Abbreviations and Antidotes PDF

Eslam Fahmy https://t.me/splenotes 00201011922837 Abbreviations AC Before meal PC After meal PRN As needed (Dangerous abbreviation)...

Eslam Fahmy https://t.me/splenotes 00201011922837 Abbreviations AC Before meal PC After meal PRN As needed (Dangerous abbreviation) HS - BT At bedtime PO By oral PR By rectum OD Once a day BID Twice a day TID Thrice a day QID Four times a day Tw Twice a week QD Every day QOD Every other day QH Every hour QAM Every morning QPM Every night Q4H Every 4 hours BD Before dinner BBF Before breakfast Per diem Daily – Per day C With CC Cubic centimeter S Without Rx Treatment Hx History Dx Diagnosis Fx Fracture G - Gm Gram Gr Grain Oz Ounce Mg Milligram Mcg Microgram Meq Milliequivalent TSF Teaspoonful = 5 ml IM Intramuscular IV Intravenous ID Intradermal SC - SQ Subcutaneous SOS If needed Cap Capsule  Eslam Fahmy https://t.me/splenotes 00201011922837 Antidotes Poison/Drug Antidote Anticholinergics (Atropine, Benztropine Physostigmine Xss CNS depression from Diazepam Isoniazid (INH) Vitamin B6 (Pyridoxine) Valproic acid L-carnitine Methotrexate (MTX) Leucovorin Methemoglobinemia inducing agents: Methylene blue Nitrites, Nitrates Digoxin Digibind, Digifab Beta blockers Glucagon Calcium channel blockers Calcium - Glucagon Opioids (Morphine, Heroin, Codeine, Fentanyl Naloxone – Naltrexone - Nalmefene Benzodiazepine (Diazepam, Zolpidem Flumazenil TCA (Imipramine, Amitriptyline) Sodium bicarbonate Warfarin Vitamin K1 (Phyto-menadione) Heparin Protamine sulfate Dabigatran Idarucizumab Thrombolytics Aminocaproic acid (Streptokinase, urokinase, alteplase, Reteplase) Tranexamic acid Nerve gases Atropine followed by Pralidoxime (2-PAM) Organophosphorus insecticides Carbamate insecticides Atropine Cyanide gas Sodium thiosulfate – Amyl nitrite – Na nitrite Chlorine gas Sodium bicarbonate Carbon monoxide 100% O2 Hydrogen sulfide Sodium nitrite Methanol Ethanol – Fomepizole – Folic acid - Leucovorin Ethylene glycol Ethanol – Fomepizole - Pyridoxine Iron (Fe) Deferoxamine Lead (Pb) D-Penicillamine – CaEDTA – Dimercaprol – DMSA - BAL Arsenic BAL Thallium Prussian blue Mercury BAL – DMSA Cupper D-penicillamine Lithium (Li) Sodium bicarbonate - Polystyrene sulfonate Paracetamol/Acetaminophen N-Acetyl cysteine (NAC) Aspirin (Salicylic acid) Alkalinization (NaHCO3) Sulfonylurea Octreotide Insulin Dextrose 50% Crotaline snake bites (e.g. Rattle snakes) Crotalidae anti-venom (CroFab) Black widow spider venom Latrodectus anti-venom Brown recluse spider bite Loxosceles anti-venom Scorpion sting Scorpion anti-venom Clostridium botulinum Botulinum anti-toxin Sevelamer controls high blood levels of phosphorus in people with chronic kidney disease who are on dialysis.  Eslam Fahmy https://t.me/splenotes 00201011922837 Protein ❖ Essential and non-essential amino acids Essential Non-essential I Isoleucine The rest Love Lysine Lucy Leucine Very Valine Much Methionine Please Phenylalanine Try Tryptophan To Threonine Help Histidine Arginine Arginine Glycine and Taurine amino acids → conjugation in liver There are 4 amino acids that are considered the best when it comes to producing keratin: Cysteine, Lysine, Arginine and Methionine. M A L C →→ Present in hair and nail. Lipid Essential fatty acids Non-essential fatty acids Linolenic acid Palmitic acid Linoleic acid Oleic acid Carbohydrates Monosaccharides Glucose Galactose Fructose Disaccharides Sucrose Maltose Lactose Polysaccharides Starch Glycogen Cellulose  Eslam Fahmy https://t.me/splenotes 00201011922837 Classification of adverse drug reactions Type Features Examples Management A Augmented Common 1- Drugs with narrow TI ✓ Reduce dose or withhold Related to pharmacological action. 2- Toxic effects of drugs: Predictable Digoxin toxicity ✓ Low mortality (↓↓) Serotonin toxicity with SSRI Dose related Anticholinergic effects of TCA B Bizarre Uncommon 1- Penicillin hypersensitivity ✓ Withhold and avoid in future Not related to pharmacological action. 2- Idiosyncratic reactions: Unpredictable Acute porphyria  High mortality (↑↑) Malignant hyperthermia Non-dose related Pseudo allergy C Chronic Uncommon 1- Cortisone for long time cause ✓ Reduce dose or withhold. Dose related → Related to cumulative dose suppression of Hypothalamic pituitary ✓ withdrawal may have to be Time related adrenal axis. prolonged. D Delayed Uncommon 1- Teratogenicity ✓ Intractable Time related 2- Carcinogenesis 3- Tardive dyskinesia E End of use (Withdrawal) Uncommon 1- Opiate withdrawal syndrome ✓ Reintroduced Occur soon after withdrawal of drug. 2- Beta blocker withdrawal ✓ withdraw slowly Myocardial ischemia) F Failure Common 1- Oral contraceptive failure when taken ✓ Increase dosage Often caused by drug interaction with enzyme inducer drug.  Eslam Fahmy https://t.me/splenotes 00201011922837 Classification of Heart Failure AHA Risk factors Disease Symptoms A ❌ ❌ B ❌ C Structural heart disease D Advanced heart disease with continued HF NYHA Severity Symptoms Exercise 1 Mild ❌ 2 Mild With moderate exercise 3 Moderate With minimal exercise 4 Severe With no exercise (At rest)  Eslam Fahmy https://t.me/splenotes 00201011922837 Corticosteroids equivalent doses Glucocorticoid Equivalent dose Cortisone 25 mg Hydrocortisone 20 mg Prednisone 5 mg Prednisolone 5 mg Methylprednisolone 4 mg Triamcinolone 4 mg Betamethasone 0.6 – 0.75 mg Dexamethasone 0.75 mg  Eslam Fahmy https://t.me/splenotes 00201011922837 Drug information resources Definition Examples Advantages Disadvantages 1 ry First hand information, Study designs 1- Access to detailed 1- Misleading conclusion based on the results of only meaning that you are Journal article of original research information about a topic. one trial without the context of other researches. reading author's own Conference papers 2- Ability to personally 2- Need good skills in medical literature account on specific topic. Dissertations assess the validity and 3- Time needed to evaluate large volume of data Technical reports utility of study results. available. 3- More recent than 2ry or Patents 3ry resources 2ry Indexing and abstracting Medline (PubMed, EBSCO, Ovid) systems that organize Iowa drug information service (IDIS) ❌❌❌ ❌❌❌ provide easy retrieval of 1 ry International pharmaceutical resources. abstracts (IPA) LexisNexis Review articles Google scholar ry 1ry and 2ry resources Textbooks/Books 1- Lag time between publication and tertiary resource 3 information which has been ATLAS ❌❌❌ 2- Information in 3ry resource may be incomplete collected and distilled. Treatment guidelines 3- Errors in transcription and interpretations They present summaries. Dictionary 4- Human bias Encyclopedia 5- Lack of experience Electronic data bases a- Micromedex b- Lexicomp Facts and comparisons Review articles in journals Review articles and editorials are not 1ry resources. ❖ Consumer health information: National library of medicine www.medlinelus.gov FDA www.fda.gov Thomson health care www.gettingwell.com Merck www.merckhomeedition.com National women's health information center www.4women.gov  Eslam Fahmy https://t.me/splenotes 00201011922837 Text books Databases/Applications Adverse drug Meyler's side effects of drugs Dailymed reactions Side effects of drugs annual 40 EMC EMA Drugs@FDA Medscape Drug.com Rxlist Pharmaceutical Trissel's stability of compounded formulations ❌❌❌ compounding Remington the science and practice of pharmacy Pediatric drug formulations IV medications Handbook of injectable drugs ASHP's interactive handbook on compatibility and King guide to parenteral admixtures injectable drugs stability Pediatric injectable drugs Renal dose Drug prescribing in renal failure ❌❌❌ adjustment The renal drug handbook Renal pharmacotherapy Medication safety Drugs in pregnancy and lactation Lexicomp in pregnancy and Drugs during pregnancy and lactation Micromedex lactation Hale's medications and mothers' milk Medicines Complete Brigg's drugs in pregnancy and lactation Clinical Key Drug interactions Stockley's drug interactions Lexi interact Drug laboratory Basic skills in interpreting laboratory data interference Laboratory tests and diagnostic procedures Pediatric dosage Pediatric injectable drugs recommendations Neonatal formulary Pharmacokinetics Winter's basic clinical pharmacokinetics Applied biopharmaceutics and pharmacokinetics Pharmacology Basic and clinical pharmacology Good and Gilman's the pharmacological basis of therapeutics Pharmacotherapy Pharmacotherapy a pathophysiologic approach Uptodate Pharmacotherapy principles and practice Dynamed plus Micromedex Access Pharmacy Access medicine Clinical Key BMJ best practice Toxicology Goldfrank's toxicologic emergencies NIH Casarett and Doull's toxicology LiverTox Poisoning and drug overdose Toxnet Herbal, natural ❌❌❌ NIH - Dietary supplements label products and database alternative Medline plus – Herbs and supplements medicine Altmedex International Martindale the complete drug reference drugs Identification of ❌❌❌ Identidex unknown pills Lexi-drug ID Clinical trials ❌❌❌ Pubmed ClinicalTrials.gov  Eslam Fahmy https://t.me/splenotes 00201011922837 Color drug refrences Orange book FDA Provides a list of approved drug products and indicates which drugs can be interchanged (e.g. Zocor can be substituted with simvastatin) Pink book CDC Provides information on epidemiology and vaccine-preventable diseases Purple book FDA Provides list of biological drug products and indicates which biological products are biosimilar Red book Pharmacy Provides drug pricing information (Micromedex) Red book Medicine Summaries of infectious diseases (AAP) Summaries of antimicrobial treatments Summaries of vaccination Yellow book CDC Provides health information for healthcare professionals who advise international travelers of health risks, vaccines and prophylaxis medications. Green book FDA Provides information about approved animal drug products  Eslam Fahmy https://t.me/splenotes 00201011922837 Questions 1- Which of the following statements is TRUE about tertiary resources? a) Tertiary resources should not include a bibliography. b) Textbooks usually include the most recent literature and/or information. c) Tertiary resources include computer databases and textbooks d) The credentials and expertise of the authors of a tertiary resource are not important =========================================== 2- Which of the following resources would be appropriate for identifying a drug manufactured in a foreign country? a) Martindale: The Complete Drug Reference b) Clinical Pharmacology c) Trissel's stability of compounded formulations d) AHFS =========================================== 3- Which of the following resources could be appropriate for identifying the tablets with the imprint code of APO-K 600? a) Identidex b) Lexi-Drugs ID (Lexicomp Online) c) Brigg's drugs in pregnancy and lactation d) A and B =========================================== 4- Which of the following resources could be appropriate for determining the adverse effects of ginkgo biloba? a) Altmedex b) Natural medicines database c) Trissel's stability of compounded formulations d) A and B =========================================== 5- Which of the following resources would be appropriate in evaluating the drug interaction between Clopidogrel and escitalopram? a) Lexi-Interact b) Trissel's stability of compounded formulations c) Stockley's drug interactions d) A and C ============================================ 6- Which of the following resources would be appropriate for determining whether Amlodipine causes edema? a) Brigg's drugs in pregnancy and lactation b) Trissel's stability of compounded formulations c) Meyler's side effects of drugs d) Stockley's drug interactions ============================================= 7- What resource should be used when searching for the most current clinical trials on the use of novel anticoagulants for pulmonary embolism? a) Pharmacotherapy, the pathophysiologic approach b) PubMed c) Uptodate d) Micromedex  Eslam Fahmy https://t.me/splenotes 00201011922837 Drugs used in pregnancy Hypertension Methyldopa Labetalol Hydralazine HTN + Hypoproteinemia + Seizures MgSO4 Asthma Cromolyn (Category B) Gestational diabetes Insulin Metformin Headache Paracetamol DVT Heparin not Warfarin (Category X) Tonic clonic seizures Valproic acid + Folic acid Epilepsy Lamotrigine or levetiracetam Depression (Mild) Fluoxetine Hypothyroidism Levothyroxine Hyperthyroidism Propylthiouracil (PTU) Methimazole Nausea and vomiting Cyclizine UTI Nitrofurantoin UTI + G6PD deficiency Cefuroxime Otitis media Azithromycin Chlamydia Syphilis Benzathine penicillin - Penicillin (Ampicillin) Vaginal discharge + Candida albicans Clotrimazole Herpes (Genital infection) Acyclovir 400 bid for 7 days Hepatitis B Tenofovir HIV Abacavir and Lamivudine Malaria Chloroquine, Hydroxychloroquine Trichomoniasis Metronidazole  Contraindications Misoprostol category X cause abortion Vitamin A is contraindicated in high doses Castor oil is contraindicated as laxative ACEi cause renal dysfunction in fetus Naproxen cause uncontrolled bleeding to baby Finasteride cause genital malformation to infant Warfarin (category X) cause cranial facial abnormalities → nasal bone hypoplasia ❖ Notes Inactivated influenza vaccine can be given in pregnancy Glargine (long acting) is category B Paracetamol oral and rectal is category B – when taken IV is category C Sensitive to ampicillin give Erythromycin ❖ Doses Dose of Thyroid Hormone in Pregnancy? 1.0 - 2.0 microgram/kg/day Eslam Fahmy https://t.me/splenotes 00201011922837  Ethics By Eslam Ashraf Fahmy https://t.me/splenotes  Eslam Fahmy https://t.me/splenotes 00201011922837 Ethics Ethics Law Unenforceable norms and values guide behavior Values written into enforceable standards of behavior There are no specific laws Laws are enforced by the justice system. ❖ Main ethical principles (Basic principles of ethics) → Moral rules 1- Autonomy The right of individuals to self-rule and make decisions about: 1- what will happen to their bodies. 2- what choices will be made among competing options 3- what they choose to take, or not take, into their bodies 4- choice among health care providers 5- choice of refusing medical treatment. Exceptions to the theory of autonomy: – weak paternalism: if one lacks the ability to make an autonomous decision, then it is up to health care provider – the harm principle: making the wrong decision or a decision that will cause harm to themselves. Privacy: another rule within the principle of autonomy which means the right of the individual to control his or her affairs without interference. 2- Beneficence To do good (Benefit the patient). 3- Non-maleficence Prevention of harm and the removal of harmful conditions. 4- Justice Treat all patients fairly (Fairness and equity to all) Example: Ask the patient to stand in que. ❖ Principles of professionalism: 1- Accountability Activities, responsibilities and results 2- Altruism Do the best for the best interest of the patient. (Not self-interest) 3- Duty Commitment to the service 4- Honor Highest standard of behavior and good conduct. 5- Integrity Adherence to ethical principles and refusal to violate personal codes. ❖ Common characteristics of professionalism 1- Knowledge 2- Ethics 3- Social sanction = Public trust ❖ Competence, Trustworthiness, and Caring Pharmacists should be aware of the basic moral responsibilities that all health care practitioners have toward their patients. There are three characteristics that a pharmacist should possess: 1- Pharmacists must be competent. They must possess the knowledge base that at least minimally allows them to carry out their Functions as reliable therapeutic experts. 2- Pharmacists must be trustworthy. Patients must know that they can seek the confidential advice and assistance of their pharmacist and that their wishes will be carried out. 3- Pharmacists must care for and about their patients. As the 1995 American Pharmaceutical (now Pharmacists) Association (APhA) Code of Ethics directs, -A pharmacist places concern for the well- being of the patient at the center of professional practice." pharmacists who do spend time with their patients and attempt to understand their concerns are much more likely to be viewed as caring. ❖ Ethical principles and moral rules: Veracity Pharmacists should be honest in their dealings with patients. (Telling the truth) violation of veracity may be ethically justifiable (as with the use of placebos) patients have a right to expect that pharmacist will be frank in dealings with them. Fidelity ❖ it means that the pharmacists demonstrate loyalty to their patients, regardless of the length of the professional relationship ❖ Trust and keep promises. 1- Covenantal fidelity: is often described as an intimate and spiritual commitment between individuals. Examples would include the fidelity of marriage and the fidelity between a member of the clergy and his or her congregation. 2- Contractual fidelity It does not involve a level of commitment beyond that owed another as the result of a binding agreement. An example of this form of fidelity would be the relationship one might have with a contractor such as a plumber or electrician. Informed Consent What and how much information about a medication should be given to a patient patients must be fully informed about the benefits and risks of their participation in a clinical trial, taking a medication, or electing to have surgery, and this disclosure must be followed by their autonomous consent. Informed consent is obtained: Formally Informally For legal and ethical reasons Whenever a pharmacist counsels a Ex: clinical trials, research, surgery patient and dispenses a medication to a patient, a type of informal occurs. The patient is informed about the benefits and any risks of the drug, and then decides whether to take it or not. Confidentiality Revealing information about a patient's medications to members of the family Medical confidentiality need not be requested by patients; all medical information, is considered confidential, unless the patient grants approval for its release. Refuse or give Ethical situations: privileged information – Members of the health care team may have access to confidential medical records without the consent of the patient. – A patient who expresses a desire not to have information reveal to a member of the health care team. – Exceptions: Weak paternalism, Harm principle Full disclosure Inform the patients about Benefit and risk then decide what to do. Patient centered care Pre-vision information about the patient: Culture competition – Confidentiality – Full disclosure Patient adherence Help the patient to stick to the drug dose and time (Help not to force) Respect for persons Duty to the welfare of the individual, particularly described in religion. Excellence Efforts and commitment of life-long learning and ongoing professional development Humanism Respect and compassion for others Distributive justice Equal distribution of the benefits and burdens of among all members of society. Pharmacists do not always provide care with equal dedication to all patients. Patient's socioeconomic status often impact the level and intensity of care provided by health care professionals. Medicaid patients are sometimes provided a much lower quality of care than a patient who is a cash-paying customer or who has a full coverage drug benefits plan. Justice demands that the focus be on patients and their medical needs, not on the financial impact on the health care professional.  ❖ Macro ethical issues vs Micro ethical situations Macro ethical issues Micro situations issues that are not specific to a given pharmacist, but issues that may confront individual pharmacists in the rather are those that must be addressed by all course of their daily practice. pharmacists and by society in general. Abortion The use of placebos Assisted suicide Patient confidentiality Genetic engineering Informed consent Rationing of and access to health care Organ transplantation In vitro fertilization. Sometimes, macro issues are manifested in micro situations. This is especially true with socially controversial issues. For example, a pharmacist may receive a prescription for a drug and know that it is intended for use in an assisted suicide. Not only must the pharmacist deal with the legal issues involved, but also with the ethical responsibility as a health care professional. A further complication in such situations is the influence of the pharmacist's personal beliefs in choosing the course of action. ❖ Ethical conflicts and issues in health care Law and Ethics Example 1 Example 2 what should a pharmacist do when a patient's what if the medication is a controlled substance prescription for heart medicine has been used for pain control in a terminally ill patient? depleted, no refills remain, and the prescriber is unavailable? Most pharmacists would do the ethical thing and The potential for legal action from drug provide such patients with a few doses to hold enforcement authorities might make a them over until a new prescription can be pharmacist reluctant to dispense extra doses, obtained, even though this course of action is even though the patient might be in just as much illegal need. Assisted Suicide Medical euthanasia (mercy killing) has long been an ethical issue Legally it is not set yet whether to support or to prohibit. From an ethical perspective, the key issue remains whether assisted suicide violates the Hippocratic responsibilities of health care practitioners to do no harm. – Those who advocate its availability to patients suggest that allowing a patient to continue to experience unrelenting pain is doing harm. – They suggest that patients have the right to make an autonomous decision to end their life; their opponents worry that legal assisted suicide would be abused. Human Drug Two important ethical aspects of human drug experimentation are Experimentation 1- The role of the institutional review board ORB Review protocol for ethical purposes, clinical experiments or before animal studies Making sure that the rights and welfare of the patient-subject are protected evaluate and approve informed consent forms used in conjunction with the research 2- The use of placebos. placebos are agents devoid of pharmacologic activity and have served as a point of comparison for determining therapeutic efficacy Patients do not receive any benefits (beneficence) Eslam Fahmy https://t.me/splenotes 00201011922837  Eslam Fahmy https://t.me/splenotes 00201011922837 Questions 1) The Drug Enforcement Administration (DEA) regulations require pharmacies to keep controlled substances records, including prescriptions for at least ………. a) two years b) three years c) four years d) five years. -------------------------------------------------------------------------------------------------------------------- 2)………… are issues that are not specific to a given pharmacist, but rather are those that must be addressed by all pharmacists and by society in general. a) Macro ethical issues b) Micro ethical issues c) Micro situations d) Macro situation -------------------------------------------------------------------------------------------------------------------- 3) revealing information about a patient's medications to members of the family is example of: a) patient confidentiality b) informed consent c) informed refusal d) express consent -------------------------------------------------------------------------------------------------------------------- 4) Pharmacist must possess the knowledge base that's at least minimally allows them to carry out their Functions as reliable therapeutic experts. This is called: A) Competency. b) Caring c) Trustworthiness. d) Knowledge. -------------------------------------------------------------------------------------------------------------------- 5) …………………………… is the right of individuals to make decisions about what will happen to their bodies, what choices will be made among competing options, and what they choose to take, or not take, into their bodies, choice among health care providers, and the choice of refusing medical treatment. a) Autonomy b) Beneficence c) Nonmaleficence d) justice -------------------------------------------------------------------------------------------------------------------- 6) …………………….. indicates that you act in a manner to do good. a) Autonomy b) Beneficence c) Nonmaleficence d) justice -------------------------------------------------------------------------------------------------------------------- 7) ……………………. is sometimes used more broadly to include the prevention of harm and the removal of harmful conditions. a) Autonomy b) Beneficence c) Nonmaleficence d) justice 8) ……………………….. means that the pharmacists demonstrate loyalty to their patients. Pharmacists have an obligation of fidelity to all their patients, regardless of the length of the professional relationship. a) Autonomy b) Beneficence c) Nonmaleficence d) Fidelity -------------------------------------------------------------------------------------------------------------------- 9) ……………………. is the ethical principle that instructs pharmacists to be honest in their dealings with patients? a) Autonomy b) Beneficence c) Nonmaleficence d) veracity -------------------------------------------------------------------------------------------------------------------- 10) ……………………refers to the equal distribution of the benefits and burdens of society among all members of this society. a) Autonomy b) Beneficence c) Nonmaleficence d) distributive justice -------------------------------------------------------------------------------------------------------------------- 11) euthanasia means: a) Autonomy b) Beneficence c) Nonmaleficence d) mercy killing -------------------------------------------------------------------------------------------------------------------- 12) if one lacks the ability to make an autonomous decision, then it is up to health care provider, this is called: a) weak paternalism b) strong paternalism c) the harm principle d) autonomy. -------------------------------------------------------------------------------------------------------------------- 13) making the wrong decision or a decision that will cause harm to themselves is called: a) weak paternalism b) strong paternalism c) the harm principle d) autonomy. -------------------------------------------------------------------------------------------------------------------- 14)………………. are unenforceable norms and values guide behavior a) ethics. b) morals. c) laws. d) rules. -------------------------------------------------------------------------------------------------------------------- 15) ………………………. values are written into enforceable standards of behavior a) ethics. b) morals. c) laws. Eslam Fahmy d) rules. https://t.me/splenotes 00201011922837  Eslam Fahmy https://t.me/splenotes 00201011922837 Immunology definitions Immunology Branch of biomedical science that covers the study of all aspects of immune system. Hapten Small molecule which could never induce an immune response when administered alone but can induce immune response when coupled to a carrier protein Antigen Foreign material causing an immune response Antibody Specific substance formed in the body in response to antigenic stimulation and react specifically with antigen 1st line defense 2nd line defense 1- Anatomical barriers 1- Inflammation Skin 2- Fever Cilia in respiratory tract 3- Natural killer cells 2- Mucous membrane and their secretions 4- Phagocytic white blood cells 3- Bacterial flora 5- Antimicrobial substances Coagulation system Lactoferrin and transferrin Lysozymes Interferons Innate & adaptive immunity T cell maturation occurs in the bone marrow, stored in thymus gland then circulate to various destinations. T-lymph found intracellularly  Eslam Fahmy https://t.me/splenotes 00201011922837 Types of hypersensitivity reactions A B Type 2 C D Type 1 Type 3 Type 4 Name Immediate Cytotoxic Immune complex Delayed Allergic Complement activation Antigen form Soluble Cell bound Soluble Cell bound & Soluble Humoral component IgE IgG - IgM IgG - IgM None Cellular component Mast cells Macrophages Neutrophils T cells - Macrophages Examples 1. Anaphylaxis 1. Blood transfusion reactions 1. Serum siCkness 1. Tubercular lesion 2. Allergies → e.g. peanut 2. ErythroBlastosis fetalis 2. Lupus 2. Contact Dermatitis 3. Hemolytic anemia 3. Graft rejection Types of Immunoglobulins IgG IgA IgM IgD IgE Other name Secretory Ig Macroglobulin Structure Monomeric Monomer in Pentameric Monomeric Monomeric serum Dimer in secretions Serum conc. nd 1st → 80% Highest 2 → 10:15 % 3rd → 5:10 % 4th → 0.2% 5th → 0.002% Lowest Half life 23 days 7 days 5 days 2:8 days 2:3 days Size Smallest Largest Pass placenta Yes No No No No Fix complement Yes No Yes No No Neutralize toxins Present in milk 1st primary immune Differentiation of Type 1 (Colostrum) response after allergic lymphocytes hypersensitivity stimulus (Allergic reactions)  Eslam Fahmy https://t.me/splenotes 00201011922837 Maslow's hierarchy of needs  Eslam Fahmy https://t.me/splenotes 00201011922837 Type of medication errors Prescribing Inappropriate drug selection, dose, dosage form or route of administration ‫الدكتور غلط في اختيار الدوا – جرعته – طريقة أخذه‬ ▪ Omission Patient doesn't receive a scheduled dose of medication. ‫ن‬ )‫مرتي (نىس جرعة‬ ‫ مرات يوميا – هو خد‬3 ‫الدوا مثال‬ ▪ 2nd most common error in the medication use process. Unauthorized drug Drug was not authorized by an appropriate prescriber ‫الل ن يف الروشتة أو من غي روشتة خالص‬ ‫المريض خد دوا غي ي‬ ▪ ‫ن‬ ‫ن‬ ▪ Medication given to wrong patient ‫مريضي‬ ‫تان – عكست دوا‬ ‫الممرضة أدت دوا لمريض ي‬ Wrong time Drug not administered in accordance to the interval ‫ ن يف األخطاء‬1 ‫رقم‬ ▪ 1st common error in the medication use process. Wrong dose The dose administered is different from that prescribed ‫الل ن يف الروشتة‬ ‫خد جرعة غلط غي ي‬ ▪ Wrong dosage form Dosage form different from that prescribed ‫مكتوبلة نيورتون حقن و انت اديتله نيوروتون أقراص‬ ▪ Wrong preparation Reconstitution error ‫المريض غلط و هو بيحل المضاد الحيوي‬ ▪ IV admixture compounding error Wrong administration Drug is given to a patient inappropriately ‫الدوا اتاخد غلط – هو عضل مثال و انت اديته وريد‬ ▪ IM drug given IV Deteriorated drug Patient given expired or deteriorated drug ‫منته‬ ‫ي‬ ‫مريض بياخد دوا بايظ أو تاري خ صالحيته‬ ▪ Monitoring Patients are not monitored appropriately ▪ Compliance Patients use medications in an inappropriate way ‫المريض مش عارف يستخدم الدوا‬ ▪ Patient use metered dose inhaler in wrong way ‫ المريض مش عارف ستخدم بخاخة الصدر‬: ‫مثال‬ ▪ Duplication error 2 drugs from the same class are prescribed. ‫مكتوبي ن يف نفس الروشتة‬ ‫ن‬ ‫دوا ن‬ ‫يي من نفس العيلة الدوائية‬ ▪  Eslam Fahmy https://t.me/splenotes NCC MERP index for categorizing 00201011922837 Classification of medication errors medication errors Error Harm Notes No error A ❌ ❌ Possibility of error but no error occurred. Error + No harm B ❌ Error did not reach patient C ❌ Error reach patient → cause no harm D ❌ Error reach patient → cause no harm, but need ↑ Monitoring Error + Harm E Temporary harm Treatment and intervention F Temporary harm Prolonged hospitalization G Permanent harm H Near death harm Anaphylaxis and cardiac arrest Error + Death I Death ❖ Medication reconciliation the process of comparing a patient's medication orders to all of the medications that the patient has been taking. This reconciliation is done to avoid medication errors such as omissions, duplications, dosing errors, or drug interactions. It should be done at every transition of care in which new medications are ordered or existing orders are rewritten  Microbiology By Eslam Ashraf Fahmy https://t.me/splenotes  Gram (+) Gram (-) Thickness (20:80) nm thickness (Thick) (2:3) nm thickness (Thin) Peptidoglycan Numerous layers of peptidoglycan (60%:90%) of the cell wall 2:3 layers of peptidoglycan (10%:20%) of the cell wall Lipopolysaccharides ❌ Outer membrane ❌ Periplasm Gelatinous material // cytoplasmic membrane and Peptidoglycan Gelatinous material // cytoplasmic membrane and Outer membrane Numerous layers of peptidoglycan → Retain crystal violet dye after 2 layers of peptidoglycan → removal of crystal violet dye after alcohol alcohol use (No decolorization) → stain dark violet use (decolorization) → accept counter stain "Safranin" → Pink Stain Eslam Fahmy https://t.me/splenotes 00201011922837  Shape Arrangement Name Draw Description Example Cocci Cocci spherical Staphylococcus aureus Bacilli rod Bacillus anthrax Coccobacilli Cocci and bacilli shape Haemophilus influenzae Vibrio comma like shape Vibrio cholera (Curved rods) Spiral wavy undulating Helicobacter pylori (Corkscrew) Bacilli Spirochaetes Tightly coiled Treponema pallidum Helical Helicobacter pylori Club Corynebacteriaceae Fusobacterium Fusobacterium novum Filamentous Actinobacteria Notes Filamentous Simple surrounded by sheath Nocardia Staphylococcus aureus → arranged in a grape like cluster Branched similar in appearance to fungal mycelia Pleomorphic Has many shapes can Mycoplasma stretch and contract similar to amoeba  Eslam Fahmy https://t.me/splenotes 00201011922837 Environmental requirements for microbial growth Temperature 1- Psychrophiles 0OC - 15 OC ✓ Flavobacterium species 2- Mesophiles 25OC - 40 OC ✓ Pseudomonads aeruginosa ✓ E. Coli & Staph 3- Moderate thermophiles 55OC - 65 OC ✓ Bacillus stearothermophilus 4- Extreme thermophiles 80OC - 113 OC ✓ Thermococcus celer PH 1- Acidophiles Acidic PH ✓ Lactobacillus acidophilus 2- Neutrophiles Neutral PH ✓ Most bacteria 3- Alkaliphiles Basic PH ✓ Vibrio cholera ✓ Streptococcus pneumonia Oxygen 1- Obligate aerobes Growth occurs only in presence of O2 ✓ Mycobacterium tuberculosis 2- Facultative anaerobes Growth occurs in presence or absence of O2 ✓ Most bacteria Greater growth in presence of O2 ✓ E. coli & Staph 3- Obligate anaerobes Growth occurs only in absence of O2 ✓ Clostridium species 4- Aerotolerant anaerobes Growth occurs in absence of O2 but can grow in presence of O2 ✓ Streptococcus pyogenes 5- Microaerophile aerobes Growth occurs only in presence of low O2 concentration. ✓ H. Pylori  Eslam Fahmy https://t.me/splenotes 00201011922837 Gram (+) bacteria Cocci Aerobic Catalase +ve Catalase -ve Staphylococcus Streptococcus Coagulase +ve Coagulase -ve α hemolysis ß hemolysis Ƴ hemolysis S. aureus Novobiocin sensitivity Partial hemolysis Complete hemolysis No hemolysis S. epidermidis Optochin sensitivity Bacitracin sensitivity Growth in 6.5% NaCl S. saprophyticus S. Pneumonia S. Pyogenes (A) Enterococci (S. Faecium, Faecalis) D ❌ S. Viridians ❌ S. Agalactia (B) ❌ Non-Enterococci (S. bovis) Bacilli Aerobic Anerobic Listeria Clostridium Bacillus Corynebacterium Branched filaments Aerobic Anerobic Nocardia → weak acid fast Actinomyces → Not acid fast  Eslam Fahmy https://t.me/splenotes 00201011922837 Gram (-) bacteria Diplococci Aerobic Maltose utilization Yes No ❌ Neisseria meningitides Neisseria gonorrhea Moraxella Coccobacilli H. Influenza B. Pertussis Pasteurella Brucella F. tularensis Bacilli Lactose fermentation Yes No ❌ Slow Fast Oxidase Yes No ❌ Citrobacter E. Coli Pseudomonads H2S producing Serratia Klebsiella Yes No ❌ Enterobacter Salmonella Shigella Proteus Yersinia Comma shaped Oxidase positive Grows in 42O C Grows in alkaline media Urease producing C. Jejuni V. Cholera H. Pylori  Aerobic Anerobic Need O2 for growth Don't need O2 for growth Gram (+) ve Gram (+) ve ❖ Cocci ❖ Bacilli S. aureus Clostridium S. epidermidis ❖ Branched filaments S. saprophyticus Actinomyces → Not acid fast S. Pneumonia S. Viridians S. Pyogenes (A) S. Agalactia (B) Enterococci (S. Faecium, Faecalis) D Non-Enterococci (S. bovis) ❖ Bacilli Listeria Bacillus Corynebacterium ❖ Branched filaments Nocardia → weak acid fast Gram (-) ve ❖ Diplococci Neisseria gonorrhea Moraxella Encapsulated bacteria SHINE K S Streptococcus Pneumonia Streptococcus group B Salmonella typhi Hi Haemophilus influenza N Neisseria meningitides E E. Coli K Klebsiella Eslam Fahmy https://t.me/splenotes 00201011922837  Eslam Fahmy https://t.me/splenotes 00201011922837 Disk Diffusion Method – Kirby-Bauer Method The bigger the circle the greater the sensitivity. Which antibiotic more susceptible/sensitive? A Which antibiotic more resistant or less susceptible/sensitive? C Which antibiotic more susceptible/sensitive? 1 Which antibiotic more resistant or less susceptible/sensitive? 2  Bacteria Disease Pathogen Plague ✓ Yersinia pestis Dental plaque/carries ✓ Streptococcus mutans Whooping cough ✓ Bordetella pertussis Peptic ulcer ✓ H. Pylori Glycocalyx is a carbohydrate-enriched coating that covers the outside of many eukaryotic cells and prokaryotic cells, particularly bacteria. The DNA of most bacteria is contained in a single circular molecule Virus Viral structure contains: 1- Nucleic acid genome 2- Protein capsid that covers the genome 3- Lipid envelope Nucleic genome + Capsid → Nucleocapsid The entire contact virus is called the virion Fungi Eukaryotic Multicellular Eslam Fahmy https://t.me/splenotes 00201011922837  Eslam Fahmy https://t.me/splenotes 00201011922837 Types of Healthcare Cost Categories: Direct Direct medical Fixed Capital For setting up the service. Counselling rooms equipment. Labor Salary of pharmacists Overhead For running the service Lighting , heating , cleaning , rent Semi fixed Staff Variable Drugs, blood products, disposable equipment Hospitalization Ambulance services – Nursing services Home medical visits / Clinic visits Emergency department visits Diagnostic tests Direct non-medical Patient and family expenses (e.g. transportation, caring) Travel costs (bus, gas, taxi) Hotel stays for patient or family Child care service for children of patients Food (Meals-on) Indirect Costs of ↓ productivity (e.g., morbidity and mortality costs). o Lost wages (morbidity) o Income forgone because of premature death (mortality) Intangible Anxiety Pain and suffering Fatigue Inconvenience Grief Opportunity Economic benefit forgone when using one therapy instead of the next best alternative therapy. Lost opportunity - Revenue forgone Incremental Additional cost that a service or treatment alternative imposes over another compared with the additional effect, benefit, or outcome it provides.  Eslam Fahmy https://t.me/splenotes 00201011922837 Models of Pharmacoeconomic Analysis Cost Minimization Analysis Cost Benefit Analysis Cost Effectiveness Analysis Cost Utility Analysis (CMA) (CBA) (CEA) (CUA) Example Comparing drug A to drug B The benefit to cost ratio of: Drug A (5$) and drug B (10$) Measure the effect of an Drug A saves you 5$ ✓ Hiring a pharmacist = 1.25 Both have the same action intervention on health units Hibiotic & Augmentin  Automated system = 1.15 Drug B cause no gastric that measure both quantity Pharmacist is better than the irritation as drug A. and quality of life. automated system. Aspirin and Aspirin enteric Cancer patient without coated treatment lives for short time in great pain but with treatment lives for longer time in less pain Type of Equivalent Economic Clinical Humanistic outcome Outcome Assumed to be equivalent in Monetary outcome ❖ Natural units Quality Adjusted Life Year measurement comparable groups analysis. Dollars $ mmHg blood pressure (QALY) unit mmol/L blood glucose = utility X expected length of time Case cure yes or no Cost measurement Dollars $ Dollars $ Dollars $ Dollars $ unit Notes The two drugs must be ❖ Measured by: ❖ Both must have the same ❖ Outcomes assess patient's equivalent therapeutically Human Capital (HC) unites to be compared. functional status or quality of life then we determine the least Willingness To Pay (WTP) ❖ Calculated by: ❖ Calculated by: costly alternative. Average Cost Effectiveness Rating Scales (RS) Ratio (ACER) Standard Gamble (SG) Incremental Cost Effectiveness Time Trade-Off (TTO) Ratio (ICER) Symptoms Free Days (SFD) % healed  Eslam Fahmy https://t.me/splenotes 00201011922837 ❖ Pharmacoeconomic definition: Description and analysis of the cost of drug therapy to healthcare systems and society.  Eslam Fahmy https://t.me/splenotes 00201011922837 Economic outcome assessment Cost The value of the resources consumed by a program or drug therapy of interest. Total All expenses directly and indirectly. Average The average cost per unit of output. Marginal Extra cost of producing one extra unit of output. Incremental Additional cost. Operating Supports the operation to provide the output. ❖ Types of Healthcare Cost Categories: direct, indirect, intangible, incremental, opportunity Consequence The effects, outputs, and outcomes of the program or treatment alternative. Types of outcomes (ECHO model) Economic The direct, indirect, and intangible costs compared with the consequences of medical treatment alternatives. Clinical The medical events that occur as a result of disease or treatment (e.g., safety and efficacy end points)? Humanistic The consequences of disease or treatment on patient functional status or quality of life along several dimensions (e.g., physical function, social function, general health and well-being, and life satisfaction) Positive Is a desired effect of a drug (efficacy or effectiveness measure), possibly manifested as cases cured, life-years gained, or improved health-related quality of life (HRQOL). Negative Is an undesired or adverse effect of a drug, possibly manifested as a treatment failure, an adverse drug reaction (ADR), a drug toxicity, or even death. Intermediate Can serve as a proxy for more relevant final outcomes. Example: achieving a decrease in low density lipoprotein cholesterol levels with a lipid-lowering agent is an intermediate consequence that can serve as a proxy for a more final outcome such as a decrease in MI rate Perspective the point of view from which a pharmacoeconomically study is conducted. It is important to understand the study perspective because it determines which outcomes and costs will be measured. Ex: If comparing the value of Alteplase (tissue plasminogen activator, or t-PA) with that of Streptokinase. From a patient or societal perspective From a small community hospital's perspective t-PA may be the best-value alternative because a 1% reduction in streptokinase may represent a better value because it provides mortality rates is observed in this large population. similar outcomes for less money. ❖ Common perspectives include those of the: 1- Patient. 2- Provider. 3- Payer. 4- Society. Pharmacogenomics By Eslam Ashraf Fahmy https://t.me/splenotes  Eslam Fahmy https://t.me/splenotes Pharmacogenomics 00201011922837 Precision medicine An approach to disease treatment and prevention that takes in consideration genes, environment and life style. Pharmacogenomics Component of precision medicine (PGX) Study relation // variation in multiple genes and variability of drug response Pharmacogenetics Study relation // variation in single gene…… and variability of drug response Nucleotide Basic structural unit of DNA & RNA Gene Stretch of nucleotides that codes for a single protein DNA Genetic material that is the main component of chromosome Double helix Genotype Set of unique genes that determine specific trait in a person (Creativity) Phenotype Observable trait of genotype (gene responsible for blue eye color) Polymorphism Genetic variation is common 1% or more Genetic variation is inherited Mutation Genetic variation is rare less than 1% Single nucleotide Change in a single nucleotide in a genetic sequence. polymorphism (SNP) Homozygous → 2 alleles are identical. Heterozygous → 2 alleles are different.  Eslam Fahmy https://t.me/splenotes 00201011922837 Abacavir HLA-B (5701) ↑ HLA-B (5701) → Hypersensitivity Allopurinol HLA-B (5801) Hypersensitivity Carbamazepine HLA-B (1502) ↑ HLA-B (1502) → severe dermatologic reactions Oxcarbazepine "Steven-Johnson-Syndrome" → Not prescribed At risk population → At south Asia Phenytoin HLA-B (1502) Hypersensitivity Fosphenytoin Clopidogrel CYP2C19*2 Prodrug that needs CYP2C19*1 for activation. CYP2C19*3 If CYP2C19*2,3 are present → clopidogrel will not be converted into the active form → ↑ CVS events Voriconazole CYP2C19 Patients with intermediate or PM have two-folds to four- folds higher voriconazole exposure. No dose adjustments or genetic recommendations. Warfarin CYP2C9*2 ↑ CYP2C9 *2,3 → ↓ warfarin metabolism → ↑ bleeding CYP2C9*3 ↑ VKORC1 → ↑ warfarin sensitivity → ↑ bleeding VKORC1 Lower doses should be started Celecoxib CYP2C9 ↑ CYP2C9*3 → ↓ Celecoxib clearance Use with caution and at lower doses Codeine CYP2D6 ↑ CYP2D6 → ↑ metabolism of codeine to morphine ↓ CYP2D6 → ↓ metabolism of codeine to morphine Morphine high dose cause side effects such as: respiratory center depression. Risperidone CYP2D6 ↑ CYP2D6 → Fast metabolizers → High exposure Atomoxetine ↓ CYP2D6 → Poor metabolizers Fluoxetine Tamoxifen CYP2D6 Trastuzumab HER2 HER2 (Positive) → Take the drug Pertuzumab HER2 (Negative) → Do not take the drug. ❌ Lapatinib Emtansine Azathioprine TPMT ↓ TPMT → ↑ Risk of Myelosuppression 6-Mercaptopurine Drug should be not given or given at low dose. Capecitabine DPD ↓ DPD → Severe toxicity 5-flurouracil Diarrhea, Neutropenia and Neurotoxicity Primaquine G6PD ↓ G6PD → Hemolytic anemia Rasburicase At risk population → African and Mediterranean Cetuximab KRAS mutation KRAS (Positive) → No response → Not use Panitumumab KRAS (Negative) → Response → use KRAS is G-protein in the EGFR pathway Cetuximab and Panitumumab inhibit EGFR Imatinib CD117 Imatinib is indicated for patients with CD117 mutation Maraviroc CCR5 Maraviroc is a CCR5 receptor antagonist Irinotecan UGT1A1*28 ↑ UGT1A1*28 → Neutropenia Homozygous with higher risk Lenalidomide Chromosome 5q Chromosome 5q deletion → Myelodysplastic syndrome → deletion Hematologic toxicity.  Eslam Fahmy Avoid if positive (+) → HLA-B & KRAS https://t.me/splenotes Avoid if negative (-) → HER2 00201011922837 HER2 → use if positive avoid if negative HLA-B → Avoid the drug if positive TPMT → ↓ TPMT → ↑ risk of myelosuppression KRAS → Avoid the drug if positive DPD → ↓ DPD → Severe toxicity (DNN) G6PD → ↓ G6PD → Hemolytic anemia Pharmacogenomics questions 1- Which of the following is correct? a. Phenotype is the observable trait that results from gene expression b. Humans have one copy of each chromosome c. If the alleles are identical, it is called heterozygous genotype d. If the alleles are different, it is called homozygous genotype 2- Pharmacogenomic testing shows a female patient with breast cancer is HER2 positive. She is likely to benefit from which of the following? a. Ivacaftor b. Leuprorelin c. Trastuzumab d. Rituximab 3- A child is rapid metabolizer of CYP2D6. How would his body respond? a. Codeine would be rapidly metabolized to morphine b. The child will have reduced opioid response c. Codeine will not be converted into morphine d. The child will have severe diarrhea 4- A Chinese patient is going to be started on carbamazepine. He should be tested for: a. HLA-B*1501 allele b. HLA-B*1502 allele c. He does not need pharmacogenomic testing as he is from Asian descent d. A gene because if he is found to have at-risk allele, he is more likely to experience agranulocytosis with the use of carbamazepine. 5- A patient is found to have been lacking in functional CYP2C19 enzyme activity. What would be your recommendation? a. He should not receive Clopidogrel b. He should not receive any CYPC19 enzyme inhibitors such as omeprazole or fluoxetine c. If clopidogrel is administered, he will have increases INR d. He is an ideal candidate to receive Clopidogrel 6- Which of the following best describes chromosome? a. Building blocks of DNA, composed of four bases: adenine (A), Guanine (G), Thiamine (T) and Cytosine (C) b. Organized into 23 pairs (46 chromosomes) as a supercoil structure c. A stretch of DNA that codes for a single protein d. Double helix molecule containing noncovalently bonded nucleotides  Eslam Fahmy https://t.me/splenotes 00201011922837 PPI equivalent doses ❖ PPI Drug Dose (Guide line 1) Dose (Guide line 2) Omeprazole 20 mg once a day 40 mg once a day Lansoprazole 30 mg once a day 30 mg once a day Pantoprazole 40 mg once a day 40 mg once a day Rabeprazole 20 mg once a day 20 mg once a day Esomeprazole 20 mg once a day 40 mg once a day )Pantoprazole( ‫ مج يوميا و هو غير متوفر و لكن متوفر‬20 ‫) بجرعة‬Omeprazole( ‫بكل بساطه لو مريض مكتوب في الوصفة (الروشتة) دواء‬ ‫ مج يوميا‬40 ‫) بنفس الجرعة ؟ على حسب الجرعة المكافئة كما موضح بالجدول أي سيتم إعطاء المريض‬Pantoprazole( ‫هل نعطي‬.‫الجرعات المكافئة قد تختلف من مرجع آلخر و على حسب الحالة المرضية‬  Regulations By Eslam Ashraf Fahmy https://t.me/splenotes  Eslam Fahmy https://t.me/splenotes 00201011922837 High Alert Medications (HAM) Adrenergic agonist Epinephrine, norepinephrine, phenylephrine Adrenergic antagonists Propranolol, metoprolol, labetalol Anesthetic agents Propofol, ketamine Antiarrhythmics Lidocaine, amiodarone Antiviral agents Anticoagulant Heparin, LMW heparin (Enoxaparin, Dalteparin Warfarin Factor 10 inhibitors (Fondaparinux, Apixaban Factor 2 inhibitors (Argatroban, Dabigatran Antiplatelet ADP receptor blocker → Ticlopidine, clopidogrel 2b/3a receptor blocker → Abciximab, eptifibatide Fibrinolytics Streptokinase, urokinase, alteplase, reteplase Chemotherapy Hormonal therapy Oxytocin Electrolytes Sterile water for injection Dextrose ≥ 20% NaCl > 0.9% KCl injectable Dialysis solutions Epidural and intrathecal solutions Inotropic drugs Digoxin Insulin Sulfonyl urea Chlorpropamide, Glimepiride Liposomal forms of drugs Amphoteracin B Narcotics and controlled drugs Morphine, Fentanyl, pethidine Lorazepam, Diazepam Neuromuscular blocking agents Succinylcholine, vecuronium Parenteral nutrition preparations Total parenteral nutrition solution (TPN) ❖ Notes: o Specific label or color ✓ Narcotic drugs → Red Label ✓ Controlled drug → Yellow Label Consultant and specialist are only allowed to prescribe HAM Telephone orders not allowed in HAM → Verbal orders are allowed in case of emergency only. Must be double checked before administration. Limit access to HAM All IV HAM are administrated via IV pump. All IV infusions are standardized in mMole or mequ. Using "U" instead of units is not accepted for insulin and Heparin Concentrated electrolytes should not be stocked in patient care area. Parenteral nutrition bags → Remove from refrigerator 0.5 hour before usage. IV anesthesia & Skeletal muscle relaxant → Stocked in ER, OR, ICU Dextrose 50% (D50W) → Stocked for dialysis patients for treating sudden hypoglycemia.  Narcotic, controlled and psychotropic drugs Narcotic drugs Addicted drugs reduce pain and induce euphoria, lead to ↑ tolerance and psychological dependence. Controlled drugs Drug with potential to be abused or addicted which is held under strict control. Psychotropic drugs Affecting mind, emotions and behavior. ❖ Patient own narcotic and controlled medication shall be kept in the inpatient pharmacy in narcotics and controlled drugs cabinet separately from the regular stock medication → not kept in patient cassette or trolly. ❖ Narcotics and controlled drugs are stored behind steel door with double lock. ❖ No one allowed to enter inside narcotic and controlled drugs except: 1- Pharmacy staff 2- Anesthesia department 3- Assigned nursing staff. Strength and quantity of narcotics and controlled drug must be written clearly in words and figures. No strike-over, erasers or misspelling of drug name, strength or quantity. ID number should be written with physician name. Physician cannot prescribe narcotic or controlled drug to himself or family. Empty ampoule returns to the pharmacy with documents. Use the closest size ampoule for required dose. Unused drugs (tablets) must be returned to the pharmacy in charge. Replace used ampoules from pharmacy within 3 days from date of Rx ❖ Prescription dispensing: Narcotics and controlled Injections not dispensed for outpatient or ambulatory patients to be used outside tablets or patches are allowed to be given to outpatients. Psychotropic IV or tablets are allowed to be given in OPD 1- Psychiatrist Dispense as long as indicated. 2- Neurologist, Neurosurgeon Dispense Maximum of 3 Months. 3- Non-Psychiatrist Dispense Maximum of 1 Month. (consultant and specialist) 4- ER department Dispense Maximum of 1 day. If drug is not available → original stamped Rx by the pharmacy department & copy given to the patient to be dispensed from other hospital or street pharmacy & Copy kept in patient File. ❖ Prescripti