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-drugP-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 CostAntimotility (+) +++ ++ +++Absorbents (+) ++ +++ +++Antisecretory (+) +++ ++ +++

Antipyretic / analgesicGroup Efficacy Safety Suitability CostNSAID Pharmacodynamics:

Inhibits cyclooxygenase and prostaglandin synthesisPharmacokinetics:PO / PR

Side effects:Hypersensitivity, GI upset and bleeding (besides paracetamol), salicylism (aspirin)

Contraindications:Bleeding disorders, peptic ulcer disease (besides paracetamol)

1

Group Efficacy Safety Suitability CostNSAID +++ +++ +++ +++

v. Choose a P-drug Antidiarrheal:

Antisecretory Efficacy Safety Suitability CostBismuth subsalicylate +++ ++ +++ Stobiol 262 mg x

120's (Rp24000)

NSAID:NSAID Efficacy Safety Suitability CostAcetaminophen

Acetaminophen possesses analgesic and antipyretic activities with few anti-inflammatory effects

Does not cause GI upset / bleeding

Occasionally, maculopapular rash or urticarial skin reactions occur;

G6PD deficiency, hypersensitivity

PanadolCap 500mg X 100 = Rp19,000

methemoglobinemia, neutropenia, and thrombocytopenic purpura are rarely reported

Allergic reactions

Syrup 160mg/5ml X 60ml = Rp9,200

Aspirin Aspirin is an analgesic, antipyretic, and anti-inflammatory agent

Anti-inflammatory properties are related to 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

GI upset and bleeding, allergic reactions, increased risk of Reye’s Syndrome in children, salicylism

Hypersensitivity, bleeding disorder, peptic ulcer disease

Aspirin BayerTab 500mg X 15 X 8 = Rp36,930

Ibuprofen It is a nonselective inhibitor of cyclo-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2) and reversibly alters platelet function and prolongs bleeding time

Gastric distress, blood loss, diarrhea, vomiting, dizziness, and skin rash occur occasionally

Better tolerated than aspirin by most patient

Syndrome of nasal polyps; angioedema; bronchospastic reactivity to aspirin or other NSAIDs

Bufect / Bufect ForteSyrup 100mg/5ml X 60ml = Rp10,765

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

NSAID Efficacy Safety Suitability CostAcetaminophen ++ +++ +++ +++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 finishedSTEP 4: Write a prescriptionDr. johnsonJl. Saturnus 3, MalangTelp. 0341582110SIP. 446.DU/012/35.73.306/2007

Malang, 27 April 2011R/ 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. - - - - ,, - - - -

IdPro: Adik MartaUmur: 10th.Alamat: Jl. Muthafukar No. 117, Malang

STEP 5: Give information, instructions and warningsi. 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 instructedv. 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 drugo Minimal effect: reconsider dosage / drug choiceo 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-drugP-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 CostBeta-lactams

Pharmacodynamics:Inhibits cross-linking of cell wall componentsPharmacokinetics:PO / IM / IV

Side effects:Hypersensitivity, rare nerve, liver or kidney toxicity

Contraindications:Known hypersensitivity of beta lactams, resistant of causative bacteria

1 (amoxicillin) & 3 (cephalexin)

Macrolide Pharmacodynamics:Inhibits protein synthesis (prevents translocation of polypeptide chain by binding to the P site of the ribosomal 50s subunit)Pharmacokinetics:PO / IV

Side effects:GI upset, increase plasma level of many drugs, toxicity may results when co-administered with theophylline, anticoagulants, carbamazepine

Contraindications:Hypersensitivity, hepatic dysfunction

2 (erythromycin)

Group Efficacy Safety Suitability CostBeta-lactams +++ +++ +++ +++ / +Macrolide +++ ++ ++ ++

NSAIDGroup Efficacy Safety Suitability CostNSAID Pharmacodynamics:

Inhibits cyclooxygenase and prostaglandin synthesisPharmacokinetics:

Side effects:Hypersensitivity, GI upset and bleeding (besides paracetamol), salicylism (aspirin)

Contraindications:Bleeding disorders, peptic ulcer disease (besides paracetamol)

1

PO / PR

Group Efficacy Safety Suitability CostNSAID +++ +++ +++ +++

ExpectorantsGroup Efficacy Safety Suitability CostAcetylcysteine

Pharmacodynamics:Acetylcysteine exerts its mucolytic action through its free sulfhydryl group, which opens the disulfide bonds and lowers mucus viscosityPharmacokinetics:PO / inhalation

Side effects:Bronchospasm, GI disturbances, stomatitis, rhinorrhea, headache, tinnitus, urticaria, shivering, fever, hemoptysis. Anaphylactic shock (rare)

Contraindications:GI upset

1

Guaifenesin Pharmacodynamics:Guaifenesin is proposed to have an expectorant action through an increased output of respiratory tract fluid, enhancing the flow of less viscid secretions, promoting ciliary action, and facilitating the removal of inspissated mucus Pharmacokinetics:PO

Side effects:Occasional nausea and vomiting, especially with excessive dosage; dizziness; headache

Contraindications:Hypersensitivity to guaifenesin

2ProbatTab 100mg X 30 = Rp8,500

Bromhexine Pharmacodynamics:It increases the production of serous mucus in the respiratory tract and makes the phlegm less sticky and thinner, which leads to secretomotoric effect that helps the cilia transport the phlegm out of the lungsPharmacokinetics:

Side effects:Diarrhea, nausea, vomiting, and other GI disturbances, allergic reaction (include rash, urticaria, bronchospasm, angioedema, anaphylactic shock), increase antibiotic (amoxicillin, erythromycin) concentration in lungs

Contraindications:Hypersensitivity to bromhexine, history of peptic ulceration; asthmatic patients, severe hepatic or renal impairment

3

PO / inhalation

Group Efficacy Safety Suitability CostAcetylcysteine +++ ++ +++ +++Guaifenesin ++ +++ +++ +++Bromhexine ++ ++ ++ +++

v. Choose a P-drug Beta-lactams

Beta-lactams Efficacy Safety Suitability CostPenicillin (amoxicillin)

Inhibits cross-linking of cell wall components

Amino side group makes it hydrophilic enough to penetrate the porins in gram negative organisms

Penicillin is the drug of choice in the treatment of Group A streptococcal pharyngitis

Nausea, diarrhea, rash Known hypersensitivity of beta lactams, resistant of causative bacteria

AmoxilCap 250mg X 100 = Rp185,009

Syrup 125mg/5ml X 60ml = Rp21,620

Syrup 250mg/5ml X 60ml = Rp37,358

Cephalosporin (cephalexin)

Inhibits cross-linking of cell wall components

Beta-lactam binds penicillin binding proteins

Inhibits cell wall synthesis and may in turn activate

Hypersensitivity reactions, GI disturbances, hematologic abnormalities, nephrotoxicity and hepatic enzyme abnormalities

Known hypersensitivity of beta lactams, resistant of causative bacteria

OspexinTab 500mg X 10 X 10 = Rp616,000

autolysins

In patients allergic to penicillin, a macrolide such as erythromycin or a first-generation cephalosporin such as cephalexin (if the reaction is non immunoglobulin E-mediated hypersensitivity) can be used

Syrup 250ml/5ml X 60ml = Rp48,500

Beta-lactams Efficacy Safety Suitability CostPenicillin (amoxicillin) +++ +++ +++ +++Cephalosporin (cephalexin)

++ ++ +++ ++

NSAIDNSAID Efficacy Safety Suitability CostAcetaminophen

Acetaminophen possesses analgesic and antipyretic activities with few anti-inflammatory effects

Does not cause GI upset / bleeding

Occasionally, maculopapular rash or urticarial skin reactions occur; methemoglobinemia, neutropenia, and thrombocytopenic purpura are rarely reported

Allergic reactions

G6PD deficiency, hypersensitivity

PanadolCap 500mg X 100 = Rp19,000

Syrup 160mg/5ml X 60ml = Rp9,200

Aspirin Aspirin is an analgesic, antipyretic, and anti-inflammatory agent

Anti-inflammatory properties are related to the inhibition of prostaglandin biosynthesis

GI upset and bleeding, allergic reactions, increased risk of Reye’s Syndrome in children, salicylism

Hypersensitivity, bleeding disorder, peptic ulcer disease

Aspirin BayerTab 500mg X 15 X 8 = Rp36,930

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-oxygenase-1 (COX-1) and cyclo-oxygenase-2 (COX-2) and reversibly alters platelet function and prolongs bleeding time

Gastric distress, blood loss, diarrhea, vomiting, dizziness, and skin rash occur occasionally

Better tolerated than aspirin by most patient

Syndrome of nasal polyps; angioedema; bronchospastic reactivity to aspirin or other NSAIDs

Bufect / Bufect ForteSyrup 100mg/5ml X 60ml = Rp10,765

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

NSAID Efficacy Safety Suitability CostAcetaminophen ++ +++ +++ +++Aspirin +++ + ++ ++Ibuprofen +++ ++ ++ +++

Expectoranto *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 finishedSTEP 4: Write a prescriptionDr. johnsonJl. Saturnus 3, MalangTelp. 0341582110SIP. 446.DU/012/35.73.306/2007

Malang, 27 April 2011R/ 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. - - - - ,, - - - -

IdPro: Adik AdamUmur: 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 instructedv. 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 treatmento 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 GITii. 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 CostMenghambat sistesis dinding sel microba

Hypersensitivity , mual muntah.

Indikasi: infeksi saluran cernaKontraindikasi: hypersensitivity and allergy penicilin

Tablet 500mg; : Rp 1300

++ ± + +++

Opiat (Non antibiotic)Efficacy Safety Suitability CostKonstipasi / anit diarrhea

Mual, muntah, epigastric distress

Hypersensitivity, not suitable for dehydrated patient

-

+ - - -

Adsorben Efficacy Safety Suitability CostMenyerap toksin bakteri dan mengikat bakteri

Mual muntah, nyeri epigastric kanstipasi dan dehidrasi

Hypersensitivity -

+ - - -

Anti CholinergicEfficacy Safety Suitability CostAnti muscarinik, menghambat sekresi saluran cerna dan peristaltik

Dry, hot skin, impared GI mortality, hypertension, tachycardia ect

Hypersensitivity hepatic diseaseobstructive GI disease

-

+ - - -

Oralit Efficacy Safety Suitability CostHydrate the body by providing electrolytes for reabsorbtion

overhydrated Indication : for minor or severe dehydration

Oralit 1L : Rp710

++ ± + ++

v. Choose a P-drug Ampisilin

Efficacy Safety Suitability Cost-Menghambat Hypersensitivity, mual, Kontraindikasi : alergi 500mg : Rp1300

mucopeptida untuk sintesis didding sel mikroba-peroral-H.L :1,3 jam urine

muntah penicillin, hypersensitivityIndikasi : infeksi saluran cerna.

Sirup 60ml, 125mg/5ml : Rp6000

++ ± ± +++

Makrolida (erithromysin)Efficacy Safety Suitability CostMenghambat sintesis protein kuman dgn mengikat ribosom-H.L 1,6 jm hepar

Hypersensitivity, mual, muntah, nyeri epigastrium

Ganguan hepar 500mg; Rp 1900

+ ± - ++

Glikopeptida (vankomisin)Efficacy Safety Suitability CostMenghambat sintesis didding sel-HL : 6-10hr filtrasi glomelurus

Sangat toksik hypersinsivitas 500mg: Rp70000

+ - - -ConclusionActive substance dosage from : Ampisilin peroral sirup, oralit peroralDosage : ampisilin-125mg(5ml)x4/day, oralit 1L x2 / day

8. Ibu Tina, 45 thn, dating ke dokter dengan keluhan sakit 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= 80/min. Lain pada batas normal.

i. Define the diagnosis : hypertension due to hormonal pill causing headacheii. Specific therapeutic obj : - Control the hypertensioniii. Make inventory of effective groups

Beta Blocker ACE inhibitor Vasodilators Diuretics

iv. Choose a drug according to criteria Beta Blocker

Efficiensy Safety Suitability CostMengurangi kontraktilitas jantung, mengurangi frekeunsi denyut jantung

Bradicardi, pusing, kelemahan otot, lelah

Indikasi : hipertensiK.indikasi:Block AV derajat 2 &3, cardiiogenic Shock, met. acidosis

PropanololPO 10mg tabRp 1012/biji

+++ +++ +++ ++

ACE inhibitor

Dr. Kishern

Jln Wonogiri 4, Malang

Telp :081805167956

SIP :446.DU/0121/25.47.588

Malang 26 april 2011

R/ Ampisilin 125mg NO 1

∫ 4dd I peroral KISH

R/ Oralit 1L NO2

∫ 2 dd I peroral KISH

Px : anak xxx

Umur : 12 thn

Alamat: xxx, Malang

Efficiensy Safety Suitability CostMengurangi volume n tekanan pengisian ventrikelMeningkatkan curah jantung

Takikardi, batuk kering , demam

Indikasi : hipertensiK.indikasi:hypersensitive hamil, laktasi, gagal ginjal

Captopril 50mgx5x10 : Rp 10700

++ + ++ +++

DiureticsEfficiensy Safety Suitability CostMenghambat Na n Cl

Hipokelemi, hiponatremi, dehidrasi, hiperglikemi.

Indikasi : hipertensiK.indikasi: hamil and laktasi gagal ginjal

Furosemid Rp21753

++ + ++ ++

v. Choose a P-drug Propanolol

Efficiensy Safety Suitability CostMengurangi kontraktilitas jantung, mengurangi frekeunsi denyut jantung

Efek: gangguan pencernaan, lelah

Indikasi : hipertensiK.indikasi:Block AV derajat 2 &3, cardiiogenic Shock, met. acidosis

PO 10mg tab.Rp1.012/biji

+++ +++ +++ +++ Atenolol

Efficiensy Safety Suitability CostMengurangi kontraktilitas jantung, mengurangi frekeunsi denyut jantung

Efek: bradicardi, gangguan pencernaan, lelah

Indikasi : hipertensiK.indikasi:Block AV derajat 2 &3, sinus bradicardi

PO 10mg tab.Rp1.400/bijiRp2.250/biji

+++ ++ ++ ++

ConclusionActive substance dosage from : Propanolol Dosage : 40mg orally twice a day

Modul 11Pak Ucup (53 th) 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 nyeri dan sudah berlangsung seminggu ini. Obat penghilang nyeri yang telah diminum selama ini tidak dapat mengurangi nyerinya. Pak Ucup juga menderita diabetes tipe 2.

Problem: nyeri akibat kanker colon stadium akhir dan menderita diabetes tipe 2.

Tujuan terapi: meredakan nyeri dan tidak memperberat diabetes tipe 2

P-treatmenta. Advis: mengurangi makanan yang berlemak, daging (terutama daging merah)

Menghindari makanan yang dibakarb. Terapi non-obat: kemoterapi

P-drugEfficacy Safety SuitabilityAcetaminophen atau paracetamol

Dr. Kishern

Jln Wonogiri 4, Malang

Telp :081805167956

SIP :446.DU/0121/25.47.588

Malang 26 april 2011

R/ Propanolol 10mg NO.II

∫ 2dd 4tab PO KISH

Px : Ibu Tina

Umur : 45 thn

Alamat: xxx, Malang

Farmakodinamik:Analgesik&antipiretikIritasi gaster (-)Hambatan agregasi trombosit (-)Farmakokinetik:Absorpsi tergantung pengosongan lambungKadar puncak 30-60 menitTerikat protein plasma 20-50%Metabolisme di hatiT1/2=1-3 jam

Efek samping:EritemaUtikariaLesi pada mukosaAnemia hemolitik pada penggunaan kronis autoimunNekrosis hati pada 10-15gramNekrosis tubulus renalis

Indikasi:Moderete pain and feverKontraindikasi:G6PD deficiencyInteraksi obat:BarbituratesAbuse hepatotoksik meningkatMemperkuat efek warfarinDosis:Dewasa 325-650 mg tiap 4-6 jam atau 1000 mg 3-4x/hr tidak melebihi 4 gram

Metampiron atau antalginFD:Menghambat enzim siklooksigenase sehingga konversi asam arakhidonat menadi PGG2 tergangguEfek analgetik dan antipiretik baik sedangkan anti inflamasi rendah

Efek samping:Kadang menimbulkan agranulositosis, anemia aplastik dan trombositopeni

Indikasi: nyeri kepala, neuralgia, sakit pinggang, nyeri pasca bedah, dismeneroe, nyeri kolik, demamKontraindikasi:Hipersensitivitas gol.pirazolonDeficiency G6PDProfiriaInteraksi obat:Menurunkan kadar siklosporin dalam darah, meningkatkan efek alkoholSediaan:Tab 500 mg dan larutan IV 500 mg/mL

Dosis:Dewasa 3x1 tab/hr sesudah makanAnak 8-12 tahun (1-2)x1/2 tab/hr sesudah makan

Pilihan golongan obat: acetaminophen

Nama obat: paracetamol 500mg 3x/hr

Modul 51. Define the diagnosis : stage 1 essential hypertension2. Goal of Diagnosis : i) reduce blood pressure without aggravating asthma attack3. Therapeutic Intervention :

A) Non Pharmaco- Reduce food intake that is high in salf and caffeine- Exercise regularly

B) Pharmacoi) To reduce blood pressure

Drug group Efficacy Safety Suitability CostBeta Blocker ++ + + +Diuretics ++ ++ ++ ++angiotensin-converting enzyme inhibitor

++ ++ ++ +

Group of choice is DiureticsDrugs Efficacy Safety Suitability CostThiazide ++ ++ ++ ++Loop diuretic ++ + + +Potassium sparing diuretic

++ + + +

Drug of choice is thiazide4.Resep5.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 dizziness6. Monitoring pt-Monitor the patient by asking the patient to return within the 1st week for check up.

MODUL 61.Define the diagnosis : Cough-Variant Asthma2.Goal of Diagnosis : To maintain the state of cleared airway and breathing3.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. Resep5. 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 1st ( 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-treatmenta. Advis: menjaga kebersihan urogenital, menggunakan kondom pada sat berhubungan untuk mencegah penularanb. Terapi non-obat: -

P-drugEfficacy Safety SuitabilityTetrasiklinFK: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

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

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 ginjalInteraksi 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 intravena. Reaksi toksik yg plg sering tjd yaitu hepatotoksisitas, tetrasiklin 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.

Tetrasiklin+penicilin aktivitas antimikrobanya dihambatSediaan:Dosis:

bakteri pada ribosomnya. Merupakan antibiotika spektrum luas, yang efektif untuk kuman gram negatif, positif, aerob dan anaerobDoxycyclinFK:Absorpsi: diserap >90%, sebagian besar di lambung dan usus halus bagian atas. Makanan dalam lambung tidak menghambat penyerapan doksisiklinDistribusi: masa paruh doksisiklin tidak pada insuficiency ginjal sehingga boleh diberikan pd org dgn gagal ginjal. Daya penetrasi ke jaringan kurang baik dibandingkan tetrasiklinEkskresi: 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: hipersensitivitasSediaan:Kapsul atau tablet 100mg; tablet 50 mg; sirup 10mg/mlDosis:Dewasa: oral dosis awal 200mg; selanjutnya 100-200mg/hrAnak: 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 anaerobSulfamethoxazole/trimethoprimFK: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 synthesis and growth of bacterial

Efek samping: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 AIDSKI: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

folic acid. Trimethoprim inhibits enzymes folic acid pathway, preventing the reaction of the dihydrolic acid to tetrahydrofolate. Co-trimoxazole 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

with pyrimethamine causes megaloblastic anaemia. Enhancement of renal damage by ciclosporin.Sediaan:Dosis:

Pilihan golongan obat: sulfamethoxazole/trimethoprimNama 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 NSAiD2. Mengurangi inflamasi NSAiD3. Menghentikan kerusakan sendi DMARDs4. Mencegah cacat

5. Memperbaiki fungsi sendi6. Memperbaiki kualitas hidup7. Mencegah kematian dini

C. Intervensi Terapi:a. Non-farmakologis :

i. Advice : mengistirahatkan sendi2 yang sakitii. 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 lainnya3. 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.

- FarmakologisGolongan Mekanisme Nama Obat Indikasi Dosis Efek Samping Cost

NSAiD Menghambat sintesa prostaglandin dg memblokir ke2 jalur cyclooxygenasi

Piroxicam 20mg/hari dosis tunggal terbagi dlm 3 hari

- Gangguan & pendarahan GI

- Ruam, pruritus

20 mg x 10 x10 (Rp 29.000)

Efficacy:+++Suitability:++Safety:+++Cost:++++

Ketoprofen 200mg 3-4x/hari - alergi- pruritus- eritema lokal

Tab salut enterik 50mgx3x10

Efficacy:+++Suitability:++Safety:+++

(Rp44.000) Cost:++DMARDs (Disease-modifying antirheumatic drugs)

membantu memperlambat atau menghentikan perkembangan RA dengan melindungi proses destruksi akibat RA

Klorokuin - Klorokuin fosfat 250 mg/hari

- Hidroksiklorokuin 400mg/hari

-penurunan penglihatan, dermatitis makulopapular, nausea, diare dan anemia hemolitik

Efficacy:++Suitability:++Safety:++Cost:++++

Senyawa emas/AST (auro sodium tiomolat gold standar yg b’fungsi memperlambat terjadinya kelainan bentuk tulang.

I:KI : tdk diberikan pada px penyakit hati dan ginjal, penyakit darah

- Suntikan IM mingguan diberikan sampai tercapai dosis total 1 gram atau sampai timbulnya efek samping atau terjadinya perbaikan yang berarti.- Jika obat ini efektif, dosisnya dikurangi secara bertahap.

ruam kulit, gatal dan berkurangnya sejumlah sel darah.

Efficacy:+++Suitability:+++Safety:++Cost:++

Penisilamin digunakan jika senyawa emas tidak efektif atau menyebabkan

-250-300mg/hari, kemudian ditingkatkan setiap 2-4minggu sebesar 250-300mg/hari

- penekanan terhadap pembentukan sel darah di dalam sumsum tulang, kelainan ginjal,

Efficacy:+Suitability:++Safety:+Cost:++

efek samping yang tidak dapat ditoleransi.

u/mencapai dosis total 4x250-300 mg/hari.

penyakit otot, ruam kulit dan rasa tidak enak di mulut.- Obat ini juga bisa

menyebabkan miastenia gravis, sindroma Goodpasture dan sindroma yang menyerupai lupus.

Sulfasalazine. Dosisnya dinaikkan secara bertahap dan perbaikan biasanya terjadi dalam 3 bulan

gangguan pencernaan, kelainan hati, kelainan sel darah dan ruam kulit.

Efficacy:++Suitability:+++Safety:+++Cost:++

Agen biologis memblokir sebuah protein inflamasi pada RA yaitu tumor necrosis factor (TNF)

TNF blocker Efficacy:++++Suitability:++Safety:++++Cost:+

Kortikosteroid Menghambat fosfolipase, shg shg pembenukan

Prednison penipisan kulit, memar, osteoporosis, tekanan darah

Efficacy:+Suitability:++++Safety:+Cost:+++

prostaglandin dan leukotrien terhambat.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.

tinggi, kadar gula darah yang tinggi dan katarak.

Immunosupresif cyclophosphamide) efektif untuk mengatasi artritis rematoid yang berat menekan pembentukan Ab

Oral: 50-200mg/hariIV 10-15mg/kg/hari setiap 3-7hari

penyakit hati, peradangan paru-paru, mudah terkena infeksi, penekanan terhadap pembentukan sel darah di sumsum tulang dan

Efficacy:+++Suitability:+++Safety:+++Cost:+

perdarahan kandung kemih (karena cyclophosphamide). Selain itu cyclophosphamide bisa meningkatkan resiko terjadinya kanker

Methotrexat RA stadium awal

Dosis awitan 5-7,5 mg /minggu. Bila dlm 4 bln tdk ada perbaikan, dosis ditingkatkan

Penurunan imunitas tubuh bahaya pd px TB-bersifat hepatotoxic

Tab 2.5mgx100 (Rp.278.000)

Efficacy:++Suitability:+++Safety:++++Cost:++

D. Resep

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 tidurSetelah 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

dr. UcaSIP : 0710710068

Praktek : Jl.Berlian 1234 MalangTelp: 0341 1234567

_______________________________________________________Malang, 27 April 2011

R/chloroquine tab 250mg no.VII ∫ 1 dd 1 h.s

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

Paraf

Pro : Pak SaminUmur : 45 tahunAlamat : Jl Emas Kuning 4567 Malang

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