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  • Adrreport Template Import Excel

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    Ramadanti Suwarny
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    This document contains 3 reports of adverse drug reactions (ADRs) in Indonesia. Report 1 describes a 20-year-old male in Indonesia who experienced urticaria after taking Dextrose and was withdrawn. Report 2 describes a 43-year-old male who experienced haemochromatosis after Zyprexa and had his dose reduced. Report 3 describes a non-COVID 19 patient who experienced lesions of the sciatic nerve after Pirazinamide and the drug was withdrawn. The reports provide information on patient demographics, suspected drugs, reactions, treatment and outcomes.

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    This document contains 3 reports of adverse drug reactions (ADRs) in Indonesia. Report 1 describes a 20-year-old male in Indonesia who experienced urticaria after taking Dextrose and was withdrawn. Report 2 describes a 43-year-old male who experienced haemochromatosis after Zyprexa and had his dose reduced. Report 3 describes a non-COVID 19 patient who experienced lesions of the sciatic nerve after Pirazinamide and the drug was withdrawn. The reports provide information on patient demographics, suspected drugs, reactions, treatment and outcomes.

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    © All Rights Reserved
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    4 views16 pages

    Adrreport Template Import Excel

    Uploaded by

    Ramadanti Suwarny
    This document contains 3 reports of adverse drug reactions (ADRs) in Indonesia. Report 1 describes a 20-year-old male in Indonesia who experienced urticaria after taking Dextrose and was withdrawn. Report 2 describes a 43-year-old male who experienced haemochromatosis after Zyprexa and had his dose reduced. Report 3 describes a non-COVID 19 patient who experienced lesions of the sciatic nerve after Pirazinamide and the drug was withdrawn. The reports provide information on patient demographics, suspected drugs, reactions, treatment and outcomes.

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    © All Rights Reserved
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    of 16

    ReportNo MFRNo Initial Country Age AgeCode Weight Sex

    1 902839ADS ABC Indonesia 5 Year 20 Male


    2 908314YSD DEF Indonesia 43 Year 85 Male
    EthnicOrigin PrimaryDisease Covid
    - Eritema + ISPA Covid 19 contoh
    Jawa Lesion of sciatic nerve Non Covid 19 contoh
    ReportNo drugName drugSuspect drugExpectedness drugJkn
    1 DEXTROSE MONOHYDRATE/ SODIUSuspected Expected JKN

    2 ZYPREXA ZYDIS Suspected Expected JKN

    2 PIRAZINAMID Not SuspectedUnexpected JKN


    drugType Program TuberculosisDrug drugManufacture drugBatchNo
    Others Unknown UNKNOWN 0

    Others Unknown PT ABC PHARMA 1000

    Tuberculosis Unknown Drug Sensitive PT DEF PHARMA 10001


    drugPharmaceutical drugRoute drugDose drugDoseUnit
    Serbuk Intra Okular BU (Buccal, bukal) 0.5 mg

    Serbuk Injeksi/+Pelarut CO (Conjunctival, konjungtiva) 400 mg

    Serbuk Injeksi/+Pelarut ED (Epidural) 400 mg


    drugDosageRegimenIn drugDosageRegimenOf drugDailyDosesTime TherapyDateFrom
    Unit satuan waktu
    3 1 day(s) pemberian obat.
    3/20/2021
    *tidak wajib diisi
    3 1 hour(s) 3/20/2021

    3 1 month(s) 3/20/2021
    atuan waktu TherapyDateTo drugIndication
    Waktu akhir drugActionTaken
    erian obat. pengobatan.
    3/11/2021 antibakteri Drug withdrawn
    wajib diisi *tidak wajib diisi
    ANTIINFLAMMATORY/ANTIRHEUMATIC
    3/11/2021 PROD.,NON-STEROIDS Dose reduced

    ARTERIOLAR SMOOTH MUSCLE, AGENTS


    ACTING ON Drug withdrawn
    drugAbate drugRechallenge ICDCode
    Yes Yes - contoh

    No No - contoh

    N/A Not applicable - contoh


    ReportNo reactionDescription reactionTerm

    1 muncul merah-merah Urticaria


    2 berwarna merah disertai nyeri Haemochromatosis
    reactionDateOnsetFrom reactionDateOnsetTo reactionTreatment reactionOutcome

    3/25/2021 3/10/2021 No treatment Recovered / resolved


    3/10/2021 1/6/1998 Non-medical treatment Recovering / resolving
    contoh
    contoh
    ReportNo AdditionalInformation LaboratoryData
    1 kemudian obat dihentikan. contoh

    setelah 13 kali minum ketoprofen, pasien mencoba


    menghentikan penggunaan obat dan kencing pasien
    kembali normal sehari setelah penghentian obat
    2 ketoprofen. - contoh
    ReportNo ReporterName TypeOfReporter InstitutionName
    1 Silfiani Industri Farmasi PT ABC PHARMA
    2 Rimania Industri Farmasi PT DEF PHARMA
    InstitutionAddress Province MobilePhone ReporterQualification
    (Unknown) 82112345678 Physician
    bali 82198765432 Pharmacist
    DateReceived TypeOfReport Seriousness ReasonOfSeriousness
    3/20/2021 Spontaneus Ya Death
    3/20/2021 Spontaneus Tidak
    DeathDate
    3/20/2021 contoh
    contoh

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