Form presentasi Pharmaceutical care

Lembar-1 :Skrining administratif

PRESCRIPTION

NamaDokter : dr. Bambang, Sp.J

Alamat : Prof. Dr. Soepomo, Yogyakarta 55164

No telp : (0274) 370141

No SIK : ………………………………………….

TanggalResep : 05/05/2011

NamaPasien : Tn Harjo Suwito

AlamatPasien : Jl. Bantulan Kelurahan Argomulyo, Kecamatan Sedayu, Kabupaten Bantul, Yogyakarta

jenis kelamin : pria

Umur : 65 tahun

No Medication Strength and Pharmaceutical Frequency Doctor Specific

total number formulary and total sign regulaties
number
1. Amlodipin 10 tablet 3 dd I

2. Gemfibrozil 2 dd I

3. Digoxin 1 dd I
4. Exenatid 2 dd I

5. Insulin garglin

6. Fenfluramin

Kesimpulan :

Resep : Legal
Lembar-2 :Riwayat pasien

PATIENT HISTORY FORM

Name : Mr. Harjo Suwito/ 65 th date :

Date and place of birth :Bantul, 15 Maret 1946

Address : Jl. Bantulan Kelurahan Argomulyo, Kecamatan Sedayu, Kabupaten Bantul, Yogyakarta

Phone : 08157996116

Height : kg Weight : cm HR :90x/menit BP: 195/100 mmHg

Gender : pria Pregnancy status :Tidak hamil

Allergies :-laktam Reactions :

Device : Kondom/ suntik/ pil KB/ pantangberkala/ IUD/ lainnya ………………………….

PRESCRIPTION MEDICATION HISTORY

Name / strength Directions Start date Stop date Physician Purpose Effectiveness

Amlodipin oral 05/02/2011 Antihipertensi

Gemfibrozil Oral 05/02/2011 Antikolesterol

Insulinegargline Injeksi 05/02/2011 Antidiabetes

Digoxin oral 05/02/2011 Gagal jantung

 NONPRESCRIPTION MEDICATION HISTORY

Name / strength Directions Purpose How Often Effectiveness

Antihipertensi Mengobati 15 tahun Tidak sembuh

hipertensi
antidiabetes Mengobati 15 tahun Tidak sembuh
diabetes

Medical Problems Have you experience or Do you have ( check Y or N )

Problem Y N Problem Y N
Kidney problem √ - Sores on Legs or feet - -
Urunary Infection - - Blood clot problems - -
Difficulty with urination - - Leg pain or swelling - -
Urination at night frequently - - Unusual bleeding or bruising - -
Hepatitis / liver problem √ - Anemia - -
Trouble eating certain food - √ Thyroid problems - -
Nausea / Vomit - √ Known hormone problem - -
Constipation / diarrhea - √ Arthritis or joint problem - -
Bloody or black bowel movement - √ Muscle cramps or weakness - -
Abdominal pain or cramps - - Memory problems - -
Frequent heatburn or indisgestion - - Dizziness √ -
Stomach ulcer in the past - - Hearing or visual problem - -
Short of breathness √ - Frequent headache √ -
Coughing with sptum - - Rash or hives - -
Chest pain √ - Change in appetite or taste - -
Fainting spell - - Walking or balanced problem - -
Racing heart or thumping - √ Other

Medical History Have you or any blood relative had ( mark al that aplly )

Self Relative Self Relative

High BP √ √ Heart disease √ -

Asthma - - Stroke - -

Cancer - √ Kidney disease √ -

Depression - - Mental illness - -

Lung disease - - Substance abuse - -

Diabetes √ - Other
Social History Please indicate your alcohol, tobacco, caffeine, and dietary habbits

Nicotin use Caffeine intake

……√… never …√…. never consumed

……… pack per day for …. years ………. drink per day

……… stopped …. years ago ………. stopped …... years ago

Alcohol consumption Diet restriction / Patterns

…√… never consumed ………. number of meals per day

……… drinks / day ………. food restriction

……… stopped ….. years ago

Kesimpulan : pasien gagal jantung ( Heart Failure )

Lembar -3, Assessment/penilaiankasus

B. Assessment : Patient : Mr. Harjo Suwito 65 years old

Location/Room :

Pharmacist :

Date :

Presence of Drug
Type of Problem Assessment Comments/notes
Related Problem

Are there without a medical indication?

1. A problem exist.
Correlation Are any medication unidentified (are any 2. More information
between drug unlabeled or are any-prior to is needed for a
therapy and administration/clinic visit-unknown)? determination
medical problem 3. No problem exist
Are there untreated medical conditions? or an intervention
Do they require drug therapy? is not needed

 Amlodipin tidak bisa digunakan pada

What is the comparative efficacy of the
1. A problem exist. pasien gagal jantung karena dapat
chosen medication(s)?
2. More information menghambat kontraksi calsium
Appropriate drug What is the relative safety of the chosen is needed for a  Insulin tidak dapat diberikan pada pasien
selection medication(s)? determination obesitas
3. No problem exist  Pada pasien dengan komplikasi hipertensi
Has the therapy been tailored to this or an intervention dengan DM, maka digunakan obat
individual patient? is not needed golongan ACE I atau ARB

Are the prescribed close and closing 1. A problem exist.

Drug regimen frequency appropriate within the usual 2. More information
therapeutic range and/or modified from is needed for a
 patient factors? determination
3. No problem exist
Are Pro uses appropriate for those or an intervention
medications either prescribed or taken that is not needed
way?

Is the route/dosage form/mode of

administration appropriate, considering
efficacy, safety, convenrence, patient
limitations, and cost?

Are do ses schedule to maximize

therapeutic effect and compliance and to
minimize adverse effects, drug interaction,
and regimen complexity?

Is there any therapeutic duplication?

1. A problem exist.
2. More information
Therapeutic is needed for a
Are there any therapeutic duplication? determination
duplication
3. No problem exist
or an intervention
is not needed
1. A problem exist.
Is the patient allergic to or intolerant of 2. More information
Drug allergy or any medicines (or chemically related Pasien alergi β-laktam
is needed for a
intolerance medications) currently being taken? determination
Is the patient using any method to alert 3. No problem exist
health care providers or the or an intervention
allergy/intolerance (or serious medical is not needed
 problem)?

1. A problem exist.
2. More information
Are there symptoms or medical problems is needed for a
Adverse drug
that may be drug induced? What is the determination
events
likehood that the problem is drug related? 3. No problem exist
or an intervention
is not needed
Are there drug-drug interaction? Are they
clinically significant?
Interaction:
Are any medications contraindicated 1. A problem exist.
Intraksi obat dengan obat :
Drug-Drug, (relatively or absolutely) given patient 2. More information
is needed for a
Drug-Disease, characteristics and current/past disease  Insulin tidak dapat diberikan pada pasien
states? determination
obesitas
3. No problem exist
Drug-Nutrient, and  Penggunaan fenfluramin menyebabkan
Are there drug nutrient interactions? Are or an intervention
menyebabkan hipokalemia
Drug-Laboratory they clinically significant? is not needed
Test
Are there drug-laboratory test interactions?
Are they clinically significant?

Is the patient’s current use social drug 1. A problem exist.

problematic? 2. More information
Social or is needed for a
recreational drug Could the sudden decrease or determination
use Cara penggunaan exenatid, cara pemakaian obat,
discontinuation of social drugs be related 3. No problem exist
to patient symptoms (e.g., withdrawal) or an intervention
is not needed
Failure to receive Has the patient failed to receive a 1. A problem exist.
therapy medication due to system error or non- 2. More information
compliance? is needed for a
 Are there factors hindering the determination
achievement of therapeutic efficacy 3. No problem exist
or an intervention
is not needed
1. A problem exist.
Is the chosen medication(s) cost 2. More information
effectiveness? is needed for a
Financial impact determination Biaya obat mahal
Does the cost of drug therapy represent a
3. No problem exist
financial hardship for the patient?
or an intervention
is not needed
Does the patient understand the purpose of
his or her medication(s), how to take it, 1. A problem exist.
and the potential side effects of therapy? 2. More information
Patient knowledge is needed for a
of drug therapy Would the patient benefit from education determination
tools (e.g., written patient education 3. No problem exist
sheets, wallet cards, and reminder or an intervention
packaging)? is not needed
Ranking Prioritas Masalah dan assessment

1. Heart Failure stage IV

2. Hypertensi

3. DM

4. Udem pulmo

5. Hyperuricemia

6. hipoksia

Lembar Rekomendasi dan rencana terapi obat

No Drugs / Medication Strength Total number Frequency Patient

Information
1. Losartan 50 mg 10 2 x sehari Digunakan
peroral, a.c
2. Digokxin 0,75-1,5 mg 10 1 x sehari Digunakan
peroral, pada
malam hari
3. Gemfibrozil 300 mg 10 1 x sehari Digunakan
peroral pada
malam hari,
p.r.n ( Cek Lab)
4. Hidroclortiazid 12,5 mg 10 2 x sehari Digunakan
peroral, pagi
hari
5. metformin 500 mg 10 3 x sehari Digunakan
peroral, saat
makan atau
sesudah makan
6. exenatid 5 mcg 2 2x sehari Digunakan
Setelah satu Subcutan,
bulan dapat diberikan dalam
ditingkatkan 10 waktu 60 menit
mcg sebelum sarapan
dan makan
malam.

C. Monitoring

Monitoring keberhasilan terapi

No Obat Parameter Rentang End point Frekuensi Rekomendasi

monitoring normal monitoring
1. Losartan Tekanan darah Turunnya Sembuh Setiap Jika tidak sembuh
tekanan darah minum dapat diganti
obat dengan obat lain
2. Hidroclortiazid Udem kaki dan Tidak terjadi Tidak terjadi Setiap Jika tidak sembuh
ascites udem udem minum diganti dengan
obat obat lain
3. Metformin Kadar gula darah Kadar gula Kadar gula Setiap Monitoring kadar
darah normal darah minum gula dalam darah
normal obat
4. exenatid Kadar gula darah Kadar gula Kadar gula Setiap Monitoring kadar
darah normal darah minum gula dalam darah
normal obat
5. Gembifrozil Kadar kolesterol Kadar Kadar Setiap Monitoring kadar
kolesterol kolesterol minum kolesterol dalam
dalam darah dalam darah obat darah
normal normal

Monitoring Efek samping obat

No Obat Parameter Rentang normal End point Frekuensi Rekomendasi

monitoring monitoring
1. Losartan Sakit kepala Tidak sakit kepala Tidak Setiap habis Menggunakan
terjadi minum obat analgesik topikal
gangguan
sakit kepala
2. Hidroklortiazid Kadar Tidak terjadi Kadar Setiap habis Jika terjadi
Kalium hipokalemia kalium minum obat hipokalemia
normal dapat diberikan
asupan kalium
3. digoksin Bradikardi 60-100 detak/menit Normal Setiap habis Jika terjadi
minum obat bradikardi maka
dosisnya
dikurangi
Ge
4. Gemfibrozil Sakit kepala Tidak sakit kepala Tidak Setiap habis Menggunakan
terjadi minum obat analgesik topikal
gangguan
sakit kepala
Mm
5. Metformin Kadar Gula  Kadar Glukosa Normal Setiap habis Jika terjadi
darah Darah Puasa 80– minum obat hipoglikemik,
120mg/dl diberi
 Kadar Glukosa penenganan yang
Plasma Puasa 90– tepat
130mg/dl
 Kadar Glukosa
Darah Saat Tidur
(Bedtime blood
glucose)
100–140mg/dl
 Kadar Glukosa
Plasma Saat Tidur
(Bedtime plasma
 glucose)
110–150mg/dl
6. Exenatid Kadar Gula  Kadar Glukosa Normal Setiap habis Jika terjadi
darah Darah Puasa 80– menggunakan hipoglikemik,
120mg/dl obatnya diberi
 Kadar Glukosa penenganan yang
Plasma Puasa 90– tepat
130mg/dl
 Kadar Glukosa
Darah Saat Tidur
(Bedtime blood
glucose)
100–140mg/dl
 Kadar Glukosa
Plasma Saat Tidur
(Bedtime plasma
glucose)
110–150mg/dl
7. Diuretik Kadar kalium 3,5-5 mEq/L Normal Setiap habis Jika terjadi
minum obat hipokalemia
diberikan asupan
kalium

Konseling :

1. Mengurangi asupan garam/diet rendah garam.

2. Menurunkan berat badan, agar tidak terjadi obese.
3. Minum air putih secukupnya
4. Olahraga ringan
5. Mengurangi aktivitas berat.
6. Hindari makanan yang dapat meningkatkan kadar kolesterol dan asam urat dalam darah.
7. Monitoring tekanan darah dan kadar gula dalam darah secara teratur.