Pharmaceutical Care: Pharmaceutical care is the responsible provision of drug

therapy for the purpose of achieving definite outcomes that improves patient’s
quality of life. Pharmaceutical care involves the process through which a
pharmacist co-operate with patient and other professionals for designing,
implementing and monitoring a therapeutic plan that will produce specific
therapeutic outcomes for patient.

Hospital Pharmacy: Hospital pharmacy is the health care service which comprises
the art, practice and profession of choosing, preparing, storing, compounding and
dispensing of medicines and medical devices & advising patients, doctors, nurses
and other healthcare professionals towards the safety, effectively and efficacy of
drug use.

Roles of Hospital Pharmacists

• To ensure that established policies and procedures are followed.

• To check for accuracy of prepared doses.
• To ensure that medicines are stored and dispensed properly.
• To ensure that medicines laws, rules, policies & procedures are strictly followed.
• To ensure that good techniques are followed in compounding I/V admixtures
and extemporaneous preparations.
• To contribute in proper medication records.
• To maintain extemporaneous record.
• To maintain intravenous admixture records and billing.
• To maintain professional competence in knowledge of medicine stability &
incompatibilities.
• To coordinate the activities of the area with the available staff to make the best
possible use of personnel and resources.
• To keep the dispensing area neat and orderly.
• To communicate with all pharmacy staff towards new developments in the area
and assists in employee evaluations.
• To provide medicine information as necessary to the pharmacy, medical and
nursing staff.
• To review and interpret each unit dose and I/V admixture medication.
• To review each patient medicine administration form periodically to ensure that
all doses are administered and recorded accurately.
• To confirm periodically that administered doses are noted correctly on the
patient’s chart.
• To ensure that records for administered narcotics and psychotropic are kept
correctly.
• To ensure that proper medication administration techniques are followed.
• To act as the liaison between the pharmacist and the nursing and medical staff.
• To communicate with nurses and physicians towards medication administration
problems.
• To periodically inspect the medication areas on the nursing units to ensure that
adequate levels of floor-stock medicines and supplies are maintained.
• To coordinate all pharmacy services on the nursing unit level.
• To obtain patient medication history (PMH) & communicates all relevant
information to physician.

Functions of Hospital Pharmacy

• Forecast of demand
• Selection of reliable suppliers
• Prescribing specifications of the required medicament
• Manufacturing of sterile or non-sterile preparations
• Maintenance of manufacturing records
• Quality control of purchased or manufactured products
• Distribution of medicaments in the wards
• Dispensing of medicaments to out-patients
• Drug information source in hospitals
• Centre for drug utilization studies Implement recommendations of the pharmacy
and therapeutic committee
• Patient counseling to enhance their compliance
• Maintaining liaison between medical, nursing and the patient

Drug Distribution Systems for In-Patients in Hospital

i. Individual Prescription Order System: This system is generally used by the
small and private hospital because of the reduced work force (men-power) and the
desirability for individualized service.
Advantages
 All the medication orders are directly reviewed by the pharmacist so that there
are less chance of medication errors.
 It provides closer liasion among pharmacist, physician, nurse and the patient in
the medication matters.
 It provides closer control of inventory.

Disadvantages
 The possible delay in obtaining the required medication.
 The increase in cost to the patient.
ii. Floor (Ward) Stock System: Each pavilion in the hospital has a supply of drugs
stored in the medicine cabinet even though the nursing unit is serviced by a unit
dose system. Drugs on the nursing station may be divided into Charge Floor Stock
Drugs and Non-Charge Floor Stock Drugs. Charge floor stocks drugs may be
defined as those medications which are stocked on the nursing station at all times
and are charged to the patient’s account after they have been administered.
Selection of such types of drugs is the responsibility of pharmacy and therapeutic
committee. Non-charge floor-stock drugs represent the group of medications which
are placed at the nursing station for the use of all the patients on the pavilion and
there may not be direct charge to the patient’s account.
Complete Floor Stock System: The nursing station pharmacy carries both Charge
and Non Charge Medications under this system. Particularly expensive drugs are
omitted from floor stock but are dispensed upon the receipt of a prescription or
medication order for the individual patient. This system is used most often in
governmental hospitals.

Advantages
 Ready availability of the required drugs.
 Elimination of drug returns.
 Reduction in number of drug order transcriptions for the pharmacy
 Reduction in the number of pharmacy personnel required
Disadvantages
 Medication errors may increase because the review of medication orders does
not happen.
 Greater drug inventory on the pavilions
 Greater opportunity for pilferage
 Lack of proper storage facilities on the ward may require capital outlay to
provide them
iii. Combination of Individual Drug Order and Floor Stock Systems: This
combination system is probably the most commonly used in hospitals today and is
modified to include the use of unit dose medications.
iv. Unit Dose Dispensing System: Unit-dose medications are defined as those
medications which are ordered, packaged, handled, administered and charged in
multiples of single dose units containing a predetermined amount of drug or supply
sufficient for one regular dose, application or use. Solid medications is pre-packed
and labeled for each patient. Liquids are pre measured, injectables are measured
and filled in sterile syringes. Strip or blisters packed tablets are common examples
of unit dose dispensing.

Advantages
 Patients receive improved pharmaceutical service for 24 hours a day and are
charged for only those doses which are administered to them.
 All doses of medication required at the nursing station are prepared by the
pharmacy and allows the nurse more time for direct patient care.
 Allow pharmacists to check a copy of physician original order & reduces
medication errors.
 Eliminates excessive duplication of orders and paper work at nursing station
and pharmacy.
 Transfers intravenous preparation and drug reconstitution procedures to the
pharmacy.
 Promotes more efficient utilization of professional and non-professional
personnel.
 Conserves space in nursing units by eliminating bulky floor stuck.
 Eliminates pilferage and drug waste.
 Communication of medication orders and delivery systems are improved.
Disadvantages
 Time consuming system
 More manpower needed
 Difficulty in case of return of the medicines

Methods of Dispensing of Unit Doses

Centralized Unit Dose Distribution System (CUDD): All the in-patients are
dispensed in unit doses from the central pharmacy. All the drugs are stored in
centrally located pharmacy and are dispensed at the time as the dose is to be
administered.
Satellite Pharmacies for Decentralized Unit Dose Distribution System
(DUDD): Satellite pharmacies are located on each floor of the hospital to operate
DUDD system. A satellite pharmacy is defined as a pharmacy in an institution
which provides specialized services for the patients of the institution and which is
dependent upon the centrally located pharmacy for administrative control, staffing
and drug procurement. The main pharmacy becomes the feeder which serves its all
satellites. The procurement job is carried out by the central pharmacy and stock
maintenance and manufacturing and packing of drugs is done centrally after which
the drugs are passed to the satellite units throughout the hospital. The medicines are
to be delivered in huge amounts so delivery is done by means of carts.
v. Automated dispensing system (ADPS): This system uses computer networking
in the physician, pharmacy, nursing and account department. Physician writes
prescription and it reaches the pharmacy department computer where pharmacist
checks and evaluates it then dispenses medicines with proper counseling.

Drug Distribution Systems for Out-Patients in Hospital

Emergency Out Patient: The person given emergency or accidental care for
conditions which require immediate medical attention.
Referred Out Patient: Patient is referred directly to out-patient department by
attending to medical practitioner for specific treatment other than an emergency
treatment.
Ambulatory Patient: The ambulatory refers to patients not occupying beds in
hospitals and required to go home after taking treatment in OPD.
Clinical Pharmacy: Clinical pharmacy is a health science specialty whose
responsibility is to assure the safe and appropriate use of drugs in patients through
the application of specialized knowledge in patient care.

Functions of Clinical Pharmacy

• Providing drug information to other health professionals

• Selecting the most appropriate therapeutic agent for drug therapy
• Prescribing the most appropriate drug regimen
• Monitoring the effect of drug therapy based upon indices of effect
• Selecting methods for drug administration
• Providing the medication counseling towards the patients
• Providing the disease screening, monitoring and maintenance care for patients
with chronic diseases
• Participation in the management of emergency medical care
• Serving as a health information and education source for the public individuals
• Participation in drug review and patient care audits

Hematological Tests
1. RBC (Erythrocytes)
 Clinical Value: 4.3 - 5.9 mil/mm3 in Male & 3.5 - 5.0 mil/mm3 in Female
 Clinical Significance: RBC is increases on the Polycythemia, COPD,
Dehydration and High Altitude & decreases on Anemia.
2. Hematocrit (Hct) or Packed Cell Volume (PCV)
 Clinical Value: 40-45% in Male & 38-42% in Female
 Clinical Significance: PVC is increases on Polycythemia, COPD, Dehydration
and High Altitude and decreases on Anemia, Overhydration, Blood loss,
Hemolysis, Hyperthyroidism & Leukemia.
3. Hemoglobin (Hb)
 Clinical Value: 14 -18g/dl in Male & 12 -16g/dl in Female
 Clinical Significance: Hb is increases on the Polycythemia, COPD,
Dehydration and High Altitude and decreases on Anemia, Overhydration, Blood
loss, Hemolysis, Hyperthyroidism & Leukemia.
4. Mean Corpuscular Volume (MCV)
 Clinical Value: 90±10 μm3 /cell
 Clinical Significance: MCV is decreases on the Microcytic RBC (Iron
deficiency anemia) while increases on Macrocytic RBC (Vitamin B12 or folic
acid deficiency anemia).
5. Mean Corpuscular Hemoglobin (MCH)
 Clinical Value: 30±4 pg/cell
 Clinical Significance: MCH is decreases on Microcytic RBC (Iron deficiency
anemia) while increases on Macrocytic RBC (Vitamin B12 or folic acid deficiency
anemia).
6. Mean Corpuscular Hemoglobin Concentration (MCHC)
 Clinical Value: 34±3%
 Clinical Significance: MCHC is decreases on Hypochromia & Microcytic
anemia and increases on severe prolonged dehydration.
7. Erythrocyte Sedimentation Rate (ESR)
 Clinical Value: 0-20mm/hr in Male & 0-30mm/hr in Female
 Clinical Significance: ESR is increases on Acute/chronic infections, Tissue
necrosis or infarction, Rheumatoid, & Collagen Disease and decreases on CHF,
Polycythemia & Sickle Cell Anemia.
8. WBC (Leukocytes)
 Clinical Value: 4000 - 11000 mm3
 Clinical Significance: Leukocytosis is observe on Leukemia & Tissue
Necrosis while Leucopenia is observe on Bone Marrow depression, Lymphoma &
Viral infection.
9. Neutrophils
 Clinical Value: 40 -60%
 Clinical Significance: Number of the Neutrophils increases on Systemic
infections by Pneumonia, Chicken Pox & Herpes zoster, Rocky mountain spotted
fever, Inflammatory diseases, Hypersensitivity reactions to drugs & Tissue necrosis
and decreases on viral infection by Mumps, Measles, Influenza & Hepatitis and on
idiosyncratic drug reaction result from chemotherapy.

10. Basophils
 Clinical Value: 0.5-1%
 Clinical Significance: Basophilia is observe on Hypersensitivity reactions,
Ulcerative colitis, & Chronic Myelogenous Leukemia (CML).
11. Eosinophil
 Clinical Value: 1-4%
 Clinical Significance: Eosinophil is associated with the immune reactions.
Eosinophilia is observed on acute allergic reactions (Asthma, Hay fever & Drug
allergy) & Parasitic infestations (Trichinosis & Amebiasis).

12. Lymphocytes
 Clinical Value: 20-40%
 Clinical Significance: Lymphocytes has a role in immunological activity and
produces the antibodies. Lymphocytosis is observed on the Viral infections (Herpes
Simplex, Herpes Zoster & Chicken Pox) and Bacterial infections (Syphilis &
Brucellosis) and Lymphopenia is observed on Acute infections, Burns, Trauma,
HIV & Lymphoma.

13. Monocytes
 Clinical Value: 2-8%
 Clinical Significance: Monocytes has a role on phagocytic action. Monocytosis
is observed on the TB, Syphilis, RA & Sub acute bacterial endocarditis and
monocytopenia is observed on Bone marrow suppression and severe stress.

14. Platelets
 Clinical Value: 150,000 - 300,000/mm3
 Clinical Significance: Thrombocytosis is observed on the Malignancy, RA,
Polycythemia, Surgery & Trauma and Thrombocytopenia is observe on Idiopathic
Thrombocytopenic Purpura & Aplastic anemia. Platelet count <100,000/mm3 is
moderate while <50,000/mm3 is severe.
Liver Function Tests
1. Serum Glutamic Oxaloacetic Transaminase (SGOT): SGOT is also known as
Aspartate Aminotransferase (AST). SGOT value is generally increases on
Myocardial Infaction, CHF, Acute Hepatitis & Alcoholic Liver Diseases. Its
clinical value is a 40 IU/L.

2. Serum Glutamic Pyruvic Transaminase (SGPT): SGPT is also known as

Alanine Aminotransferase (ALT). SGPT is primarily found on Liver and also found
on Heart, Skeletal muscle & Kidney. Its clinical value is a 35 IU/L.

3. Alkaline Phosphatases (ALP): It is produced primarily in liver and bones. It is

particularly sensitive to partial or mild biliary obstruction. Its level is generally
increased in Paget’s disease, hyperthyroidism & osteomalacia. Its clinical value is
a 90-270 IU/L.

4. Total Serum Bilirubin: 0.1 - 1.0mg/dl

5. Albumin: 3.5 - 5.0g/dl
6. Globulins: 25 - 35g/L
7. Normal Serum Protein Value: 6.0 - 8.0g/dl
 Renal Function Tests
Blood Urea 15 - 40mg/dl
Serum Creatinine 0.6 - 1.2mg/dl
Sodium 135 - 147 mEq/L or mmol/L
Potassium 3.5 - 5.0 mEq/L or mmol/L
BUN 8 - 18mg/dl
Serum Uric Acid 3.6 - 8.5 mg/dl in Male and 2.3 - 6.6 mg/dl in Female

TDM: TDM is a process by which dose of drug is adjusted according to its plasma
concentration.

Specific Points Towards TDM

 There should be good relation between drug concentration & response for
performing TDM.
 TDM is done for drugs having wide variation in ADME parameters.
 TDM is done for the drugs having low or narrow therapeutic index like
Theophylline, Gentamicin, Lithium, Cyclosporine, Phenytoin, Digoxin,
Vancomycin, Carbamazepine, Verapamil, Isoniazid and Amiodarone.
 TDM is done for specific drugs whose effect cannot be easily measured.
 TDM is not done for drugs which produce active metabolites and when
pharmacological tolerance is suspected and when there is poor relation between
drug concentration and effect.
Clinical Trial: Clinical Trial means the act of testing of a new drug by
administering it to any patient or person with his consent in hospital or other health
centers as specified in the letter of permission for the purpose of ascertain whether
it is proper to bring any new drug into use or not.

Phase Name Volunteer Purpose

Zero (Micro- Healthy volunteers in 1/100th of human dose of drug is
dosing studies) small number given to know pharmacokinetics
I (Human Safety Healthy volunteers  To know maximum Tolerability
& Pharmacology) (20 - 100) dose and Safety of drugs.
II (Therapeutic Homogenous Patients  To establish therapeutic efficacy
Exploratory) (100 - 150 Patients)  Dose ranging and ceiling effect
III (Therapeutic Heterogeneous  To confirm therapeutic
Confirmatory) Patients (Upto 5000 efficacy
patients from several  To establish value of drug in
centers) relation to existing therapy
IV (Post Large number of  To know rare & long-term
marketing patients being treat by adverse effects
Surveillance) physicians  Safety & comparisons with
other medicines
ADR: WHO defines ADR as any response to a drug which is noxious, unintended
and occurs at doses used in for prophylaxis, diagnosis or therapy of disease or for
the modification of physiological function.

Specific Points Towards ADR

 Side effect are unintended effects of a pharmaceutical product occurring at doses

used in man which is related to the pharmacological properties of the product and
in which there is no deliberate overdose.

 Toxic effects are result of excess pharmacological action of drug due to overdose
or prolonged use & the effects are predictable & dose related.

 Intolerance is the appearance of characteristic toxic effects of a drug in a

individuals at therapeutic doses.

 Type A ADR shows Augmented Pharmacologic Effect, Dose Dependent &

Predictable Effect. Ex: Hypoglycemia caused by anti-hyperglycemic drugs like
sulfonylureas
 Type B ADR shows Bizarre Effect or Idiosyncratic Effect, Dose independent
and the Unpredictable Effect. Ex: Allergic reactions caused by Penicillin
 Type C ADR shows chronic effect. Ex: Peptic ulcer caused by chronic use of
NSATD
 Type D ADR shows delayed effect. Ex: Teratogenicity caused by thalidomide
 Type E ADR shows End-of-treatment effect. Ex: Withdrawal response to
morphine

 Pharmacovigilance is the activities related to the detection, assessment,

understanding & the prevention of adverse effects or any other possible drug -
related problems. Uppsala Monitoring Centre (Sweden) is international center for
Pharmacovigilance.

Various Regional Centers for Reporting of ADR to DDA

a. Tribhuvan University Teaching Hospital, Maharajgunj

b. Civil Service Hospital, Minbhawan
c. Manipal Teaching Hospital, Pokhara
d. Nepal Medical College Teaching Hospital, Jorpati
e. Norvic International Hospital, Thapathali
f. Nepal Cancer Hospital and Research Center, Harisiddhi
g. Patan Hospital, Lalitpur
h. Dhulikhel Hospital, Banepa
i. KIST Medical College, Imadol
j. Shree Birendra Hospital, Chhauni
k. B.P. Koirala Institute of Health Science, Dharan
National / Hospital Formulary

Modern definition: List of medicines which are recommended or approved for use
by a group of practitioners.

Hospital formulary: List of medicines which are covered by specific health care
plan administrators.

Benefits of National Formulary

• Improves prescribing practice and reduces expenditure on medicines.
• Prescribing policies assist prescribers by using formulary medicines & specific
treatment protocols to make even more useful.
• Clinical guidelines help to ensure that medicine of patient is based on evidence
of best practice.
• Formularies, clinical guidelines & medicine protocols can ensure that standards
of prescribing medicines are both uniform & high quality.
• Formularies are used to promote rational & cost-effective prescribing of
medicines.
Contents of Formulary
1. Formulary list or • Alphabetic & therapeutic category lists
essential medicines
2. Brief information • Generic name with dosage strength & dosage
about each medicines • Indications, contraindications and precaution
• Side effects
• Instructions and warnings
• Drug, food, laboratory interactions
3. Supplementary • Brand names with Drug Price
information for • Regulatory category
medicines • Storage guidelines
• Patient Counseling & Labeling information
4. Prescribing and the • Rational prescribing techniques
dispensing guidelines • Principles of prescription writing
• Guidelines for quality to be dispensed
• Controlled drug requirements
• ADR reporting requirements
• Dispensing guidelines
• List of precautionary labels
• Common drug interaction tables
 5. Rx Protocols • I/V drug administration guidelines
• Drugs used in renal failure, pregnancy and
lactation
• Poisoning (intoxication) guidelines
• Drugs prescribing in the eldery
• ADR form
6. Other components • Formulary request form
• Indexes & Abbreviations

Community Pharmacy: A community pharmacy is a healthcare facility that

emphasizes providing pharmaceutical services to a specific community. It includes
the compounding, counseling, checking and dispensing of prescription drugs to the
patients with care, accuracy and legality. Community pharmacy has appropriate
procurement, storage, dispensing & documentation of medicines.

Roles of Community Pharmacists

• To identify the appropriateness of dose for patient
• To identify the patient allergy to the medication
• To identify the potential interactions with POM and OTC medicines
• To identify the contraindication of medication with various diseases
• To identify the appropriate dose scheduling to minimize the ADR
• To identify the appropriateness of the medication for the patient for the health
condition
• To assure the accuracy of dispensing & labeling of medication
• To provide the information of patient towards the proper storage of medication
• To advise patient towards the potential risks & benefits of medication
• To advise patient on how to deal with missed doses & ADR
• To assess the patient understanding towards the prescription instructions to
maximize adherence towards the instructions
• To identify the appropriateness of pharmacological care plan
• To monitor the results of pharmacological care plan
• To offer specialized compounding services

Drug and Therapeutic Committee / Pharmacy and Therapeutic Committee /

Medicine and Therapeutic Committee: PTC is a policy recommending body to
the medical staff and the administration of hospital on matters related to the
therapeutic use of drugs. It also serves as a means of communication between the
healthcare professional and pharmacy department. PTC is composed of Physician
(Chairman), Chief Pharmacist (Secretary), Nurses (Joint secretary) & Hospital
administrator. The committee should meet regularly at least six times in a year and
more often when necessary. Minutes of the committee meetings should be prepared
by the member-secretary and maintained in the permanent records of the hospital.
Functions of Pharmacy and Therapeutic Committee (PTC)
• To develop a formulary of drugs accepted for use in the hospital and provide for
its constant revision. The selection of items to be included in the formulary will be
based on objective evaluation of their relative therapeutic merits, safety and cost.
• To advise the medical staff and hospital administration towards the use of drugs
• To establish programs and procedures that helps to ensure cost-effective drug
therapy.
• To establish suitable educational program for hospital staff towards the drug use.

• To participate in quality assurance activities related to distribution, administration

and use of medications.
• To monitor and evaluate the adverse drug reactions occur in the hospital.
• To initiate drug use review of programs and studies and review the results of such
activities.

• To advise the pharmacy towards the implementation of effective drug distribution

and control procedures.
• To make recommendations towards the drugs to be stocked in hospital patient-
care areas.
Essential Medicines Nepal (2021): Essential medicines have been defined by World
Health Organization (WHO) as ‘those that satisfy the priority health care needs of the
population’. These medicines are selected with regard to public health relevance,
evidence on efficacy and safety, and comparative cost-effectiveness. Careful and
prudent selection of limited range of essential medicines help in higher quality of care,
better drug management, value added supply chain, rational use, availability and cost
effectiveness of health resources.
Government of Nepal/DDA first published National List of Essential Medicines
(NLEM) in 1986. The list was revised in 1992, 1997, 2002, 2011 and 2016 AD.
Department of Drug Administration (DDA) has brought out this sixth revision of
National List of Essential medicine, 2021 approved by Ministry of Health and
Population, Government of Nepal dated on April, 21, 2021.
The list has been approved and published and is aligned with the main objectives of the
National Drug Policy 1995 to ensure the availability and affordability of efficacious,
safe and good quality medicines relevant to the quality healthcare needs and service of
the people in a sustainable and equitable manner and to promote the rational use of
medicines by healthcare professionals and consumers.
Based on the current version of WHO Model List of Essential medicines 2019, DDA
has revised the National List of Essential Medicines (NLEM). The NLEM, 2021
contains 398 drug molecules therapeutic category.
The core list presents a list of minimum medicine needs for a basic health-care system,
listing the most efficacious, safe and cost–effective medicines for priority conditions.
Priority conditions are selected on the basis of current and estimated future public
health relevance, and potential for safe and cost-effective treatment.
Where the [c] symbol is placed next to an individual medicine or strength of medicine
on the core list it signifies that there is a specific indication for restricting its use to
children.
The complementary list presents essential medicines for priority diseases, for which
specialized diagnostic or monitoring facilities, and/ or specialist medical care, and/or
specialist training are needed. In case of doubt medicines may also be listed as
Complementary on the basis of consistent higher costs or less attractive cost-
effectiveness in a variety of settings.
The [a] symbol indicates that there is an age or weight restriction on use of the
medicine; details for each medicine.

National List of Essential Medicines first published in 1986

First revision 1992 Fourth revision 2011
Second revision 1997 Fifth revision 2016
Third revision 2002
Criteria for inclusion of a Medicine in NLEM
● Cost effective, Approved and licensed medicine in the country
● Relevance for disease posing public health problem
● Provide efficacy and safety profile based on valid scientific evidence
● Based on Genetic, demographic and environmental factors
● Performance of drugs in general has been proved in a variety of medical setting
● Pattern of prevalent disease and treatment facilities
● Aligned with the current treatment guidelines under public health program
● Stable under the storage conditions
● Safety, efficacy, cost-effective & should be access easily

1. ANAESTHETICS, PERIOPERATVE MEDICINES AND MEDICAL GASES

1.1 General Anaesthetics and Oxygen

1.1.1 Inhalational medicines: Halothane, Isoflurane, Nitrous oxide
Complementary List: Sevoflurane
1.1.2 Injectable Medicines: Ketamine, Propofol
1.2 Local Anaesthetics: Bupivacaine, Lidocaine (Lignocaine), Lidocaine +
Epinephrine (adrenaline)
Complementary List: Ephedrine
Preoperative medication and sedation for short-term procedures: Atropine
[a], Diazepam, Glycopyrrolate, Midazolam and Morphine

2. MEDICINES FOR PAIN AND PALLIATIVE CARE

2.1 Opioid Analgesics: Codeine, Fentanyl, Morphine, Pethidine

2.2 Non-opioid analgesics and non-steroidal anti-inflammatory:
Ibuprofen [c] [a], Paracetamol
Complementary List: Acetylsalicylic acid (Aspirin), Diclofenac
sodium

3. ANTIDOTES AND OTHER SUBSTANCES USED IN POISONINGS

3.1 Non-specific: Charcoal Activated

3.2 Specific: Acetylcysteine, Atropine [a], Calcium gluconate, Naloxone,
Methylthioninium chloride (methylene blue), Potassium ferric Hexa-
cyanoferrate (II).2H2O (Prussian blue), Pralidoxime, Sodium nitrite
Complementary List: Deferoxamine, Dimercaprol, Fomipezole
Sodium calcium edetate
4. ANTIALLERGICS AND MEDICINES USED IN ANAPHYLAXIS

Main List: Levocetirizine, Dexamethasone, Epinephrine (adrenaline),

Hydrocortisone, Pheniramine, Prednisolone
Complementary list: Fexofenadine

5. Anticonvulsants/ Antiepileptics: Carbamazepine, Diazepam, Magnesium sulfate,

Phenobarbital, Phenytoin Valproic acid
6. ANTI-INFECTIVE MEDICINES

6.1 Anthelminthics
6.1.1 Intestinal anthelminthics: Albendazole, Ivermectin, Mebendazole,
Niclosamide, Praziquantel
6.1.2 Antifilarials: Albendazole, Diethylcarbamazine

6.2 Antibacterials
To assist in the development of tools for antibiotic stewardship at primary,
secondary and tertiary level hospitals to reduce antimicrobial resistance, the
Access, Watch, Reserve (AWaRe) classification of antibiotics was developed -
where antibiotics are classified into different groups to emphasize the importance
of their appropriate use.
ACCESS GROUP ANTIBIOTIC
This group includes antibiotics that have activity against a wide range of commonly
encountered susceptible pathogens while also showing lower resistance potential
than antibiotics in the other group. Selected Access group antibiotics are
recommended as essential first or second choice empiric treatment options for
infectious syndromes as reviewed by the WHO EML Expert Committee. They are
listed as individual medicines in the National List of Essential Medicines to
improve access and promote appropriate use. They are essential antibiotics that
should be widely available, affordable and quality assured.
WATCH GROUP ANTIBIOTICS
This group includes antibiotic classes that have higher resistance potential and
includes most of the highest priority agents among the Critically Important
Antimicrobials for Human Medicine and/ or antibiotics that are at relatively high
risk of selection of bacterial resistance. These medicines should be prioritized as
key targets of stewardship programs and monitoring. Selected Watch group
antibiotics are recommended as essential first or second choice empiric treatment
options for a limited number of specific infectious syndromes as reviewed by the
WHO EML Expert Committee.
RESERVE GROUP ANTIBIOTICS
This group includes antibiotics and antibiotic classes that should be reserved for
treatment of confirmed or suspected infections due to multi-drug-resistant
organisms. Reserve group antibiotics should be treated as ‘last resort’ options.
Selected Reserve group antibiotics are listed as individual medicines in the National
List of Essential Medicines when they have a favourable risk-benefit profile and
proven activity against ‘Critical Priority’ or ‘High Priority’ pathogens identified by
the WHO Priority Pathogens List. These antibiotics should be accessible, but their
use should be tailored to highly specific patients and settings, when all alternatives
have failed or are not suitable. These medicines could be protected and prioritized
as key targets of stewardship programs involving monitoring and utilization
reporting, to preserve their effectiveness.
6.2.1. Access group antibiotics: Amoxicillin, Ampicillin, Benzathine,
benzylpenicillin, Benzylpenicillin (Penicillin G), Cephalexin, Chloramphenicol,
Cloxacillin, Doxycycline [a], Gentamicin, Metronidazole, Nalidixic acid,
Nitrofurantoin, Phenoxymethylpenicillin (Penicillin V), Procaine
benzylpenicillin, Sulfamethoxazole + Trimethoprim
Complementary list: Cefazolin [a]
6.2.2 Watch group antibiotics: Amikacin, Amoxicillin + clavulanic acid,
Azithromycin, Cefixime, Ciprofloxacin, Clindamycin, Erythromycin
Complementary list: Cefotaxime, Ceftriaxone [a], Ciprofloxacin,
Clarithromycin
6.2.3 Reserve group antibiotics: Meropenem, Polymyxin B, Piperacillin +
Tazobactam, Vancomycin
Complementary list: Colistin, Linezolid
6.2.4 Antileprosy medicines: Clofazimine, Dapsone, Rifampicin
6.2.5 Antituberculosis medicines: Ethambutol, Ethambutol + Isoniazid +
Pyrazinamide + Rifampicin, Ethambutol + Isoniazid + Rifampicin, Isoniazid,
Isoniazid +Pyrazinamide + Rifampicin, Isoniazid + Rifampicin, Pyrazinamide,
Rifabutin, Rifampicin
Complementary list: Amikacin, Amoxicillin +Clavulanic acid, Bedaquiline
[a], Clofazimine, Cycloserine, Delamanid [a], Ethionamide, Levofloxacin,
Linezolid, Meropenem, Moxifloxacin, P-aminosalicylic acid, Streptomycin [c]
6.3 Antifungal medicines: Amphotericin B, Clotrimazole, Fluconazole,
Flucytosine, Itraconazole, Nystatin
6.4 Antiviral medicines

6.4.1 Antiherpes medicines

Complementary list: Aciclovir
6.4.2 Antiretroviral
6.4.2.1 Nucleoside / Nucleosite reverse transcriptase inhibitors: Abacavir
(ABC), Lamivudine (3TC), Tenofovir disoproxil fumarate (TDF), Zidovudine
(ZDV or AZT)
6.4.2.2 Non-nucleoside reverse transcriptase inhibitors: Efavirenz (EFV or
EFZ) [a], Nevirapine (NVP) [a]
6.4.2.3 Protease inhibitors: Atazanavir + ritonavir [a], Darunavir [a],
Lopinavir + ritonavir (LPV/r), Ritonavir (c)
6.4.2.4 Integrase inhibitor: Dolutegravir [a], Raltegravir
6.4.2.5 Fixed-dose combinations: Abacavir + Lamivudine, Dolutegravir +
Lamivudine + Tenofovir, Efavirenz + Lamivudine + Tenofovir, Emtricitabine +
Tenofovir, Lamivudine + Tenofovir, Lamivudine + Nevirapine + Zidovudine,
Lamivudine + Zidovudine
6.4.3 Other antivirals: Oseltamivir
Complementary list: Ganciclovir: Valganciclovir [c]
6.4.4 Antihepatitis medicines
6.4.4.1 Medicines for hepatitis B
6.4.4.1.1 Nucleoside/Nucleotide reverse transcriptase inhibitors: Entecavir,
Tenofovir disoproxil fumarate (TDF), Tenofovir alafenamide
6.4.4.2 Medicines for hepatitis C: WHO guidelines recommend the use of
pangenotypic direct-acting antiviral (DAA) regimens for the treatment of
persons with chronic HCV.
6.4.4.2.1 Pangenotypic direct-acting antiviral combinations: Sofosbuvir +
Velpatasvir
6.4.4.2.2 Non-pangenotypic direct-acting antiviral combinations:
Ledipasvir + Sofosbuvir
6.4.4.2.3 Other antivirals for hepatitis C: Ribavirin
6.5 Antiprotozoal medicines
6.5.1 Antiamoebic and antigiardiasis medicines: Metronidazole
Complementary list: Secnidazole, Tinidazole
6.5.2 Anti-leishmaniasis medicines: Miltefosine
Complementary list: Amphotericin B, Paromomycin
 6.5.3 Antimalarial medicines
6.5.3.1 For curative treatment: Artemether, Artemether + Lumefantrine [a],
Chloroquine, Dihydroartemisinin + Piperaquine [a], Primaquine [a],
Sulfadoxine + Pyrimethamine
Complementary list: Artesunate , Quinine
6.5.3.2 For chemoprevention: Atovaquone + proguanil, Chloroquine,
Doxycycline [a], Mefloquine [a]

7 Antimigraine Medicines: Paracetamol (For acute attack), Propanolol (For

Prophylaxis of drug)

8. Immunomodulators, Anti-neoplastic & Medicines used in Palliative care

8.1 Immunomodulators for non-malignant diseases

Complementary list: Azathioprine, Cyclosporine
8.2 Antineoplastic and supportive medicines
8.2.1 Cytotoxic medicines: Bleomycin, Bendamustine, Calcium leucovorin,
Capecitabine, Carboplatin, Chlorambucil, Cisplatin, Cyclophosphamide,
Cytarabine, Dacarbazine, Dactinomycin, Daunorubicin, Docetaxel, Etoposide,
Fluorouracil, Gemcitabine, Hydroxyurea, Ifosfamide + Mesna, L-asparaginase,
Melphalan, Mercaptopurine, Methotrexate, Mitomycin, Paclitaxel, Vinblastine,
Procarbazine [c], Vincristine, Doxorubicin, Epirubicin
9 ANTIPARKINSONISM MEDICINES: Levodopa + Carbidopa, Benzhexol

10 MEDICINES AFFECTING THE BLOOD

10.1 Antianaemia medicines: Cyanocobalamin, Ferrous salt, Ferrous salt +

Folic acid, Folic acid, Iron dextran
10.2 Medicines affecting coagulation: Enoxaparin, Heparin sodium [c],
Phytomenadione, Protamine sulfate [c], Warfarin [c], Tranexamic acid
10.3 Other medicines for haemoglobinopathies
Complementary List: Deferasirox, Deferiprone, Deferoxamine, Hydroxyurea

11 BLOOD PRODUCTS OF HUMAN ORIGIN & PLASMA SUBSTITUTES

11.1 Plasma-derived medicines

11.1.1 Human immunoglobulins: Anti-D immunoglobulin, Anti - rabies
hyperimmune serum, Anti-tetanus immunoglobulin
11.2 Blood coagulation factor
Complementary list: Coagulation factor VIII, Coagulation factor IX
11.3 Plasma substitutes: Albumin, Polygeline
12 CARDIOVASCULAR MEDICINES

12.1 Antianginal medicines: Bisoprolol, Glyceryl trinitrate, Isosorbide dinitrate

Metoprolol, Verapamil
12.2 Antiarrhythmic medicines
Complementary list: Amiodarone, Digoxin, Epinephrine (adrenaline),
Isoprenaline, Lidocaine, Metoprolol, Verapamil
12.3 Antihypertensive medicines: Amlodipine, Amlodipine + Losartan,
Enalapril, Hydralazine, Hydrochlorothiazide, Labetalol, Losartan, Methyldopa
Nifedipine, Prazosin
Complementary List: Sodium nitroprusside
12.4 Medicines used in Heart failure: Digoxin, Furosemide [c], Losartan
Ramipril, Spironolactone
Complementary list: Dobutamine, Dopamine, Norepinephrine
12.5 Antithrombotic medicines
12.5.1 Anti-platelet medicines: Acetylsalicylic acid, Clopidogrel
12.5.2 Thrombolytic medicines
Complementary List: Streptokinase
12.6 Lipid lowering agent: Atorvastatin, Fenofibrate
13 DERMATOLOGICAL MEDICINES (TOPICAL)

13.1 Antifungal medicines: Benzoic acid + Salicylic acid, Clotrimazole

13.2 Anti-infective medicines: Povidone iodine, Silver sulfadiazine [a]
Complementary list: Mupirocin, Fusidic acid
13.3 Anti-inflammatory and antipruritic medicines: Calamine
13.4 Medicines affecting skin differentiation and proliferation: Peroxide,
Salicylic acid
Complementary list: Podophyllotoxin
13.5 Scabicides and pediculicides: Permethrin, Benzyl benzoate [a]

14 DIAGNOSTIC AGENTS

14.1 Ophthalmic medicines: Fluorescein

14.2 Radiocontrast media
Complementary list: Amidotrizoate, Barium sulfate [c], Iohexol
Complementary list: Meglumine iotroxate

15 DISINFECTANTS AND ANTISEPTICS

15.1 Antiseptics: Chlorhexidine, Ethanol (Rectified spirit), Povidone iodine

15.2 Disinfectants: Alcohol, Chlorine compound , Glutaraldehyde
16 DIURETICS: Furosemide, Hydrochlorothiazide, Mannitol [c], Spironolactone
[c]

17 GASTROINTESTINAL MEDICINES

17.1 Antacids and antiulcer medicines: Omeprazole, Ranitidine

17.2 Antiemetic medicines: Domperidone, Ondansetron [c] [a], Promethazine,
Metoclopramide [a]
17.3 Anti-inflammatory medicines: Sulfasalazine
17.4 Laxatives: Lactulose [c], Magnesium sulfate
Complementary list: Bisacodyl, Ispaghula husk
17.5 Medicines used in diarrhea
17.5.1 Oral rehydration: Oral rehydration salts
17.5.2 Medicine for diarrhea: Zinc sulfate
17.6 Antispasmodic medicines: Hyoscine butylbromide [c]
Complementary list: Drotaverine hydrochloride, Hyoscine hydrobromide
18 MEDICINES FOR ENDOCRINE DISORDERS

18.1 Adrenal hormones: Dexamethasone, Prednisolone, Hydrocortisone

Complementary list: Fludrocortisone
18.2 Androgens: Testosterone
18.3 Estrogens: Ethinylestradiol
18.4 Progestogens: Norethisterone: Medroxyprogesterone acetate
18.5 Medicines for diabetes
18.5.1 Insulins: Insulin (soluble), Intermediate acting insulin (NPH)
18.5.2 Oral hypoglycemic agent: Gliclazide, Metformin [c]
Complementary list: Glipizide
18.6 Thyroid hormones & antithyroid medicines: Carbimazole [c], Lugol’s
iodine [c], Levothyroxine
18.7 Posterior Pituitary Hormone: Desmopressin [c]

19 IMMUNOLOGICALS

19.1 Diagnostic agents: Tuberculin, Purified Protein Derivative (PPD)

Injection
19.2 Sera and immunoglobulins: Diphtheria antitoxin (immunoglobulin)
Polyvenom anti-snake serum, Tetanus antitoxin (immunoglobulin)
19.3 Vaccines
19.3.1 For universal immunization: BCG Vaccine, Diphtheria, Tetanus,
Pertussis, Hepatitis B, Haemophilus Influenzae Type B Vaccine, Japanese
Encephalitis Vaccine, Measles Rubella (MR) Vaccine, Poliomyelitis (oral)
Vaccine, Poliomyelitis (inactivated) Vaccine, Pneumococcal Vaccine, Rotavirus
Vaccine, Tetanus diphtheria (Td) Vaccine
19.3.2 For specific groups of individuals
Complementary list: Hepatitis A Vaccine, Hepatitis B Vaccine, Human
Papiloma Vaccine (HPV) Vaccine, Haemophilus Influenzae Type B Vaccine,
Influenza (seasonal) Vaccine, Meningococcal Meningitis Vaccine, Measles
Vaccine, Mumps Vaccine, Rubella Vaccine, Tetanus Toxoid Vaccine, Typhoid
Vaccine. Yellow fever Vaccine, Rabies vaccine, Freeze-dried Vaccine

20. THE MUSCLE RELAXANTS (PERIPHERALLY ACTING) AND

CHOLINESTERASE INHIBITORS)

Main List: Neostigmine, Suxamethonium (succinylcholine), Vecuronium [c]

Complementary list: Atracurium
21. OPHTHALMOLOGICAL PREPARATIONS

21.1 Anti-infective agents: Aciclovir, Ciprofloxacin, Natamycin

Complementary list: Chloramphenicol, Fluconazole, Ofloxacin, Tetracycline
21.2 Anti-inflammatory agents: Prednisolone
21.3 Local anaesthetics: Lidocaine (lignocaine), Proparacaine
Complementary list: Tetracaine [a]
21.4 Miotics & antiglaucoma medicines: Acetazolamide, Pilocarpine, Timolol
21.5 Mydriatics: Atropine [a], Tropicamide

22 MEDICINES FOR REPRODUCTIVE HEALTH AND PERINATAL

CARE

22.1 Contraceptives
22.1.1 Oral hormonal contraceptives: Ethinylestradiol + Levonorgestrel,
Ethinylestradiol + Norethisterone, Levonorgestrel,
22.1.2 Injectable hormonal contraceptive: Medroxyprogesterone acetate
22.1.3 Intrauterine devices: Copper-containing devices
22.1.4 Barrier methods: Condoms
22.1.5 Implantable contraceptives: Levonorgestrel releasing implant
22.1.6 Miscellaneous: Ring pessary, silicon ring pessary
22.2 Ovulation inducers: Clomifene
22.3 Uterotonics: Methylergometrine, Oxytocin
Complementary list: Mifepristone- Misoprostol, Misoprostol
22.4 Antioxytocics (Tocolytics): Nifedipine
Complementary list: Terbutaline
22.5 Other medicines administered to the mother: Dexamethasone,
Tranexamic acid
22.6 Medicines administered to the neonate: Caffeine citrate [c],
Chlorhexidine [c]
Complementary List: Ibuprofen [c], Surfactant [c]
23 Peritoneal Dialysis Solution: Intraperitoneal dialysis solution

24 MEDICINES FOR MENTAL AND BEHAVIOURAL DISORDER

24.1 Medicines used in Psychotic Disorders: Chlorpromazine, Fluphenazine,

Haloperidol, Olanzapine
Complementary list: Risperidone
24.2 Medicines used in mood disorders
24.2.1 Medicines used in depressive disorders: Amitriptyline, Fluoxetine [c]
[a]
24.2.2 Medicines used in bipolar disorders: Carbamazepine, Lithium
carbonate, Valproic Acid (Sodium Valproate)
24.3 Medicines used in generalized anxiety and sleep disorders: Diazepam,
Chlordiazepoxide, Lorazepam
24.4 Medicines used for obsessive compulsive disorders: Fluoxetine [c] [a]
24.5 Medicines used in Disorders due to Psychoactive Substance Use:
Methadone, Nicotine replacement therapy (NRT)
Complementary list: Buprenorphine, Disulfiram, Nicotine replacement
therapy (NRT)

25 MEDICINES ACTING ON THE RESPIRATORY TRACT

25.1 Antiasthmatic and medicines for chronic obstructive pulmonary
disease: Aminophylline, Epinephrine (adrenaline), Hydrocortisone,
Ipratropium bromide, Salbutamol
Complementary list: Beclometasone
26. SOLUTION CORRECTING WATER, ELECTROLYTE AND ACID
BASE DISTURBANCES
26.1 Oral: Oral rehydration salts
26.2 Parenteral: Solution of sodium lactate (ringer’s lactate), Glucose, Sodium
chloride,Glucose with NaCl, Potassium chloride, Sodium bicarbonate (sodium
hydrogen carbonate)
26.3 Miscellaneous: Water for injection

27. VITAMINS AND MINERALS

Main List: Ascorbic acid, Calcium, Colecalciferol [c], Pyridoxine, Retinol,
Riboflavin, Thiamine
Complementary: Calcium gluconate

28. EAR, NOSE AND THROAT PREPARATIONS AND DENTAL

PREPARATIONS
28.1 Ear, nose and throat preparations: Betamethasone, Chloramphenicol,
Ciprofloxacin [c], Clotrimazole, Lidocaine (lignocaine), Oxymetazoline [c] [a],
Sodium bicarbonate + Glycerin
28.2 Dental: Benzocaine, Chlorhexidine, Zinc oxide
29. MEDICINES FOR DISEASES OF JOINTS
29.1 Medicines used to treat gout: Allopurinol, Colchicine
29.2 Disease modifying agents used in rheumatic disorders (DMARDs):
Methotrexate
Complementary list: Azathioprine, Hydroxychloroquine

Clinical Pharmacy Services in Specific Conditions

1. Dosage Adjustment in Elderly Patient: Patients at elderly are at more risk to
adverse reaction of drugs. Adverse drug reaction observed in patients above age 65
is two or three times more compared to younger patients.

Factors affecting ADR in Elderly Patient

 Patients with multiple medications have a greater chance of experiencing ADR
due to drug-drug interactions.
 There are predictions about the possible change in pharmacokinetic and
pharmacodynamics profiles with age.
 Factors related to gender, lower socioeconomic status and poly-pharmacy
complex drug regimens are also responsible for ADR.
 Improper drug therapy and drug monitoring may add up the ADR in elderly.
Pharmacological Risks
Absorption: There is delayed absorption due to the change in physiology such as
gastric emptying, decreased splanchnic blood flow, elevated gastric pH and
impaired intestinal movement.

Distribution: Elderly patients has decreased water content so there is a decreased

in volume of distribution of water soluble drugs such as Acetaminophen. Similarly
volume of distribution of lipid soluble drugs such as Diazepam & Propranolol is
increased because they have high mass of adipose tissues and less lean muscles.
Pharmacodynamic Profiles: There is decrease in receptor sensitivity as compared
to younger people. There is decreased baroreceptor sensitivity and increases
response benzodiazepines and opioid alkaloids.
Renal Excretion: Serum creatinine is decreased with the age. The drugs eliminated
from kidney can result in increased concentration & subsequent adverse reaction.
The certain drugs such as Digoxin, Procainamide and Aminoglycosides may cause
serious complications if dose is not adjusted with renal function of the patient.
Hepatic Metabolism: Age related changes affecting liver includes the reduction of
hepatic blood flow and decreased hepatic metabolism.
General Principles for Prescribing Medicines in Elderly Patients

 Medication should be start with low dose and reduce slowly

 Half-life of many drugs will be prolonged in elderly due to reduced renal &
hepatic function.
 The fewest number of drugs should always be used to treat patients
 Always evaluate the possible drug toxicity. Geriatric patients can have typical
presentations of ADR which may manifest as CNS changes.

2. Dosage Adjustment in Impaired Liver Patient: Liver is the main route of

elimination of many drugs. A few drugs such as Rifampicin and Fusidic acid are
excreted in bile on unchanged form and may accumulate on the patients with
intrahepatic or extra hepatic obstructive jaundice.

Hepatic disease may lead to form active/inactive metabolites, increased

bioavailability and shows possible alternation in drug protein binding. Liver
function test is done to know the liver function which indicates only about liver
damage but does not assess the function of CYP450 enzymes or intrinsic clearance
by liver. Reduced hepatic synthesis of blood-clotting factors indicated by a
prolonged prothrombin time increases the sensitivity to oral anticoagulants such as
Warfarin & Phenindione. Similarly drugs which causes fluid retention such as
NSAID and corticosteroids may worse edema and causes chronic liver diseases.
Considerations Comments
Nature & severity Not all liver diseases affect the pharmacokinetics of the
of liver disease drugs to the same extent
Drug elimination Drugs eliminated by the liver >20% are less likely to be
affected by liver disease. Drugs which are eliminated
mainly through renal route will be least affected by liver
disease.
Route of drug Oral drug bioavailability may be increased by liver disease
administration due to decrease in first-pass effects.

Protein Binding Drug protein binding may be altered due to alteration in

hepatic synthesis of albumin
Hepatic Blood Drugs with flow dependent hepatic clearance will be more
Flow affected by change in hepatic blood flow.
Intrinsic Clearance Metabolism of drug with high intrinsic clearance may be
impaired.
Biliary Biliary excretion of glucuronide metabolites may be
Obstruction impaired.
Pharmacodynamic Tissue sensitivity to drugs may altered.
Changes
Therapeutic Range Drugs with a wide therapeutic will be less affected by
moderate hepatic impairment.
3. Dosage Adjustment in Impaired Kidney Patient: The level of renal function
below which the dose of the drug needs to be changed depends upon whether the
drug is eliminated by renal excretion. Accurate dose reduction is not required for
drugs showing minor or dose independent side effects while dose regimens based
on GFR should be used for drugs showing severe toxicity with low margin of safety.

For certain drugs if the size of maintenance dose is reduced than a loading dose
might be necessary to produce an instant effect. This is because it takes more than
5 half-lives to achieve plasma steady state concentration. The loading dose in such
a case must be the same as the initial dose for a patient with normal renal function.

Nephrotoxic drugs should be avoided in patients with renal disease as far as

possible. This is because the consequences of Nephrotoxicity are likely to be more
severe when the renal function is not proper. The renal function declines with age.
Many elderly patients have a GFR below 50m1/min because of reduced muscle
mass. Renal impairment is expressed in terms of GFR which is measured by the
creatinine clearance. The renal impairment is generally divided into 3 grades:

Grade GFR Serum creatinine

Mild 20-50m1/min 150-300 μmol/litre
Moderate 10-20m1/min 300-700 μmol/litre
Severe <10ml/min >700 μmol/litre
 Drug and Degree of impairment Comment
Amantadine (Mild to moderate Severe) Reduce dose
Aminoglycosides (Mild) Reduce dose & monitor the plasma
levels
Ampicillin and Amoxicillin (Severe) Reduce the dose
Ceftriaxone (Severe) Monitor the plasma concentration
Ciprofloxacin (Moderate) Reduce the dose to half
Ephedrine (Severe) Avoid
Fluconazole (Mild) Reduce dose for multiple drug therapy
Probenecid (Moderate) Avoid

(140−Age)×Body weight on Kg×1.23

Creatinine clearance rate on male =
Plasma Creatine (μmol/L)

(140−Age)×Body weight on Kg×1.04

Creatinine clearance rate on female =
Plasma Creatine (μmol/L)

Creatinine Clearance rate for infants 0.55 ×Height (cm)

=
and Children of age 1 to 12 years Plasma Creatine (μmol/L)
General Principles for Prescribing Medicines in Impaired Kidney Patients

 Long acting opioid preparations should be avoided as the metabolites

accumulate in renal failure. An exception to this rule is transdermal fentanyl as
renal failure does not affect the pharmacokinetics of the drug.
 NSAIDs should be avoided if possible unless a patient is already on dialysis.
 Estimated GFR should be used to determine renal function.
 Drug doses should be reduced or dosing intervals should increase as appropriate
in severe renal impairment.
 Patients should be closely monitored for evidence of drug toxicity or drug
induced renal impairment while prescribing medicines.
 Drugs with flow dependent clearance are avoided if possible or dose is reduced
to 1/10th of the conventional dose.

 Enzyme dependent drugs are usually given in half doses or in less doses in
patients with hepatic failure.

 There should be moderate decrease in drug doses when creatinine clearance

is less than 25-30 mL/min and the substantial decrease in drug doses when
creatinine clearance is more than 15mL/min. The typical human reference
ranges for serum creatinine are 45-90 μmol/L for women and 60-110 μmol/L
for men.
4. Dosage Adjustment in Neonate & Children: Pharmacokinetics profile of
children changes as they get mature from birth to adolescence. Antibiotics
(Vancomycin, Cephalosporin and Penicillin), Anticonvulsant, Narcotics,
Antiemetic Agents & Contrast agents are leading cause of ADR in children

Factors affecting Drug Profile in Children

i. Gastrointestinal Absorption: Oral absorption is altered during first year of life.
The gastric PH is Achlorhydric (i.e. PH > 4) in neonate due to which the
bioavailability of basic drugs is increases and the bioavailability of acidic drugs
gets decreases. The intestinal peristalsis increases slowly after birth over the first
four months of life. Different disease states such as Pyloric stenosis, GERD,
Respiratory distress syndrome & congestive heart disease significantly affect
gastric absorption. The rate of bile production is reduced by 50% in premature and
infants. Neonates have low secretion of lipase so lipid soluble drugs may be left
insoluble and unabsorbed in the intestine e.g. Chloramphenicol.
ii. Percutaneous Absorption: Skin hydration and stratum corneum maturity at
different stages of mature or premature neonates affects drug profile in children.
iii. Drug Distribution: The plasma protein binding is less in newborn and infants
so the apparent volume of distribution gets increases significantly.
iv. Metabolism: Drug Metabolism is substantially slower in infants as compare to
the older children and adults. Pathways of metabolism are less matured so the doses
of Theophylline, Phenytoin and Diazepam should be decrease on premature infants.
v. Excretion: Processes of glomerular filtration, tubular secretion and tubular
reabsorption takes several weeks to 1 year after birth to develop fully.
Chloramphenicol and Aminoglycosides are avoided because their metabolites are
accumulated due to immature kidney function.

Various Equations for Finding the Dose of Child

a. Young’s rule
(For calculating doses for children two years of age or older)
Age
Dose for child = × Adult dose
Age+12

b. Cowling’s Rule
(For calculating doses for children two years of age or older)
Age at next birthday in years
Dose for child = × Adult dose
24

c. Fried’s Rule
(For calculating doses for infants younger than one year of age)
Age in months
Dose for infants = × Adult dose
150
d. Clark’s Rule
Weight in Ib
Dose for child = × Adult dose
150 (average weight of adult in Ib)

e. Catzel’s rule
BSA (Body Surface Area) of child in m2
Dose for child = × Adult dose
1.73 m2 (average adult BSA )

General Principles for Prescribing Medicines in Neonates and Children

 The pediatric pharmacokinetic parameters change during maturation from
neonates into adolescents.
 There should be needed to calculate pediatric dose.
 Dosage formulations may need to be altered.
 IV solution may be prepared as more concentrated solution
 TDM is often essential
 Differences in ADR between children and adults should be monitor
5. Dose Adjustment in Pregnancy & Lactation: It is important to note that
approximately 3-5% of all live births have fetal abnormality. The exposure of the
fetus during 18- 55 days of life results in malformations of organs while after 55
days adverse effect of the drug may be shown as dysfunction of the fetal organs.
Teratogenicity refers to the congenital malfunctions grossly visible at birth and
caused by the exposure to the exogenous agents which are known as teratogens.
Drugs which are contraindicated during pregnancy are Erythromycin, Sulfonamide,
Flouroquinolones, Aminoglycosides, Clarithromycin & Tetracycline.

Pharmacological Risks
Clearance (CI): The clearance rate of drugs is increased along with liver
metabolism and renal elimination during pregnancy. The cardiac output is
increased up to 30% during pregnancy and increases the renal blood flow and GFR.
Therefore the maintenance doses of drugs often need to be increased during
pregnancy.
Volume of Distribution: Volume of distribution may be increased by 20% for both
lipid soluble and water soluble drugs. This may cause loading dose to be increased.
Protein Binding: Maternal albumin level decrease throughout the pregnancy to a
low at the time of delivery.

General Principles for Prescribing Medicines in Pregnancy

 Avoid all drugs as possible including smoking, drinking alcohol and caffeine.
 Avoid drugs in the first trimester.
 Choose the drugs with least toxicity.
 Use short courses and the smallest doses.
 FDA Pregnancy Labeling for Prescription Drugs
Category A Well controlled studies in pregnant women showed no evidence of
risk to the fetus in first trimester of pregnancy or in later trimesters.
Ex: Multi Vitamins, Magnesium Sulphate
Category B Animal reproduction studies did not show fetal risk and there were
not adequate and well-controlled studies in pregnant women. Ex:
Amoxicillin, Paracetamol
Category C Animal reproduction studies have shown adverse effects on fetus
and there are not adequate & well-controlled human studies and
the drug benefits in pregnant women may be acceptable despite
potential risks. Ex: Morphine, Atropine
Category D Positive evidence shown the fetal risk in humans based on adverse
events data from investigational or marketing experience or studies
in humans but the potential benefits in pregnant women may be
acceptable despite potential risks. Ex: Aspirin, Phenytoin,
Paroxetine, Diazepam
Category X Studies in humans or animals have shown fetal abnormalities or
there is the positive evidence of fetal risk based on the adverse
event reports from investigational or marketing experience and
risk clearly outweighs any benefits to pregnant women. Ex:
Progesterone, Isotretinoin, Tazarotene, Thalidomide
Drugs Not Recommended for Use in Breast Feeding
 Antibacterial Drugs: Sulfonamides, Tetracyclines, Chloramphenicol,
Isoniazid, Nalidixic Acid, Erythromycin
 Analgesics: Indomethacin, Phenylbutazone, Aspirin in large doses, Opioids
 Psychoactive Drugs: Diazepam, Lithium
 Antithyroid Drugs: Thiouracil, Methimizole, Carbimazole, Antineoplastic
Drugs
 Miscellaneous Drugs: Amantadine, Cimetidine, Anthraquinones,
Amiodarone, Ephedrine, Aminophylline, Ergotamine, Vitamin D

Standard Treatment Guidelines: The systematically developed statements to

help prescribers to make decisions about appropriate medicine for specific clinical
conditions. It contains information on clinical features, diagnostic criteria, non-
medicine and medicine treatment and referral criteria.

Uses of Standard Treatment Guidelines

• Provide guidance to health professionals on diagnosis and treatment of specific
clinical conditions
• Orient new staff about the accepted norms in the treatment of various diseases
• Provide prescribers with justification for prescribing decisions
• Provide a reference point to judge the quality of prescribing medicine
• Help in efficient estimation of needs of medicine and setting priorities for
procuring medicine

Steps in developing & implementing STG

Step 1: Identify the working group to develop hospital STG
Step 2: Develop an overall plan for developing & implementing STG
Step 3: Identify diseases for which STG are needed.
Step 4: Determine appropriate medicine
Step 5: Determine what information should be included in STG
Step 6: Draft STG for comments & pilot test
Step 7: Implements, Publish, Launch, Disseminate, Train & Supervise STG
Step 8: Update the STG
Drug Financing Scheme: Drug Financing Scheme include Public Financing,
Health insurance, Private or co-operative not for profit financing, Donors and
International loans. There are mainly three types of health financing methods. The
first is the full cost recovery scheme. Second is the cost-sharing program initiated
by GON/WHO & the third is a pre-payment scheme in the form of compulsory
insurance.
Logistics Management of Drug: The phenomenon of management of drug supply
on the society or hospital or clinic through the appropriate selection, procurement,
distribution and rational use of drug is called as Logistics Management of Drug.

Steps involved during Logistics Management of Drug

a. Selection: Ministries of health normally determine the types of drugs and dosage
forms which are selected according to national formulary and national drug list.
Selection of essential drugs within needs of peoples helps to estimate rational use
of drugs. Drugs are classified as Ka, Kha and Ga groups in the context of Nepal.

b. Procurement: The pharmaceutical procurement is a specialized professional

activity that requires a combination of knowledge, skills and experience. An
effective procurement process helps to ensure the availability of the right medicines
in the right quantities at reasonable prices and at recognized standards of quality.

Steps involved on Procurement Cycle

a. Review drug selections
b. Determine quantities needed
c. Reconcile needs and funds
d. Choose procurement method
e. Locate and select supplier
f. Specify contract terms
g. Monitor order status
h. Receive and check drugs
i. Distribute drugs
j. Collect consumption information
c. Drug distribution: Drug distribution concerns mainly with dispensing of drugs
to patients.

d. Rational use of drugs: Trained and motivated health staff is needed to ensure
safe and effective treatments and for minimizing the risks during irrational
prescribing and use of medicines.

Rational Use of Drugs includes

 Right Dose for Right patient  Right education towards medicines
 Right route of administration  Right evaluation of medications
 Right medication for Right time  Right documentation of patient profile
 Right assessment of medicines  Right documentation of medications

Patient Counseling: Patient counseling refers to process of providing information

& advice to the patients towards the use of their drug in appropriate way.

Stages in the Counseling Process

Recognizing the need for counseling
 Assessing and prioritizing the needs
 Specifying the assessment methods to be used
 Implementation and
 Assessing the success of the process
Informations to be included in Counseling
 How to take or use the medicine?
 When to take or use the medicine?
 How much to take or use the medicine?
 How long to continue to take or use the medicine?
 Why the medicine is being taken or used?
 What to do if something goes wrong if a dose is missed?
 How to recognize the side effects and minimize their incidence?
 What type of lifestyle changes to be made?
 What type of dietary changes to be made?

Primary Health Care: Primary health care is a scientifically based essential health
care which is made universally accessible to individuals and acceptable to them
through their full participation and at a cost that the community and country can
afford. PHC is generally regulated by Medical Doctor, Health Assistant (HA), Staff
nurse, Assistant Health Workers (AHW), Auxiliary Nurse Midwifery (ANM), Lab
assistant & Village Health Workers (VHW).

Major Four Principles of Primary Health Care

 Equitable Distribution  Community Participation

 Intersectoral Co-ordianation  Appropriate Technology
Eight Components of Primary Health Care (Alma Ata Declaration)
 Education concerning towards the prevailing health problems and the methods
for preventing & Controlling Them
 Promotion of Food Supply & Proper Nutrition
 Adequate Supply of Safe Water & Basic Sanitation
 Maternal & Child Health Care including Family Planning
 Immunization Against Major Infectious Diseases
 Prevention & Control of Locally Endemic Diseases
 Appropriate Treatment of Common Diseases & Injuries
 Provision of Essential Drugs

Characteristics of PHC
 PHC reflects the economic, sociocultural and political characteristics of country
& its communities.
 PHC is based on the application of the relevant results of social, biomedical and
health services research and public health experience.
 PHC addresses the main health problems in the community by providing
Promotive, Preventive, Curative and Rehabilitative Services.
 PHC includes Education towards prevailing health problems and methods of
preventing and the controlling them, Promotion of food supply and proper nutrition,
Adequate supply of safe water and basic sanitation, Maternal and child health care
including Family planning, Immunization against the major infectious diseases,
Prevention and control of locally endemic diseases, Appropriate treatment of
common diseases and injuries and Provision of essential drugs.
PHC should be sustained by integrated, functional and mutually supportive
referral systems and leads to the progressive improvement of comprehensive health
care for all.
 PHC is generally regulated by Medical Doctor, Health Assistant (HA), Staff
nurse, Assistant Health Workers (AHW), Auxiliary Nurse Midwifery (ANM), Lab
assistant & Village Health Workers (VHW) to fulfill the health needs in the
community.
First Aid: First Aid is an emergency medical measures delivered at the site in cases
of accidents & sudden illnesses. The First Aider can be anybody from lay person
to skilled health personnel. The main objective should be to preserve life, prevent
worsening & promote recovery.

Purpose of First aid

• To preserve and sustain the life of the casualty
• To stabilize the patient & prevent contamination
• To aid in better and more rapid recovery
• To aid in the safe transportation of the patient to a hospital of doctor

Principle of First Aid

• Assessment of the situation
• Making the area safe or removing casualty from the hazardous place
• Triage in cases of multiple casualties
• Immediate transfer of victim to medical, facility or summoning of expert help to
site.
Note: Triage is defined as the provision of care to patients on the basis of need or
severity of the illness. Generally it is done to prioritize the patients. It is done by
leveling the human body by different colors. Red labelled patient will die in few
minutes, Yellow labelled patient will die in 24 hours if no treatment, Green labelled
patient can wait & Black labelled patient is dead. So the people labeled with yellow
color are inmost need of First Aid.
1. Cardiopulmonary Arrest: Cardiopulmonary Resuscitation (CPR) is done in
case of cardiopulmonary Arrest. It has to be done quickly as the brain can survive
only for 4 minutes without oxygen.
Airway Maintenance: Open the airway by tilting head back and lifting their chin
upwards. This will remove the tongue from blocking the airway.
Breathing: Ensure the appropriate air exchange within chest. The patients without
adequate spontaneous respiratory effort require artificial ventilation which can be
Mouth - Mouth.
Circulation: Chest compression should be started simultaneously with the
establishment of airway & initiation of breathing. In one - rescuer CPR two breaths
should be followed by 30 chest compressions & in 2 rescuer CPR one ventilation
should be provided for every 5 chest compressions. It should be done with the
patient lying in the supine position and compression should be done by placing the
heel of one hand on top of another by compressing 4-5 cm deep in adults. The
effectiveness of the compressions can be checked by feeling the pulse. The
compression should be done at the rate of 80-100/minutes.
2. Shock: The main objective of the First Aid is to increase the perfusion of the
Vital Organs (Brain, Heart & Kidney) in case of shock.
 The patient is laid down with head clown & legs up with placement of pillows
underneath.
 Resuscitation of the patient, give fluids, oxygen & ionotropes.
 Correct the blood volume by blood transfusion in case of shock due to
hypovolemia while gives the antibiotics in case of septic shock.
 Correct electrolytes imbalance.
 Adrenaline should be given in case of life threatening anaphylactic shock
which may appear within few minutes due to the exposure to the irritant
substances such as shell fish, insect bites or drugs like penicillin.
3. Haemorrhage (Bleeding)
 Remove the cloths to expose the wounds & compress the bleeding site firmly
with a clean cloth but don’t remove the clot around the bleeding site.
 Check the vital signs and look for the signs of the impending shock.
 Restoration of the blood volume if the blood loss is expected to be > 10 %, TT
vaccination, Suture & dressing of the wound.
 The golden time to prevent vascular ischemia to any organ is 6 hours.
Management Strategies in case of Bleeding from Nose (Epixtasis)
 Keep the patient in the sitting up position
 Keep victim’s head bent slightly forward so that blood can flow out from the
nose outside & does not go back to the throat
 Pinch both the nostrils with steady pressure for 5 minute
 Apply ice pack over the nose area to help control bleeding
 Rush for medical help if bleeding does not stop
4. Fracture
The wound is cover with a sterile dressing in case of open fracture & secure it
with bandage & apply pressure around the wound to control any bleeding.
Immobilize the injured parts with splints or any fixed parts which may help to
relieve pain & prevent further injuries.
 Control the bleeding & shock.
 Transfer the patient to health center and check the distal neurovascular status.
 Plastering is done by using Plaster of Paris (Gypsum salt) and the patient
should be asked to move the fingers after the plaster because the tight plaster
might cause compartment syndrome.
5. Burn
 Fluid replacement, pain management & wound dressings are the important
aspects in the management of the burn.
 IV fluid should be given if burn exceeds 10% in children & 15% in adults.
 In case of Fire burns remove the casualties form the site and douse the burning
fire with water or wrapping with a coat or rug. Cover the burn site with clean cloth
but don’t burst the blisters. Burns in face, hand, foot, and perineum should be
treated as severe burn. In case of facial burn early intubation should be done.
 Alkali burns are more dangerous than the acid burn because alkali burns causes
liquefactive necrosis & penetration into deep tissues.
 Electrical burns are most dangerous because it can cause immediate death due
to cardiac arrhythmia. The rescuer should switch off the lights before going to
rescue. Electrocution is death due to electricity. The electric burn might look small
but it might have caused severe muscle damage. Alternating Current (AC) is more
dangerous than the DC.
 Frost bite is cold burn & scald is burn by moist heat.
6. Choking: In case of choking the patient is asked to bend forward and sharp blow
is given with the palm in between the shoulder blades.
Maternal & Child Health: MCH (Maternal & Child health) is the promotive,
preventive, curative & rehabilitative health care of mothers & children. MCH
includes Antenatal Care, Intranatal Care, Postnatal Care & Care of under Five
Children.

Antenatal care (ANC): ANC is the care of the woman during pregnancy. The
primary aim of ANC is to achieve at the end of a pregnancy a healthy mother & a
healthy baby. Complete medical checkup & identification of high risk cases is done
in this stage.

Pregnant female should at least have 4 ANC visits:

i. 1st visit: As soon as the pregnancy is diagnosed
ii. 2nd visit: 5months-7months of Pregnancy
iii. 3rd visit: 9 months
iv. 4th: last week when the baby is expected to be delivered.
Iron tablets should be given from 4 months of pregnancy to 6 weeks after delivery.
TT vaccination should be given twice. 1st during the first ANC visit & 2nd after 1
month but it should be given before 9 months. Folic acid, Calcium & Vitamin A
supplementation is also given. Albendazole is given for deworming. X-ray should
be avoided during first trimester. During Pregnancy, the mother should consume
extra 300 kcal/day. Average weight gain is about 10 kg during pregnancy.
Intranatal care: Intranatal care is the care during delivery. The aim of good
intranatal care are:
i. Thorough asepsis.
ii. Delivery with minimum injury to the infant & mother.
iii. Readiness to deal with complications such as prolonged labour, antepartum
haemorrhage, convulsions, prolapse of cord.
iv. Care of the baby at delivery-resuscitation, care of cord, care of eyes
Post natal care: The post natal care is a care of the mother & the new born after
delivery. The objective are as follows:
i. To prevent complications of postnatal period like puperal sepsis, urinary tract
infections, mastitis.
ii. To provide care for the rapid restoration of mother to optimum health.
iii. To check adequacy for breast feeding.
iv.To provide Family Planning and Immunization services.
v. To provide basic health education to mother/family.
 Neonate: From birth to under 28 days
 Infant: From birth to 1 year
 Toddler: 1-3 years
 Term baby: Any neonate between 37-42 weeks of pregnancy irrespective of
birth weight
 Preterm baby: Any neonate before 37 weeks of pregnancy irrespective of
birth weight
 Post term baby: A neonate born at a gestational age of 42 weeks or more
irrespective of weight.
 Normal Birth Weight: Normal birth weight lies between 2.5 - 3.5 kg. The
average birth weight is 2.8 kg.
 Low Birth Weight (LBW): Any neonate weighing less than 2500gms at birth
irrespective of gestational age.

Normal Development Milestones of a Child

Age Milestones
8 Weeks Social Smile
3 Months Head Control, Recognizes mother
6 Months Sits with support
9 Months Crawls, Stranger anxiety:
10 Months Stands with support, First word
12 Months Stands without support, Walk few steps, Says 2-3 Words,
Play Tarabaji
18 Months Can run
2 Years Climbs upstairs and Can speak simple sentences
3 Years Climbs down stairs
5 Years Goes to School

Care of under 5 Year Children: Care of under 5 is especially important as they

are at risk of high morbidity and mortality. Common diseases in this age group are
ARI, Diarrhea, Worms, Skin infection, Malnutrition, Measles, etc.
Breast Feeding: Breast Feeding provides 67 kcal of energy per 100ml. Colostrum
is thick & yellow milk secreted in first few days after delivery. It is rich in
immunoglobulins so it is considered as baby’s first immunization. Exclusive breast
feeding should be done untill 4-5 months & breast-feeding should be continued
untill 2 years of age.
Weaning: It is an introduction of new extra food to the baby at about the age of 4-
5 months when the mother milk is not sufficient to the baby. Common weaning
food in Nepal are Dal, Maad, Jaulo, Lito, Animal milk, Vegetables & Fruits. The
best weaning food is Sarbottom Pitho. Sarbottorn pitho is made of 2 Parts of
Soyabean + 1 Part of Wheat & 1 Part of Maize. Sarbottom Pitho provides 350-
370kcal, 25 gm protein, 4 gm of fat & 60 gm of carbohydrates per 100 grams.

Protein Energy Marasmus (Sukenas, Kwashiorkar (Fukenas)

Malnutrition Monkey Face)
Deficiency Energy Protein
Edema Absent Present
Muscle wasting Obvious Not obvious
Appetite Good Poor
Skin & Hair Change Not seen Present, Hair - sparse
Mental Change Quiet, Apathetic Irritable
Subcutaneous Fat Severe Loss Often retained
Vaccination: Vaccination is the administration of a vaccine to help the immune
system develop protection from a disease.

1. Killed or Inactivated Vaccine: Vaccines of this type are created by inactivating

a pathogen by using chemicals, heat, radioactivity or antibiotics. Ex: Hepatitis A,
Influenza, Anthrax and Cholera vaccine

2. Lived or attenuated vaccine: An attenuated vaccine is a vaccine created by

reducing the virulence of a pathogen by keeping it on viable state. Examples of
attenuated vaccines are the BCG, Sabin polio, MMR (Measles, Mumps and
Rubella) Vaccine.
3. Toxoids: Toxoids are vaccines which consist of exotoxins that have been
inactivated either by heat or chemicals. These vaccines are intended to build
immunity against the toxins. Ex: Tetanus toxoid and diphtheria toxoid

4. DNA vaccines: These vaccines show great promise and several types are being
tested in humans. DNA vaccines take immunization to a new technological level.
Example: Influenza vaccine
 Expanded Immunization Schedule
Vaccines Dose Administration Age Route
BCG 1 (0.05ml) At birth Intradermal
DPT-Hepatitis B 3 (0.05ml) 6,10,14 weeks Intramuscular
Oral Polio Vaccine 3 (0.05ml) 6,10,14 weeks Oral
Injectable Polio 1 (0.05ml) 14 weeks Intramuscular
Vaccine
PCV (Pneumococcal 3 (0.05ml) 6 Weeks, 10 Weeks Intramuscular
Conjugate Vaccine) & 14 Months
MR (Measles-Rubella) 2 (0.05ml) 9 & 15 months Subcutaneous
JE (Japanese 1 (0.05ml) 12 months Subcutaneous
Encephalitis)
TD (Tetanus - 2 (0.05ml) Pregnancy (2 doses Intramuscular
Diphtheria) of TD)

Sampling technique: It is the process of selecting a portion of population which

represents whole population

A. Non-probability Sampling
a. Accidental Sampling/ Convenient Sampling: In this technique the
researcher tries to collect data from those people who meets criteria. It is
economical in terms of time and effort. It is mostly used in pilot test studies
b. Quota sampling: Quota sampling is named from procedure of establishing
quota from the various strata of population

c. Purposive Sampling or Judgmental Sampling: This method is used when

the investigation attempts to ensure the specific elements in the sample. This
approach employs a high degree of selectivity.

d. Snowballing Sampling: The snowball sampling is used intensively in the

sociological studies where a specific behaviors or characteristic is present in
few individual who are used to locate others with same specific behaviors or
similar characteristics.

B. Probability Sampling
a. Simple Random Sampling: Sampling units are selected in such a way that
each and every unit of universe has an equal chance of being selected. This
method is used when population is small and homogenous.

Merits
This method is economical and saves times and money.
Subjectivity or personal bias is completely eliminated as the sample units
are selected at random giving each unit an equal chance of being selected.
 Maximum information can be obtained in less time and at minimum cost.
Demerits
 Simple random sampling requires up to date frame which is not readily
available in practice.
 This method is quite time consuming and costly because simple random
sample may result in selection of sampling units which are highly dispersed
and creates sample administrative inconvenience.

b. Systematic Sampling: This method is used when a complete list of population

from which the sample is drawn is available. It is used when population is large,
scatter and non-homogenous. The first unit is selected at random and remaining
units are selected by taking Kth item from list where K refers as sample interval
as:
Total population
K=
Sample size desired

For example to select 8 students out of class of 80. Then K = 80/8 = 10. Therefore
we have to select random number from number 1 to 10. Suppose we got 7 then
the sample will contain students numbered 7, 17, 27, 47, 57, 67 & 77.

Merits
 It is operationally convenient than other sampling technique.
 Time and cost involved in this design is also relatively much less.
It is more efficient than simple random sampling if the frame is complete and
up to date.

Demerits
 Sampling frame for systematic sampling should be up to date which is hardly
available.
 Systematic sampling may yield highly biased estimates if there are periodic
features associated with sampling interval.
c. Stratified Random Sampling: This method is used when population is not
homologous. In this method, population is first divided into homogenous groups
or classes which are called as strata and suitable sample size is selected from each
strata for sampling.

For example to study examination results of 4000 students in a campus we should

first divide students into different faculties (strata) such as science, humanities
and management. Suppose the students in these faculties are about 1000, 1400
and 1600 respectively. Then when we want to select 10% from each faculty we
have to select 100, 140 and 160 students by using stratified random technique.

Merits
It provides a more representative cross section study of the population and is
frequently regarded as efficient system of sampling.
 It provides more efficient estimation with more precision.
 The investigator first uses his judgment to divides the population into
different strata. Then select the sample by random method. Therefore this
technique involves both judgment method and random method for sampling.

Demerits
 This method will not be effective if each stratum does not contain
homogenous units.
 This method consume considerable amount of time and cost.
d. Multistage Sampling: Sampling is carried out on several stages. In the first
stage, random sample of population is taken from districts. Then from VDC on
2nd stage and again from Wards on 3rd stage and so on for its accuracy.

e. Cluster Sampling: The population is first divided into primary sampling

units and a sample of such units is selected. Every element found in each
primary sampling unit will be included in the study.

Example of Cluster Sampling: This sampling method can be used to study the
practice of ICU nurses such as the initial stage might be divided the hospital of
Nepal into geographic region and obtain a list of hospital in each region. Then
select the specific hospitals randomly then select ICU nurses from this hospital
randomly.
1. Which committee provide advice to health care staffs and on matter relating to
therapeutic use of the drugs?
a. Hospital ethics committee b. Drug and therapeutic committee
c. Medical ethics committee d. All of above

2. Which is not the function of pharmacy and therapeutic committee?

a. Develop hospital formulary b. Initiate drug use review program
c. Procure medicine for the hospital d. Advice pharmacy for drug distribution

3. Which is following is not the aim of drug therapeutics committee in a hospital?

a. Uniformity in clinical practice b. Income generation for hospital
c. Appropriate medication d. Improved quality of service

4. A position of a Pharmacist in Hospital Drug and Therapeutic Committee is:

a. Secretary b. Chairman
c. Member d. Vice Chairman

5. Who is the chairman of pharmacy and therapeutic committee?

a. Pharmacist b. Physician
c. Nurse d. Doctor

01 B 02 C 03 B 04 A 05 B
6. Which of the following is not the aim of hospital formulary system?
a. Evaluation & selection of medicine
b. Guide the physicians for prescribing medicines
c. Appraisal & use of non-formulary drugs
d. Listing of drugs in generic name

7. Teratogenic drug affect:

a. Liver b. Kidney
c. Foetus d. Skin

8. Hospital formulary provides:

a. General information of drugs that are available in the country
b. Information for procuring, processing, dispensing & administering of drugs
c. Information of latest adverse drug reactions & regulatory information on drugs
d. None of above

9. The objective of PTC is:

a. Advisory
b. Educational
c. Drug safety and adverse drug monitoring
d. All of the above

06 C 07 C 08 B 09 D
10. Which is not the aim of Standard Treatment Guidelines?
a. Uniformity in practice b. No need of referral
c. Avoid mistakes d. Managing in low cost

11. All of the following are roles of clinical pharmacists except:

a. Drug interaction surveillance b. ADR reporting
c. Purchase & inventory control d. Clinical trial

12. Which of following is not a medicine distribution system for in-patient?

a. Floor stock system
b. Patient prescription system
c. Unit dose system
d. FEFO system

13. Nepalese National formulary provides guidelines for the following areas for
prescribing medication except:
a. For pregnant patient b. For renal impairment patient
c. For cardiac patient d. For terminal care

14. Most common method for maintaining drug inventory is an:

a. FIFO b. Self-life
c. Potency d. ABC system

10 B 11 C 12 D 13 C 14 D
15. List of drugs that have been approved for use on the basis of therapeutic and
economic consideration is known as:
a. Therapeutic drug list b. Narcotic list
c. Formulary d. Investigational drug list

16. Nepalese National Formulary has been prepared for:

a. Procurement of drug
b. Formulation of drug policy
c. Rational use of drug
d. Formulation of drug

17. Ambulatory patients are:

a. Required to admit in the ward for treatment
b. Required to go home after taking treatment in OPD
c. Require emergency treatment
d. None of the above

18. Which one of these is a genetically determined adverse drug reaction?

a. Addiction b. Teratogenecity
c. Carcinogenicity d. Idiosyncrasy

15 C 16 C 17 B 18 D
19. Thalidomide tragedy is related with:
a. Teratogenecity b. Allergic reaction
c. Hypersensitivity reaction d. None of the above

20. Catheters are used for:

a. Drain bladder in case of urine retention
b. Bowel clearance
c. Diarrhoea
d. Incontinence

21. There is an increased level of ……in liver damage.

a. Red blood cell b. SGPT
c. WBC d. Platelets

22. Plasma drug monitoring is done to:

a. Drug with high safety margin b. Drug with low safety margin
c. Drug with high therapeutic index d. None of above

23. The therapeutic blood range of theophylline is an:

a. 0-5 microgram per mililitre b. 5-10 microgram per mililitre
c. 5-15 microgram per mililitre d. 5-20 microgram per mililitre

19 A 20 A 21 B 22 B 23 D
24. Therapeutic monitoring of plasma level of drug is done for all of following
drugs except:
a. Warfarin b. Gentamicin
c. Cyclosporine d. Phenytoin

25. Therapeutic plasma level of digoxin is an:

a. 0.1-0.3 ng/Ml b. 0.8-1.5 ng/mL
c. 1.2 to 2 ng/mL d. More than 2.4 ng/mL

26. A list of medication available for use within a Health care system is called as:
a. Inventory booklet b. Inventory control list
c. Perpetual Inventory d. Formulary

27. Therapeutic level of phenytoin is an:

a. 0-9 μg/ml b. 10-20 μg/ml
c. 20-29 μg/ml d. 30-39 μg/ml

28. National formulary contains:

a. Information on medicines in hospitals
b. Disease in the country
c. Information on medicines available in country
d. All of above

24 A 25 B 26 D 27 B 28 C
29. Therapeutic levels of lithium in a patient of acute mania is an:
(a) 0.4-0.8 mEq/L (b) 0.8-1.2 mEq/L
(c) 1.2-1.6 mEq/L (d) 1.6-2.0 mEq/L

30. Good clinical practice (GCP) isn’t required in:

a. Preclinical phase b. Phase I trial
c. Phase II studies d. Phase IV trial

31. Safety & efficacy of drugs are best studies in:

a. Phase I b. Phase II
c. Phase III d. Phase IV

32. The aim of post-marketing studies is to determine:

a. Efficacy of the drug
b. Dosage of the drug
c. Deals with alteration of drug includes absortion, distribution, binding/storage
d. Safety and comparisons with other medicines

33. The micro dosing is directly given to the patient without pre-clinical testing in
which clinical Phase?
a. Zero phase b. I phase
c. II phase d. III phase

29 B 30 A 31 C 32 D 33 B
34. Phase-IV clinical trials deal with:
a. Post marketing survey b. Safety and efficacy
c. Micro dosing d. Bioequivalence study

35. Design of the study aimed to assess the maximum tolerable dose of a new
drug is best described as:
a. Case control study
b. Phase II Randomized control trial
c. Phase I trial
d. Phase III Randomized control trial

36. Pharmacovigilance means:

a. Monitoring of drug safety
b. Monitoring of unethical trade of drugs
c. Monitoring pharma students
d. Monitoring drug efficacy

37. An undesirable but the unavoidable pharmacodynamics effects of a drug is

known as:
a. Toxic effects b. Idiosyncrasy
c. Side effects d. Intolerance

34 A 35 C 36 A 37 C
38. The Type A (augmented) adverse drug reactions are characterized by all of the
following features except:
a. Qualitatively abnormal responses to drug
b. Predictable from the drug’s known pharmacological or toxicological effects
c. Generally dose-dependent
d. All of above

39. Type B adverse drug reaction is:

a. Augmented effect of the drug
b. Allergic effect of the drug
c. Effect seen on chronic use of the drug
d. Delayed effect of the drug

40. Which of the following adverse drug effect is more common in children as
compared to adult?
a. Isoniazid induced neuropathy
b. Chlorpromazine induced muscle dystonia
c. Digoxin induced cardiac arrhythmia
d. Penicillin hypersensitivity

38 A 39 C 40 B
41. Which of following drug adverse effect is specially noted in men as compared
to women?
a. Tardive dyskinesia due to neuroleptics
b. Levodopa induced abnormal movements
c. Ampicillin induced loose motions
d. Ketoconazole induced loss of libido

42. Which of following ADR is due to genetic abnormality?

a. Tetracycline induced sunburn like skin lesions
b. Quinidine induced thrombocytopenia
c. Metoclopramide induced muscle dystonia
d. Primaquine induced massive haemolysis

43. Which of the following is a type B (unpredictable) adverse drug reaction?

a. Side effect b. Toxic effect
c. Idiosyncrasy d. Physical dependence

44. Essential medicines should be formulated as:

a. Single compound b. Multiple compounds
c. Fixed dose combinations d. All of above

41 D 42 D 43 C 44 C
45. Essential drugs are:
a. Life saving drugs
b. Drugs that meet the priority healthcare needs of the population
c. Drugs that must be present in the emergency bag of a doctor
d. Drugs that are listed in the pharmacopoia of a country

46. Latest revision of Nation list of essential medicine was done in:
a. 2010 AD b. 2011 AD
c. 2012 AD d. 2016 AD

47. Which of the following does not fall under essential medicine of Nepal?
a. Clavulanic acid b. Miltefocine
c. Colchicine d. Morphine

48. Which of the following does not fall under essential medicine list of Nepal?
a. Paracetamol b. Ibuprofen + Paracetamol combination
c. Amoxycillin d. Insulin

49. How many revisions are made in national list of essential drugs of Nepal untill
2016?
a. 2 b. 3
c. 4 d. 5

45 B 46 D 47 A 48 B 49 D
50. Essential drug has all properties except:
a. Vital in hospital b. Affordable and widely available
c. New Molecule d. Selected by formulary

51. National list of essential drug of Nepal was prepared on:

a. 1970 b. 1972
c. 1977 d. 1986

52. When was Nepalese Formulary was published?

a. 1996 AD b. 1998 AD
c. 1997 AD d. 1999 AD

53. Which one is the pharmacovigilance center in the country?

a. Department of Health service
b. Department of drug administration
c. Ministry of health
d. None of above

54. Promotion of rational use of drugs is done through:

a. Standard treatment protocol b. National list of essential medicines
c. Hospital formulary d. All of the above

50 C 51 D 52 C 53 B 54 D
55. An expected & well known reaction to a drug resulting in little or no change
in patient management is known as:
a. ADR b. Causality
c. AEFI d. Side effect

56. Tachyphlaxis is generally refers to:

a. Responsiveness increased rapidly after administration of a drug
b. Responsiveness decreased rapidly after administration of a drug
c. Responsiveness increased rapidly after maintenance of a drug (hypersensitive)
d. Responsiveness decreased rapidly after maintenance of a drug (desensitized)

57. Who is known as the Father of Public Health?

a. Cholera
b. Paul Ehrich
c. Samuel
d. Winslow

58. A study of distribution & determinants of health related states or events in

specified populations & the application of this study to control of health problems
is known as:
a. Demography b. Epidemiology
c. Antropology d. Sociology

55 A 56 B 57 A 58 B
59. Iatrogenic infection means:
a. Pharmacy induced infection
b. Hospital acquired infection
c. Physician induced infection
d. Latrine acquired infection

60. Total element of PHC (Primary Health Care) are:

a. 8 b. 9
c. 10 d.12

61. Which is not a part of primary health care service?

a. Curative services b. Preventive medicines
c. Tertiary cure service d. Emergency service

62. Which of the following is not a principle of Primary Health Care?

a. Equitable Distribution b. Community Participation
c. Intersectoral Co-ordination d. Internal Co-Ordination

Note: The major Four Principles of Primary Health Care are the Equitable
Distribution, Community Participation, Intersectoral Co-ordianation and
Appropriate Technology.

59 C 60 A 61 C 62 D
63. Which of the following is a Holy Trinity of epidemiology?
a. Time, Place, Agent
b. Person, Place, Environment
c. Agent, Environment, Time
d. Agent, Host, Environment

64. Causative organism for syphilis is an:

a. G. lamblia
b. Plasmodium
c. Trepnonema pallidium
d. Trypanosoma brucei

65. Varicella zoster virus is the causative organism for:

a. Small Pox
b. Dermatophytosis
c. Herpes virus
d. Infectious mononucleosis

66. Rubella virus is associated with:

a. Enterovirus infection b. Progressive encephalitis
c. Yellow fever d. Brucellosis

63 D 64 C 65 A 66 B
Disease Causative Agent Incubation period
Chicken pox Varicella Zoster 14-16 days
Measles RNA Paramyxovirus 10-14 days
Rubella (German RNA Togavirus 14-21 days
measles)
Mumps RNA Myxovirus 14-21 days
Diphtheria Corynebacterium diphtheriae 2-6 days
Whooping cough Bordetella pertusis 7-14 days
Tetanus Clostridium Tetani 6-10 days
Meningitis Neisseria Meningitidis 3-4 days
SARS Corona Virus 3-5 days
Tuberculosis Mycobacterium tuberculosis Min. 3-6 Weeks
Poliomyelitis Poliovirus 7-14 days
Hepatitis A Enterovirus 72 (Picornavirus 15-45 days
Hepatitis B Hepadna Virus 45-180 days
Hepatitis C Hepacivirus 30-120 days
Cholera Vibrio cholerae 1-2 days
Typhoid fever Salmonella typhi 10-14 days
Ascariasis Ascaris lumbricoides 2 months
Hookworm Ancylostoma duodenale 5 Wks -9 Months
Plasmodium vivax 8-17 days
Malaria Plasmodium falciparum 9-14 days
Plasmodium malariae 18-40 days
Plasmodium ovale 16-18 days
Disease Causative Agent Incubation period
Lymphatic filariasis Wuchereria bancrofti 8-16 months
Rabies Rhabdovirus 3-8 weeks
Yellow fever Flavivirus fibricus 2-6 days
Japanese encephalitis Arbovirus B (Flavivirus) 5-15 days
Chikungunya Fever Arbovirus A 4-7 days
Leptospirosis Leptospira interrogans 4-20 days
Bubonic plague 2-7 days
Pneumonic plague Yersinia pestis 1-3 days
Septicemic plague 2-7 days
Scrub typhus Rickettsia tsusugamushi 10-12 days
Q fever Coxiella Burnetti 2-3 weeks
Tape worm Taenia Solium / 8-14 weeks
Taenia Sagineta
Kala Azar Leishminia Donovani 1-4 months
Trachoma Chlamydia trachomatis 5-12 days
AIDS HIV Months to 10 Years
Swine flu H1N1- Type A influenza 1-4 days
Ebola disease Ebola virus 2-21 days
Anthrax Bacillus anthracis 1-7 days
Brucellosis Brucella Melitensis 5-60 days
Viral Diseases Clinical Symptoms
Chicken Pox (Varicella Rash with a fever, headache, sore throat, Dew
Zoster) Drops or stomachache
Measles (RNA Coryza (Running Nose), Cough, Conjunctivitis,
Paramyxovirus) Photophobia, Koplik’s Spot
Rubella (RNA Togavirus) Mild Fever, Coryza, Macula Rashes, Auricular
Lymphadenopathy
Mumps (RNA Myxovirus) Orchitis, Oophoritis, Pancreatitis
Yellow fever (Flavivirus Sudden onset of fever, Chills, Severe headache,
fibricus) Back Pain, Nausea and Vomiting, Fatigue
Dengue (Dengue Virus) Break Bone Fever
Rabies (Rabdovirus) Headache, Fever, Sore threat, Hydrophobia
Japanese encephalitis High Grader Fever, Neck Rigidity, Headache,
Arbovirus B (Flavivirus) Vomiting, Convulsions, Altered Sensorium
Influenza (H5N1 Virus) Sudden onset of Fever, Chills, Malaise, Cough,
Muscular Pain, Cramps
Poliomyelitis (Poliovirus) Asymmetrical Flaccid Paralysis
AIDS (SLIM Disease) Fever, Fatigue, Malaise, Lymphadenopathy,
Splenomegaly, Opportunistic Diseases, Weight
Loss
Hepatitis Fever, Anorexia, Dark Urine, Jaundice,
Hepatomegaly
Bacterial Diseases Clinical Symptoms
Diphtheria (Corynebacterium Sore Throat, Difficulty on in swelling, Bull
diphtheria) Neck
Whooping cough Mild fever with irritating cough
Tetanus (Clostridium Tetani) Trimus (Locked Jaw), Risus Sardonicus (False
Smile) & Opthisthotonus (Bow Shaped Body)
Typhoid fever (Salmonella Payer Patch, Step ladder pattern of fever,
typhi) Abdominal pain, Diarrhea, Myalgia
Plague Buboes (Painful enlargement of lymph node)
Brucellosis Irregular swinging fever, Hepatosplenomegaly,
Profuse sweating, Arthritis
Cholera Rice Water Stool, Shrunken Eyes, Muscular
Cramps
Leprosy (Mycobacterium Hypopigmented patches on skin with partial or
Leprae) complete loss of sensation and thickening of
superficial nerve like ulnar nerve
Tuberculosis Evening rise of fever, Loss of weight, Chest
Pain, Hemoptysis, Cough>2 Weeks,
Meningitis Intense Headache, High Fever, Vomiting, Neck
Stiffness
 Bacterial Diseases Clinical Symptoms
Amoebiasis Severe profuse diarrhea and mucus blood
stained stool
Diarrhoea Dehydration (Loss of electrolyte on body)
ARI Rhinorrhoea, Cough, Sore threat, Difficulty in
breathing and Fever
Trachoma Keratoconjunctivitis, Discharging eyes with
conjunctival irritation
Scabies Itching initially between fingers webs, on
buttocks or genitals and later all over the body
Syphillis (Bhirangi) Chancre (Painfull lesion on genitals),
Condyloma (Mild Fever, Malaise, Headache,
Rashes, Enlargement of lymph node) and
Gumma
Gonorrhoea Dysuria, Purulent discharge from the genitals
and increased frequency of micturition

 Small pox is totally eradicated from Nepal on Baisakh 1, 2034.

ELISA (Enzyme Linked Immunosorbent Assay) Test is used to detect antibody
while Western Blot Test (Confirmatory Test) is used to detect protein on HIV.
 Hepatitis A is known as Travelers Hepatitis, Hepatitis B is called as Serum
Hepatitis while Hepatitis C is called as Silent Killer Hepatitis.
Important Days of Public Health importance

30th January Anti- Leprosy day

4th February World Cancer day
2nd Wednesday of March No Smoking day
15th March World Disabled day
24th March Anti TB day
7th April World Health day
25th April World Malaria day
8th May World Red Cross day
31st May No Tobacco day
5th June World Environment day
14th June World Blood Donor day
1st July Doctor’s day
11th July World Population day
28th July World Hepatitis day
28th September World Rabies day
9th October World Sight day
10th October World Mental Health day
24th October UN day
10th November Universal Immunization day
1st December World AIDS day
3rd December International day of Disabled Persons
10th December Human Rights day
Last week of April World Immunization Week
67. AIDS day is celebrated in:
a. 1st December b. 1st September
c. 2nd December d. 2nd May

68. Dengue fever is mainly transmitted to man through:

a. Anopheles mosquito b. Aedes mosquito
c. Mansonoides mosquito d. Culex mosquito

69. Which of the following statement is False towards Tetanus?

a. Tetanus is caused by Clostridium tetani.
b. Incubation period of tetanus varies between 3 and 21 days.
c. It causes jaw cramp & muscle spasms.
d. Incubation period of tetanus varies between 1 and 5 days.

70. The commonest organism culture in UTI is an:

a. E. coli b. Klebsiella
c. Pseudomonas d. Proteus

71. Latent infection is not seen in:

a. Chicken pox b. Small pox
c. Adeno virus d. Measles

67 A 68 B 69 B 70 A 71 B
72. Positive tuberculin test indicated:
a. Exposure of TB b. Sensitivity of tuberculin protein
c. Tuberculosis infection d. Fulminant tuberculosis

73. Identical twins is due to:

a. One ova & one sperm b. One sperm & two ova
c. Two sperms & one ova d. Two sperms & two ova

74. Which of following effects on respiratory center?

a. Oxygen b. Carbon dioxide
c. Nitrogen d. Halogen

75. Exclusive breast feeding of babies should continue for:

a. 6 months b. 12 months
c. 2 years d. 16 months

76. Primary lymphoid organs include:

a. Thymus & spleen
b. Thymus & bone marrow
c. Thymus, bone marrow & spleen
d. Thymus, bone marrow, spleen & lymph nodes

72 C 73 A 74 B 75 A 76
77. The most effective disposal method of hospital waste is an:
a. Dumping b. Sanitary landfills
c. Incineration d. All of the above

78. Antibodies are formed in:

a. Eosinophils b. Neutrophils
c. Basophiles d. Plasma cells

79. Post mortem is associated with:

a. Anatomical structure b. Forensic medicine
c. Department of pharmacology d. None of above

80. Ringworm is due to:

a. Bacteria b. Fungus
c. Algae d. Virus

81. The cheapest & best method of water Purification system is an:
a. Chlorination b. Filtration
c. Boiling d. None of above

82. Which is not the aim of first aid?

a. To preserve life b. To promote recovery
c. To prevent further damage d. To cure the diseases

77 C 78 D 79 B 80 B 81 A 82 D
83. ABC in term of First Aid illustrates:
a. Air way, Breathing, Cardiac
b. Assessment, Breathing, Circulation
c. Air way, Body check, Cardiac
d. Air way, Breathing, Circulation

84. What is the main aim of first aid?

a. Prevent physiological deformity
b. Provide Psychological support to cope the injury
c. Preserve life & prevent injury from being worse
d. Initiate the correct course of treatment

85. Which of the following component lies under Maternal & Child Health?
a. Antenatal Care b. Intranatal Care
c. Postnatal Care d. All of above

86. All of following are the Millennium Development Goal except:

a. Eradicate extreme poverty & hunger
b. Improve adolescent health
c. Achieve universal primary education
d. Ensure environmental sustainability

83 D 84 C 85 D 86 B
Millennium Development Goals
a. Eradicating extreme poverty & hunger
b. Reduce child mortality
c. Achieving universal primary education
d. Improve maternal health
e. Combat HIV/AIDS, malaria & other diseases
f. Ensuring environmental sustainability

87. Which is not part of rational use of medicine?

a. Right dose b. Cheap Medicine
c. Appropriate to clinical need d. Right duration

88. All of the followings are the essential requirements for Good Pharmacy
Practice Except:
a. Patient welfare
b. Proper quality assurance of drug
c. Proper Publicity of drug
d. Rational use of drug

89. Which of the following disease is also known as Silent Killer?

a. Hepatitis B b. Hepatitis C
d. AIDS d. Cancer

87 B 88 C 89 B
90. Koplik spots are seen on which of the following disease?
a. Mumps b. Chicken Pox
c. Small Pox d. Measles

91. Dew Drop Rashes are seen on which of the following disease?
a. Tena Pox b. Chicken Pox
c. Small Pox d. Measles

92. Corya, Cough and Conjunctivitis is seen on which of the following disease?
a. TB b. Chicken Pox
c. Measles d. Influenza

93. Confirmatory test for AIDS is an:

a. CFT b. ELISA
c. Immunofluorescence d. Western blot

94. Which of the following is not true about Ascariasis?

a. It is transmitted by feco oral route.
b. Its incubation period is about 2 months.
c. Clay soil is most favorable for the development of ascaris eggs.
d. High infection rate on adults.

90 D 91 B 92 C 93 D 94 D
95. Which of the following is a blood/lymph parasite?
a. Trichuria trichuri b. Ascaris
c. Wucheria bancrofti d. Nectar American

96. A most common cancer among Nepalese female is an:

a. Cervix Cancer b. Breast Cancer
c. Oral Cancer d. Lung Cancer

97. The antidote for carbon monoxide is an:

a. Atropine b. Physostigmine
c. Vitamin K d. 100% Oxygen

98. The composition of Sarbottam Pitho is an:

a. 1 Part of Soyabean, 1 Part of wheat and 1 Part of Rice
b. 2 Part of Soyabean, 1 Part of wheat and 1 Part of Corn
c. 2 Part of Corn, 1 Part of wheat and 1 Part of Cereals
d. 2 Part of Wheat, 1 Part of Soyabean and 1 Part of Corn

99. The growth of brain is rapid on:

a. First 2 Year of life b. 2-5 Year of life
c. 5-15 Year of life d. 15-20 Year of life

95 C 96 A 97 D 98 B 99 A
100. A very thin baby with prominent bone and monkey face is most likely to be
suffer from:
a. Runche b. Kwashiorkor
c. Marasmus d. Pellagra

101. The most heat sensitive vaccine is an:

a. Polio b. Measles
c. Mumps d. DPT

102. Vaccines are sterilized at:

a. 55-60°C b. 134-138°C
c. 115-118°C d. 90-100°C

103. Which of the following vaccine is not included in new immunization

schedule of Nepal?
a. BCG b. Oral Polio Vaccine
c. Injectable Polio Vaccine d. Hepatitis

104. Polio virus is storage at:

a. 2-8°C c. Below 0°C
b. 5°C d. -10°C

100 C 101 A 102 A 103 D 104 D