Dispensing (PHA 055)

CHAPTER 5
MEDICATION RELATED PROBLEMS
Drug related problems - an event or circumstance involving drug therapy that
actually or potentially interferes with desired health outcomes; a patient problem that
is either caused by a drug or may be treated or prevented by a drug.
Drug therapy problems - is any undesirable event experienced by a patient which
involves, or is suspected to involve, drug therapy, and that interferes with achieving
the desired goals of therapy.
COMPONENTS:
1. Problem – undesirable event or risk of an event experience by the patient.
2. Drug therapy involved.
3. Relationship that exists between the patient and drug therapy.
a. Consequence of drug therapy.
b. Require the addition or modification of drug therapy.
CATERGORIES AND CAUSES OF DRUG RELATED PROBLEMS

Need Problem Causes

Appropriate indication Unnecessary drug therapy  No medical
indication
 Addiction/
Recreational use
 Non drug therapy
more appropriate
 Duplicate therapy
 Treating avoidable
ADR
Effectiveness Wrong drug  Dosage form
inappropriate
 Contradiction
present
 Condition refractory
to drug
 Drug not indicated
condition
 More effective drug
available
Effectiveness Dose too low  Wrong dose
 Frequency
inappropriate
  Duration
inappropriate
 Incorrect storage
 Incorrect
administration
 Drug interaction
Safety Adverse drug reaction  Unsafe drug for
patient
 Allergic reaction
 Incorrect
administration
 Drug interaction
 Dose increase/
Decrease too fast
 Undesirable effect
Safety Dose too high  Wrong dose
 Frequency
inappropriate
 Dose inappropriate
 Drug interaction
Compliance Inappropriate compliance  Drug not available
 Patient cannot afford
drug
 Patient cannot
swallow/take
 Patient doesn’t
understand
 Patient prefers not to
take
No untreated indications Needs additional therapy  Untreated indication
 Synergistic therapy
 Prophylactic therapy
PROBLEMS:
1. Unnecessary drug therapy

 There is no valid medical indication for the drug therapy at this time.
 Multiple drug products are being used for a condition that requires single
drug therapy.
 The medical condition is more appropriately treated with non-drug therapy
 Drug therapy is being taken to treat an avoidable adverse reaction
associated with another medication.
 Drug abuse, alcohol use, or smoking is causing the problem.
2. Wrong drug/ Ineffective drug

 The drug product is not the most effective for the indication being treated.
 The medical condition is refractory to the drug product.
 The dosage form of the drug product is inappropriate.
 The drug is not effective for the medical problem.

3. Dose too low

 The dose is too low to produce the desired response.

 The dosage interval is too infrequent to produce the desired response.
 A drug interaction reduces the amount of active drug available.
 The duration of drug therapy is too short to produce the desired response.

4. Adverse drug reaction

 The drug product causes an undesirable reaction that is not dose related.
 A safer drug product is required due to risk factors.
 A drug interaction causes an undesirable reaction that is not dose-related.
 The dosage regimen was administered or changed too rapidly.
 The drug product causes an allergic reaction.
 The drug product is contraindicated due to risk factors.

5. Dosage too high

 Dose is too high.

 The dosing frequency is too short.
 The duration of drug therapy is too long.
 A drug interaction occurs resulting in a toxic reaction to the drug product.
 The dose of the drug was administered too rapidly.

The patient developed bradycardia and second degree heart block

resulting from a 0.5 mg daily dose of digoxin used for congestive heart
failure.

6. Inappropriate compliance
Noncompliance is defined as the patient's inability or unwillingness to take a
drug regimen that the practitioner has clinically judged to be appropriately indicated,
adequately efficacious, and able to produce the desired outcomes without any
harmful effects.

 The patient does not understand the instructions.

 The patient prefers not to take the medication.
 The patient forgets to take the medication.
 The drug product is too expensive for the patient.
 The patient cannot swallow or self-administer the drug product
appropriately.
 The drug product is not available for the patient.

7. Needs additional drug therapy

 Illness that requires drug therapy

 Preventive drug therapy to reduce developing condition.
 Synergistic or additive effects

Preventive drugs are considered to be used for preventive purposes if they

are being prescribed primarily, to prevent the symptomatic onset of a
condition in a person who has developed risk factors for a disease that has not
yet become clinically apparent.

The patient is at high risk to contract pneumonia and therefore requires a

pneumococcal vaccine.

Statement describing patient DTPs:

1. A description of the patient's medical condition.
2. The drug therapy involved
3. The specific association between the drug therapy and the patient's
condition.
Example:
WRONG: "the drug she is taking for her high cholesterol is not working."
RIGHT: "The Lipitor (atorvastatin) therapy that she has been taking for the past 3
months for hyperlipidaemia has only resulted in 5% reduction of her total
cholesterol using an aggressive dosage of 80 mg daily."
 PRIORITY IN DRUG THERAPY PROBLEM:
1. Which problems must be resolved (or prevented) immediately and which
can wait.
2. Which problems can be resolved by the practitioner and patient directly.
3. Which require the interventions by someone else (perhaps a family
member, physician, nurse, or some other specialist).

Example:
Consider a 57-year-old male patient who feels the medication he is taking for
his back pain is not being effective (acetaminophen 1000 mg three times
daily). This patient is taking a daily dose of 0.200 mg of levothyroxine (Synthroid)
to manage hypothyroidism. He is also taking 81 mg of enteric-coated aspirin
each morning as primary prevention of heart attack.]

Documenting drug therapy problems

The standard for documenting the patient's drug therapy problems is that each
problem identified is added to the patient's record and includes the medical
condition, illness, or complaint involved, the drug therapy or therapies
involved, and the likely cause of the drug therapy problem.
“Take a break for 10 min”
Rest is also a part of studying

CHAPTER 6
ADVERSE DRUG REACTION
Adverse drug reaction is an unwanted, undesirable effect of a medication that
occurs during usual clinical use.
Adverse drug reactions occur almost daily in health care institutions and can
adversely affect a patient’s quality of life, often causing considerable morbidity
and mortality.
Note Within these few definition I want the reader to only memorize WHO
meaning and make their own understanding for the rest.
ADE as “any untoward medical occurrence that may present during treatment with a
pharmaceutical product but which does not necessarily have a causal relationship with
this treatment”
ADR as “a response to a drug which is noxious and unintended and which occurs
at doses normally used in man for prophylaxis, diagnosis, or therapy of disease or for
the modification of physiologic function.”
WORLD HEALTH ORGANIZATION

ADR
An appreciably harmful or unpleasant reaction, caused by an intervention related
to the use of a medicinal product, which predicts hazard from future administration
and warrants prevention or specific treatment, or alteration of the dosage regimen, or
withdrawal of the product (Edwards).
Any unexpected, unintended, undesired, or excessive response to a drug that requires
discontinuing the drug (therapeutic or diagnostic), requires changing the drug therapy,
requires modifying the dose (except for minor dosage adjustments), necessitates
admission to a hospital, prolongs stay in a health care facility, necessitates supportive
treatment, significantly complicates diagnosis, negatively affects prognosis, or results in
temporary or permanent harm, disability or death (ASHP).
Harm is directly caused by a drug at normal doses (Edwards).
Unexpected Adverse Reaction
An "unexpected" adverse reaction is one, the nature or severity of which is not
consistent with information in the relevant source documents.
Serious Adverse Effect
Any untoward medical occurrence that at any dose results in death, requires hospital
admission or prolongation of existing hospital stay, results in persistent or significant
disability/incapacity, or is life- threatening (Edwards).
Signal
Reported information on a possible causal relation between an adverse event and a
drug, the relation being previously unknown or incompletely documented (Edwards).
Medication Error
Any preventable event that may cause or lead to inappropriate medication use or
patient harm while the medication is in the control of the health care professional,
patient, or consumer (NCC MERP).
Errors in the process of ordering or delivering a medication, regardless of whether
an injury occurred or the potential for injury was present (Bates).
Inappropriate use of a drug that may or may not result in harm (Nebeker).

SOURCES OFMEDICATION ERROR

● Unauthorized drug error
● Extra dose error
● Omission error
● Wrong dose error
● Wrong route
● Wrong time
● Wrong dosage form

CATEGORY A Capacity to cause error

CATEGORY B Error occurred but medication did not reach the patient
CATEGORY C Error reaches the patient but did not cause harm
CATEGORY D Error occurred resulted in the need of increase patient
monitoring
CATEGORY E Error occurred that resulted in the need of treatment or
intervention
CATEGORY F initial or prolonged hospitalization
CATEGORY G permanent patient harm
CATEGORY H near death
CATEGORY I death

Side Effect
Intended effect at normal doses related to the pharmacology of the drug.
Extension effect
Aka. excessive actions
Associated with the MOA/Pharmacological activity of the drug
Overdosage
Results from drug levels above the therapeutic levels
Pharmacovigilance
Science and activities relating to detection, assessment, understanding and
prevention of adverse effect and medication-related problems.

FACTORS AFFECTING ADRs

1. Duration of therapy

 Likelihood of ADR
2. Ethnicity and genetics

 Genetic Polymorphism
 N-acetyl Transferase
 Fast Acetylators – Asians, Eskimos
 Slow Acetylators – Caucasian, African-American
3. Age

 Pediatrics - underdeveloped organs

 Geriatrics
4. NTI drugs

 Theophylline - Warfarin
 Heparin - Digoxin
 Anticonvulsant - Lithium
5. Sex

 Differences in pharmacokinetics parameters (Hormones)

 Immunologic factor
 Females are more likely to an increase in ADR than in Males

6. Concurrent medicines

 Drugs with synergistic effects

 ASA + Warfarin
7. Comorbidities

 Polypharmacy
8. Cytotoxic reaction

 Hepatic necrosis associated with the overdose APAP

9. Immunologic reaction

 Quinidine
 HIPS drugs (Analgesic Drugs)
10. Genetically determined enzyme deficiency

 Hemolytic anemia
11. Dose of the drug
12. Alcohol and Cigarette
13. Error in self medication

DRUG CLASSES CAUSE THE GREATEST INCIDENT OF ADR:

1. Antibiotics
2. Analgesics
3. Cardiovascular drugs
4. Anticonvulsant
5. Sedatives
6. Anticoagulants
7. Psychotherapeutics

TYPES OF ADR:
A. AUGMENTED TYPE A
B. BIZARRE TYPE B
C. CONTINUOUS TYPE C
D. DELAYED TYPE D
E. END OF USE TYPE E
F. FAILURE OF THERAPY TYPE F

A. AUGMENTED
DOSE-RELATED
  Common
 Related to the pharmacologic action of the drug
 Exaggerated
 Predictable
 Low mortality
B. BIZARRE
NON-DOSE RELATED

 Uncommon
 Not related to the Pharmacologic action of drug
 Unpredictable; High mortality
Hypersensitivity

 unusual susceptibility
 immune response to environmental antigens resulting in symptomatic reactions
upon secondary exposure to the same antigen (allergens)
Idiosyncrasy – unknown mechanism influenced by genetic and environmental factor.
TYPE OF IMMUNOLOGIC REACTIONS

TYPE 1 IgE – mediated Most common -Anaphylaxis from

Anaphylactic category of Penicillin and
Reactions allergic rxn re- Cephalosporins
exposure to the -Penicillin
same allergen →  Cross reactivity
cross linking  act as
of the cell bound Penicilloyl
IgE → CHON
degranulation -Hay fever, Urticaria,
Asthma
TYPE 2 IgG and IgM – Found in the cell -Hemolytic anemia
Cytotoxic membrane of a Methyldopa
Reactions given target cell -Aplastic anemia
(leukocyte, (Chloramphenicol)
erythrocyte) → -Granulocytopenia
complement and
mediated lysis -Thrombocytopenia/
ITP (ASA/Ibuprofen)
TYPE 3 IgG mediated Tissue deposition -Blood
Immune Complex of antigen- dyscrasias/serum
Reactions antibody sickness
complexes -Arthus reaction
with complement -induce SLE caused
activation and by HIPS drugs
 tissue damage

TYPE 4 T-cell mediated - Weeks to month -Tuberculin test

Delayed -Poison ivy
Reactions

C. CONTINUOUS
DOSE-RELATED AND TIME-RELATED; CHRONIC

 Uncommon
 Related to the cumulative
Drug resistance
A decrease in responsive of the invading microorganism to chemotherapeutic agents.
Tachyphylaxis
Correct by changing the dose “DRUG HOLIDAY”
SUBTYPE:
Addiction

 A condition where patient compulsively taking drugs. Regardless the potential

harm or the desire to stop.
 Marjuana, Opiates
Drug Dependence

 Compulsion to take the drug repeatedly and experiences unpleasant symptoms if

discontinued.
 Resulting to tolerance and physical/psychological dependence
 Nicotine, Codeine, Caffeine, Opioid, BZD, Steroids
Drug Tolerance

 Reduce pharmacological response due to “desensitization” of receptors.

 Atropine, Histamine, Alcohol, BB, Nitrates, Nicotine
D. DELAYED
TIME-RELATED

 Uncommon
 Usually dose-related
 Occurs or becomes apparent sometime after use of the drug
E. END OF USE
WITHDRAWAL

 Uncommon
 Occurs soon after withdrawal of the drug
F. FAILURE OF THERAPY
UNEXPECTED

 Common
 Dose related
 Often caused by drug interaction

TEN COMMANDMENTS TO REDUCE ADRs:

1. Critically review the total condition of the patient.
2. Use as few drugs as possible.
3. Know well the drugs that you use.
4. Do not change too readily from one drug you know to one drug you do not know.
5. Do not hesitate to use textbooks and other references providing information on drug
reactions and interactions.
6. be especially careful when prescribing drugs known to exhibit a large variety of
reactions and interactions.
7. be aware of interactions of drugs with certain foods, alcohols, and even household
chemicals.
8. Review all drugs used by your patient regularly.
9. If your patient shows signs and symptoms not clearly explained by the course of their
illness, think of ADR.
10. If you suspect any ADR, consider stopping the drug or reducing the dosage as soon
as possible and notify the case to the nearest BFAD/DOH office.
EXAMPLES FOR THE TYPES OF ADR IS AT ADR PPT
You deserve a rest bro, 10 min
The higher the tree, the tastier the fruit
Kung di mo gets tanong mo saakin

CHAPTER 7
SIDE EFFECTS, TOXICITY, AND INTERVENTION
Side effects are any effects caused by a drug other than the intended therapeutic effect
whether it is beneficial or harmful. It can be based on the same therapeutic effect of the
drug.
Sometimes called adverse effects. Any unwanted effects of a drug that are expected
to happen.
Example:
Atropine: Pre anaesthetic medication, Decreases secretion. As side effects, it causes
dryness of the mouth.
Codeine: Analgesic or cough suppressant. As side effect it leads to constipation. It
allows codeine to be used as an anti-diarrheal medication.
Minoxidil: Anterior vasodilator. First used as a treatment to hypertension and was
found to cause Hirsutism as a side effect. Side effect explains the use of topical
minoxidil in treating alcopecia.
SIDE EFFECTS:
a) Mild – digestive disturbances such as nausea, constipation, diarrhea; fatigue;
headaches; vague muscle aches; malaise; change in sleep patterns.
b) Moderate – rashes, visual disturbances, muscle tremor, difficulty with urination;
any perceptible change in mood or mental function, changes in blood
components, such as a temporary, reversible decrease in the white blood cell
count or in blood levels of some substances, such as glucose.
c) Severe – Life threatening; Liver failure, Abnormal heart rhythms, certain types
of allergic reactions that results in persistent or significant disability.
d) Lethal (Deadly) – drug reactions directly or indirectly cause death.

Tips to lower the risk of medication side effects:

 Talk to your healthcare provider about what side effects to look out for, and what
to do if you experience one of them;
 Read the information that comes printed on your medicine labels so that you are
aware of the side effects associated with your medicines and know what to be on
the lookout for;
 Ask if there are ways to prevent or manage drug side effects like taking a
medicine with food, or at bedtime;
 Ask whether you can drink alcohol when using the medicine, as combining
alcohol with certain medicines can be dangerous;
 Make sure your healthcare providers are aware of any allergies you have; and
 Contact your healthcare professional if you experience any side effects.
Toxicity any toxic adverse effect that a chemical or physical agent might produce
within a living organism.
TYPES OF TOXIC STUDIES:
a) Acute toxicity – refers to those adverse effects occurring following oral or
dermal administration of a sing dose of a substance, or multiple doses given
within 24 hours, or an inhalation exposure of 4 hours.
b) Sub-acute toxicity – resembles acute toxicity except that the exposure
duration is greater, form several days to one month.
c) Subchronic toxicity – it is the toxic exposures repeated or spread over an
intermediate time range (1-3months).
d) Chronic toxicity – it is the exposure (either repeated or continuous) over a
long (greater than 3 months) period of time.
Overdose the toxic effect refers to the direct cell damaging action of the drug
often when used at high dose. All drugs are toxic in overdose.
Overdose can be:
1) Absolute – acute high dose of the drug is administered as in suicidal attempt
or by accident.
2) Relative – the therapeutic dose of the drug is used but it may turn out toxic
because of underlying abnormalities in the patient.
Example:
a) Paracetamol at a dose of 4g/ day therapeutic dose can lead to fulminant
liver failure in a patient suffering from alcohol liver disease.
b) When Gentamicin is given to a patient with pre-existing renal impairment,
ototoxicity is more likely to occur.
Interventions:
A. Gastrointestinal decontamination
 Activated charcoal – universal antidote (for the majority of poisons)
Substances not absorbed by activated charcoal: caustics, heavy
metals (lead, zinc, mercury), hydrocarbons, iron preparations,
lithium, toxic alcohols.
 Gastric lavage – (tube through oral or nasal) using saline solution to flush
out poison in the stomach followed sanction of gastric contents. Indicated
if substances were consumed within 1 hour.
 Cathartics – emptying of the bowels (purgative) that causes catharsis.
Commonly known as laxatives. Magnesium sulphate, magnesium citrate,
sorbitol.
 Whole bowel irrigation – same as gastric lavage. But can be taken by
tube or orally. GoLYTELY, CoLyte orally or gastric tube.
 B. Hemodialysis – filtration of blood. Can correct fluid and electrolyte
imbalances.
C. Charcoal hemoperfusion – filtering blood through cartilage containing activated
charcoal.
Advantage – faster than hemodialysis.
Disadvantage – cannot correct fluid and electrolyte imbalance.

TAKE A BREAK DUDE DAMN!

‘It’s not about how fast you finish, but how well you finished it’

CHAPTER 8
PHYSICAL INCOMPATIBILITIES
Incompatibility

 Problems which could arise during the compounding or dispensing of a

prescription.
 Interaction of two or more drugs or chemical are combined.
 Incompatibility can become:
 Intentional an obvious change once compounds are combined but their
therapeutic effect is maintained.
 Non-intentional changes which affect the therapeutic value of the
medication.
 Na Phenobarbital, Lactated Pepsin Elixir
 Remedy: To make it a solution or add a suspending agent. To
prevent precipitation of the mixture or compound
TYPES OF INCOMPATIBILITY
1. PHYSICAL INCOMPATIBILITY

 A condition arising in the process due to conflicting physical properties of the

ingredient in a solvent.
 Visible physical change.
 Colour, odour, taste, viscosity, morphology
2. CHEMICAL INCOMPATIBILITY

 A condition arising from chemical reaction that changes the original composition
of a substance.
 Change of chemical properties of a pharmaceutical dosage forms.
 Immediate incompatibility – interaction take place immediately after
compounding.
 Delayed incompatibility – Take place in a period of time.
3. THERAPEUTIC INCOMPATIBILITY

 A condition arising from conflicting property in the action of a drug.

 Drug interaction and adverse drug reaction.
 Wrong dose, wrong drug, wrong dosage form, wrong route, synergism,
antagonism, contraindication, drug interactions.
PHYSICAL INCOMPIBILITIES

 Between two or more ingredients that leads to a visible recognizable change.

 Causes non-uniform or non-palatable mixture which may possess a potential
danger.
 Same drug is present, state is altered (oo = o/o)
 Easy to correct and predictable.
MANIFESTATION
1. Incomplete solution
a. Insolubility
 Inability of the solid material to dissolve in a particular solvent
system.
 Change in NPH, Surfactant, Chemical reactions, Melene, Complex
formation, and Cosolvent
 Suspensions
 Camphor + Water
Remedy: change water into alcohol
 Gum + Alcohol
Remedy: change alcohol into water
 Iodine + Water
Remedy: Add solubilizing agent
MIXTRURE OF PREPARED CHALK
Chalk powder + plasticulture catechu + cinnamon water
Remedy: Have to use suspending agent
Tragacanth + Chalk powder + Plasticulture catechu + Cinnamon water

b. Immiscibility
 Two or more liquids fail to mix with one another homogeneously.
 Incomplete mixing, Addition of surfactant with unsuitable
concentration, False time of addition, Unsuitable for a type of
emulsion, Presence of microorganism, and temperature.
 Emulsions
  Cod liver oil + Water
Remedy: Add emulsifying agent
 1ml Phenol + 10ml Water
Remedy: Use co solvent or glycerine drop by drop
CASTER OIL EMULSION
Caster oil + Water
Remedy: Have a emulsifying agent
Caster oil + Acacia + Water
2. Precipitation

 The solute which is originally dissolved in the solvent is thrown out of the
solution.
 A substance is generally precipitated from its solution in one solvent in which it is
insoluble when added to a solution.
CAUSES:
a. Salting-out/Dehydration
 Concentrated solutions of electrolytes are mixed in prescription in
solutions of non-electrolytes.
 Occurs with liquids aside from solids where the less soluble component is
pushed out of the solutions
 Non-electrolyte + Water
 KBr + Camphor water
Remedy: Dispense them separately
 Acacia mucilage + NaCl = decrease Acacia
Remedy: Decrease acacia content
 [Water + Gum acacia] + ethanol
Remedy: Dispense them separately

b. Change in solvent system

 NH4Cl + Camphor + Alcohol + Water
Remedy: Dispense them separately
 TINCTURE BENZOIN + GLYCERIN + ROSE WATER
(Lotion of compound tincture of benzoin)
Remedy: Rapid stirring when adding tincture

c. Change in temperature

 Endothermic reaction
 Absorbs heat from the surroundings
 Increased temperature of the solution increased solubility
 NH4Cl + Water
 Reminder: Have to store in hot environment
 KI and Boric Acid
Reminder: Have to store in hot environment
 Exothermic reaction
 Gives heat to the surroundings
 The increasing the temperature decreases the solubility of the
solute.
 Lime water/Ca(OH)2 is more soluble in cold preparation than
in hot water
d. Change in PH
Phenobarbital Na + Syrup of Orange
Remedy: Change syrup of orage to simple syrup
3. Liquefacation of solid infredient
a. Efflorescent – There is a release of water or crystallization
 Na2SO4 . 10H2O
 CaSO4
 CuSO4
 NaCO3
 FeSo4
 Atropine SO4
 Alum
 Citric Acid
b. Deliquescence – Upon absorbing moisture there is liquefaction
 NaOH
 KOH
 CaCl2
 MgCl2
 FeCl3
 NaNO3
 NH4Cl
c. Hygroscopic – Absorbs moisture but does not liquefy (DRYING AGENT)
 NaCl
 Sucrose
 CaO
 CuO

d. Eutexia

 Decrease melting point of a solid in contact with another component.

 Lowering of melting point.
 ASA, Phenol, Menthol, Thymol, Camphor, Salol and other
Aldehydes and Ketones
  Menthol + Camphor + water
Remedy:
 Method 1 – Triturate together to form into a liquid and mix in
an absorbent to produce a powder.
 Method 2 - Triturate individually to make a powder
separately and then mixed together with an absorbent.
Intentional:
 Vick’s ointment
 EMLA cream
4. Vaporization / Volatilization

 Drug with increase vapour pressure

 Liberation of the active ingredient
 Liquid to Gas
 NTG
 Volatile oils
 Ketone
 Esters
 Aldehyde
 Alcohol
5. Polymorphism

 Existence of one or more crystalline and/or amorphous form.

 Drugs exist in several crystalline structures.
 Different Polymorph = Different Properties
Chloramphenicol
Polymorphic forms:
Chloramphenicol A – Stable form, biologically inactive modification
Chloramphenicol B – Meta stable, Active modification
Chloramphenicol C – Unstable

Structural categories which crystalline solids are assigned:

MONOCLINIC SUCROSE
TRICLINIC BORIC ACID
TETRAGONAL UREA
RHOMBIC IODINE
 RHOMBIC NaCl
HEXAGONAL IODOFORM

6. Water loss - Reverse of liquefaction

 Emulsion (phase inversion in O/W emulsion) - CRACKING

 Ointments - CRUMBLING
 Gels – SYNERESIS(separation of liquid from a gel due to contraction)
Remedy: Add of humectant
7. Sorption - Collection term of:

 ABSORPTION – absorbing process

 ADSORPTION – surface phenomenon

CONGRATULATIONS FOR FINISHING

REST FOR A WHILE AND REVIEW AGAIN
“Happiness is not all about being happy, but on how you live your life well”