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 :Riwayatpasien

PATIENT HISTORY FORM

Name : Mr. HarjoSuwito/ 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: 180/100 mmHg

Gender : pria Pregnancy status :Tidak hamil

Allergies :-laktam Reactions :kulit memerah, syok anafilaksis, sesak nafas.

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 Gagaljantung

 07/03/2011

NONPRESCRIPTION MEDICATION HISTORY

Name / strength Directions Purpose How Often Effectiveness

Antihipertensi Mengobati 15 tahun Tidak sembuh

hipertensi
antidiabetes Mengobati 15 tahun
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 : Tn. 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
determination No
therapy and administration/clinic visit-unknown)?
medical problem 3. No problem exist
Are there untreated medical conditions? or an intervention
Do they require drug therapy? is not needed
What is the comparative efficacy of the
chosen medication(s)?
1. A problem exist.  Exenatid tidak boleh diberikan pada
2. More information pasien yang menggunakan insulin karena
Appropriate drug What is the relative safety of the chosen is needed for a dapat menyebabkan hipergikemia
selection medication(s)? determination  Pada pasien dengan komplikasi hipertensi
3. No problem exist dengan DM, maka digunakan obat
Has the therapy been tailored to this or an intervention golongan ACE I dan ARB
individual patient? is not needed
Are the prescribed close and closing 1. A problem exist.
frequency appropriate within the usual 2. More information
Drug regimen
therapeutic range and/or modified from is needed for a
patient factors? determination
 Are Pro uses appropriate for those 3. No problem exist
medications either prescribed or taken that or an intervention
way? is not needed

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
Is the patient allergic to or intolerant of 1. A problem exist.
any medicines (or chemically related 2. More information
Drug allergy or medications) currently being taken? Pasien alergi β-laktam
is needed for a
intolerance 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)?

Adverse drug Are there symptoms or medical problems 1. A problem exist.

 events that may be drug induced? What is the 2. More information
likehood that the problem is drug related? is needed for a
determination
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.
Drug-Drug, (relatively or absolutely) given patient 2. More information Intraksi obat dengan obat :
characteristics and current/past disease is needed for a
Drug-Disease, determination  Exenatid dengan insulin karena dapat
states? menyebabkan hipergikemia
Drug-Nutrient, and 3. No problem exist
Are there drug nutrient interactions? Are or an intervention
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 Biaya obat mahal
recreational drug Could the sudden decrease or determination
use Cara penggunaan insulin, 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
Has the patient failed to receive a 1. A problem exist.
medication due to system error or non- 2. More information
Failure to receive
compliance? is needed for a
therapy
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. Acites

Lembar Rekomendasi dan rencana terapi obat

No Drugs / Medication Strength Total number Frequency Patient

Information
1. Kaptopril 12,5 mg 10 2 x sehari Digunakan
peroral, a.c
2. carvedilol 3,125mg 10 2 x sehari Dugunakan
peroral, a.c
3. Gemfibrozil 300 mg 10 1 x sehari Digunakan
peroral pada
malam hari,
p.r.n ( Cek Lab)
4. Acarbose 50 mg untuk 15 3 x sehari Digunakan
dosis awal, 150- peroral, saat
600 mg/hari makan
5. Digokxin 0,75-1,5 mg 10 1 x sehari Digunakan
peroral, pada
malam hari
6. Insulin Glargine 0,44 unit/Kg I 1x sehari Digunakan
Subcutan

C. Monitoring

Monitoring keberhasilan terapi

No Obat Parameter Rentang End point Frekuensi Rekomendasi

monitoring normal monitoring
1. Captopril 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. Acarbose Kadar gula darah Kadar gula Kadar gula Setiap Monitoring kadar
darah normal darah minum gula dalam darah
normal obat
4. Insulin garglin 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. captopril Batuk Tidak Batuk Tidak terjadi Setiap Jika masih batuk
gangguan habis obat dapat diganti
batuk minum dcengan golongan
obat ARB cara kerja
sama tapi tidak
ada efek samping
batuk
2. Hidroclortiazid Hipokalemia Tidak terjadi Kadar Setiap Jika terjadi
hipokalemia kalium habis hipokalemia dapat
normal minum diberikan asupan
obat kalium
3. Acarbose Hipoglikemia  Kadar Glukosa Kadar gula Setiap Jika terjadi
Darah Puasa 80– darah habis hupoglikemik,
120mg/dl normal minum diberi penenganan
 Kadar Glukosa obat yang tepat
Plasma Puasa 90–
130mg/dl
 Kadar Glukosa
Darah Saat Tidur
(Bedtime blood
glucose)
100–140mg/dl
 Kadar Glukosa
Plasma Saat Tidur
(Bedtime plasma
glucose)
110–150mg/dl
4. Diuretik Kadar kalium 3,5-5 mEq/L Normal Setiap Jika terjadi
habis hipokalemia
minum diberikan asupan
obat kalium

Konseling :

1. Mengurangi asupan garam/diet rendah garam.

2. Menurunkan berat badan, agar tidak terjadi obese.
3. Perbanyak konsumsi air putih.
4. Mengurangi aktivitas berat.
5. Hindari makanan yang dapat meningkatkan kadar kolesterol dalam darah.
6. Monitoring tekanan darah dan kadar gula dalam darah secara teratur.