PC Kelompok 6 Gagal Jantung
PC Kelompok 6 Gagal Jantung
PC Kelompok 6 Gagal Jantung
PRESCRIPTION
No SIK : ………………………………………….
TanggalResep : 05/05/2011
AlamatPasien : Jl. Bantulan Kelurahan Argomulyo, Kecamatan Sedayu, Kabupaten Bantul, Yogyakarta
Umur : 65 tahun
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 :Riwayat pasien
Address : Jl. Bantulan Kelurahan Argomulyo, Kecamatan Sedayu, Kabupaten Bantul, Yogyakarta
Phone : 08157996116
Name / strength Directions Start date Stop date Physician Purpose Effectiveness
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 )
Asthma - - Stroke - -
Diabetes √ - Other
Social History Please indicate your alcohol, tobacco, caffeine, and dietary habbits
……… pack per day for …. years ………. drink per day
Location/Room :
Pharmacist :
Date :
Presence of Drug
Type of Problem Assessment Comments/notes
Related Problem
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
1. A problem exist.
Is the patient allergic to or intolerant of 2. More information
Drug allergy or any medicines (or chemically related Pasien alergi β-laktam
is needed for a
intolerance medications) currently being taken? 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)?
1. A problem exist.
2. More information
Are there symptoms or medical problems is needed for a
Adverse drug
that may be drug induced? What is the determination
events
likehood that the problem is drug related? 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.
Intraksi obat dengan obat :
Drug-Drug, (relatively or absolutely) given patient 2. More information
is needed for a
Drug-Disease, characteristics and current/past disease Insulin tidak dapat diberikan pada pasien
states? determination
obesitas
3. No problem exist
Drug-Nutrient, and Penggunaan fenfluramin menyebabkan
Are there drug nutrient interactions? Are or an intervention
menyebabkan hipokalemia
Drug-Laboratory they clinically significant? is not needed
Test
Are there drug-laboratory test interactions?
Are they clinically significant?
2. Hypertensi
3. DM
4. Udem pulmo
5. Hyperuricemia
6. hipoksia
C. Monitoring
Konseling :