Sheet 1 : Patient’s assesment

PATIENT HISTORY FORM

Name : Ny Rahmi (50 tahun) Date : 8 Maret 2021

Date and place of birth : -
Address : -
Phone : -
Height :- Kg Weight: - cm HR: - BP: …. mm/Hg
Gender: Male/Female Pregnancy status: Pregnant/not …month
Allergies : Reactions :
Device : Condom/ injection/ pill/ IUD/other: -
PRESCRIPTION MEDICATION HISTORY

Name / Sto
strength Directi Start p Physici Purpose Effectiveness
ons date dat an
e
Metformin p.o - - - Pengobat Muncul
an DM mual
Humalog Septem Pengobat
mix 25 ber - - an DM -
2018
Lantus Januari Pengobat
28 unit 2020 an DM
sekali -

Novorapi Januari Pengobat -

d3x4 2020 - - an DM
unit

NONPRESCRIPTION MEDICATION HISTORY

Name /
strength Directions Purpose How Often Effectiveness

- - - - -
Conclusion : Pasien memiliki riwayat pengobatan sebelumnya.
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 √ Muscle cramps or weakness √
movement
Abdominal pain or cramps √ Memory problems √
Frequent heatburn or √ Dizziness √
indisgestion
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 (Hipertensi, √
dyslipidemia, nefropati,
neuropati, retinopati)
Medical History Have you or any blood relative had (mark all that
apply )
Self Relative Self Relative
High BP …√… . √.. Heart disease …x… ..x..
Asthma …x… ..x.. Stroke …x… ..x..
Cancer …x… ..x.. Kidney disease …x… ..x..
Depression …x… ..x.. Mental illness …x… ..x..
Lung disease …x… ..x.. Substance abuse…x… ..x..
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

Conclusion :
Sheet 2: Case study (Assessment)
Assessment with PAM Method
A. Problem
Patient : Ny Rahmi (50 th) No RM.: -
Room/Ward :-
Intervention regarding
Date DRP
the DRP

8 Maret 2021 Drug regimen Dosis allopurinol

Dosis allopurinol untuk diturunkan menjadi 50 mg
pasien CKD dan dosis yang diminum 1 x sehari
insulin lantus pada pagi hari

Dosis Insulin Lantus

diturunkan menjadi 1 kali
sehari 14 unit pada malam
hari

Pemilihan obat tidak Untuk nyeri neuropati

tepat Vitamin B 12 diganti
Untuk nyeri neuropati Pregabalin

Pengetahuan Pasien Memberikan informasi

tentang terapi obat kepada pasien tentang
Penggunaan dan penggunaan dan
penyimpanan insulin penyimpanan insulin