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action=print&AdrId=29956&AdrLang=0

ADR Case Report

Printed by # WAHYU RELLY SETIAWAN
Printed date # 07/11/2022

Type Report : Initial

Personal Data
Form No Vigiflow No Vigiflow By Reporter Qualification Type of Report Serious Patien Initial Sex Age Ethnic Origin Body
20221000262 WAHYU RELLY SETIAWAN Pharmacist Other S Female 67 Year(s) 55 Kg

Primary Disease : EFUSI PLEURA DEXTRA

Adverse Reaction
Reaction Description : 1. MUAL MUNTAH

Adverse Reaction Date Onset End Date Duration Treatment of Reaction

Vomiting 13/09/2022 15/09/2022 No treatment Unkno

Drug(s)
Characterisation
Medicinal Expected/ Batch Pharmaceutical Route of
Drug JKN (Suspected or Manufacture Daily Dose Treatment
treatment Unexpected No Form Administration
Concomitant)

Began Terminated Durati

LEVOFLOXACIN HEMIHYDRATE JKN Others Suspected Expected PT DEXA MEDICA Infus IV (Intravenous) 750mg(750x1day(s)) 13/09/2022 14/09/2022

Other Data
Additional Information : RIWAYAT ESO TIDAK ADA, ESO TERATASI SETELAH TERAPI DIHENTIKAN (PASIEN KRS)
Laboratory Data : SGOT: 3024 SGPT: 649 BUN: 22.5 CR: 1.53

Reporter Information
Reporter : WAHYU RELLY SETIAWAN
Institution : RS Umum Wonolangan - Jl. Raya Dringu No 118 Desa Kedungdalem Kec. Dringu, Kab. Probolinggo
Phone/Mobile No : 085236366708
Manufacturer Control No :
Date Received by Manufacturer :

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