isotonic,
Lactate  Bicarbonate near isotonic
Formulation of TPN:
c. IV Admixtures  when one or more sterile products are added
1. Protein  source of amino acid
to an IV fluid for administration 2. Carbohydrates  provide energy
 it is prepared w/ aseptic technique or 3. Lipid  source of essential fatty acids
environmental provided by laminar flowhood, 4. Electrolytes  for proper enzymatic & energy conserving or expending
in which the air is filtered through HEPA (high reactions within the body
efficiency particulate air) filter (Examples: Sodium, Potassium, Magnesium, Calcium,
Chloride, Phsphate)
HEPA filter remove 99.97% of all particles 5. Trace Elements  Examples: Zinc, Copper, Selenium, Chromium,
larger than 0.3 m Iron, Manganese, Cobalt, Molybdenum
 the flow of air may be in either a horizontal or 6. Vitamins  for long-term therapy
vertical pattern 7. Fluids
 the best way to determine the proper Container: Silicone based bags, superseded by PVC
functioning of a HEPA filter is to use the & ethylvinyl acetate
dioctylphthalate (DOP) test using the vapor at Storage & Packaging: Stored at 2-6C, not allowed to be stored at room
room temperature temperature for periods in excess of 12-24 hours required for
expiry date within 24 hours unless the solution administration. It is packaged in polystyrene containers
is known to be less stable chemically (earlier  Enteral Nutrition  method of providing support via tubes inserted into
expiry date) the stomach or small intestines
40 meq
Ex: KCl drip = The WHO-recommended formula for oral rehydration preparation
100 mL NSS replaced sodium bicarbonate w/ Trisodium Citrate Dihydrate
=IV infusion  Venoclysis
Direct IV Injection  small volumes of drugs are injected into F. Marketing
the vein over a short period of time 4 P’s of Marketing: Price
Volume Control Sets  unit consist of calibrated, plastic, fluid Place
chamber Product
Piggy back Administration  method of intravenous Promotion
administration by which solution
Sources of Profit of a Hospital
form two containers flow into the
patients’ vein through a common -Patient
tubing & a common injection site -Government
(venipuncture) -Hospital Insurance
 most commonly associated w/ -Voluntary Contribution
Intermittent Therapy
Profit Margin  amount above the break even cost of providing a
Standard Dosing Schedules:
product or service, necessary to provide for
TID  9am  1pm  5pm
replacing & upgrading of hospital equipment &
BID  10am 10pm
facilities
QID  9am  3pm  9pm  3am
Revenue Deduction percentage of third party allowances, bad
debts which reduces the actual revenue
Seven Basic Nutrients for Intravenous Inlets: (TPN)
received form charges
Macronutrients: Carbohydrate (Dextrose)
Costs:
Protein (for tissue synthesis)
Direct Personnel Costs  salaries for personnel
Fat
Direct Supply Costs  for supplies like syringe, vials, needles, etc
Micronutrients: Electrolyte
Fixed Overhead Costs  management, supervision, clerical cost
Vitamins
office supplies, equipment depreciation
Trace Elements
Pricing Methods:
Sterile water for Injection
Dispensing Fee Method  most common
 adding a fixed fee (dispensing fee) to
Daily Reference Values:
the acquisition cost
For energy producing nutrients (% daily value)
Percentage Mark Up Method  based on the cost of the
-Total fat  20-35% of calories product
-Saturated Fat  <10% of calories  cost mark up
-Carbohydrate  45-65% of calories  assumes that the holding cost
-Protein  10-35% of calories for a more costly product in
-Fiber  11.5g of fiber per 1000 calories higher
Quantities of Nutrients (considered the upper limit of Per diem Method  cost are expressed as prices per number of
maintenance of good health) days of the patients hospital stay
-Total fat  <65g Special Methods
-Saturated Fat  <20g
-Cholesterol  <300mg
-Sodium  <2800mg Procurement Methods for Drugs:
(person w/ hypertension: 1. Open Bid  aka Open Tender
<1500mg)  the group sets budget & suppliers come to bidding
2. Close Bid  aka Restrictive/Selective Tender
Free Foods: (per serving)  supplier selected upon prequalification
Calorie Free Fewer than 5 calories 3. Direct Procurement  most expensive
Sugar Free <0.5g 4. Negotiated  competitive negotiation
Fat Free <0.5g
Sodium Free <5mg Procurement  process of obtaining dugs
Cholesterol Free <2mg of cholesterol &
2 g of saturated fat
Gantt Chart  a visual display technique that can be used as a
Low Foods: (per serving)
scheduling tool for the entire planning process
Low Calorie 40 calories
 can be modified to show activities, persons
Low Sodium 140mg of sodium
responsible, & the time schedule in graphic
Very Low Sodium 35 mg of sodium
Low Fat 3g of fat
Fixed Capital  corresponds to the land, building, fixtures, &
Low Saturated Fat 1g of fat equipment needed to set up the pharmacy
Low Cholesterol 20mg of cholesterol & Working Capital  corresponds to the active funds that are
2g of saturated fat invested in the merchandise cycle covering
insurance, payments, taxes.

Tube Feeding Complications: Product Research  involves competitive studies, testing


Mechanical: Gastrointestinal: products currently in market & studies
-aspiration pneumonia -cramping on packaging
-mucosal erosion -diarrhea Test Marketing  small scale & done to determine product
-tube lumen obstruction -distention acceptability
-tube displacement -vomiting
-nasopharyngeal irritation
Metabolic:
-electrolyte imbalance
-fluid overload
-glucose intolerance
-hypertonic dehydration
IV. Bioethics
Bioethical Principles:
1. Autonomy  individuals’ liberty of choice, action & thought
 should not be interfered w/
 right to make decisions, to choose procedures that
he/she wants
 in conflict w/ medical paternalism = health care
professionals know best
 obligation to respect patients as individuals & to honor
their preferences in medical care
2. Informed Consent  involves autonomy
 informed of all benefits & risk of procedures
informal: Counselling
 formal: Clinical Trials Reliability  the extent to which a technique consistently measures
 elements: whatever it measures regardless of the investigator or
-disclosure  provide all pertinent the situation
-understanding  full understanding by the Validity  the extent to which a technique measures what it is
patient intended to measure
-voluntariness  free from coercion
-competence  patients are autonomous &
can make decision Primary Care  the provision of integrated, accessible health-care
-consent  final legal & moral criterion services by clinicians who are accountable for
3. Confidentiality  also involves autonomy addressing a large majority of personal health-care
 withholding private information about the patient needs developing a sustained partnership w/ the
from others unless the patient gives permission to patient, & practicing in the context of family &
release community
 no need to be requested
 may be breached if the patient is a threat to Disease management  an evaluative approach to health-care
him/himself or to others delivery that attempts to improve outcomes
 also in conflict with medical paternalism for patients w/ a specific disease while
4. Beneficence & Non-maleficence optimizing the overall use of health-care
Beneficence  doing good resources
 ethical responsibility to act in the patient’s best
interest Case Management  a process by which an experienced professional
 patient autonomy may conflict with beneficence. If works w/ patients, providers, & insurers to
the patient makes an informed decision, ultimately coordinate all services deemed necessary to
the patient has the right to decide provide the patient w/ medically appropriate
Non-maleficence  doing no harm (Primum non nocere) health care
 However, if the benefits of an intervention
outweigh the risks, a patient may make an
informed decision to proceed
5. Fidelity  loyalty bond between the patient & professional
 act in the best interest of the patient]
must be the same with a regular customer as with an
occasional customer
 forms: Covenantal  intimate & spiritual commitment
(marriage clegy)
Contractual  limited to a binding agreement
6. Veracity  honesty
7. Distributed Justice  equal distribution of benefits & risk among the
members of society
 involves the health care delivery system
pay patients may be given a higher quality of care
V. Clinical Laboratory Tests
A. Hematology  CBC = Complete Blood Count
Formed RBC
elements WBC
Blood (solid) Platelets
Plasma Proteins
(liquid) Serum
1. Red Blood Cells (Erythrocytes)
principal means of oxygen delivery to the body
3 2. White Blood Cells (Leukocytes)
 M: 4.3 -5.9 M/mm  testosterone   hematopoeisis
 cells of the immune system
RBC production 3
3  no. of WBCs found in a mm of whole blood:
F: 3.5-5M/mm 3
4000-11,000 WBC/mm
 RBC = anemia
 : inflammation, infection, (leukocytosis)
a. Hemoglobin (Hgb) : heme  porphin ring
 : bone marrow depression (leukopenia)
globin  protein
HIV  TH cell count
Fe  containing oxygen transparent protein
-Diffrential WBC Count: N > L > M > E > B
M: 13-18 mg/dL
-Bands  immature neutophils
F: 12-16 mg/dL
Hgb: IDA (Iron Deficiency Anemia)  blood loss -Segs  mature, polymorphonuclear cells (PMNs)
b. Hematocrit  percentage volume of blood occupied by RBC *Neutrophils   bacterial, acute infection, inflammation
 thickness of the blood *Lymphocytes  viral, chronic infection, inflammation
M: 42-52% *Monocytes  inflammation, TB, fungi
F: 37-47% *Eosinophils  allergies, parasitic
Polycythemia vera *Basophils  rarely increased
(RBC production in the bone marrow)
Dehydration: 3. Platelets (Thrombocytes)
Vit B9 & Vit B12 Deficiency  Megaloblastic  smallest formed elements
Anemia  responsible for initiating hemostasis
(RBC size)  form platelet plug, cytokine, & mediators
IDA (Microcytic Anemia) = RBC size promote hemostasis
Overhydration  involved in blood clotting
Blood loss  NV: 150,000 – 300,000/mm3
c. Mean Cell Hemoglobin (MCH) Moderate thrombocytopenia: <100,000
average hemoglobin content/ RBC : 26-34 pg/cell Severe thrombocytopenia: <50,000 (bleeding)
 Hyperchromic: >34
Hypochromic: <26 ;  hypochromia (IDA/ hypochromic
anemia) B. Electrolytes
d. Mean Cell Hemoglobin Concentration (MCHC) 1. Sodium 135-145 mmol/L Major extracellular Cation
 average haemoglobin concentration in the RBC: 2. Calcium 2.2-2.6 mmol/L
31-37 mg/dL (31-37%) 3. Potassium 3.5-5 mmol/L Major Intracellular Cation
 Hyperchromic: >37 4. Magnesium 1.6-2.4 mmol/L
 Hypochromic: <31 5. Phosphate 0.8-1.4 mmol/L Major Intracellular Anion
e. Mean Cell Volume (MCV) 6. Chloride 102-109 mmol/L Major Intracellular Anion
 average volume of the individual RBCs: 80-100
<80 –microcytic: Iron defienciency anemia
>100 – macrocytic: Vit. B9 & B12 deficiencies
(megaloblastic anemia
f. RBC Distribution Width (RDW)
reflects RBC size distribution
 RDW = RBC size is variable
 Normal: <14.5 -15%
g. Erythrocyte Sedimentation Rate (ESR)
measure the rate of RBC settiling of whole,
uncoagulated blood over time
 inflammation, infection, tissue necrosis or infarction,
malignancy, rheumatoid collagen diseases
M: 1-30 mm/hr
F: 1-13 mm/hr
h. Reticulocytes  immature RBC that contains residual RNA &
protoporphyrin but no nucleus
 NV: 0.1-2.4%
 >2.4% (): lack of maturation
recovery from hemolyric anemia –
Comb’s Test (Methyldopa)
(bone marrow is responsive) –still
produces RBC
<0.1% (): aplastic anemia; polychromasia
(bone marrow is not able to produce
RBC)
C. Cardiac Test F. Hepatobiliary Test
1. Creatinine Kinase (CK) 1. Aspartate Amino Transferase (AST)
enzyme in tissues that cleave phosphocreatinine previously called as SGOT (Serum Glutamate Oxalo-
subunit: B – subunit = brain type acetate Transminase)
M –subunit = muscle type  intracellular enzyme found in the heart, liver &
Types: CK-BB: Brain skeletal muscles
CK-MM: Skeletal Muscles NV: 12-38V/L
CK-MB: Cardiac Muscles increase(): cellular injury in MI, liver damage,
NV: M: 60-400 V/L rhabdomyolysis
F: 40-150 V/L 2. Alanine Aminotransferase (ALT)
increase: previously called as SGPT (Serum Glutamate Pyruvate
CK-BB = cerebrovascular accidents (CVA) or strokes Transaminase)
CK-NN= rhabdomyolysis  statins intracellular enzyme, found specifically in liver cells
CK-MB= myocardial infarction (hepatocytes)
2. Lactate Dehydrogenase (LDH) NV: 7-41 V/L
 intracellular enzyme increase(): Hepatocellular damage
 diagnosis of MI, hepatic & lung disease 3. Bilirubin
 NV: 110-210 V/L
 Types:
LDH1 & LDH2 = heart
LDH3 = lungs
LDH4 & LDH5 = liver & skeletal muscles
3. Cardiac Troponin (CTn)
 gold standard in the diagnosis of myocardial infarction
 detected 6-112 hours after MI, peaks after 24 hours
gradually decreasing over the following weeks
Types:
cTnT = binds to tropomyosin, cardiac & skeletal muscle
a. Total Bilirubin  NV: 0.3-1.3 mg/dL
cTnI = binds to active site, cardiac muscle
 increase (): Liver & Gall Bladder Disease
cTnC = ninds to calcium, cardiac & skeletal muscle
b. Direct (Conjugated) Bilirubin  water soluble
4. AST or SGOT
 NV: 0.1-0.4 mg/dL
 increase (): (>20% total
D. Blood Test for Coagulation: bilirubin)
1. Prothrombin Time (PT)  extrinsic pathway  biliary
 monitor warfarin therapy obstruction
2. International Normalized Ratio (INR) c. Indirect (Unconjugate) Bilirubin  water-insoluble
3. Activated Partial Thromboplastin Time (aPTT)  intrinsic pathway  NV: 0.2-0.9 mg/dL
Monitor heparin therapy  increase (): (>90% total
bilirubin)
hemolysis
4. Albumin  main plasma protein
E. Spirometry:  produced in the liver
1. Forced Vital Capacity (FVC)  “true liver functions test”
 volume of liquid of exhaled air after full inspiration & forced  NV: 4.1-5.3 g/dL (serum)
expiration  decrease (): liver disease, albuminuria
decrease (): restrictive lung diseases 5. Alkaline Phosphate (ALP)
(intestinal lung disease – pneumoconiosis)  enzyme found in bone biliary tract & placenta
2. Forced Expiratory Volume (FEV)  NV: 33.96 V/L
volume of air expired forcefully in 1 second  increase (): biliary obstruction
𝐹𝐸𝑉 6. Gamma Glutanyl Transferase (GGT)
 > 80%
𝐹𝑉𝐶  present in the kidneys, liver, pancreas & intestines
decrease (): (<70%)  obstructive lung diseases
 activity in the serum is primarily from the liver
-asthma
 NV: 9-60 V/L
-COPD
 increase ():liver disease, regardless of cause (non-specific)
-hepatocellular
-hepatobiliary
-alcoholic liver disease

Agents Requiring dosage adjustment or which


may even have to be avoided in Patients w/
Hepatic Impairment include:
-Erythromyscin
-Clindamycin
-Metronidazole.
G. Pancreatic Enzymes J. Thyroid Function Test
1. Amylase (AMY)
enzyme for carbohydrate metabolism found in the
pancreas
AMYs AMYp
salivary amylase pancreatic amylase
 amylase  amylase
ptyalin amylopsin
NV: 28-100 V/L
increase (): acute pancreatitis, elevated before 3-4th day
2. Lipase (LPS)
 enzyme for lipid metabolism found in the pancreas
NV: <38V/L
increase (): acute pncreatitis, elevated late after the peak
of amylase

H. Blood Sugar Test


1. Fasting Blood Sugar (FBS)
8-10 hours
normal: 75-110 mg/dL
impaired fasting glucose: 100-125 mg/dL (pre-diabetes)
Diabete Mellitus: >200mg/dL on two or more sample
increase (): DM, insulin resistance
2. Postprandial Blood Sugar = 75-120 mg/dL
 2 hors after a meal
3. Oral Glucose Tolerance Test (OGTT) = <140mg/dL
2 hours after a 75g oral glucose load 1. Free Thyroid Hormones
increase (): insulin resistance not bound to TBG
-impaired glucose tolerance fT4: 0.8-1.7 ng/dL
4. Random Blood Sugar (RBS) fT3: 2.4-4.2 ng/dL
NV: <200 mg/dL increase: Hyperthyroidism
5. Glycosylated Hemoglobin (HbA1C) decrease: Hypothyroidism
amount of HbA that has been glucosylated 2. Total Thyroid Hormones
reflects the average blood sugar over the preceding 120 days free+bound
(3-4 months) T4= 5.4-11.7 mcg/dL
NV: 4-6%
T3=77-135 ng/dL
Prediabetes: 5.7-6.4%
3. Thyrotropin (TSH)
Diabetes: >6.5%
 preferred method of screening thyroid dysfunction
monitor glycemic controls
NV: 0.4-5.5 mV/mL
increase: Hypothyroidism
I. Lipid Profile
decrease: Hyperthyroidism
1. Total Cholesterol (TC)
4. Thyroglobulin (Tgb)
Normal: 75-169 mg/dL (20 year old or younger)
protein from which thyroid hormones are produced
100-199 mg/dL (21 year old or older)
NV: 0.5-5.3 ng/mL
Desirable: TC<200 mg/dL
 increase: Thyroid Malignances
Borderline High: TC = 200-249 mg/dL
5. Thyroid-Binding Globulin TBG
High: TC >240 mg/dL
protein that binds circulating thyroid hormones
2. High Density Lipoprotein (HDL)
NV: 1-3 mg/dL
NV >40 mg/dL
6. Anti-Thyroid Antibody
good cholesterol
NV: <0.21 V/mL
  protein content
increase: Autoimmune Thyroiditis (Hashimotos Thyroiditis)
reverse cholesterol transport (tissue  liver)
3. Low-Density Lipoprotein (LDL)
”bad” cholesterol
  protein content
 increase cholesterol deposition to tissues
 target for high-risk patients <70mg/dL K. Arterial Blood Gases (ABG)
Normal <100 mg/dL Ranges Increased Decreased
Near Optimal: 100-129 mg/dL
1 pH 7.35-7.45 Alkalemia Acidemia
 Borderline High: 130-169 mg/dL
2 pCO3 35-45 mmHg Respiratory Acidosis Respiratory Alkalosis
High: 160-189 mg/dL
3 pO2 80 mmHg Normal Hypoxemia
Very High: 190 mg/dL
Approximated by Friedwald Equation: 4 HCO3 22.26 meq/L Metabolic Alkalosis Metabolic Acidosis
TG
𝐿𝐷𝐿 = 𝑇𝐶𝐻𝐷𝐿
5
not usable if TG >400mg/dL
4. Triglycerides NV: 30-200 mg/dL
Cholesterol  naturally occurring alcohol
precursor molecule for the synthesis of bile acids &
steroids hormone
used by the body to from cell membranes.
L. Renal Function Tests
1. Blood Urea Nitrogen (BUN)
measure of the amount of nitrogen in the blood as urea
 Urea = by product of protein metabolism in the liver
= removed from the blood by the kidneys
 8.18 mg/dL
increase: renal impairment muscle wasting high protein
diet
decrease: hepatic impairment protein malnutrition
2. Creatinine (SCr)
breakdown product of creatinine phosphate in the
muscle
freely filtered in the nephron/glomerulus & is not
absorbed, secreted, synthesized or metabolized by the
kidney
0.6-1.2 mg/dL
increase: renal impairment
decrease: decreased muscle mass, protein malnutrition
3. Creatinine Clearance (CrCl)
volume of plasma cleared of creatinine per unit time
[mL/min]
approximate GFR, since creatinine is filtered but not
significantly secreted or reabsorbed
alternative: Inulin Clearance (need insulin to e infused)
 determined by measuring urine creatinine & SCr
calculated using the Cockroff-Gault Equation:
140 − 𝐴 𝐵
𝐶𝑟𝐶𝑙 = ×𝑓
72𝐶
F=M-1, F=0.85
A=age -(years)
B=body weight -(kg)
C=creatinine (serum) -(mg/dL)
 normally = 70-135 mL/min
 if the patient has severe renal impairment
use the Jeliffe Equation
4. Urinalysis
COlor: Straw-colored (yellow)
SpGr: 1.003-1.040
pH:4.6-8
Na:10-40 meq/L
K: <8meq/L
Cl: <8 meq/L
protein: 1-5 mg/dL
protein=proteinuria “frothy urine”
osmolality: 8 300 mOsm/L
Well hydrated patient dehydrated patient
Normal Output: 1.5L/d or 1mL/Kg/d
urine output: Polyuria
urine output: Oliguria
Almost no urine output: Anuria
normally sterile: (+) bacteria = bactruria
casts, cells, crystals may indicate UTI or renal disease
5. Uric Acid
breakdown product of purine catabolism in humans
guanine & adenine
produced mostly in the liver & intestinal mucosa
excreted by the kidneys & GI tract
 weak acid
ionized: urates  serum & synovial fluid
(pH 7.4)
pH= precipitate as monosodium urate crystals
 M: 2.5 – 8 mg/dL
F: 1.9 -7.5 mg/dL
 increase: Gout, Renal Failure, Diuretics (Thiazides),
Barbiturates, Aspirin (2g/d),
high protein diet, high alcohol
intake
 decrease: Uricosuric Agents (Probenecid)
urinary excretion of uric acid
allopurinol  inhibits xanthine oxidase  aspirin (4g/d)
VI. Therapeutics 6. Drugs to Avoid in Pregnancy
A. Drugs in Pregnancy & Lactation Effects
1. Pharmacokinetic Changes Sulfonamides Kernicterus (bilirubin in the CNS)
vomiting Aminoglycosides Ototoxicity, damage to CN VIII-
gastric emptying vestibulocochelar
GI motility Fluoroquinolones Abnormal cartilage development
absorption Tetracyclines Discoloured teeth
 Ribavirin Teratogenic
volume of DIstribution Griseofulvin Teratogenic
Plasma Proteins
Chloramphenicol Gray Baby Syndrome
Metabolism -characteristic gray color
excretion -abdominal distention
2. Placental Transfer -progressive shock
Placenta cellular membrane that separates maternal & fetal -hypotension
-respiratory distress
blood
Live Vaccines Possible risk of vertical transmission
most drugs cross the placenta by passive diffusion
(varicella, MMR,
placental enzymes: Endogenous Steroid Metabolism
yellow fever)
Drug Metabolism
Thalidomide Polyneuritis
3. Stage of Development
Mental Retardation
Fertilization

Implantation 0.17 days –“All or None” response
Limb Defects
-Phocomelia (Short)
Embryonic Stage/ Organogenesis (organ formation) -Amelia (None)
(17-57 days) – teratogenesis – malformation  teratogens -Meromelia (Fused)
teratogens =substance that can cause Valproic
birth deformities
Warfarin
=”teratos” (monster)
Ace Inhibitors Renal Dysgenesis
Fetogenic Stage  Organ Maturation
Retinoids
Delivery & Birth
Phenytions Fetal Hydantoin Syndrome
Lithium Ebstein Anomaly (Heart)
4. US FDA Pregnancy Categories
NSAIDs Premature closing of PDA (Patent ductus
Category HumansAnimalsExamples % arteriosus)
No Fetal Risk () () Prenatal Vitamins 1 PGE (maintains he patency of ductus arteiosus
A factors Thyroid Hormone Diethylstilbestrol Vaginal adenocarcinoma, upon adolescence
demonstrated
Lack of Human (N) () Penicilline 71 6. Drugs to Relative Safety in Pregnancy
Studies, Acetaminophem Bacterial Infection -Penicillins -Macrolides
B
maybe harm to (N) (+) Insulin, Nystatin -Cephalosporins -Metronidazole
animals TB -Rifampicin
Lack of Human (N) (+) Furosemide, 25 -Ethambutol
studies, Methyldopa, Aspirin, -Isoniazid
C
maybe harmful to (N) (N) Chlorpromazine Cough & Colds -Chlorphenamine -Gaifenesin
animals -Diphenhydarmine -Dextromethorphan
Known Human risk, (+) Diazepam, 1 Nausea & Vomiting -Pyridoxine (Vit B6)
maybe used if Progestin, -Doxylamine
D benefits outweigh Tetracyclines, Pain -Paracetamol -Pethidine
the risks Pethidine, -Ibuprofen -Lidocaine
Corticosteroids -Naproxen
Proven Fetal Risk, (+) Isotretinoin, Diarrhea -Kaolin-pectin
contraindicated in Thalidomide, -Loperamide
X
pregnancy Diethylstilbestrol, Asthma -Theophyline -Steroids
CCPs -Salbutamol -LT modifiers
N Not Categorized Convulsions -Use anticonvulsnats w/ caution
(most are in Category D)
Pregnancy Risk Categories  listed by application of the US Food & Hypertension -Methyldopa -Labetalol
Drug Administration definitions to -Hydralazine -Nefidipine
available clinical data in ordered to -Sodium Nitroprusside
define a drug’s potential to cause Diabetes -Insulin, avoid Oral Hypoglycemic Agents (OHAs)
birth defects or fetal death Hyperthyroidsm -PTU
Anticoagulants -Heparin
PUD -Antacids
-H2 blockers

7. Drugs to Avoid in Lactation


Beta Blockers Fetal bradycardia
Bromocriptine -suppress lactation
-dopamine agonist
inhibitor of Prolactin
Methimazole -risk of Hypothyroidism
Metronidazole -gives milk an unpleasant taste
B. Drugs in Pediatrics D. Infectious Diseases
– new born: 0.28 days 1. UTI – Escherichia coli
– infant: 1 month-1 year 2. Sexually Transmitted Diseases
– child: 1 year-12 years Gonorrhea = Neisseria gonorrhoea
– adolescent: 12-16 years –drug of choice: Penicillin
1. Pharmacokinetic Changes Syphilis = Treponema pallidum
-Slower GIT –Stages: Primary: Chancre
Absorption -Faster IM Secondary: Maculopapular rash
-Faster percutaneous (thin skin) Tertiary: Gumma
- body fat Genetic Hepes (HSV-2 > HSV-1)
- Vd for Fat soluble drugs 3. Respiratory Tract Infections
Distribution –viruses, bacteria, mycoplasma
- Albumin
- binding of drugs –URTI = upper RTI
-less glucoronidation –LRTI = lower RTI
-sore sulfation –Mycoplasma pneumonia = walking Pneumonia
Chloramphenicol – metabolized by Patient is ambulatory
Glucoronidation asymptomatic
Metabolism –accumulation  Gray Baby Syndrome –Legionaires Disease – Legionella pneumophilia
-gray 4. Tuberculosis = Mycobacterium tuberculosis
- BP 5. Infectious Diarrhea
Paracetamol: Glucoronidation E. coli -Traveler’s Diarrhea
Sulfation (ETEC=Enterohepatic E. coli)
Excretion -GFR in neonates Staphylococcus aureus -food poisoning
Clostridium difficile -psudomembranous colitis
2. Classic Pediatric ADRs Vibrio cholerae -cholera – (+) rice watery stools
Aspirin -Reyes Syndrome Entamoeba histolytica -protozoans
Tetracylcine -permanent-discoloration of teeth Giardia lamblia -Giardiasis (+) steatorrhea
(do not give below 8 years) Shigella sp. -shigellosis
Fluroquinolones -damage to growing cartilage Salmonella typhi -typhoid fever
-do not give below 18 years Cryptococcus -immnocompromised
6. CNS Infection
–meningitis = meninges
–encephalitis = brain parenchyma
–Strep. pneumonia
Haemophilus influenzae
Neisseria meningitides
C. Drugs in Geriatrics 7. Infective Endocarditis
1. Pharmacokinetic Changes – heart valves
Absorption - absorption of Fe, Ca, Vitamin B1 – endocardial lining
- Vd for Fat soluble drugs 8. AIDS (Acquired Immunodeficiency Syndrome)
- Vd for water soluble drugs –retroviruses: (HIV –Human Immunodeficiency Virus)
Distribution
-fat (HTLV –Human T-Lymphocyte Virus)
-lean body mass +
– TH cells or CD4 cells
Metabolism - hepatic metabolism ( hepatic blood flow)
Excretion - renal excretion ( renal blood flow)

2. Pharmacodynamic Changes
–  sensitivity to CNS effects
–  incidence of postural hypotension
(orthostatic hypotension)
–  toxicity to NSAIDs
–  clotting factor synthesis
Antibacterials
Bactericidal Bacteriostatic
Aminoglycoside Protein synthesis inhibitors except
aminoglycosides
Cell wall synthesis Antimetabolites when given alone
inhibitors
Cell membrane
disrupting agents
Nucleic Acid synthesis
inhibitors

Cell Wall Synthesis Inhibitors


 Lactam Antibiotics Non-  Lactam
Penicllin Glycopeptides (Vancomycin)
Cephalosporins Polypeptides
Carbapenems Anti-mycobacterials
Monobactams (Aztreonam)
-lactamase inhibitors

Protein Synthesis Inhibitors


Buy AT 30, CEL at 50
Acting on the 30s Acting on the 50s
Aminoglycosides Chloramphenicol
Streptomycin  Macrolides
Kanamycin Erythromycin
Neomycin Clarithromycin
Tobramycin Azithromycin
Gentamicin Dirithromycin
Netilmicin Troleadromycin
Amikacin Telithromycin
Tetracyclines Roxithromycin
Tetracycline Lincosamides
Oxytetracycline Lincomycin
Methacycline Clindamycin
Demeclocycline Oxazolidinones
Doxycycline Linezolid
Minocycline  Streptogrannins
Chlortetracycline Quinopristin
Tigecycline Dalfopristin

Nucleic Acid Synthesis Inhibitors


Rifampicin inhibit DNA gyrase
Quinolones inhibit RNA gyrase

Antimycobacterials
DOTS (Direct Observed treatment-short course)
Phases: Initiation/intensive: 3-4 drugs (2 months)
HRZ or HRZE
Contunuation phase: 2 drugs (4months)
HR
SE
R Rifampicin -R  inh. RNA polymerase Discoloration
of Fluids
H Isoniazid -I  inh. Mycolid Acid Peripheral
neuropathy
Z Pyrazinamide -P  inh. Fatty Acid synthesis Hepatotoxic
E Ethambutol -E  inh. Arabinogalactan Optic neuritis
S Streptomycin -S  inh. Protein synthesis Ototoxic
E. Cardiovascular 5. Dysrrhythmias = abnormalities in cardiac rhythm
1. Atherosclerosis = narrowing of the arteries due to the presence of Supraventricular sinus =brady (slow)
lipid deposits (atheromes) =tacgy (fast)
 Ischemic Heart Disease atrial =Flutter atrium
 Cerebrovascular Accidents ventricular
2. Coronary Artery Disease = Ischemic Heart Disease =Fibrillation atrium w/
= inadequate Oxygen supply to the ventricles
myocardium
nodal =AV block
3. Myocardial Infarction = dead myocardium
SV Tachycardia
4. Heart Failure
Ventricular ectopic beats
Inotropes Unloaders
(+) : Digoxin Pre-load Diuretics tachycardia  Torsade de Pointes
Milrinone –PDE inh. (tructing of Points)
Aldosterone
Antagonists  Fibrillation
() : -blockers (w/ other drugs, After-load Vasodilators
prevent counter Acei, ARBs, ERP (Effective
sympathetic Aldosterone resting
activation) Antagonist period)
Class IA moderate binding 
Preload  refers to the force exerted on the ventricular muscle

Na Channel
Class IB mild binding 
at the end of diastole that determines the degree of Blockers
Class IC Marked binding No change
muscle fiber stretch
Class II Beta Blockers
 aka Ventricular End-diastolic Pressure
Class III Potassium Channel Blockers
 a key factor in contractibility because more these
Class IV Calcium Channel Blockers
muscles are stretched I the diastole, the more
powerfully they contract in systole.
Afterload  aka Intraventricular Systolic Pressure 6. Hypertension  primary: Idiopathic w/out underlying cause
 refers to the tension in ventricular muscles during  secondary: w/ underlying cause
contraction. It is sometimes used to describe the
amount of force needed in the right ventricle to Example: Pheochromcytoma: episodic headache,
overcome the pressure in the pulmonary artery sweating, and
 determined by the amount of force needed to tachycardia
overcome pressure in the aorta. Adrenal Medulla Tumor
Frank-Sterling mechanism  is a concept that works w/ the Secrete NE & E BP
premise that increased fiber According to the Seventh Report of the Joint National
dilation heightens the contractile Committee on Prevention, Detection, Evaluation, &
force, which then increases the Treatment of Blood Pressure, the Classification of Blood
energy released Pressure for Adults is as follows:
Blood Pressure Systolic Blood Diastolic Blood
Classification Pressure Pressure
(mmHg) (mmHg)
NYHA Classification Normal <120 <80
Class I (Mild) no limitation of physical activity Prehypertension 120139 8089
Class II (Mild) slight physical activity, ordinary Stage 1 Hypertention 140159 9099
activities fatigue, dyspnea Stage 2 Hypertension 160 100
Class III (Moderate) moderate physical activity, less than
ordinary  palpitation Routine Laboratory Tests for Hypertension Before
Class IV (Severe) cannot carry out physical activity, Initiating Therapy:
restpalpitaion -Electrocardiogram
-Blood Glucose & Hematocrit
The Following Table shows the classification developed by the New -Lipid Profile
York Association (NYHA) to quantify the functional limitations of -Urinalysis
Heart Failure (HF) patients: -Serum potassium
NYHA Functional Limitation -Creatinine / (GFR)
Class -Calcium
Class I Degree of effort necessary to elicit HF symptoms equals Optional Test:
those that would limit normal individuals -Urinary Albumin Excretion/
Class II Degree of effort necessary to elicit HF symptoms occurs Albumin/Creatinine Ratio
with ordinary exertion Stable or Classic Angina  can be induced by excretion, emotional
Class III Degree of effort necessary to elicit HF symptoms occurs stress or a heavy meal, & can be relieved by
with less-than-ordinary exertion rest, nitroglycerin, or both
Class IV Degree of effort necessary to elicit HF symptoms occurs  is characteristically due to fixed obstruction
while at rest in a coronary artery.
 usually builds to a peak, radiating to the jaw,
neck, shoulder & arms, & then subsides
without residual sensation
Prinzmetal’s Angina  precipitated by coronary artery spasm that
reduces blood flow, & usually occurs at rest
rather that with exertion or emotional stress
Angina decubitus  occurs in the recumbent position & Is not
specifically related to either rest or exertion
F. Pulmonary Disease G. Neurology
1. Restrictive Lung Diseases: FVC 1. Epilepsy
2. Obstructive Lung Diseases: FEC Epilepsy = disorder characterized by recurrent, stereotyped
FVC seizures.
Decreased Vital Capacity Seizure = paroxysmal disturbance of CNS function due to
Increased Residual Volume excessive neuronal discharge
Normal Total Lung Capacity Convulsion = seizure w/ motor component
a. Bronchial Asthma = reversible obstructive airway disease Simple = no loss of consciousness (LOC)
b. COPD = chronic obstructive pulmonary disease Complex = w/ LOC
= cough w/ sputum for most days of the week for 3 Generalized = both hemisphere
months/ year x 2 consecutive days 2. Parkinsonsm
= Primary Contributors of COPD: described by James Parkinson
Chronic bronchitis  “blue bloaters”  dopamine in the substantia nigra;  Acetylcholine
Difference of Chronic Bronchitis from Asthma: drug-induced parkinsonism = antipsychotics (dopamine
-Slower to develop & is non specific antagonist)
-Predominance of IL-8 treatment:
-Relative absence of IL-5 & eosinophils Levodopa + Carbidopa
-Predominance of type 1 helper (CD8) Tcells
 decarboxylase inhibitor
Emphysema  enlargement of air spaces distal to Metabolized into dopamine
the terminal bronchioles w/
Dopamine Agonist
destructive of walls
COMP inhibitor
 “pink puffers”
MAO-B-inhibitor
= Primary Initial intervention in the Mx of COPD:
COMT & MAO-B  are enzymes that degrades
Smoking Cessation
Dopamine
= Primary Pharmacologic Therapy:
3. Dementia
Beta Agonist
declining cognitive function
Anticholinergics
Alzheimer’s Disease  named after Alois Alzheimer
Methylxanthines
 Acetylcholine
 Theophylline
deposition of amylod plaques & tau proteins
Recommended Bronchodilator therapy for COPD
FEV1, %
Stage Treatment
Predicted
I >50 Beta 2 agonist PRN H. Nephrology
Combined Anticholinergic & Beta 2 1. Glomerulonephritis (GN)  inflammation of the filtering unit of the
II 35-49
agonist nephron (glomerulus)
Long acting B@ agonist &/or sustained chronic renal failure
III <35 release theophylline, consider oral ex: Post-streptococcal GN (after strep
glucocorticoids trial throat of strep skin infection)
2. Nephrotic Syndrome  protein leakage in the glomerulus
proteinuria
Quick Relief (PRN drugs) Controllers 3. Renal Failure
SABA (Short acting  2 agonist LABA (Long-acting  2 agonists Stages of Chronic Kidney Disease GFR (mL/mm)
–Salbutmol) Salmeterol) 1Kidney Damage, Normal or GFR  90
Anticholinergics (Ipratropium) mast cells stabilizers (Cromolyn) 2Kidney damage, Mild or GFR 6089
Short term Oral Steroids LT modifiers (Montelukast) 3Moderate GFR 3059
(Prednisone) Glucocorticoids:inhaled steroids
4Severe GFR 1529
Methylxanthines (Fluticasone)
5Kidney Failure (End-stage Renal Disease) < 15 (needs dialysis)
Classification of Asthma arranged according to increasing
Acute Renal Failure  commonly occurs in hospitalized patients
severity according to NIH Guidelines:
& has been reported to account for nearly
-Intermittent
two-thirds of all nephrology consultations.
-Mild Persistent
This incidence commonly caused by:
-Moderate Persistent
-Prerenal Azotemia
-Severe Persistent
-Postoperative Complications
-Nephrotoxin Exposure
Azotemia  the accumulation of
nitrogenous waste products
due to the abrupt decrease
in renal function due to
catabolism
Three Distinct Phases of ARF:
a. Oliguric Phase  progressive decrease in urine output & may
last from days to several weeks
Oliguria: Urine production of <400mL/day
Anuria: Urine Production of <50mLday
b. Diuretic Phase  increase urine production for over several
days
 signals the initial repair of the kidney insult
c. Recovery Phase
I. Rheumatology
1. Arthritis
a. Osteoarthrtis
 Degenerative Joint Disease c. Gouty Arthritis
 loss of circular cartilage ( cuchioning effects)   serum uric acid (hyperuricemia) & disposition of
 weight-bearing joint monosodium urate crustals in the synovial fluid
 osteophytes-body spurs (typhus)  needle-shaped
 nodules:  “pseudogout”  calcium phosphate
Herbende’s nodules  Distal interphalangeal jt.  great toe (podagra), knees, elbows
 (DIP jt)  acute onset: within-hours (greater during the night)
Bouchard’s nodules  Proximal Interophalangeal jt.  treatment:
 (PIP jt) Acute: Colchicine
onset: Months Chronic: Allopurinol, Uricosuric Agents
 minimal inflammation Febuxostat (antibody against xanthine
 Treatment: Analgesic oxidase)
 non pharmacological tx: Aerobic Exercise  to reduce risk, Maintain high fluid intake (2L/day)
Weight Loss Take 1 g of NaHCO3, 3-4 times a day
Physical Therapy
Patient must avoid: Prolonged Standing, Kneeling,
Squatting 2. Systematic Lupus Erythematus (SLE)
autoimmune disease
b. Rheumatoid Arthritis  caused by antibodies that attack genetic materials
autoimmune disease anti-nuclear antibody (ANA)
inflammation of the synovium (synovitis) anti-double-stranded DNA (Anti-ds DNA)
 synovial thickening, leading to pannus formation  caused by drugs (Drug-induced Lupus)
 loosening of tendon sheath & other pariarticular  ISoniazid
structures  Procainamide
 erosion of articular surfaces  Hydralazine
 (+) anti-histone antibody
manifestation: malar rash, discoid rash
”butterfly”
treatment: Steroids, NSAIDs

small peripheral joints symmetrically


rheumatoid nodules
*swan-neck deformity
*Boutonierre deformity
onset: week to months
 (+) rheumatoid fator
 RBC, ESR, CRP = C-related protein
  inflammation (acute phase reactants)
Anemia of
Chronic inflammation
treatment: DMARDs  Methotreaxate
 Gold Compounds
 Sulfasalzine
 Penicilamine
 Hydroxychloroquine
 Azathioprine
 Leflunamide  indicated as
monotherapy for
RA
J. Endocrinology Metabolism
1. Pituitary Disorder 4. Pancreatic Disorders
Anterior Posterior Endocrine Pancreas (“Islets of Langerhans”)
GH Oxytocin * -cell  glucagon * -cell  somastatin
Prolactin Vasopressin (ADH * -cell  insulin *F
TSH
ACTH DM Type 1 DM Type 2 DM Type 3
LH,FSH autoimmune  insulin sensitivity Gestational DM
a. Anterior Pituitary disease that =insulin resistance maturity-onset
Gigantism  GH before puberty (proportionate growth) attacks the -cells adult onset diabetes of the
Acromegaly  GH after puberty (disproportionate) (-cells; prev. NIDDM young (MODY)
Dwarfism   GH insulin) less prone to chromiun
Prolactinoma  Prolactin  secreting tumor of the anterior prev. Insulin Ketoacidosis deficiency
pituitary gland Dependent treatment: Cr = glucose
 hyperprolactinemia DM (IDDM) -Oral tolerance
b. Posterior Pituitary prone to Hypoglycemic factor
Diabetes Insipidus  ADH Ketoacidosis Agent (OHAs)
insipid urine, bland urine
Syndrome of Inapropriate ADH scretiob (SIADH) 5. Calcium metabolism
= ADH hormones:
=concentrated -Parathyroid Hormones (PTH)
-Calcitonin
2. Thyroid Disorder -Vitamin D = active form comes form the kidney
a. Hypothyroidism b. Hyperthyroidism a. Hyperparathyroidism = PTH
T3, T4, TSH T3, T4, TSH -Primary = PTH  Ca
cretinism =congenital Grave’s Disease -Secondary = CA  PTH chronic renal failure
mental retardation -goiter b. Hypothyroidism = PTH
myxedema -ophthalmopathy most commonly due to Thyroidectomy
accumulation of (exolphthalmus) removal of the thyroid
mucopolysaccharides -dermopathy gland
in the dermis layer of c. Mineralizing Disorders
the skin -Rickets  mineralization of growing bone (pedia)
dry, course hair thin hair -Osteomalacia  mineralization of fully-grown bone (adult)
bradycardia tachycardia d. Osteoporosis
cold intolerance heat intolerance bone resorption = bone formation
dry skin sweaty skin  bone density  DEXA scan
constipation diarrhea treatment: Biphosphates (Alendronate, Risendionate)
brittle nails soft nails SERMS = Selective Estrogen Receptor Modulators
menstruation menstruation (Raloxifene)

3. Adrenal Disorder 6. Lipoproteinemias


a. Cushing’s Syndrome =  glucocorticoids (Cortisol, Cortisone) a. Familial Hypercholesterolemia = LDL
endogenous = form a tumour b. Familial Hypertriglyceridemia = VLDL  TG
exogenous = steroid use c. Cmbined = LDL, VLDL, TG
maifestation: Cushioid Appearance
-moon facies
-buffalo hump
-thin skin
-HTN
-central obesity, pendulous abdomen
-violaceous striae
-osteoporosis
b. Aldosteronism =  mineralcorticoids (aldosterone)
K secretion,
= HTN, hypokalemia
 Na & H2O retention
c. Adrenal Virilism =  adrenal androgens
d. Addison’s Disease = primary Adrenal Insufficiency
=  adrenal hormones
= bronze skin
K. Gastroenterology L. Hematology
1. Gastroesophangeal Reflux Disease (GERD) 1. Anemias
reflux of stomach contents to the esophagus (“Heartburn”) a. Megaloblastic Anemia
acids  harmful to esophangeal mucosa deficiency in Vit B9 & B12
due to incomponent LES (Lower Esophangeal Sphincter) MCV, Hcl (Macrosystic Anemia)
-Treatment: Healesophangeal mucosa, fish tapeworm (Diphylllobotrium latum)
prevent recurrence b. Iron-Deficiency Anemia (IDA)
deficiency in Fe
2. Peptic Ulcer Disease (PUD) MCV, Hcl (microcystic)
cause: Helicobacter Pylori MCH, Hgb (hypochromic)
a. Gastritis  inflammation of the gastric mucosa & glands c. Anemia of Chronic Disease
b. Gastric Ulcer  ulcers in the gastric mucosa chronic inflammation & infection
c. Duodenal Ulcer  ulcers in the duodenal mucosa RBC (normocytic, normochromic anemia)
Gastric Ulcer Doudenal Ulcer d. Anemia of Kidney Disease
left epigastric pain right epigastric pain   erythropoietin
worsened by food relieved by food hormone produced by the kidney’s,
treatment: promotes hematopoiesis
-H2 blockers (Ranitidine) e. Hemolytic Anemia
-Proton Pump Inhibitors autoimmune
(Omeprazole,Pantoprazole) due to G^PD deficiency
-Antibiotics drug-induced
 indirect bilirubin, RBC, (+) Coomb’s test
3. Pancreatitis f. Sickel cell Anemia
-Acute: (due to gallstone, alcohol intake) genetic defect of the -chain of globin
-Chronic: (chronic alcoholism) HbS (instead of the normal adult hemoglobin HbA)
sticky RBC
4. Bowel Dysfunction occlude capillaries (pain, sickle cell crisis)
Diarrhea Constipation g. Thalassemia
bowel movement bowel movement genetic defect of the  or -chain of globulin
large volume  S.I. causes: IBD (Inflammatory h. Pernicious Anemia
Small volume  L.I. Bowel Disease)  intrinsic factor (megaloblastic anemia)
causes: Infectious Hypothyroidism -Castle factor
fiber treatment: fiber in the Diet -Gastric parietal cells
Hyperthyroidism Laxatives -Needed to absobs
treatment: Antiperistaltic -bulk -Vit B12 (intrinsic factor)
Antidiarrheals -osmotic i. Aplastic Anemia
Antibiotics -stimulant cells in the Bone marrow
-lubricants hypoproliferation bone marrow
pancytopenia = reduction in the number of red and
5. Viral Hepatitides  inflammation of the liver due to viral infections white blood cells, as well as platelets
A self-limiting, (fecal-oral)


B 2. Coagulopathics  disorders in coagulation
C Chronic, (Parenteral, Sexual) a. Idiopathic Thrombocytopenia Purpura (ITP)
D  platelets life-span
E self-limiting, (fecal-oral) predisposes the patient to bleeding
DNA  Hep B b. Hemophilia
RNA  Hep ACDE  deficiency in clotting factor
Hep D  coinfection of Hep B bleeding
types: A- Factor VIII
6. Cholelithiasis  gallstones B- Factor IX
-cholesterol c. Warfarin Toxicity  Vitamin K – dependent factor
-pigment = bile pigment (factor X, IX, VII, II)
-mixed = cholesterol + bile pigment 10, 9, 7, 2
FFemale
Increase chance
FForty
to have
FFat
Cholelithiasis
FFertile
VII. Complementary & Alternative Medicine
A. Introduction
CAM = practices outside the purview of conventional medicinal
Traditional Medicine = native therapeutics of a certain region Containers:
medicinal tradition of a culture Prescription bottles  are used to dispense liquids of low viscosity
RA 8342 (Traditional & Alternative Medicine Act of 1997) Wide Mouth bottles  are used to dispense viscous liquids
-TAMA 1997 Application Bottles  used for applying liquid medication to a wound
PITAHC (Philippine Institute for Traditional & Alternative or skin surface
Healthcare) Round Vials  are used primarily for solid dosage forms as capsule &
tablets
B. CAM Practices: Aerosol Containers  used for powders to applied by sprinkling
1. Acupressure  application of fingertip pressure on different body Slide boxes  are used for dispensing suppositories & powders
parts as therapy prepared in packets
2. Acupuncture  ancient Chinese art of healing Ointment jars & Collapsible tubes  used to dispense semi-solid
 employs here needles to restore energy flow (qi) dosage forms, such as creams &
through the meridians. ointments
3. Ayurvedic Medicine  ancient Indian Philosophy Dropper Bottles  are used for dispensing ophthalmic, nasal, otic, or
 use of Physical & mental abilities to achieve oral liquids to be administered
harmony w/ the environment
4. Allopathy  using remedies that produce effects opposite or Nutraceutical  any substance that may be considered a food or part
different from those of the disease of a food & provides medical or health benefits,
5. Chiropractic  manipulation & treatment of structure of the body including the prevention & treatment of disease
(spiral column) Phytochemical  substance found in edible fruits & vegetables that
6. Homeopathy  Law of similar (“like cures like”) may ingested by humans daily in gram quantities &
 Dr. Samuel Hahneman that exhibit a potential for modulating human
 uses medicinally active potentialized substances at metabolism in a manner favourable for cancer
weak or infinitesimal doses prevention
7. Hypnosis  state of altered consciousness, sleep or trane induced Chemopreventive agent  nutritive or non-nutritive food component
artificially by suggestion being scientifically investigated as a
 comparable to surgical anesthesia potential inhibitor of carcinogenesis for
8. Iridology  diagnosis based on the properties of the iris primary & secondary cancer prevention
9. Reflexology  treatment by irritation of an area of the body Designer Food  processed food that are supplemented w/ food
distant from the lesion ingredients naturally rich in disease-preventing
10. Naturopathy  described as healing by the use of natural substances
remedies w/ no drugs or surgery Investigational Drug/ New Drug  any drug that has not yet released
for general use, & has not yet been
cleared for sale in commerce
Seven Categories of Complementary & Alternative Medicines:
-Mind-Body Interventions
-Bioelectromagnetic Therapies
-Alternative Systems of Medical Practice Nuclear Pharmacy  aka Radiopharmacy
-Manual Healing Methods  referred to a specialty practice of pharmacy
-Pharmacological & Biological Treatments that focuses upon the safe & efficacious use of
-Herbal Medicine radioactive drugs
-Diet & Nutrition Radioactive Drugs  exhibits spontaneous disintegration of unstable
nuclei w/ the emission of nuclear particles or
photons
 includes any non-radioactive kit or nuclide
generator that is intended to be used in the
preparation of any such substance
Radiopharmaceuticals  lack pharmacological effects
 employed as tracers of physiological
functions
 small amounts produce negligible effects on
biological processes
Investigational Drug/ New Drug  any drug that has not yet released
for general use, & has not yet
been cleared for sale in
commerce

Pharmacovigilance  continual monitoring for unwanted effects


 science & activities relating to the detection,
assessment, understanding, & prevention of
adverse effect or any other drug-related
problem.
Pharmacoeconomics  comparing value of drugs or therapy w/
another
Other Important Facts:
Definitions Health:
WHO: “state of somplete physical, mental, & social well-being &
not merely the absence of disease”
Medical: “Absence of Disease”
Wellness: “Health promotion & progress toward higher
functioning, energy, comfort”
Environmental: “Adaptation to physical & social surroundings.”

Quality of Life (QOL)  value assigned to duration of life

Health Outcomes  end results associated w/ medical care delivery


system

Responsiveness  ability or power of the measure to detect clinically


important change

Disease  is an objective phenomenon involving particular pathological


processed occurring in the body.

Illness  is a psychosocial concept & a reaction to perceived biological


pattern
 having a disease

Infirmatory  a place where the sick are given care or treatment

Sickness  is a social status conferred to individual by others

Iatrogenic Disease  refers to complications or disease induced by the


physician’s treatment plan

PPhA  Philippines Pharmacist Association

PHAP  states that a maximum of 7 doctors can be subsidized by a


pharmaceutical company for continuing medical education

PSPH  Philippine Society of Hospital Pharmacist (1962)


 First President: Rosario Capistrano Tan

Aesculapius  Greek God of Medicine

Hospital of Jesus of Nazareth  first hospital on the American Continent


built by the Spaniards in 1524
Hospital Survey & Construction  act provided federal funds for hospital
construction on matching on matching
basis w/ local communities
San Lazaro Hospital  for Infectious Disease/ Contagious Disease
Fabella Hospital  Maternal & Newborn Services
Quezon Institute  for Tuberculosis

Social Security Amendments of 1965  had along impact on the


development & expansion of
hospitals because funds are
made available to pay for
services of medicinally indigent
patient

Push  also known as the allocation or ration system


Pull/ Requisition  system where peripheral facility determines drug
quantities acquired from procurement group.
Logistics  science of obtaining the right amounts of right things at the
right places at the right time

Sterilization Assurance level  probability of finding a non-sterile unit

Terminal Sterilization  carried out the end of processing

Aseptic Processing  processing operation involving sterile products


carried out in a laminar air flow
Cleanroom  designed & maintained, to present particulate & microbial
contamination of drug products

Laminar Flowhood  is an equipment that is designed to reduce risk of


airborne contamination during IV admixture

Patient-controlled Analgesia  a system for delivery of IV or SC narcotics


by direct patient intervention

Fixed-Dose Combination  increased Compliance


 potentially incompatible Pharmacodynamics
Multivitamins + Iron  a fixed dose which is not recommended
by WHO

NIRPROMP  concerns mostly about Medicinal Plants

SALAD  Sound-alike, Looks-alike Drugs

SSRI  Selective Serotonin Reuptake Inhibitor


Sliding Scale regular Insulin

Nitro Drip  Nitroglycerin Infusion –ISMP

X3D  for 3 days

Use of Ear Drops or Spray:


Lying Down  is the most comfortable position for instillation of ear
drops & sprays.
The main difference when administering ear drops or spray to a child
is that Ear Lobe needs to be pulled backward.

Use of Eye Drops/ Eye ointment:


It would be easier to detect that the cold drop has actually entered the
eye if drops are stored at cold temperature
Soft Contact Lenses should not be worn.
 Wait at least 5-10 minutes after putting the first drop before using the
second drop
If Babies/ small children wriggle & try to put their hands to their eyes
to prevent instillation of drops, wrap childe with a blanket with arms
tucked out of the way
If using eye drops & eye ointment: Eye Drops first.
When applying eye ointments, the pharmacist should reminded the
patient to pull down the lower eyelid.
The patient should be reminded that after administration of the eye
ointment, vision will be blurred.

Use of Metered Dose Inhalers:


Mist comes from the sides of the mouth is an indication that another
dose is required because of poor technique.
In taking inhaled medications, Bronchodilators should be first then
Corticosteroid inhalers could follow

Use of Cigarettes:
𝑃𝑎𝑐𝑘 𝑦𝑒𝑎𝑟𝑠 = 3 𝑝𝑎𝑐𝑘𝑠/𝑑𝑎𝑦 × # 𝑜𝑓 𝑠𝑚𝑜𝑘𝑖𝑛𝑔 𝑦𝑒𝑎𝑟𝑠
Parenteral Routes
Intra-arterial Joint space
Intrasynovial Joint fluid are
Intrathecal Spinal column
Intra-arterial Arteries
Intracardiac Heart
Intravenous, IV Into the vein
Intamuscular, IM Into the muscles
Intradermal, IB/ Intracutaneous Into the skin
Subcutaneous, SC/ Sub-Q, SQ/ hypodermic Under the Skin

2-mL syringe  is used for most subcutaneous injections.


Subcutaneous  thigh, abdomen, upper arm @ 45-60 degree angle
 usually 23-gauge needle of ¾ in length
#25-gauge, 5/8-inch needle  is used for adults of normal weight and
the needle is inserted at a 45-degree
angle.
#20- to #23-gauge needle  is used for IM injections
(3-4mL max. vol.) @ 90 degree angle
# 26-gauge 3 5/8  is a needle that has the smallest diameter
smaller the gauge=larger diameter of needle
Basic parts of a syringe: Barrel, Plunger, & Tip
 Barrel is a tube that is open at one end and
tapers into a hollow tip at the other end.
 Plunger is a piston-type rod with a slightly
cone-shaped top that passes inside the
barrel of the syringe.
 Tip of the syringe provides the point of
attachment for a needle.

Three Parts of Needle: Hub, Shaft, & Bevel


 Hub is at one end of the needle and is the part that attaches
to the syringe.
 The shaft is the long slender stem of the needle that is
beveled at one end to form a point.
 The hollow bore of the needle shaft is known as the lumen.

Needle lengths range from 3/8 inch to 3 1/2 inches;


some special use needles are even longer. The
gauge of a needle, used to designate the size of
the lumen, ranges from 27 (the finest) to 13 (the
largest).

Syringe Infusers  are used for controlling the delivery of small volume
of IV infusion over a predetermined period of time

Intramuscular: Deltoid & Gluteal


 recommended maximal volume 3-4 mL
inserted at a 90 angle
Types of malnutrition

Malnutrition is a group of conditions in children and adults generally related to poor quality or insufficient quantity of nutrient intake, absorption, or
utilization.

There are two major types of malnutrition:


 Protein-energy malnutrition - resulting from deficiencies in any or all nutrients
 Micronutrient deficiency diseases - resulting from a deficiency of specific micronutrients

Protein-energy malnutrition
There are three types of protein-energy malnutrition in children:
Type Appearance Cause
Acute malnutrition Wasting or thinness Acute inadequate nutrition leading to rapid weight loss or failure to gain weight normally
Chronic malnutrition Stunting or shortness Inadequate nutrition over long period of time leading to failure of linear growth
Acute and chronic malnutrition Underweight A combination measure, therefore, it could occur as a result of wasting, stunting, or both

These forms of protein-energy malnutrition in children can be pictured like this:

Wasting and stunting are very different forms of malnutrition.


Stunting is chronic and its causative factors are poorly understood. Stunting usually does not pose an immediate threat to life and is relatively common in
many populations in less-developed countries. This is not to say that it is unimportant, just less important than wasting in humanitarian
emergencies.
Wasting results from an acute shortage of food, is reversible with refeeding, and has a relatively high mortality rate. For these reasons, wasting is the
highest priority form of malnutrition in humanitarian emergencies.
Urticaria  skin rash
 composed central wheal surrounded by an
Erythematosus halo

Hemorrhoids  clusters of dilated blood vessels in the lower


rectum or arms.

Cathartic Colon  a condition characterized in a poorly functioning


colon & resembles the symptoms of ulcerative
colitis, caused by chronic use of stimulant
laxatives.

Melanosis Coli  a dark pigmentation of the colonic mucosa that


results from long-term use of Anthraquinone
laxatives.

Glaucoma  a condition characterized by an increase in intraocular


pressure (IOP) & is influenced by the production of
aqueous humor through the trabecular meshwork

Ocular Hypertension  an IOP greater than 21mmHg, normal visual


fields, normal optic discs, open angles, &
the absence of any ocular disease
contributing to the elevation of IOP.

Primary Open Angle Glaucoma  a condition in which the aqueous


humor, outflow from the anterior chamber
is constantly subnormal primarily because
of degenerative process in the trabecular
meshwork.
Vertigo  medical term to describe the feeling of spinning or
whirling, maybe a symptom of a tumor or stroke

Impetigo  skin infection caused by Staph/ Strep

Vitiligo  hypopigmentation of skin

Carpal Tunnel Syndrome  usually results from excessive texting,


typing or during an increased pressure
on the median nerve at the wrist.

Osmotic Diarrhea  was observed in areas where water supply had


high levels of this nutrient

H7N9  emerging Bird flu in China

Respiratory Acidosis  is best associated w/ High CO2

Macular degeneration  involves in eyes

Kernecterus  accumulation of bilirubin in the brain


Bilirubin  is associated w/ jaundice characterized by yellowish
staining of the skin
Urobilin  color of urine
Stercobilin  color of feces
Hemoglobin  color of Blood

Dysmenorrhea  painful menstruation


Amenorrhea  absence of menstrual period
Metorrhagia  refers to vaginal bleeding occurring between
regular menstrual periods
Dystocia  difficulty in labor

Psoriasis  a chronic skin disease in which scaly pink patches form


on the elbows, knees, scalp

Muscle Paralysis  increase by Hypothermia,


Hypokalemia,
Hypermagnesemia.

Kawasaki Disease  autoimmune disease


Thalidomide Toxicity:
Phocomeila  absence of upper arm/leg/hand/ feet/ both
Amelia  absence of arm/ leg

Meromelia  mermaid-like

Polydactylyl  have more than the normal # of fingers & ties.

Japanese 5S in the workplace:


Set in Order Seiso
 Sort Seiri
Standardize Seiketsu
Sustain Shitsuke
Shine Seiton

Four Big Pollution Diseases in Japan:


- Minimata Disease
- Itai-itai Disease
- Yokkaichi-Asthma Disease
- Niigata Disease
PHARMACEUTICAL CALCULATIONS
I.
Pharmaceutical Calculations is the area of study that applies the basic
principles of mathematics to the
preparation and safe and effective use of
pharmaceuticals.

Common Fractions  are portions of a whole, expressed at 1⁄3, 7⁄8, and


so forth. They are used only rarely in pharmacy
calculations nowadays. It is recalled, that when
adding or subtracting fractions, the use of a
common denominator is required.
Fraction  is the numerator is part of the denominator
 is the numerator & denominator represents parts of the
whole. The denominator described the total number of
equal parts in the whole; the numerator describes the
number or parts being considered.
 may be expressed using a slash to separate two
quantities
 may also be expressed as the result of the fraction in
decimals
*Note: Two Fractions having a common denominator are
directly proportional
Two Fractions having a common numerator are inversely
proportional to their denominator
Decimal Fraction is a fraction with a denominator of 10 or any power of
10 and is expressed decimally rather than as a
common fraction. Thus, 1/10 is expressed as 0.10 and
45/100 as 0.45. It is important to include the zero
before the decimal point.

Ratio  is the relative magnitude of two quantities .


 the quantities (counts) compared are separated using a colon or
as a fraction, but not as the result of the fraction
(decimal form)
 the numerator is NOT part of the denominator
Proportion  is the expression of the equality of two ratios
 is the expression showing the numerical relationship of two
systems
 is the expression showing the equality of

Dimensional Analysis  also known as factor analysis,


factor-label method, or
unit-factor method
 a method involves the logical sequencing and
placement of a series of ratios (termed factors)
into an equation.
 a method whereby one particular unit of
measurement is converted to another unit of
measurement by use of a conversion
Steps in Dimensional Analysis:
a. Determining the quantity & unit to be converted & the desired
unit in the final answer.
b. Formulating a conversion equation consisting of a sequence of
factors, in which successive units can be cancelled until the
desired unit is reached
c. Solving the conversion equation by use of cancellation & simple
arithmetic

Ratio & Proportions


 This is the one of the easiest ways to make conversions, whether
they are within the same system or between systems
 To convert, a proportion must be set up that expresses a
numerical relationship between the two systems.
 A proportion may be written in a colon format or as a fraction
when making conversion
II. System of Measurements
System of weights & Measures
Metric System
Common System
Apothecaries (for smaller quantity)
Avoirdupois (for larger quantity)
Household System

A. Metric System
International System of Units (SI),
 formerly called the metric system, is the internationally
recognized decimal system of weights and measures.
 is based on the decimal system, each unit differing from
the next smaller or larger unit by a factor of 10.
 is a more precise system as compared to the
Apothecaries & Households system
Basic Units for measurement in the metric system
for Weight  grams
for Volume  liter
for Length  meter
Metric System
Prefix Symbol Numerical value
Kilo K 1000
Hecto H 100
Deca D 10
Deci d 0.1 1/10
Centi c 0.01 1/100
Milli m 0.001 1/1000
Micro  or mc 0.000001 1/1000 000
Nano n 0.000000001 1/1000 000 000

B. Apothecaries’ & Avoirdupois system


•Apothecaries  is one of the oldest systems of measurement.
 *there are still some medications which have
been used for many years which are customarily
written using this system.
Ex: Morphine Sulfate
Atropine Sulfate
Codeine
Sodium Phenobarbital
Aspirin
•Avoirdupois  widely used in the United States in measuring body
weight and in selling goods by the ounce or pound,
is slowly giving way to the international system.
Note: The Apothecaries’ & Avoirdupois System share some similar
units of measurements but, they have different values.
Measurable in the common system are recorded in
Compound Quantities.
Compound Quantities also known as the Weighable or
Measurable Denominations
 quantities expressed in the
two or more denominations,
from the largest units to the
smallest.
Simplification  is the process of reducing a quantity to a
weighable or measurable denominations
beginning with the highest possible
denominations.

C. Household System
 is the least accurate of the three systems of measures.
However, this is a system involving measures which are easily
understood by the patients & may be safely used during self
medications at home
 Basic unit: Drop – “gtt”
 it does not represent a definite quantity, since drops of
different liquids vary greatly.
Official dropper: 20 drops per mL
A. METRIC SYSTEM B. APOTHECARY SYSTEM

LENGTH – uses the meter as the primary unit WEIGHT


millimeter(mm)* 20 grains (gr) = 1 scruple (э)
10 mm = 1 cm centimeter (cm)* 3 scruples (э) = 1 dram (Z)
7
10 cm = 1 dm decimeter (dm ) 8 drams (Z) = 1 ounce ( Z)
7
10 dm =1m meter (m)* 12 ounces ( Z) = 1 p0und (lb)
10 m = 1 Dm dekameter (Dm)
10 Dm = 1 hm hectometer (hm) 1 dram (Z) = 60 grains (gr)
7
10 hm = 1 km kilometer (km) 1 ounce ( Z) = 480 grains (gr)
1 p0und (lb) = 5760 grains (gr)
WEIGHT – uses the gram as the primary unit
nanogram (ng)* VOLUME
1000 ng = 1 mcg microgram (mcg) * 60 minims (M) =1 fluid dram (f Z)
7
1000 mcg = 1mg milligram (mg)* 8 fluid drams (f Z) =1 fluid ounce(f Z)
7
10 mg = 1 cg centigram (cg) 16 fluid ounces(f Z) =1 pint (pt)
10 cg = 1dg decigram (dg) 2 pints (pt) =1 quart (qt)
10 dg = 1g gram (g)* 4 qarts (qt) =1gallon (cong)
10 g = 1 Dg dekagram (Dg)
10 Dg = 1 hg hectogram (hg)
10 hg = 1 kg kilogram (kg)
AVOIRDUPOIS SYSTEM
VOLUME – uses the liter as the primary unit WEIGHT
milliliter (ml)* 437.5 grains (gr) = 1 ounces (oz)
10 ml = 1 cl centiliter (cl) 16 ounces (oz) = 1 pound (lb)
10 cl = 1dl deciliter (dl) 7000 grains (gr) = 1 pound (lb)
10 dl = 1L liter (L)* *There is no volume measure in the
10 L = 1 Dl dekaliter (Dk) avoirdupois system.
10 Dl = 1 hl hectoliter (hl)
10 hl = 1 kl kiloliter (kl)
*These are units commonly used in pharmacy.

ADDITIONAL
C. HOUSEHOLD MEASURE
1g = 1000 mg
1L = 1000 ml 1 teaspoon = 5ml =60 drops
1k = 1000 m 1 tablespoon = 15 ml
1 kg = 1000 g 1 glass = 240 ml
1m = 100 cm 30 ml = 1 fl oz
1 ft = 12 inches = 30.48 cm
1 inch = 2.54 cm
1 yard = 3 ft APPROXIMATE EQUIVALENT
FOR HOUSEHOLD MEASURES

1fZ = 1 teaspoonful = 5 ml
7
1/2 f Z =3 teaspoonful = 15ml
= 1 tablespoonful
7
1f Z = 2 tablespoonful =30 ml
= 6 teaspoonful
7
2f Z =1 wineglassful =60 ml
7
4f Z =1 teacupful =120 ml
7
8 f Z or = 1 glass/tumbler =240 ml
½ pint
EQUIVALENTS AND CONVERSION

1 gram = 15.432 grains (gr)


1 grains = 64.8 mg
1 apothecary ounce = 31.1 g
1 apothecary pound = 373.2 g = 7000 gr
1 avoirdupois ounce = 28.35 g = 437.5 gr
1 avoirdupois pound = 454 g
1 ml = 16.23 minims
1 minim = 0.062 ml
1 fluid once = 29.57 ml
1 pint = 473 ml
1 gallon = 3, 785 ml
1 kilogram = 2.2 lbs
1 lb = 454 g

THE UNITED STATES PHARMACOPEIA TABLE OF METRIC-


APOTHECARY APPROXIMATE DOSE EQUIVALENTS

LIQUID MEASURE
1000ml = 1 quart 3 ml = 45 minims
750 ml = 1 ½ pints 2 ml = 30 minims
500 ml = 1 pint 1 ml = 15 minims
250 ml = 8 fl. oz. 0.75 ml = 12 minims
200 ml = 7 fl. oz. 0.6 ml = 10 minims
100 ml = 3 ½ fl. oz. 0.5 ml = 8 minims
50 ml =1 ¾ fl.oz. 0.3 ml = 5 minims
30 ml = 1 fl. oz. 0.25 ml = 4 minims
15 ml = 4 fl. dr. 0.2 ml = 3 minims
10 ml = 2 ½ fl. dr. 0.1 ml = 1 ½ minims
8 ml = 2 fl.dr. 0.06 ml = 1 minim
5 ml = 1 ½ fl.dr. 0.05 ml = ¾ minim
4 ml = 1 fl.dr 0.03 ml = ½ minim

WEIGHT
30 g = 1 ounce 30 mg = ½ grain
15 g = 4 drams 25 mg = 3/8 grain
10 g = 2 ½ drams 20 mg = 1/3 grain
7.5 g = 2 drams 15 mg = ¼ grain
6g = 90 grains 12 mg = 1/5 grain
5g = 75 grains 10 mg = 1/6 grain
4g = 60 grains (1 dram) 8 mg = 1/8 grain
3g = 45 grains 5 mg = 1/12 grain
2g = 30 grains 4 mg = 1/15 grain
1g = 15 grains 3 mg = 1/20 grain
0.75 g = 12 grains 2 mg = 1/30 grain
0.6 g = 10 grains 1.5 mg = 1/40 grain
0.5 g = 7 ½ grains 1.2 mg = 1/50 grain
0.4 g = 6 grains 1 mg = 1/60 grain
0.3 g = 5 grains 800 mg = 1/80 grain
0.25 g = 4 grains 600 mg = 1/100 grain
0.2 g = 3 grains 500 mg = 1/120 grain
0.15 g = 2 1/2 grains 400 mg = 1/150 grain
0.125 g = 2 grains 300 mg = 1/200 grain
0.1 g = 1 1/2 grains 250 mg = 1/250 grain
75 g = 1 1/4 grains 200 mg = 1/300 grain
60 g = 1 grains 150 mg = 1/400 grain
50 g = 3/4 grains 120 mg = 1/500 grain
40 g = 2/3 grains 100 mg = 1/600 grain
III. Percentage Error
The maximum potential error multiplied by 100 & divided by the
quantity desired.
𝐸𝑟𝑟𝑜𝑟
%𝐸 = × 100%
𝑄𝑢𝑎𝑛𝑡𝑖𝑡𝑦 𝑑𝑒𝑠𝑖𝑟𝑒𝑑

𝐸𝑟𝑟𝑜𝑟
%𝐸 = × 100%
𝑇𝑕𝑒𝑜𝑟𝑖𝑡𝑖𝑐𝑎𝑙

𝑇𝑕𝑒𝑜 − 𝐴𝑐𝑡𝑢𝑎𝑙
%𝐸 = × 100%
𝑇𝑕𝑒𝑜𝑟𝑖𝑡𝑖𝑐𝑎𝑙
Sensitivity Requirement (SR)  the maximum change in load that
will cause a specified change, one subdivision on the
index plate, in the position of rest of the indicating
element or elements of the balance
If a certain percentage or errors is not to be exceeded, & the
maximum potential error is know, it is possible
tocalcualte the smallest quantity that can be measured
within the desired accuracy.

𝑀𝑎𝑥𝑖𝑚𝑢𝑚 𝑝𝑜𝑡𝑒𝑛𝑡𝑖𝑎𝑙 𝑒𝑟𝑟𝑜𝑟


𝑜𝑟 𝑆𝑒𝑛𝑠𝑡𝑖𝑣𝑖𝑡𝑦
𝑆𝑚𝑎𝑙𝑙𝑒𝑠𝑡 𝑄𝑢𝑎𝑛𝑡𝑖𝑡𝑦 = × 100%
𝑃𝑒𝑟𝑚𝑖𝑠𝑠𝑖𝑏𝑙𝑒 𝑝𝑒𝑟𝑐𝑒𝑛𝑡𝑎𝑔𝑒 𝑒𝑟𝑟𝑜𝑟

IV. Calculation of Doses


A. Dosage based on Age:
Cowling’s Rule
𝐴𝑔𝑒 𝑎𝑡 𝑁𝑒𝑥𝑡 𝐵𝑖𝑟𝑡 𝑕𝑑𝑎𝑦 𝑦𝑟𝑠
𝐶𝑕𝑖𝑙𝑑 𝐷𝑜𝑠𝑒 = × 𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒
24

Young’s Rule
𝐴𝑔𝑒
C𝑕𝑖𝑙𝑑 𝐷𝑜𝑠𝑒 = × 𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒
𝐴𝑔𝑒 +12
Fried’s Rule (for infants)
𝐴𝑔𝑒 (𝑖𝑛 𝑚𝑜𝑛𝑡 𝑕𝑠)
C𝑕𝑖𝑙𝑑 𝐷𝑜𝑠𝑒 = × 𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒
150

B. Dosage based on Body Weight


Clark’s Rule
𝑊𝑒𝑖𝑔 𝑕𝑡 (𝑙𝑏 )
C𝑕𝑖𝑙𝑑 𝐷𝑜𝑠𝑒 = × 𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒
150

C. Dosage based on BSA (Body Surface Area)


𝐵𝑆𝐴 𝑜𝑓 𝐴𝑑𝑢𝑙𝑡 (𝑚 2 )
Adult 𝐷𝑜𝑠𝑒 = × 𝑢𝑠𝑢𝑎𝑙 𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒
1.73 𝑚 2

If Adult dose is given:


𝐵𝑆𝐴 𝑜𝑓 𝐶𝑕𝑖𝑙𝑑 (𝑚2 )
𝐶𝑕𝑖𝑙𝑑 𝐷𝑜𝑠𝑒 = × 𝑢𝑠𝑢𝑎𝑙 𝐴𝑑𝑢𝑙𝑡 𝐷𝑜𝑠𝑒
1.73 𝑚2
If Adult dose is given:
𝐶𝑕𝑖𝑙𝑑 𝐷𝑜𝑠𝑒 = 𝐵𝑆𝐴 𝑜𝑓 𝐴𝑑𝑢𝑙𝑡 𝑚2 × 𝐷𝑜𝑠𝑒 𝑝𝑒𝑟 𝑚2

If the BSA are not given:


1. Approximate Equation:
4𝑤 × 7
𝑆=
𝑤 + 90 2
Where: S= surface area in m
W= weight in Kg
2. Exact Equation:
1×𝑃
𝑆=
3131
2
Where: S= surface area in m
I= height in inches
P= weight in pounds
𝐶×𝐾
𝑆=
3600
Where: C= height in Centimeter
K= weight in Kilograms
V. Density, Specific Gravity, & Specific Volume

Density  mass per unit volume of a substance (g/mL)


𝑚
𝐷=
𝑣
Specific Gravity  a ratio, expressed decimally, of a weight of a
substance to the weight of an equal volume of a
standard determined at the same temperature
(if not stated 25C/25C, except when specified in
the monograph & for alcohol which is at 15.56C/
15.56C)
𝑚
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑔𝑟𝑎𝑣𝑖𝑡𝑦 = 𝐷𝑒𝑛𝑠𝑖𝑡𝑦 =
𝑣
 Density: g/mL
 Specific Gravity: No unit

Note: Density & Specific Gravity is numerically equal in the metric


system, but they are different when the density is expressed in
the common system.

A. Specific Gravity of Liquids


 done by dividing the weight of certain volume of liquid
to the weight of an equal volume of water
may also determined by Displacement Method
(Archimedes Principles)

1. Pycnometer:
𝑤𝑡 𝑜𝑓 𝑃𝑦𝑐 + 𝐿𝑖𝑞𝑢𝑖𝑑 − 𝑤𝑡 𝑜𝑓 𝑃𝑦𝑐
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝐺𝑟𝑎𝑣𝑖𝑡𝑦 =
𝑤𝑡 𝑜𝑓 𝑃𝑦𝑐 + 𝐻2 𝑂 − 𝑤𝑡 𝑜𝑓 𝑃𝑦𝑐

𝑤𝑡 𝑜𝑓 𝐿𝑖𝑞𝑢𝑖𝑑
=
𝑤𝑡 𝑜𝑓 𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝐻2 𝑂

2. Archimedes Principles: A body immersed in a liquid displaces an


amount of the liquid equal to its own
volume & suffer an apparent loss in
weight equal to the weight of the
displaced liquid
𝑙𝑜𝑠𝑠 𝑖𝑛 𝑤𝑡 𝑖𝑛 𝐿𝑖𝑞𝑢𝑖𝑑
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝐺𝑟𝑎𝑣𝑖𝑡𝑦 =
𝑙𝑜𝑠𝑠 𝑖𝑛 𝑤𝑡 𝑖𝑛 𝐻2 𝑂

𝑤𝑡 𝑜𝑓 𝐴𝑖𝑟 − 𝑤𝑡 𝑖𝑛 𝐿𝑖𝑞𝑢𝑖𝑑
=
𝑤𝑡 𝑖𝑛 𝐴𝑖𝑟 − 𝑤𝑡 𝑖𝑛 𝐻2 𝑜

B. Specific Gravity of Soilds


𝑤𝑡 𝑖𝑛 𝑎𝑖𝑟
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝐺𝑟𝑎𝑣𝑖𝑡𝑦 =
𝑙𝑜𝑠𝑠 𝑖𝑛 𝑤𝑡 𝑖𝑛 𝑆𝑡𝑎𝑛𝑑𝑎𝑟𝑑 𝐻2 𝑂

𝑤𝑡 𝑜𝑓 𝐴𝑖𝑟
=
𝑤𝑡 𝑖𝑛 𝐴𝑖𝑟 − 𝑤𝑡 𝑖𝑛 𝐻2 𝑜

(a) Heavier, insoluble


(b) Heavier, soluble
(c) Lighter, insoluble
(d) Heavier, insoluble, granulated

C. Specific Volume
 reciprocal of Specific gravity
 no unit
1
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑉𝑜𝑙𝑢𝑚𝑒 =
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝐺𝑟𝑎𝑣𝑖𝑡𝑦
𝑉𝑜𝑙𝑢𝑚𝑒
𝑆𝑝𝑒𝑐𝑖𝑓𝑖𝑐 𝑉𝑜𝑙𝑢𝑚𝑒 =
𝑀𝑎𝑠𝑠
VI. Expressions of Concentration
1. Percent by weight
𝑔 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒
grams of solute in 100 grams of Mixtures %𝑤/𝑤 =
100𝑔 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛
Mixture= wt of solute + wt of solvent
2. Percent by Volume 𝑚𝐿 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒
%𝑣/𝑣 =
mL os solute in 100 mL of Mixture 100𝑚𝐿 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛
3. Percent weight by volume 𝑔 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒
%𝑤/𝑣 =
grams of solute in 100mL of Mixture 100𝑚𝐿 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛
4. Milligrams Percent
 mg of solute in 100mL of Mixture 𝑚𝑔 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒
important in expressing concentrations 𝑚𝑔 % =
100𝑚𝐿 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛
of biological fluids such as BUN,
Creatinne, Blood Sugar
5. Molarity (M) 𝑚𝑜𝑙𝑒𝑠 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒
𝑀 =
moles of solute 𝐿 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛
in a liter of Solution
A 1 molar (M) of a solution contains the 𝑤𝑡/𝑀𝑊
=
molecular weight in grams dissolved in 1 𝐿
liter of water
Concentration expression which could be
affected by temperature 𝑔𝑟𝑎𝑚𝑠
𝑀𝑜𝑙𝑒𝑠 𝑛 =
𝑀𝑊
Mole = molecular weight of a substance 𝑚𝑔
𝑚𝑀𝑜𝑙𝑒𝑠 =
expressed in grams (GMW) 𝑀𝑊
6. Molality (m)
𝑚𝑜𝑙𝑒𝑠 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒
moles o solute in 1000grams of Solvent 𝑚 =
𝐾𝑔 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛
Molal concentration is not affected by
temperature. 𝑤𝑡/𝑀𝑊
This is not also affected by the contraction =
𝐾𝑔
or expansion of volume of solvents
Appear more in theoretical studies
7. Normality (N) 𝑀𝑊
𝑤𝑡/
the number of equivalents in each liter of 𝑓
𝑁 =𝑀×𝐹 =
solution or the number of mEq in each 𝐿
𝑀𝑤
mL of solution 𝑚𝐸𝑞 𝑤/
𝑓
𝑁= =
𝐿 𝐿
𝑒𝑞𝑢𝑖𝑣𝑎𝑙𝑒𝑛𝑐𝑒 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒
𝑁=
𝐿 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑖𝑜𝑛

Acid/Base GEW
HCl MW
GEW (gram equivalent weight) MW
HNO3
= MW divided by the number of
H2SO4 MW/2
replaceable hydrogen/hydroxyl
atoms for acids & bases H3PO4 MW/3

+
factor=acid/base: f=# of replaceable H /OH
HCl: f=1 NaOH: f=1
H2SO4: f=2 Ca(OH)2: f=2
H3PO4: f=3 Al(OH)3: f=3

Substance GEW
NaCl MW
CaCl2 MW/2
=MW divided by the number of MW/6
Al2O3
electrons shared by atoms in a
molecules (Total positive charge)
Salt: f= total (+) charge
NaCl: f=1
CaCl2: f=2
Al2O3: f=3
8. Osmolarity 𝑀𝑊
𝑂𝑠𝑚𝑜𝑙 𝑤𝑡/ Factor f= i = Van hoff Factor
mOsm per Liter of solution 𝑓
𝑂𝑠𝑚𝑜𝑙𝑎𝑟𝑖𝑡𝑦 = =
𝐿 𝐿 Non-electrolyte: f=1
Electrolyte:
9. Osmolality 𝑀𝑊 -Strong: f=# of ions
𝑂𝑠𝑚𝑜𝑙 𝑤𝑡/
number of osmol per 1000 g of SOLVENT 𝑓 NaCl: f=2
𝑂𝑠𝑚𝑜𝑙𝑎𝑟𝑖𝑡𝑦 = =
𝐾𝑔 𝐾𝑔 CaCl2: f=3
AlCl3: f=4
-Weak: f=(# of ion) (% dissociated)
+ (% undissociated)
Ex: f=2 (0.7) + 0.3 = 1.7
+
*NaCl 70%  Na +Cl
-If it is not stated whether strong or weak
electrolyte, assume 80% dissociation
# of ions factor
2 2(0.8) + (0.2) = 1.8
3
4
5
10. Mole Fraction 𝑁𝐴 𝑁𝐴
𝑀𝐴 = =
ratio of solute to thetotal moles of all 𝑁𝑇 𝑁𝐴 + 𝑁𝐵
components (Solute+Mixtures) Where:MA= mole fraction of component A
NA= number of moles of A
NT= total moles of the Mixture
11. Parts per million (ppm) 1𝑔 𝑤𝑡 𝑜𝑓 𝑠𝑜𝑙𝑢𝑡𝑒 (𝑚𝑔)
𝑝𝑝𝑚 = =
important expressing concentrations of 1000 000 𝑔 𝐿 𝑜𝑓 𝑆𝑜𝑙′𝑛/ 𝑀𝑖𝑥𝑡𝑢𝑟𝑒
ions in water & very dilute solutions 1𝑚𝐿 1𝑔
= =
1000 000𝑚𝐿 1000 000𝑚𝐿
𝑚 𝑔
∗ 𝑝𝑝𝑚 = =
𝐿 1000𝐿

12. Ratio Strength 1 𝑝𝑎𝑟𝑡 𝑜𝑓 𝑆𝑜𝑙𝑢𝑡𝑒


𝑅𝑎𝑡𝑖𝑜𝑛 𝑆𝑡𝑟𝑒𝑛𝑔𝑡𝑕 =
1 part of solute to the nth part of the 𝑛𝑡𝑕 𝑝𝑎𝑟𝑡𝑕 𝑜𝑓 𝑚𝑖𝑥𝑡𝑢𝑟𝑒
mixture
Convert:
RS to %
1
%= × 100%
𝑅𝑆
% to RS
100
𝑅𝑆 = 1:
%

VII. Dilution & Concentration: C1V1 = C2V2

VIII. Alligation  is an arithmetic method of solving problems relating mixtures of components of different strengths.
 an arithmetical method of solving problems that involve the mixing of solutions or mixtures of solids
possessing different percentage strengths
Two Types of Alligation:
Alligation Medial Alligation Alternate
method by which the “weighted average” percentage method by which we may calculate the number of parts
strengths of a mixture of two or more substances of known of two or more components of a given strength when
quantity & concentration may be quickly calculated. they are to be mixed to prepare a mixture of desired
may be used to determine the strength of a common strength.
ingredient in a mixture of two or more preparation may be used to determine the proportion or quantities of
The percentage strength, expressed as a whole number, of two or more components to combine in order to prepare
each component of the mixture is multiplied by its a mixture of a desired strength.
corresponding quantity, & the sum of the products is divided The strength of the mixture must lie somewhere between
by the sum of the quantities to give the percentage strength the strength of its components
of the mixture. The concentration lies nearer to that of its weaker or
stronger components depending on the relative amounts
involved.
Given: Given:
concentration of components concentration of compounds
quantity of components final concentration of compound
Find: Final Concentration Find: Quantity of Component
IX. TPN & Rates of Infusion
Kilocalorie (kcal)  is the unit used in metabolic studies.
 is the amount of heat required to raise the
temperature of 1 Kg of water from 0C to 1C
HarrisBenedict Equation  is used to estimate the resting
metabolic energy (RME) requirement
for non-protein calories.
 is used to maintain the patients present
weight
Males: RME= 66 + (13.7x w) + (5 x H)  (6.8 x A)
Females: RME= 655 + (9.6 x w) + (1.8 x H)  (4.7 x A)

Where: W = weight in Kg
H = height in centimeter
A = age in years

RME is adjusted according to the conditions of the patient


Patient Condition Factor
Mild Stress (Nonsurgical Patient) 1.2  1.4
Moderates Stress (Severe infections) 1.5  1.75
Severe Stress (Patient with severe burns) 1.75  2.0

Patient Condition RME Requirement


Mildly Stressed Patient 25 kcal/Kg/day
Moderately Stressed Patient 35 kcal/Kg/day
Postoperative Patient 45 kcal/Kg/day
Hypercatobolic Patient 60 kcal/Kg/day

Sources of Calories= Carbohydrates, Proteins, Lipids


Fat is restricted to less than 60% of the total daily calories
administered.
Amino Acid administration may also depend on the patients
condition
Patient Condition Amino Acid Requirement
Mildly Stressed Patient 0.75 g/Kg
(Ave healthy adult)
Moderately Stressed Patient 0.9 g/Kg
Severely Stressed Patient 1.25 g/Kg

Steps in TPN preparation


1. Determine the total caloric requirement of the patient using the
Harris-Benedict Equation
2. Determine the amount of protein based on 0.75 g/Kg (adjusted
according to patient condition) & the caloric value of the
computed proteins
3. Compute for the remaining caloric requirement that would be
supplied by dextrose & lipid emulsions
TPN Component Caloric Value
Lipid 9 kcal/g
Medium Chain FA 8.3 kcal/g
Alcohol 5.6 kcal/g
Glycerol 4.3 kcal/g
Dextrose (Anhydrous) 4 kcal/g
Amino Acids 4 kcal/g
Dextrose (Hydrous) 3.4 kcal/g
20% fat emulsion 2.0 kcal/ mL
10% fat emulsion 1.1 kcal/mL
X. Pharmacoeconomics Calculations
Discounts & Pricing based on Mark Up
Mark Up  relates to the difference between the cost of the
merchandise & its selling
Mark Up%  % of gross profit

𝑀𝑎𝑟𝑘 𝑈𝑝 (𝑔𝑟𝑜𝑠𝑠 𝑝𝑟𝑜𝑓𝑖𝑡)


%𝑀 =
𝑆𝑒𝑙𝑙𝑖𝑛𝑔 𝑃𝑟𝑖𝑐𝑒

% Gross Profit
Based on Cost:
𝑀𝑎𝑟𝑘 𝑈𝑝
%𝐺𝑟𝑜𝑠𝑠 𝑃𝑟𝑜𝑓𝑖𝑡 = × 100
𝐶𝑜𝑠

Based on Selling Price:


𝑀𝑎𝑟𝑘 𝑈𝑝
%𝐺𝑟𝑜𝑠𝑠 𝑃𝑟𝑜𝑓𝑖𝑡 = × 100
𝑆𝑒𝑙𝑙𝑖𝑛𝑔 𝑃𝑟𝑖𝑐𝑒

𝑆𝑒𝑙𝑙𝑖𝑛𝑔 𝑃𝑟𝑖𝑐𝑒 = 𝐶𝑜𝑠𝑡 + 𝑀𝑎𝑟𝑘 𝑈𝑝 𝑜𝑟 𝐺𝑟𝑜𝑠𝑠 𝑃𝑟𝑜𝑓𝑖𝑡

Discount:
Selling:
𝐷𝑖𝑠𝑐𝑜𝑢𝑛𝑡 𝑃𝑟𝑖𝑐𝑒 = 𝑂𝑟𝑖𝑔𝑖𝑛𝑎𝑙 𝑃𝑟𝑖𝑐𝑒 1 − 𝑑𝑖𝑠𝑐𝑜𝑢𝑛𝑡
Serial:
𝐷𝑖𝑠𝑐𝑜𝑢𝑛𝑡 𝑃𝑟𝑖𝑐𝑒 = 𝑂𝑟𝑖𝑔. 𝑃𝑟𝑖𝑐𝑒 1 − 𝑑𝑖𝑠𝑐𝐴 1 − 𝑑𝑖𝑠𝑐𝐵 ….

XI. Proof Strength


Proof Spirit  is an aqueous solution containing 50% (v/v) of absolute
alcohol
Proof Gallon  is the taxable unit for alcohols & alcoholic beverages

𝑃𝑆 = 2 (% 𝑣/𝑣)

𝑊𝐺 × %𝑣/𝑣
𝑃𝐺 =
50%

𝑊𝐺 × 𝑃𝑟𝑜𝑜𝑓 𝑆𝑡𝑟𝑒𝑛𝑔𝑡𝑕
𝑃𝐺 =
100

-Alcohol, USP = 95% v/v


-Diluted Alcohol, USP = 49.5% v/v  50% v/v
Specific Gravity = 15.56C/ 15.56C

XII. Body Mass Index (BMI)


𝑤𝑒𝑖𝑔𝑕𝑡 𝐾𝑔
𝐵𝑀𝐼 =
𝐻𝑒𝑖𝑔𝑕𝑡 𝑚2

𝑤𝑒𝑖𝑔𝑕𝑡 𝑙𝑏
𝐵𝑀𝐼 = 2
× 704.5
𝐻𝑒𝑖𝑔𝑕𝑡 𝑖𝑛𝑐𝑕

Underweight Less than 18.5


Normal weight 18.5  24.9
Overweight 25.0  29.9
Obese 30 & above
Extremely Obese Over 40