Ketrampilan panum farmako (modul)

Case 3:`
Marta, 10 tahun, berat badan 35kg, sejak 3 hari yang lalu menderita diare 5-6 kali perhari, feses cair, berlendir, tidak ada darah. Mulai tadi pagi Marta
mengeluh badannya demam, buang air besar sedikit-dikit dan kotoran terlihat darah. Saat buang air besar terasa sakit. Pagi ini buang air besar sudah 8 kali.
Pada pemeriksaan kesadaran, keadaan umum dan aktivitas masih baik. Suhu tubuh 38°C. Abdomen rata, supel, nyeri tekan distal umbilicus, bising usus
sedikit meningkat.
Marta, 10 years old with body weight 35kg, suffers from 5-6 episodes of diarrhea per day since 3 days ago. The feces are watery and slimy without blood.
Since this morning, Marta complains of fever, small amount of defecation and bloody feces. She also felt pain while passing motion and have 8 episodes of
bowel discharges since this morning. Upon examination; consciousness, general condition, and activeness remain normal; body temperature 38°C;
abdomen is flat, soft, pain in distal of the umbilicus when pressed, bowel sound slightly increased.
STEP 1: Define the patient's problem
 Watery diarrhea since 3 days ago (5-6 episodes per day)
 Fever, pain while passing motion, and small amount bloody feces since this morning (8 episodes of bowel discharges since this morning)
 38°C in body temperature, pain in distal of umbilicus when pressed, and slight increased bowel sound
STEP 2: Specify the therapeutic objective
 Diagnosis: Acute infectious (inflammatory) diarrhea
 The therapeutic objectives include prevent dehydration / replacement of fluid loss, terminate diarrhea, and relieve fever and pain
STEP 3: Verify the suitability of your P-drug
P-drug
i. Define the diagnosis
 Acute infectious (inflammatory) diarrhea
ii. Specify the therapeutic objective
 The therapeutic objectives include prevent dehydration / replacement of fluid loss, terminate diarrhea, and relieve fever and pain
iii. Make an inventory of effective groups of drugs
 Rehydration / Replacement of loss: Oral Rehydration Solutions (ORS)
 Terminate diarrhea: Antimotility, Absorbents, Antisecretory
 Relieve of fever and pain: NSAID
iv. Choose an effective group according to criteria
  Antidiarrheal:
Group Efficacy Safety Suitability Cost
Antimotility (+) +++ ++ +++
Absorbents (+) ++ +++ +++
Antisecretory (+) +++ ++ +++

 Antipyretic / analgesic
Grou Efficacy Safety Suitability Cost
p
NSAI Pharmacodynamics: Side effects: Contraindications: 1
D Inhibits cyclooxygenase and Hypersensitivity, GI upset and bleeding (besides Bleeding disorders, peptic ulcer disease
prostaglandin synthesis paracetamol), salicylism (aspirin) (besides paracetamol)
Pharmacokinetics:
PO / PR

Group Efficacy Safety Suitability Cost

NSAID +++ +++ +++ +++

v. Choose a P-drug
 Antidiarrheal:
Antisecretory Efficacy Safety Suitability Cost
Bismuth subsalicylate +++ ++ +++ Stobiol 262 mg x
120's (Rp24000)

 NSAID:
NSAID Efficacy Safety Suitability Cost
Acetaminophe Acetaminophen possesses analgesic and Does not cause GI upset / bleeding G6PD deficiency, Panadol
n antipyretic activities with few anti- hypersensitivity Cap 500mg X
inflammatory effects Occasionally, maculopapular rash or 100 =
urticarial skin reactions occur; Rp19,000
 methemoglobinemia, neutropenia, and
thrombocytopenic purpura are rarely Syrup
reported 160mg/5ml X
60ml =
Allergic reactions Rp9,200
Aspirin Aspirin is an analgesic, antipyretic, and anti- GI upset and bleeding, allergic reactions, Hypersensitivity, bleeding Aspirin Bayer
inflammatory agent increased risk of Reye’s Syndrome in disorder, peptic ulcer Tab 500mg X
children, salicylism disease 15 X 8 =
Anti-inflammatory properties are related to Rp36,930
the inhibition of prostaglandin biosynthesis

Aspirin non selectively inhibits cyclooxygenase-

1 (COX-1), which is associated with GI and
renal effects and inhibition of platelet
aggregation, and cyclooxygenase-2 (COX-2),
which is associated with the inflammatory
response
Ibuprofen It is a nonselective inhibitor of cyclo- Gastric distress, blood loss, diarrhea, Syndrome of nasal polyps; Bufect / Bufect
oxygenase-1 (COX-1) and cyclo-oxygenase-2 vomiting, dizziness, and skin rash occur angioedema; Forte
(COX-2) and reversibly alters platelet function occasionally bronchospastic reactivity Syrup
and prolongs bleeding time to aspirin or other NSAIDs 100mg/5ml X
Better tolerated than aspirin by most 60ml =
patient Rp10,765

Syrup
200mg/5ml X
60ml =
Rp15,100
NSAID Efficacy Safety Suitability Cost
Acetaminophen ++ +++ +++ +++
Aspirin +++ + ++ ++
Ibuprofen +++ ++ ++ +++

 Conclusion:
o Active substance, dosage form:
 Bismuth subsalicylate, PO Tab 262mg
 Ibuprofen, PO syrup 100mg/5ml X 60ml
o Dosage schedule:
 Bismuth subsalicylate, ½-1 tablet every 30-60 minutes as needed
 Ibuprofen, 20mg/kg/day divided into 3 doses for about 10 days
o Duration: length of monitoring interval / until the dispensed drug is finished
STEP 4: Write a prescription
Dr. johnson
Jl. Saturnus 3, Malang
Telp. 0341582110
SIP. 446.DU/012/35.73.306/2007
Malang, 27 April 2011
R/ Bismuth subsalicylate 262mg tab No. XX
∫ q1h dd tab 1, max 5 tab/day
- - - - ,, - - - -
Ibuprofen 200mg syrup fl No. II
∫ 3 dd cth 1 pc.
- - - - ,, - - - -
ORS sachet No. XX
∫1 sachet setiap kali sesudah BAB, 1 sachet diencer dengan 1 gelas air putih, prn.
- - - - ,, - - - -
 Id
Pro: Adik Marta
Umur: 10th.
Alamat: Jl. Muthafukar No. 117, Malang

STEP 5: Give information, instructions and warnings

i. Effects of the drug
 Bismuth subsalicylate treats symptoms of diarrhea
 Ibuprofen relives the fever and pain
 All the symptoms will be reduced and finally disappear
 The effect is expected to start after the first 2 doses
 The symptoms will remained if the drug is not taken correctly / not at all
ii. Side effects
 Bismuth subsalicylate may cause darkening of tongue &/or feces, and toxic if overdose
 Ibuprofen might cause gastric distress, blood loss, diarrhea, vomiting, dizziness, or skin rash
 If felt excessive side effects, stop the medication, and immediately refer to doctor
iii. Instructions
 Bismuth subsalicylate is taken ½-1 tablet every 30-60 minutes as needed up to 5 tablets a day
 Ibuprofen is taken a spoon (5ml) 3 times daily
 ORS is taken a sachet that have been diluted in a glass of clean water every time after passing motion
 The treatment should be continue as long as it is effective / after the dispensed drug is finished
iv. Warnings
 The drug should be taken as instructed, do not increase / reduce the amount to be taken, and do not increase / reduce the frequency of the
drug that should be taken as instructed
v. Future consultations
 Come back for follow up after 2 days of treatment, if the diarrhea persists
 Come back to doctor earlier if experiencing side effects
vi. Everything clear?
  Repeat the important information and clarified the doubts
STEP 6: Monitor (and stop?) the treatment
 Treatment effectiveness:
o Effective: continue the drug
o Minimal effect: reconsider dosage / drug choice
o Not effective: verify all steps
Case 4:
Seorang anak berusia 4 tahun, dibawa ke dokter dengan keluhan panas 3 hari ini. Sudah diberi parasetamol, panas turun sebentar kemudian naik lagi. Pagi
ini anak tersebut batuk-batuk, tanpa diikuti pilek. Nafsu makan anak menurun, tapi masih mau bermain. Pada pemeriksaan didapat data: BB: 20kg. suhu
tubuh: 38.5°C. Tenggorokan: Pharynx merah, sekret +, kental, warna kekuningan. Selain itu tidak ada kelainan lain.
A 4 years old child was brought to the doctor with complaint of fever since 3 days ago. After the child was given paracetamol, the fever subsided but
returned again. This morning, the child starts coughing without flu / cold. The child still wanted to play. Upon examinations, the child’s body weight is 20kg,
body temperature is 38.5°C, pharynx appeared red, and thick yellowish secrete is present. Other physical examinations results are within the normal range.
STEP 1: Define the patient's problem
 Complaint of fever since 3 days ago
 Fever subsided temporally with paracetamol but returned shortly after that
 This morning, the child has cough without flu / cold
 Moderate fever, pharynx appeared red, and present of thick yellowish secrete
STEP 2: Specify the therapeutic objective
 Diagnosis: bacterial pharyngitis
 The therapeutic objectives for this patient are to eradicate bacterial infection, relieve fever and inflammation, and remove secrete
STEP 3: Verify the suitability of your P-drug
P-drug
i. Define the diagnosis
 Bacterial pharyngitis
ii. Specify the therapeutic objective
 The therapeutic objectives for this patient are to eradicate bacterial infection, relieve fever and inflammation, and remove secrete
iii. Make an inventory of effective groups of drugs
  Eradication of bacterial infection: Beta-lactams (Penicillin, cephalosporin), macrolide
 Relieve of fever and inflammation: NSAID
 Removal of secrete: Acetylcysteine, guaifenesin, bromhexine
iv. Choose an effective group according to criteria
 Antibiotics
Group Efficacy Safety Suitability Cost
Beta- Pharmacodynamics: Side effects: Contraindications: 1 (amoxicillin) & 3
lactams Inhibits cross-linking of cell wall Hypersensitivity, rare nerve, liver or kidney Known hypersensitivity of (cephalexin)
components toxicity beta lactams, resistant of
Pharmacokinetics: causative bacteria
PO / IM / IV
Macrolide Pharmacodynamics: Side effects: Contraindications: 2 (erythromycin)
Inhibits protein synthesis (prevents GI upset, increase plasma level of many Hypersensitivity, hepatic
translocation of polypeptide chain by drugs, toxicity may results when co- dysfunction
binding to the P site of the ribosomal 50s administered with theophylline,
subunit) anticoagulants, carbamazepine
Pharmacokinetics:
PO / IV

Group Efficacy Safety Suitability Cost

Beta-lactams +++ +++ +++ +++ / +
Macrolide +++ ++ ++ ++

 NSAID
Grou Efficacy Safety Suitability Cost
p
NSAI Pharmacodynamics: Side effects: Contraindications: 1
D Inhibits cyclooxygenase and Hypersensitivity, GI upset and bleeding (besides Bleeding disorders, peptic ulcer disease
prostaglandin synthesis paracetamol), salicylism (aspirin) (besides paracetamol)
 Pharmacokinetics:
PO / PR

Group Efficacy Safety Suitability Cost

NSAID +++ +++ +++ +++

 Expectorants
Group Efficacy Safety Suitability Cost
Acetylcystein Pharmacodynamics: Side effects: Contraindications: 1
e Acetylcysteine exerts its mucolytic action through Bronchospasm, GI disturbances, GI upset
its free sulfhydryl group, which opens the disulfide stomatitis, rhinorrhea, headache,
bonds and lowers mucus viscosity tinnitus, urticaria, shivering, fever,
Pharmacokinetics: hemoptysis. Anaphylactic shock (rare)
PO / inhalation
Guaifenesin Pharmacodynamics: Side effects: Contraindications: 2
Guaifenesin is proposed to have an expectorant Occasional nausea and vomiting, Hypersensitivity to guaifenesin Probat
action through an increased output of respiratory especially with excessive dosage; Tab
tract fluid, enhancing the flow of less viscid dizziness; headache 100mg X
secretions, promoting ciliary action, and 30 =
facilitating the removal of inspissated mucus Rp8,500
Pharmacokinetics:
PO
Bromhexine Pharmacodynamics: Side effects: Contraindications: 3
It increases the production of serous mucus in the Diarrhea, nausea, vomiting, and other GI Hypersensitivity to
respiratory tract and makes the phlegm less sticky disturbances, allergic reaction (include bromhexine, history of peptic
and thinner, which leads to secretomotoric effect rash, urticaria, bronchospasm, ulceration; asthmatic patients,
that helps the cilia transport the phlegm out of angioedema, anaphylactic shock), severe hepatic or renal
the lungs increase antibiotic (amoxicillin, impairment
Pharmacokinetics: erythromycin) concentration in lungs
 PO / inhalation

Group Efficacy Safety Suitability Cost

Acetylcysteine +++ ++ +++ +++
Guaifenesin ++ +++ +++ +++
Bromhexine ++ ++ ++ +++

v. Choose a P-drug
 Beta-lactams
Beta-lactams Efficacy Safety Suitability Cost
Penicillin Inhibits cross-linking of cell wall components Nausea, diarrhea, rash Known hypersensitivity of Amoxil
(amoxicillin) beta lactams, resistant of Cap 250mg X
Amino side group makes it hydrophilic enough to causative bacteria 100 =
penetrate the porins in gram negative organisms Rp185,009

Penicillin is the drug of choice in the treatment of Syrup

Group A streptococcal pharyngitis 125mg/5ml X
60ml =
Rp21,620

Syrup
250mg/5ml X
60ml =
Rp37,358
Cephalosporin Inhibits cross-linking of cell wall components Hypersensitivity reactions, GI Known hypersensitivity of Ospexin
(cephalexin) disturbances, hematologic beta lactams, resistant of Tab 500mg X 10
Beta-lactam binds penicillin binding proteins abnormalities, nephrotoxicity and causative bacteria X 10 =
hepatic enzyme abnormalities Rp616,000
Inhibits cell wall synthesis and may in turn activate
 autolysins Syrup
250ml/5ml X
In patients allergic to penicillin, a macrolide such as 60ml =
erythromycin or a first-generation cephalosporin Rp48,500
such as cephalexin (if the reaction is non
immunoglobulin E-mediated hypersensitivity) can
be used

Beta-lactams Efficacy Safety Suitability Cost

Penicillin (amoxicillin) +++ +++ +++ +++
Cephalosporin ++ ++ +++ ++
(cephalexin)


NSAID
NSAID Efficacy Safety Suitability Cost
Acetaminophe Acetaminophen possesses analgesic and Does not cause GI upset / bleeding G6PD deficiency, Panadol
n antipyretic activities with few anti- hypersensitivity Cap 500mg X
inflammatory effects Occasionally, maculopapular rash or 100 =
urticarial skin reactions occur; Rp19,000
methemoglobinemia, neutropenia, and
thrombocytopenic purpura are rarely Syrup
reported 160mg/5ml X
60ml =
Allergic reactions Rp9,200
Aspirin Aspirin is an analgesic, antipyretic, and anti- GI upset and bleeding, allergic reactions, Hypersensitivity, bleeding Aspirin Bayer
inflammatory agent increased risk of Reye’s Syndrome in disorder, peptic ulcer Tab 500mg X
children, salicylism disease 15 X 8 =
Anti-inflammatory properties are related to Rp36,930
the inhibition of prostaglandin biosynthesis
 Aspirin non selectively inhibits cyclooxygenase-
1 (COX-1), which is associated with GI and
renal effects and inhibition of platelet
aggregation, and cyclooxygenase-2 (COX-2),
which is associated with the inflammatory
response
Ibuprofen It is a nonselective inhibitor of cyclo- Gastric distress, blood loss, diarrhea, Syndrome of nasal polyps; Bufect / Bufect
oxygenase-1 (COX-1) and cyclo-oxygenase-2 vomiting, dizziness, and skin rash occur angioedema; Forte
(COX-2) and reversibly alters platelet function occasionally bronchospastic reactivity Syrup
and prolongs bleeding time to aspirin or other NSAIDs 100mg/5ml X
Better tolerated than aspirin by most 60ml =
patient Rp10,765

Syrup
200mg/5ml X
60ml =
Rp15,100

NSAID Efficacy Safety Suitability Cost

Acetaminophen ++ +++ +++ +++
Aspirin +++ + ++ ++
Ibuprofen +++ ++ ++ +++

 Expectorant
o *Refer to iv*
 Conclusion:
o Active substance, dosage form:
 Amoxicillin, PO syrup 250mg/5ml X 60ml
  Ibuprofen, PO syrup 100mg/5ml X 60ml
 Guaifenesin, PO tab 100mg
o Dosage schedule:
 Amoxicillin, 40-50mg/kg/day divided into 3 doses for about 10 days
 Ibuprofen, 20mg/kg/day divided into 3 doses for about 10 days
 Guaifenesin, 50-100mg every 4 hours, maximum 1200mg/day
o Duration: length of monitoring interval / until the dispensed drug is finished
STEP 4: Write a prescription
Dr. johnson
Jl. Saturnus 3, Malang
Telp. 0341582110
SIP. 446.DU/012/35.73.306/2007
Malang, 27 April 2011
R/ Amoxicillin 250mg syrup fl No. II
∫ 3 dd cth 1 pc.
- - - - ,, - - - -
Ibuprofen 100mg syrup fl No. II
∫ 3 dd cth 1 pc.
- - - - ,, - - - -
Guaifenesin 100mg tab No. XX
∫ 3 dd tab 1 pc.
- - - - ,, - - - -

Id
Pro: Adik Adam
Umur: 4th.
Alamat: Jl. Muthafukar No. 117, Malang

STEP 5: Give information, instructions and warnings

 i. Effects of the drug
 Amoxicillin eradicates the causative bacterial
 Ibuprofen relives the fever and inflammation
 Guaifenesin facilitates the removal of secrete / mucus / phlegm
 All the symptoms will be reduced and finally disappear
 The effect is expected to start after the first 2 doses
 The symptoms will remained if the drug is not taken correctly / not at all
ii. Side effects
 Amoxicillin might cause nausea, diarrhea, or rash
 Ibuprofen might cause gastric distress, blood loss, diarrhea, vomiting, dizziness, or skin rash
 Guaifenesin might cause nausea, vomiting, dizziness, or headache
 If felt excessive side effects, stop the medication, and immediately refer to doctor
iii. Instructions
 Amoxicillin and ibuprofen are taken a spoon (5ml) each 3 times daily
 Guaifenesin is taken 1 tablet 3 times daily
 It is recommended to be taken with food
 The treatment should be continue until the dispensed drug is finished
iv. Warnings
 The drug should be taken as instructed, do not increase / reduce the amount to be taken, and do not increase / reduce the frequency of the
drug that should be taken as instructed
v. Future consultations
 Come back for follow up after the drug is finished / when the effect of the drug is still absent / minimal after 2 doses
 Come back to doctor earlier if experiencing side effects
vi. Everything clear?
 Repeat the important information and clarified the doubts
STEP 6: Monitor (and stop?) the treatment
 Treatment effectiveness:
o Effective: end of treatment
 o Minimal effect: reconsider dosage / drug choice
o Not effective: verify all steps

7. Seorang anak berumur 12 thn, sejak 3 hr menderita BAB 6-7X 1hr, cair, ada lender, tidak ada darah. Mulai tadi pagi terasa demam (menggigil) dan
pada kotoran terliaht ada darah dan frequency BAB pagi tadi adalah 8X. Kesadaran, keadaan umum dan aktifitas fisik masih cukup baik.
i. Define the diagnosis : - Dysentry (Acute bloody diarrhea) caused by infection of lower GIT
ii. Specific therapeutic obj : - Stop the dysentery by curing infection.
-Hydrate the patient.
iii. Make inventory of effective groups
 Anti diarrhea with antibiotic
 Opiat (Non antibiotic)
 Adsorben
 Anti Cholinergic
 Oralit
iv. Choose a drug according to criteria
 Anti diarrhea with antibiotic
Efficacy Safety Suitability Cost
Menghambat sistesis Hypersensitivity , mual Indikasi: infeksi saluran Tablet 500mg; : Rp
dinding sel microba muntah. cerna 1300
Kontraindikasi:
hypersensitivity and
allergy penicilin
++ ± + +++

 Opiat (Non antibiotic)

Efficacy Safety Suitability Cost
Konstipasi / anit Mual, muntah, Hypersensitivity, not -
diarrhea epigastric distress suitable for
dehydrated patient
+ - - -

 Adsorben
Efficacy Safety Suitability Cost
Menyerap toksin Mual muntah, nyeri Hypersensitivity -
bakteri dan mengikat epigastric kanstipasi
bakteri dan dehidrasi
+ - - -

 Anti Cholinergic
Efficacy Safety Suitability Cost
Anti muscarinik, Dry, hot skin, impared Hypersensitivity -
menghambat sekresi GI mortality, hepatic
saluran cerna dan hypertension, diseaseobstructive GI
peristaltik tachycardia ect disease
+ - - -

 Oralit
Efficacy Safety Suitability Cost
Hydrate the body by overhydrated Indication : for minor Oralit 1L : Rp710
providing electrolytes or severe dehydration
for reabsorbtion
++ ± + ++

v. Choose a P-drug
 Ampisilin
Efficacy Safety Suitability Cost
-Menghambat Hypersensitivity, mual, Kontraindikasi : alergi 500mg : Rp1300
mucopeptida untuk muntah penicillin, Sirup 60ml,
sintesis didding sel hypersensitivity 125mg/5ml : Rp6000
mikroba Indikasi : infeksi
-peroral saluran cerna.
-H.L :1,3 jam urine
++ ± ± +++

 Makrolida (erithromysin)
Efficacy Safety Suitability Cost
Menghambat sintesis Hypersensitivity, mual, Ganguan hepar 500mg; Rp 1900
protein kuman dgn muntah, nyeri
mengikat ribosom epigastrium
-H.L 1,6 jm hepar
+ ± - ++

 Glikopeptida (vankomisin)
Efficacy Safety Suitability Cost
Menghambat sintesis Sangat toksik hypersinsivitas 500mg: Rp70000
didding sel
-HL : 6-10hr filtrasi
glomelurus
+ - - -
Conclusion
Active substance dosage from : Ampisilin peroral sirup, oralit peroral
Dosage : ampisilin-125mg(5ml)x4/day, oralit 1L x2 / day
 Dr. Kishern

Jln Wonogiri 4, Malang

Telp :081805167956

SIP :446.DU/0121/25.47.588

8. Ibu Tina, 45 thn, dating ke dokter dengan keluhanMalangsakit

26 april 2011
kepala sudah satu minggu dan minum obat paramex, tetapi sakit tetap. Pasien baru alih dari IUD
ke Pil KB dan punya riwayat hipertensi ringan. Selain itu ada riwayat ibunya meningal akibat kanker payudara. Pada pemeriksaan T= 160/95mmHg, N=
R/ Ampisilin 125mg NO 1
80/min. Lain pada batas normal.
i. Define
∫ 4dd the diagnosis : hypertension due to hormonal
I peroral KISH pill causing headache
ii. Specific therapeutic obj : - Control the hypertension
R/ iii.
Oralit
Make1L inventory
NO2 of effective groups
∫ 2 dd Iperoral
Beta Blocker KISH
 ACE inhibitor
Px : anak xxx
Vasodilators
 Diuretics
Umur : 12 thn
iv. Choose a drug according to criteria
Alamat:  xxx,
Beta Blocker
Malang
Efficiensy Safety Suitability Cost
Mengurangi Bradicardi, pusing, Indikasi : hipertensi Propanolol
kontraktilitas jantung, kelemahan otot, lelah K.indikasi:Block AV PO 10mg tab
mengurangi frekeunsi derajat 2 &3, Rp 1012/biji
denyut jantung cardiiogenic Shock,
met. acidosis
+++ +++ +++ ++

 ACE inhibitor
 Efficiensy Safety Suitability Cost
Mengurangi volume n Takikardi, batuk Indikasi : hipertensi Captopril 50mgx5x10 :
tekanan pengisian kering , demam K.indikasi:hypersensitive Rp 10700
ventrikel hamil, laktasi, gagal
Meningkatkan curah ginjal
jantung
++ + ++ +++

 Diuretics
Efficiensy Safety Suitability Cost
Menghambat Na n Hipokelemi, Indikasi : Furosemid
Cl hiponatremi, hipertensi Rp21753
dehidrasi, K.indikasi: hamil
hiperglikemi. and laktasi gagal
ginjal
++ + ++ ++

v. Choose a P-drug
 Propanolol
Efficiensy Safety Suitability Cost
Mengurangi Efek: gangguan Indikasi : PO 10mg tab.
kontraktilitas pencernaan, lelah hipertensi Rp1.012/biji
jantung, K.indikasi:Block
mengurangi AV derajat 2 &3,
frekeunsi denyut cardiiogenic
jantung Shock, met.
acidosis
+++ +++ +++ +++
 Atenolol
 Efficiensy Safety Suitability Cost
Mengurangi Efek: bradicardi, Indikasi : PO 10mg tab.
kontraktilitas gangguan hipertensi Rp1.400/biji
jantung, pencernaan, lelah K.indikasi:Block Rp2.250/biji
mengurangi AV derajat 2 &3,
frekeunsi denyut sinus bradicardi
jantung
+++ ++ ++ ++

Conclusion
Active substance dosage from : Propanolol
Dosage : 40mg orally twice a day
 Dr. Kishern

Jln Wonogiri 4, Malang

Telp :081805167956

SIP :446.DU/0121/25.47.588

Malang 26 april 2011

R/ Propanolol 10mg NO.II

Modul 11
∫ 2dd(53
Pak Ucup 4tab
th)PO KISH
menderita kanker colon stadium akhir. Keluarganya meminta ia dirawat di rumah dan dokter mengunjunginya seminggu sekali. Hari ini
istrinya menelpon dokter agar datang ke rumah karena Pak Ucup kesakitan. Pada pemeriksaan didapat Pak Ucup tidak bisa tidur semalaman karena merasa
Px : Ibu Tina
nyeri dan sudah berlangsung seminggu ini. Obat penghilang nyeri yang telah diminum selama ini tidak dapat mengurangi nyerinya. Pak Ucup juga menderita
diabetes
Umurtipe: 45
2. thn

Alamat:
Problem: nyerixxx, Malang
akibat kanker colon stadium akhir dan menderita diabetes tipe 2.

Tujuan terapi: meredakan nyeri dan tidak memperberat diabetes tipe 2

P-treatment
a. Advis: mengurangi makanan yang berlemak, daging (terutama daging merah)
Menghindari makanan yang dibakar
b. Terapi non-obat: kemoterapi

P-drug
Efficacy Safety Suitability
Acetaminophen atau
paracetamol
Farmakodinamik: Efek samping: Indikasi:
Analgesik&antipiretik Eritema Moderete pain and fever
Iritasi gaster (-) Utikaria Kontraindikasi:
Hambatan agregasi trombosit Lesi pada mukosa G6PD deficiency
(-) Anemia hemolitik pada Interaksi obat:
Farmakokinetik: penggunaan kronis autoimun Barbiturates
Absorpsi tergantung Nekrosis hati pada 10-15gram Abuse  hepatotoksik
pengosongan lambung Nekrosis tubulus renalis meningkat
Kadar puncak 30-60 menit Memperkuat efek warfarin
Terikat protein plasma 20-50% Dosis:
Metabolisme di hati Dewasa 325-650 mg tiap 4-6
T1/2=1-3 jam jam atau 1000 mg 3-4x/hr tidak
melebihi 4 gram
Metampiron atau antalgin
FD: Efek samping: Indikasi: nyeri kepala,
Menghambat enzim Kadang menimbulkan neuralgia, sakit pinggang, nyeri
siklooksigenase sehingga agranulositosis, anemia aplastik pasca bedah, dismeneroe, nyeri
konversi asam arakhidonat dan trombositopeni kolik, demam
menadi PGG2 terganggu Kontraindikasi:
Efek analgetik dan antipiretik Hipersensitivitas gol.pirazolon
baik sedangkan anti inflamasi Deficiency G6PD
rendah Profiria
Interaksi obat:
Menurunkan kadar siklosporin
dalam darah, meningkatkan
efek alkohol
Sediaan:
Tab 500 mg dan larutan IV 500
mg/mL
 Dosis:
Dewasa 3x1 tab/hr sesudah
makan
Anak 8-12 tahun (1-2)x1/2
tab/hr sesudah makan

Pilihan golongan obat: acetaminophen

Nama obat: paracetamol 500mg 3x/hr

Modul 5
1. Define the diagnosis : stage 1 essential hypertension
2. Goal of Diagnosis : i) reduce blood pressure without aggravating asthma attack
3. Therapeutic Intervention :
A) Non Pharmaco
- Reduce food intake that is high in salf and caffeine
- Exercise regularly
B) Pharmaco
i) To reduce blood pressure
Drug group Efficacy Safety Suitability Cost
Beta Blocker ++ + + +
Diuretics ++ ++ ++ ++
angiotensin- ++ ++ ++ +
converting enzyme
inhibitor

Group of choice is Diuretics

Drugs Efficacy Safety Suitability Cost
Thiazide ++ ++ ++ ++
Loop diuretic ++ + + +
Potassium ++ + + +
sparing
diuretic

 Drug of choice is thiazide

4.Resep
5.KIE
- Take in the morning once
- Patient might regularly have the urge to urinate
- Eat balanced food without excessive salt intake
- Ask the patient to return if is experiencing any side effects such as dizziness
6. Monitoring pt
-Monitor the patient by asking the patient to return within the 1 st week for check up
.

MODUL 6
1.Define the diagnosis : Cough-Variant Asthma
2.Goal of Diagnosis : To maintain the state of cleared airway and breathing
3.Therapeutic Intervention :
A) Non Pharmaco
- Avoid cold drinks and food
- Use enough clothes to keep warm
- Refer to Rehab Medic lab for coughing exercises
B) Pharmaco
- Already given in case that the drug is theophylline IV and for maintenance theophylline oral tablets.
4. Resep
5. KIE
-Return to doctor if the is any side effects such as allergy reaction, fast or irregular breathing or heartbeat.
- Do not smoke cigarette or marijuana
- Patient should have a fast acting reliever if having sudden shortness of breath as theophylline does not effect immediately
- Do not consume other drugs without informing the doctor 1 st ( cimetidine,phenytoin )

6. Monitoring
-Throughout the usage of the medicine

Modul 12
Bu Ati (38 th), 3 hari ini mengeluh sering kencing, sedikit-sedikit. Setiap kencing dirasakan tidak tuntas dan diakhir kencing terasa sakit dan panas di daerah
kemaluan. Warna kencing kuning bening. Badan terasa demam dan tidak ada keluha lain. Lain-lain dalam batas normal.

Problem: keluhan kencing yang mengarah pada uretritis

Tujuan terapi:
 Membunuh kuman penyebab timbulnya keluhan kencing
 Menghilangkan gejala

P-treatment
a. Advis: menjaga kebersihan urogenital, menggunakan kondom pada sat berhubungan untuk mencegah penularan
b. Terapi non-obat: -

P-drug
Efficacy
Tetrasiklin
FK:
Absorpsi: 30-80% diserap dalam
saluran cerna yang sebagian
besar berlangsung di lambung
dan usus halus bagian atas.
Adanya makanan menghambat
penyerapannya. Selain itu,
absorpsi akan berjalan lambat
bila terbentuk kompleks
tetrasiklin dengan zat lain yang
sukar diserap, seperti aluminium
hidroksida, garam kalsium dan
magnesium. Tetrasiklin diberikan
Safety
Efek samping:
Reaksi kepekaan: tjd reaksi kulit
seperti erupsi morbiliformis,
utikaria, dermatitis eksfoliatif.
Reaksi yang lbh hebat yaitu
edema angioneurotik dan syok
anafilaksis. Selain itu juga
demam dan eusinofilia tjd pd
saat terapi.
Reaksi toksik dan iritatif: iritasi
lambung bil diberikan dlm dosis
besar. Diare timbul akibat iritasi
td. Tromboplebitis akibat
Suitability
Indikasi: riketsiosis, infeksi
klamidia, uretritis non spesifik,
infeksi mycoplasma pneumonia,
infeksi basil, infeksi kokus, infeksi
venerik, acne vulgaris, infeksi lain
(Actinomycosis, frambusa,
leptospira, infeksi GIT)
Kontraindikasi:
Pd px yang hipersensitifitas, gagal
ginjal
Interaksi obat:
Tetrasiklin+metoksifluoran
nefrotoksik
sebelum makan atau 2 jam
setelah makan.
Distribusi: terikat dengan protein
plasma dalam jumlah yang
bervariasi. Pemberian oral
250mg tetrasiklin tiap 6 jam
menghasilkan kadar sekitar 2-2,5
mcg/ml. Dalam CSS, kadar
tetrasiklin hanya 10-20% kadar
serum. Penetrasi ke jaringan
baik. Obat yang ditimbun dalam
sistem retikuloendotelial di hati,
limpa, dan sumsum tulang,
dentin, email dari gigi yang
belum bererupsi. Obat ini juga
menembus sawar uri dan berada
dalam ASI dalam kadar yang
relatif tinggi.
Ekskresi: diekskresikan melalui
urine, filtrasi glomerolus, dan
melalui empedu. Sebagian obat
yang diekskresi melalui usu ini
mengalami siklus enterohepatik,
dan masih terdapat dalam darah
meskipun terapi sudah
dihentikan.
FD:
Bersifat bakteriostatik,
menghambat sintesis protein
pemberian tetrasiklin Tetrasiklin+penicilin aktivitas
intravena. Reaksi toksik yg plg antimikrobanya dihambat
sering tjd yaitu Sediaan:
hepatotoksisitas, tetrasiklin Dosis:
akan akumulasi di dalam tubuh.
Kontraindikasi pada pasien dgn
gangguan ginjal. Pertumbuhan
tulang akan terhambat, tjd
terutama pada pertengahan
masa hamil smp anak umur 3
thn. Pada gigi susu maupun gigi
tetap, tetrasiklin menimbulkan
disgenesis, perubahan warna
dan karies.
Efek samping akibat perubahan
biologis: tjd nya super infeksi
oleh kumanyg resisten.
Enterokolitis streptokokus
dapat timbul setiap saat pada
waktu terapi. Kandidiasis
intestinal dan kolitis
pseudomembranosa.
bakteri pada ribosomnya.
Merupakan antibiotika spektrum
luas, yang efektif untuk kuman
gram negatif, positif, aerob dan
anaerob
Doxycyclin
FK:
Absorpsi: diserap >90%,
sebagian besar di lambung dan
usus halus bagian atas. Makanan
dalam lambung tidak
menghambat penyerapan
doksisiklin
Distribusi: masa paruh doksisiklin
tidak pada insuficiency ginjal
sehingga boleh diberikan pd org
dgn gagal ginjal. Daya penetrasi
ke jaringan kurang baik
dibandingkan tetrasiklin
Ekskresi: Sebagian obat yang
diekskresi melalui usu ini
mengalami siklus enterohepatik,
dan masih terdapat dalam darah
meskipun terapi sudah
dihentikan.
FD:
Bersifat bakteriostatik,
menghambat sintesis protein
bakteri pada ribosomnya.
Sama dengan tetrasiklin, hanya
doksisiklin boleh diberikan pada
pasien gagal ginjal
Indikasi:
riketsiosis, infeksi klamidia,
uretritis non spesifik, infeksi
mycoplasma pneumonia, infeksi
basil, infeksi kokus, infeksi venerik,
acne vulgaris, infeksi lain
(Actinomycosis, frambusa,
leptospira, infeksi GIT)
KI: hipersensitivitas
Sediaan:
Kapsul atau tablet 100mg; tablet
50 mg; sirup 10mg/ml
Dosis:
Dewasa: oral dosis awal 200mg;
selanjutnya 100-200mg/hr
Anak: oral hari pertama
4mg/kgBB/hr, selanjutnya
2mg/kg/hr dosis tunggal
Merupakan antibiotika spektrum
luas, yang efektif untuk kuman
gram negatif, positif, aerob dan
anaerob
Sulfamethoxazole/trimethopri
m Efek samping:
FK:
Absorption: Oral: Almost
complete (90-100%). Time to
peak, serum: Within 1-4 hr.
Distribution: Protein binding:
Sulfamethoxazole: 68%;
Trimethoprim: 45%.
Metabolism: Sulfamethoxazole:
N-acetylated and
glucuronidated; Trimethoprim:
Metabolised to oxide and
hydroxylated metabolites.
Excretion: Both are removed in
urine as metabolites and
unchanged drug.
FD:
Co-trimoxazole exhibits the
synergistic actions of its
components (sulfamethoxazole
and trimethoprim) by 10-fold.
Sulfamethoxazole inhibits
dihydrofolic acid formation from
PABA, thus interfering with
Renal failure, nausea, vomiting,
diarrhoea, anorexia; skin
rashes, urticaria.
Potentially Fatal: Stevens-
Johnson syndrome,
agranulocytosis, toxic
epidermal necrolysis, hepatic
necrosis.
Indikasi:
Susceptible infection, UTI, GI
infection, respiratory tract
infection, pneumocystis jiroveci
pneumonia, hepatic impairment,
profilaksis infeksi pada pasien AIDS
KI:
Hypersensitivity; severe renal or
hepatic insufficiency; infants <4 wk;
megaloblastic anaemia; pregnancy
and lactation.
G6PD deficiency; potential folate
deficiency; hepatic and renal
impairment; elderly; porphyria;
thyroid dysfunction; maintain
adequate hydration.
IO:
Reduced ciclosporin concentrations
in blood when used concurrently.
Increases toxicity of methotrexate.
Inhibitsphenytoin clearance.
Potentiates warfarin and oral
hypoglycaemics.
Potentially Fatal: Co-admin
synthesis and growth of bacterial with pyrimethamine causes
folic acid. Trimethoprim inhibits megaloblastic anaemia.
enzymes folic acid pathway, Enhancement of renal damage
preventing the reaction of the by ciclosporin.
dihydrolic acid to Sediaan:
tetrahydrofolate. Co-trimoxazole Dosis:
possesses bactericidal effects
against E coli, Klebsiella
spp, Enterobacter spp, M
morganii, P mirabilis, P
vulgaris, H influenzae, Strep
pneumoniae, Pneumocystis
(carinii) jiroveci,Cyclospora spp

Pilihan golongan obat: sulfamethoxazole/trimethoprim

Nama obat: cotrim

Modul 15.
pak samin, umur 45 tahun, pekerjaan tukang becak, datang ke poliklinik dengan keluhan sering merasa nyeri otot dan sendi (pegel-linu), terutama pada
sendi2 tangan. Rasa sakit ini diderita sudah 3 bulan terakhir, kadang muncul, kadang tidak. Walaupun tidak terlalu berat, tapi penderita merasa terganggu
kegiatan sehari2nya. Rasa nyeri juga disertai kaku sendi tangan, terutama pagi hari. Kalau sedang kumang sering diberi antalgin, teteapi tidak banyak
menolong. Pemeriksaan fisik lain dalam batas normal.
A. Problem: nyeri otot dan sendi2 tangan yang mengarah pada RA (rheumatoid arthritis)
B. Tujuan terapi:
1. Mengurangi nyeri  NSAiD
2. Mengurangi inflamasi  NSAiD
3. Menghentikan kerusakan sendi  DMARDs
 4. Mencegah cacat
5. Memperbaiki fungsi sendi
6. Memperbaiki kualitas hidup
7. Mencegah kematian dini
C. Intervensi Terapi:
a. Non-farmakologis :
i. Advice : mengistirahatkan sendi2 yang sakit
ii. Non drug :
1. rehabilitasi (fisioterapi) u/ meningkatkan kualitas hidup pasien  Segera setelah rasa sakit pada sendi berkurang/minimal :
terapi mekanik, pemanasan(hidrotherapy maupun electrotherapy), occupational therapy
2. pemakaian alat yg diperlukan seperti : bidai, walking machine, kursi roda, alat protetik lainnya
3. jika fisioterapi tdk berhasil  tindakan operatif
b. Farmakologis :
i. NSAID : obat simptomatik untuk mengurangi rasa sakit dan inflamasi tetapi tidak memperlambat kemajuan RA.
ii. Disease-modifying antirheumatic drugs (DMARDs) membantu memperlambat atau menghentikan perkembangan RA. DMARD yang
paling umum digunakan untuk mengobati rheumatoid arthritis adalah metotreksat. DMARDs lainnya termasuk Arava, Azulfidine,
Cytoxan, Imuran, Neoral, Plaquenil, sulfasalasin, kloroquin dapat digunakan. Namun kekurangan dari penggunaan obat tersebut
adalah efek samping yang ditimbulkan cukup besar, prosedur penggunaan cukup rumit, efek lambat, dan angka kegagalan yang
cukup besar.
iii. Yang perlu diingat adalah bahwa kunci keberhasilan pengobatan RA yaitu diagnosa dini dan pengobatan awal yang prograsif, yaitu
sesegera mungkin menggunakan obat pengubah perjalanan penyakit (DMARD) bila diagnosa telah ditegakkan.
- Farmakologis
Golongan Mekanisme Nama Obat Indikasi Dosis Efek Samping Cost
NSAiD Menghambat Piroxicam 20mg/hari dosis - Gangguan & 20 mg x 10 Efficacy:+++
sintesa tunggal terbagi pendarahan GI x10 (Rp Suitability:++
prostaglandin dlm 3 hari - Ruam, pruritus 29.000) Safety:+++
dg memblokir Cost:++++
ke2 jalur Ketoprofen 200mg 3-4x/hari - alergi Tab salut Efficacy:+++
cyclooxygenasi - pruritus enterik Suitability:++
 - eritema lokal 50mgx3x10 Safety:+++
(Rp44.000) Cost:++
DMARDs membantu Klorokuin - Klorokuin fosfat -penurunan Efficacy:++
(Disease- memperlambat 250 mg/hari penglihatan, Suitability:++
modifying atau - Hidroksikloroku dermatitis Safety:++
antirheumatic menghentikan in 400mg/hari makulopapular, Cost:++++
drugs) perkembangan nausea, diare dan
RA dengan anemia hemolitik
melindungi Senyawa I: - Suntikan IM ruam kulit, gatal Efficacy:+++
proses destruksi emas/AST KI : tdk mingguan dan berkurangnya Suitability:+++
akibat RA (auro sodium diberikan pada diberikan sampai sejumlah sel darah. Safety:++
tiomolat px penyakit hati tercapai dosis Cost:++
gold standar dan ginjal, total 1 gram atau
yg b’fungsi penyakit darah sampai timbulnya
memperlamba efek samping
t terjadinya atau terjadinya
kelainan perbaikan yang
bentuk tulang. berarti.
- Jika obat ini
efektif, dosisnya
dikurangi secara
bertahap.

Penisilamin  -250-300mg/hari, - penekanan Efficacy:+

digunakan jika kemudian terhadap Suitability:++
senyawa emas ditingkatkan pembentukan sel Safety:+
tidak efektif setiap 2-4minggu darah di dalam Cost:++
atau sebesar 250- sumsum tulang,
 menyebabkan 300mg/hari kelainan ginjal,
efek samping u/mencapai dosis penyakit otot,
yang tidak total 4x250-300 ruam kulit dan rasa
dapat mg/hari. tidak enak di
ditoleransi. mulut.
- Obat ini juga bisa
menyebabkan
miastenia gravis,
sindroma
Goodpasture dan
sindroma yang
menyerupai
lupus.

Sulfasalazine. Dosisnya gangguan Efficacy:++

dinaikkan secara pencernaan, Suitability:+++
bertahap dan kelainan hati, Safety:+++
perbaikan kelainan sel darah Cost:++
biasanya terjadi dan ruam kulit.
dalam 3 bulan
Agen biologis memblokir TNF blocker Efficacy:++++
sebuah protein Suitability:++
inflamasi pada Safety:++++
RA yaitu tumor Cost:+
necrosis factor
(TNF)
Kortikosteroid Menghambat Prednison penipisan kulit, Efficacy:+
fosfolipase, shg memar, Suitability:++++
shg osteoporosis, Safety:+
 pembenukan tekanan darah Cost:+++
prostaglandin tinggi, kadar gula
dan leukotrien darah yang tinggi
terhambat. dan katarak.
Obat ini paling
efektif untuk
mengurangi
peradangan di
bagian tubuh
manapun,
namun
cenderung
kurang efektif
digunakan
dalam jangka
panjang,
padahal RA adl
penyakit yang
biasanya aktif
selama
bertahun-tahun.
Immunosupresif cyclophosphami Oral: 50- penyakit hati, Efficacy:+++
de) efektif 200mg/hari peradangan paru- Suitability:+++
untuk IV 10- paru, mudah Safety:+++
mengatasi 15mg/kg/hari terkena infeksi, Cost:+
artritis rematoid setiap 3-7hari penekanan
yang berat  terhadap
menekan pembentukan sel
pembentukan darah di sumsum
 Ab tulang dan
perdarahan
kandung kemih
(karena
cyclophosphamide)
.
Selain itu
cyclophosphamide
bisa meningkatkan
resiko terjadinya
kanker
Methotrexat  Dosis awitan 5- Penurunan Tab Efficacy:++
RA stadium 7,5 mg /minggu. imunitas tubuh  2.5mgx100 Suitability:+++
awal Bila dlm 4 bln bahaya pd px TB (Rp.278.000) Safety:++++
tdk ada -bersifat Cost:++
perbaikan, dosis hepatotoxic
ditingkatkan

D. Resep
 dr. Uca
SIP : 0710710068
Praktek : Jl.Berlian 1234 Malang
Telp: 0341 1234567
_______________________________________________________
Malang, 27 April 2011

R/chloroquine tab 250mg no.VII

∫ 1 dd 1 h.s
Paraf
R/ Piroxicam tab 20mg no.VII
∫ 1 dd 1 h.s
Paraf

Pro : Pak Samin

Umur : 45 tahun
Alamat : Jl Emas Kuning 4567 Malang

E. Komunikasi obat (KIE)

Bapak, Saya buatkan resep untuk anda. Ada 2 macam obat :
 Pertama : chloroquine, untuk memperlambat/menghentikan perusakan peradangan pada sendi bapak, sehingga rasa nyerinya juga akan
hilang, diminum 1 kali sehari sebelum tidur
 Kedua : piroxicam, menekan rasa nyeri, diminum 1 kali sehari sebelum tidur
Setelah mengkonsumsi obat ini, mungkin anda akan mengalami gatal-gatal dan nyeri perut spt mag (efek samping obat),Jika terjadi efek samping
tersebut, maka segera kembali dan konsultasi ke dokter

F. Monitoring dan Evaluasi

Setelah meminum obat ini jika bertambah parah, atau timbul efek samping yang sangat mengganggu atau gejala tidak berkurang segera kembali ke
dokter.