Clinical CAse Reports - International Online Medical Council

Transcription

2015
Vol 06, Issue 01,
Supplement I
DRUNPP Association of
Sarjevo, Bosnia &
Herzegovinia
INTERNATIONAL JOURNAL OF
PHARMACY TEACHING & PRACTICES
(IJPTP)
[CLINICAL CASE REPORTS]
www.iomcworld.com\ijptp
email: Ijourptp@gmail.com
ISSN:1986-8111
International Journal of Pharmacy Teaching & Practices, Vol6, issue01, Supplement I, 1609-2092.
EDITORIAL BOARD
Editor-in-Chief
Dr. Syed Wasif Gillani
Associate Prof. Dr. Azmi Sarriff
Editorial Assistant
Dr. Mostafa Nejati
Executive Editors
Prof. Dr. Syed Azhar Syed Sulaiman
Dr. Waffa Mohamed El-Anor Ahmed Rashed
Prof. Dr. Mark Raymond
Mr. Robert Hougland
Advisory Board Members
Dr. Mensurak Kudumovic
Dr. Jasmin Musanovic
Dr. Monica Gaidhane
Assoc.Prof. Dr. Mok.T Chong
Dr. Syed Tajuddin Syed Hassan
Dr. Sumeet Dwivedi
Dr. Dibyajyoti saha
EDITORIAL ADDRESS: KA311, KEYANGANG, BANDAR SUNWAY, SELANGOR, MALAYSIA
PUBLISHED BY: DRUNPP, SARAJEVO, BOLNICKA BB. VOLUME 5, ISSUE 3, SUPP I, 2014
ISSN: 1986-8111,
INDEXED ON: EBSCO PUBLISHING (EP)USA, INDEX COPERNICUS (IC) POLAND
1610
Contents
EVALUATION OF THE TREATMENT OF PATIENTS WITH NEPHROTIC SYNDROME AT PGI CIKINI
HOSPITAL .......................................................................................................................................... 1617
DIABETES MELLITUS AT PGI CIKINI HOSPITAL .................................................................................. 1622
EVALUATION OF DRUG RELATED PROBLEMS IN STROKE HEMORRHAGIC PATIENTS WITH CHRONIC
KIDNEY DISEASE COMPLICATIONS WHICH TREATED IN RSPAD GATOT SOEBROTO STROKE UNIT.. 1627
DRUG INTERACTIONS AND THE SELECTION OF MISSING RIGHT FOR MASSIVE ASCITES TREATMENT At
PGI CIKINI HOSPITAL ......................................................................................................................... 1635
Retention of Urine BPH (Benign Prostate Hyperplasia) Treatment in PGI CikiniHospital Jakarta ... 1640
Treatment of The Dyspepsia Patient At the PGI Cikini Hospital....................................................... 1645
EVALUATION OF DRUG RELATED PROBLEMS IN THE TREATMENT OF PATIENT WITH CKD (Chronic
Kidney Disease) AT THE PGI CIKINI HOSPITAL .................................................................................. 1653
THE CASE STUDY KIDNEY STONES (UROLITHIASIS) AT THE PGI CIKINI Hospital ............................... 1656
DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT FOR OBSTRUCTIVE JAUNDICE PATIENT
IN PGI CIKINI HOSPITAL .................................................................................................................... 1660
HIPERGLICEMIA IN PATIENT DIABETIC MELITUS TIPE II AT ISLAMIC CEMPAKA PUTIH JAKARTA
HOSPITAL (RSIJ) ................................................................................................................................ 1664
EVALUATION OF DRUG RELATED PROBLEMS IN DIABETES MELLITUS DISEASE AND CELLULITIS IN
HOSPITAL CENTER OF ARMY (RSPAD) GATOT SOEBROTO JAKARTA Samir1, Diana Laila Rahmatillah2,
Aprilita Rinayanti Efi2 ........................................................................................................................ 1669
DRUG RELATED PROBLEMSTHERAPY FOR IMPAIRMENT OF CONCIOUSNESS IN PATIENT WITH
EPILEPSY AND TUBERCULOUS MENINGITIS SUSPECTED IMMUNOCOMPROMISED ........................ 1679
EVALUATION OF MEDICINE AND THERAPY FOR HEBEPHRENIC SCHIZOPHRENIA WITH TRAUMATIC
BRAIN INJURY ................................................................................................................................... 1685
TREATMENT OF THE CHRONIC KIDNEY DISEASE (CKD) PATIENT IN THE PGI HOSPITAL CIKINI JAKARTA
.......................................................................................................................................................... 1690
DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT FOR CEREBROVASCULAR DISEASE
PATIENT IN PGI CIKINI HOSPITAL...................................................................................................... 1696
1611
EVALUATION OF DRUG RELATED PROBLEMS (DRP) AT VOMITING TREATMENT IN PATIENT WITH
HEMORRHAGIC STROKE IN PGI CIKINI HOSPITAL, CENTRAL JAKARTA ............................................. 1699
DRPs OF SCHEIZOPRENIA DRUGS AT ARMY GATOT SOEBROTO HOSPITAL JAKARTA ...................... 1703
EVALUATION OF DRUG RELATED PROBLEM IN TREATMENT OF APPENDICITIS PATIENT................ 1707
DRUG RELATED PROBLEMS IN ISCHEMIC STROKE AT ROYAL PROGRESS HOSPITAL........................ 1712
DRUG RELATED PROBLEM IN THE TREATMENT OF COMPLEX FEBRILE SEIZURE ............................. 1717
OPEN FRACTURES WITH HEART AND DIABETES MELLITUS TYPE II IN THE HOSPITAL WARD K PGI
CIKINI ................................................................................................................................................ 1722
DRUG RELATED PROBLEMS IN THE TREATMENT OF PATIENT OF ENDOMETRIAL HYPERPLASIA WITH
ENOMETRORRHAGIA SUSPECT IDIOPATHIC THROMBOCYTOPENIA PURPURA (ITP) IN PGI CIKINI
HOSPITAL .......................................................................................................................................... 1730
DRUG RELATED PROBLEMS THAT OCCURRED IN PATIENT SEPSIS MACROVASCULAR DISEASE
COMPLICATIONS GENERAL HOSPITAL TREATMENT ROOM CENTRAL OF THE ARMY (ARMY HOSPITAL)
GATOT SUBROTO .............................................................................................................................. 1734
EVALUATION OF DRUG RELATED PROBLEMS IN TREATMENT HEMORRHAGIC STROKE ................. 1742
EVALUATION OF THE TREATMENT OF PATIENT WITH PULMONARY TUBERCULOSIS (TB) BTA
CATEGORY ONE AND SYNDROME DYSPEPSIA AT PULMONARY DISEASE WARD GOVERNMENT
GENERAL PERSAHABATAN HOSPITAL............................................................................................... 1746
EVALUATION OF DRUG RELATED PROBLEMS (DRPs) TREATMENT OF CHOLELITHIASIS WITH
DYSPEPSIA DISEASE AT THE INTERNAL DISEASE WARD OF PGI CIKINI HOSPITAL ........................... 1751
NON- Hemorrhagic STROKE At Islamic Cempaka Putih Jakarta Hospital (RSIJCP) .......................... 1758
EVALUATION OF TREATMENT ON BREAST CANCER PATIENT (Ca mammae) AT PGI CIKINI HOSPITAL,
JAKARTA............................................................................................................................................ 1764
CASE REPORT TYPHOID FEVER AT PGI CIKINI HOSPITAL, JAKARTA .................................................. 1769
DRUG RELATED PROBLEMS (DRPs) ASSOCIATED WITH THE TREATMENT OF PATIENT WITH STROKE
HEMORAGIK IN PGI CIKINI HOSPITAL ............................................................................................... 1773
EVALUATION OF DRUG RELATED PROBLEMS IN SCHEZOPHRENIA PARANOID IN RSPAD GATOT
SOEBROTO ........................................................................................................................................ 1778
EVALUATION OF DRUG RELATED PROBLEMS IN DISPEPSIA IN WARD MEDICINE IN RS.PGI CIKINI . 1782
1612
DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT FOR ISCHEMIC STROKE AND DIABETES
MELLITUS TYPE II AT PGI CIKINI HOSPITAL ....................................................................................... 1785
EVALUATION OF PATIENT OF HEMAPTOE SUSPECTED TBC AT ISLAMIC HOSPITAL JAKARTA CEMPAKA
PUTIH ................................................................................................................................................ 1791
EVALUATIONDRUG RELATED PROBLEM (DRP) OF AT THE RSUP PERSAHABATAN HOSPITAL JAKARTA
.......................................................................................................................................................... 1796
MANAGEMENT OF PATIENT IN HOSPITAL WITH TUBERCULOSIS MENINGITIS AT HOSPITAL JAKARTA
AT PGI CIKINI..................................................................................................................................... 1803
KIDNEY STONES IN PGI CIKINI HOSPITAL .......................................................................................... 1808
DRUG RELATED PROBLEMS ASSOCIATED NON HEMORRHAGIC STROKE AT INSTALLATION OF
INPATIENT NUMFOR DR. MINTOHARDJO HOSPITAL ....................................................................... 1816
CASE REPORT : DRUG RELATED PROBLEMS IN TREATMENT OF NON HAEMORRHAGIC STROKE
DISEASE AT MINTOHARDJO HOSPITAL ............................................................................................. 1820
DRUG RELATED PROBLEM TOWARDS THE TUBERCULOSIS AND DIABETES MELLITUS DISEASE ATTHE
INTERNAL WARD OFPULAU SANGEANG DR. MINTOHARDJO NAVY HOSPITAL JAKARTA ................ 1830
DRUG RELATED PRLOBLEM ASSOCIATED DYSPEPSIA SYNDROME AND TUBERCOLOSIS AT
MINTOHARDJO NAVY HOSPITAL ...................................................................................................... 1836
CASE REPORT : DRUG RELATED PROBLEMS OF DEEP VENOUS THROMBOSIS (DVT) DISEASE AT PGI
CIKINI HOSPITAL ............................................................................................................................... 1841
CASE REPORT : DRUG RELATED PROBLEMS (DRP) IN OSTEOMYELITIS DISEASE AT MINTOHARDJO
HOSPITAL JAKARTA ........................................................................................................................... 1847
CASE REPORT : DRUG RELATED PROBLEMS (DRPs) ASSOCIATED HYPERTENSION DISEASE AT
MINTOHARDJO HOSPITAL JAKARTA ................................................................................................. 1850
CASE STUDY : DRUG RELATED PROBLEMS (DRP) IN ANGINA PECTORIS DISEASE AT MINTOHARDJO
HOSPITAL .......................................................................................................................................... 1855
CASE REPORT : DRUG RELATED PROBLEMS IN PATIENT WITH BENIGN PROSTATIC HYPERPLASIA
DISEASE AT DR. MINTOHARDJO HOSPITAL ...................................................................................... 1860
CASE REPORT: DRUG RELATED PROBLEM ON THERAPY THE DISEASE TUBERCULOSIS (TB) AND
HEMAPTUE CATEGORY I ON THE WARD SANGEANG DISEASE IN MINTOHARDJO HOSPITAL ......... 1864
1613
CASE REPORT : DRUG RELATED PROBLEM IN PATIENT WITH SPONDYLODISCITIS DISEASE AT PGI
CIKINI HOSPITAL ............................................................................................................................... 1870
CASE STUDY: DRUG RELATED PROBLEMS IN TREATMENT OFDIABETES MELLITUS COMPLEX ........ 1874
CASE REPORT : EVALUATION OFDRUGRELATEDPROBLEMS IN PATIENT MELENA AT MINTOHARDJO
HOSPITAL .......................................................................................................................................... 1880
CASE REPORT : DRUG RELATED PROBLEMS IN THE TREATMENT OF DISEASES DISPEPS IT IN WARD
MEDICINE RS.PGI CIKINI ................................................................................................................... 1884
CASE STUDY: DRUG RELATED PROBLEM IN PATIENT WITH PULMONARY TBC, DYSPEPSIA SYNDROME
AND HYPERTENTION AT PERSAHABATAN HOSPITAL ....................................................................... 1888
DRUG RELATED PROBLEM IN PATIENT WITH HYPERTENSION HEART DESEASE (HHD) AND
PARAPARESE INFERIOR DISEASE AT MINTOHARJO HOSPITAL JAKARTA .......................................... 1896
CASE REPORT : DRUG RELATED PROBLEM IN VERTIGO DISEASE AT MINTOHARDJO HOSPITAL
JAKARTA............................................................................................................................................ 1902
CASE REPORT: DRUG RELATED PROBLEMS IN TREATMENT CAD, HHD, BULLA LUNG AT PGI CIKINI
HOSPITAL .......................................................................................................................................... 1906
STUDY OF DISEASE OF STRUMA THYROID WITH ANNOYANCE COMPLICATED BALANCE ELECTROLYTE
IN GATOT SOEBROTO ARMY HOSPITAL............................................................................................ 1913
EVALUATION OF PATIENT TREATMENT OF DIABETES MELLITUS AND RBBB (RIGHT BUNDLE BRANCH
BLOCK) AT ISLAMIC CEMPAKA PUTIH JAKARTA HOSPITAL .............................................................. 1918
EVALUATION TREATMENT OF ACUTE LYMPHOBLASTIC LEUKEMIA PATIENTS AT GATOT SUBROTO
ARMY HOSPITAL ............................................................................................................................... 1923
CASE REPORT : EVALUATION OF DRUG RELATED PROBLEMS PATIENT WITH URINARY TRACT
INFECTION DISEASE AND THYPOID AT MINTOHARDJO HOSPITAL................................................... 1928
CASE REPORT : DRUG RELATED PROBLEM (DRP) ASSOCIATED WITH THE TREATMENT OFCONGESTIVE
HEART FAILURE (CHF)IN PGI CIKINI HOSPITAL ................................................................................. 1933
CASE REPORT : DRUG RELATED PROBLEM (DRP) ASSOCIATED WITH THE TREATMENT OF
INFLAMMATIONOFTHEGALLBLADDER (CHOLECYSTITIS) IN PGI CIKINI HOSPITAL ........................... 1939
LIVER CIRRHOSIS AND CONGESTIVE HEART FAILURE AT PGI CIKINI HOSPITAL................................ 1945
DRUG RELATED PROBLEM TUBERCULOSIS RELAPSE AND DISEASE HYPERTENSION AT
PERSAHABATAN HOSPITAL ............................................................................................................... 1951
1614
DRUG RELATED PROBLEMS IN TREATMENT OF BRONCHIECTASIS INFECTED WITH SEPSIS ............ 1957
Evaluation of Drug Related Problems In Patient With Dyspepsia Disease At PGI Cikini Hospital .... 1962
TREATMENT FOR DIABETES MELLITUS WITH HYPERLIPIDEMIA DISEASE AT MINTOHARDJO HOSPITAL
.......................................................................................................................................................... 1968
CASE REPORT: DRUG RELATED PROBLEM IN THERAPY HYPERTENSIVE HEART DISEASE AT
MINTOHARDJO HOSPITAL ................................................................................................................ 1972
CASE REPORT: DRUG RELATED PROBLEM IN THERAPY DYSPEPSIA SYNDROME AT MINTOHARDJO
HOSPITAL .......................................................................................................................................... 1977
EVALUATION OF DRUG RELATED PROBLEMS ( DRP ) IN THE TREATMENT OF MYOCARDIAL
INFARCTION AT HOSPITALS OF ISLAM JAKARTA CEMPAKA PUTIH (RSIJCP) .................................... 1982
HEMORRHAGIC STROKE WITH DIABETES MELITUS TYPE II IN UNIT STROKE RSPAD GATOT SOEBROTO
.......................................................................................................................................................... 1991
DRUG RELATED PROBLEM IN PATIENT WITH STROKE DISEASE, TYPE II DIABETES, HYPERTENSION AT
DRUG RELATED PROBLEM IN PATIENT WITH COPD EXACERBATION AND HEART FAILURE AT
PERSAHABATAN HOSPITAL Fatimah Maulida1, Aprilita Rinayanti Eff.2 and Diana Laila Rahmatillah2
.......................................................................................................................................................... 2005
DRUG RELATED PROBLEM IN PATIENT WITH TUBERCULOSIS HEMOPTYSIS DISEASE AT
EVALUATION OF DRUG RELATED PROBLEMS IN PERINATOLOGY SEPSIS ec Psuedomonas pufida IN
HIGH RISK PERINATAL ROOM RSPAD GATOT SOEBROTO ................................................................ 2020
CASE STUDY DIABETES MELLITUS IN WARD MEDICINE RS.PGI CIKINI ............................................. 2027
TREATMENT OF GASTROENTERITIS ACUTE WITH CORONARY ARTERY DISEASE FOR PATIENT AT PGI
CIKINI HOSPITAL JAKARTA Diah Fatmawati1, Diana Laila Rahmatillah2, Aprilita Rinayanti Eff2,
Stefanus Lukas2................................................................................................................................. 2032
DRUG PROBLEM RELATED DISEASE IN CHRONIC RENAL FAILURE COMPLICATIONS CONGESTIVE
HEART FAILURE ................................................................................................................................. 2037
CASE REPORT: DRUG RELATED PROBLEM ASSOCIATED WITH KIDNEY STONE DEASE AT PGI CIKINI
HOSPITAL .......................................................................................................................................... 2042
1615
CASE REPORT: DRUG RELATED PROBLEMS IN PATIENT WITH TYPE II DIABETES MELLITUS, DYSPEPSIA
AND FATIQUE AT MINTOHARDJO HOSPITAL.................................................................................... 2049
CASE REPORT:DRUG RELATED PROBLEM IN PATIENT WITH ASCITES DISEASE AT PGI CIKINI
HOSPITAL JAKARTA ........................................................................................................................... 2053
EVALUATION OF DRUG RELATED PROBLEMS IN TREATMENT OF OSTEOMYELITIS DISEASE at
MINTOHARDJO HOSPITAL ................................................................................................................ 2058
CASE REPORT : DRUG RELATED PROBLEM (DRP) ASSOCIATED WITH THE TREATMENT OF PATIENTS
WITH HYPOGLYCEMIA IT WARDS PGI CIKINI HOSPITAL ................................................................. 2063
DRUG RELATED PROBLEMS IN PATIENT WITH LUNG RIGHT PNEUMONIAE DISEASE AT THE K ROOM
OF PGI CIKINI HOSPITAL JAKARTA .................................................................................................... 2069
EVALUATION OF DRUG RELATED PROBLEMS IN STROKE HEMORRHAGIC IN GATOT SOEBROTO ARMY
HOSPITAL .......................................................................................................................................... 2076
CASE REPORT : DRUG RELATED PROBLEM ON TUBERCULOSIS DISEASE AND PLEURAL EFFUSION IN
PGI CIKINI HOSPITAL ......................................................................................................................... 2083
CASE REPORT : DRUG RELATED PROBLEMS IN PATIENT WITH SPONDYLITIS ARTHROSIS
LUMBOSACRALIS DISEASE AND TYPE II DIABETES MELLITUS AT MINTOHARJO HOSPITAL JAKARTA
.......................................................................................................................................................... 2087
1616
EVALUATION OF THE TREATMENT OF PATIENTS WITH NEPHROTIC
SYNDROME AT PGI CIKINI HOSPITAL
Rinda Monica1, Diana Laila Rahmatillah2, Aprilita Rinayanti Efi2, Stefanus Lukas2
1
Student of Pharmacist Professional Program Student,
Faculty Of Pharmacy UTA’45 Jakarta
2
Lecturer of Faculty of Pharmacy UTA’45 Jakarta
Email : rindamonica10@gmail.com
ABSTRACT
Nephrotic syndrome is a disease with symptoms of edema, proteinuria, hypoalbuminemia and
hypercholesterolemia, sometimes there is hematuria, hypertension, and decreased kidney
function4. Patient 16-year old male who was admitted to hospital with complaints of swelling in the
body especially in the legs with urination foaming. Have a history of appendicitis surgery on class 2
SD. Based on the results of the examination was known an increase in creatinine of 1.2 mg/dL and
an increase in total cholesterol is 631 mg/dL. Patient treated with hexilon tablets, ranitidine tablets,
atorvastatin tablets, lasix ampoules, vitamin K ampoule, Neurobion 5000 tablets, and albumin 25 %
100 ml. In this case found a DRP ( Drug Related Problems ) between hexilon and lasix drug
interactions.
Keywords : Nephrotic Syndrome, Drug Related Problems, PGI CIKINI Hospital
1617
INTRODUCTION
The kidney is one of the vital organs in the human body as a regulator of the balance of the body's
organs and organ disposal of substances that are not useful and toxic6. Kidney is the most important
organ to maintain normal homeostatic bio chemical in the body, this is done by way of excreting
substances that are no longer needed by the process of glomerular filtration, reabsorption and
secretion tubulus6. Nephrotic syndrome is a kidney disease that is often found in children, which is a
collection
of
clinical
symptoms
consisting
of
massive
proteinuria,
hypoalbuminemia,
hypercholesterolemia and edema6. Approximately 90% of cases children are primer Nephrotic
Syndrome6. Nephrotic syndrome is the most common type of minimal change that is about 76% 6.
Patients suffering from Nephrotic Syndrome for the first time largely come to the hospital with
symptoms edema6. In pediatric patients with Nephrotic Syndrome is common for a weight gain that
can reach up to 50 % of the weight before Nephrotic Syndrome6. This happens due to the onset of
the edema which is one of the clinical features of the Nephrotic Syndrome6.
ETIOLOGY
This nephrotic syndrome causes are unknown, but lately is regarded as an autoimmune disease, the
antibody-antigen reaction6. Where 80 % of children with nephrotic syndrome who performed renal
biopsy showed only slight abnormality, while the remaining 20 % of renal biopsy showed an
abnormality such as glomerulonefritis5. The pathogenesis may be due to metabolic disorders,
biochemical and physicochemical which causes increased glomerular membrane permeability to
protein8. Most ( 90 % ) of the children who suffer from nephrosis have some form of idiopathic
nephrotic syndrome, minimal change disease is found in about 85 %6. Nephrotic syndrome is largely
mediated by some form of glomerulonephritis (infection of the glomerulus)1.
MANAGEMENT
Treatment of nephrotic syndrome consists of a specific treatment aimed against basic diseases and
specific treatment to reduce proteinuria, edema control and treat complications7. Secondary
etiology of nephrotic syndrome should be sought and given therapy, and medications are the cause
remove7.
1618
CASE PRESENTATION
16-year-old male patient, complaining of swelling in the body, especially in the second leg urination
accompanied by foaming. Patient diagnosed by a physician with nephrotic syndrome.
CLINICAL EVALUATION
In this case, patient treated for 10 days from the date of 24 November 2014-3 December 2014 by
using the hexilon tablets, ranitidine tablets, atorvastatin tablets, Lasix ampoules, vitamin K ampoule,
Neurobion 5000 tablets, and albumin 25 % 100 ml.
THE RESULTS OF LABORATORY EXAMINATION
On the results of examination of Hematology blood creep rate increase occurred 77 mm/h (0 – 20
mm/h), the increased hemoglobin that is 16.4 g/dL (12.0-14.0 g/dL), decreased esinophil i.e. 0% (13%), decreased neutrophil stem 0% (2 – 6%), decreased neutrophil segments i.e. 43% (50 – 70%), an
increase of lymphocyte that is 50% (20-40%), an increase of 66.3 patient APTT seconds (26,4 – 37.5
seconds), and an increase in the patient's PT is 11.6 seconds (9.4-11.3 seconds). Immunological
examination showed abnormal complement C3 on the high 164,8 mg/dL (75,0 – 135,0 mg/dL).
Chemical screening clinics, shows an abnormal protein that is low i.e. 3.3 g/dL (6.0–8.0 g/dL), the
value of albumin are low i.e. 0,8 g/dL (3.4-4.8 g/dL), the value of the 60 high Uremia mg/dL (10-50
mg/dL), the value of a high i.e. creatinine 1.2 mg/dL (0.6 – 1,1 mg/dL), the value of triglycerides is
high i.e. 332 mg/dL (<200 mg/dL), the value of total cholesterol is high i.e. 631 mg/dL (< 200 mg/dL),
high LDL cholesterol values of 557 mg/dL (< 130 mg/dL), the value of chloride (Cl) high blood i.e. 112
mmol/L (100 – 106 mmol/L) and calcium (Ca) i.e. low 7,5 mg/dL (8.8 – 103 mg/dL).
The result of the examination was known to an increase in levels of urea, creatinine, triglycerides,
total cholesterol and LDL cholesterol which is a parameter to determine the decline in kidney
function. The presence of urea levels were as high as 60 mg/dL, high creatinine reached 1.2 mg/dL,
high triglycerides reach 332 mg/dL, high total cholesterol reaches 631 mg/dL and LDL cholesterol
reaches 557 mg/dL of the patient indicates that the patient was suffering from nephrotic syndrome.
As well as the clinical examination albumin levels were low at 0.8 g/L. Where as the normal rate is
3.4-4.8 g/L. Decreased albumin may result in discharge leading to vascular tissues, causing oedema.
During hexilon drug treated patients given 16 mg tablets as an antiinflammatory , ranitidine 150
1619
mg tablets to suppress stomach acid, atorvastatin 20 mg tablet to reduce total cholesterol, LDL, and
triglycerides increased in patients, ampoules lasix 10 mg/ml as a diuretic that is discharge body
through urine, vitamin K ampoule 10 mg to help blood clotting, 5000 Neurobion tablets for the
treatment of deficiency of vitamin B1 , B6 and B12 and albumin 25 % 100 ml for hipoproteinemia
therapy with or without edema .
GUIDELINE NEFROTIK SYNDROME TREATMENT
 Prednisolone
When the diagnosis of nephrotic syndrome has been made , prednisolone can be initiated in
children with typical features3. Children should be referred to the nephrology child for kidney
consideration3. Prednisolone dose was based on surface area3.
60 mg/m2/day for 4 weeks (maximum 80 mg).
40 mg/m2/day for 4 weeks alternative (60 mg maximum).
Reduce the dose of 5-10 mg/m2 weekly for 4 weeks then stop.
Prednisolone can be given as a single dose in the morning with food, or as divided doses during the
day3. Patients should be aware of the side effects and risks of treatment steroid3.
 Albumin
Clinical indications for albumin in the form of clinical hypovolemia and edema symptomatic3. A low
serum albumin alone is not an indication for intravenous albumin3. If there is evidence of
hypovolemia, give 1 g/kg of 20 % albumin (5 ml/kg) more than 4-6 hours3.

Penicillin Prophylaxis
When experiencing nephrotic, children are at increased risk of infection, particularly as
pneumococcus3. Doses below 125 mg given 5 years and over 5 years given 250 mg3.
 Salt or fluid restriction
Low-salt diet is used to prevent fluid retention and edema further3.
 Vaccination
Pneumococcal vaccination is recommended for children who have nephrotic syndrome3. At the time
of diagnosis of administration should be considered3.
DRUG RELATED PROBLEMS (DRPs)
1620
Drug Interactions:

Methylprednisoline + furosemide
If Methylprednisoline + furosemide is used simultaneously, thus it should be required for dose
adjustment2.
In this treatment of corticosteroid Methylprednisoline included in the class. The dose for the
treatment of the patient used 16 mg. If the patient's condition gradually improved, the dose should
be decreased gradually methylprednosolon but if the patient's condition does not improve
Methylprednisoline dose can be increased up to 30 mg/kg. Long-term use of Methylprednisoline or
exceed the dose may increase the risk of adrenal gland disorders.
Pharmaceutical Intervention : Used with caution and should be monitored closely.
CONCLUSION
Based on the results of the examination of patient found a DRP is Hexilon and Lasix, which was used
together, the dose adjustment was necessary, as this combination can cause muscle pain or cramps,
loss of appetite, weakness, dizziness, or confusion.
REFERENCES
1. Behrman, N. 2000. Ilmu Kesehatan Anak. Jakarta. EGC.
2. Drug. Com. Drug Interaction.2014.
3. Dokter, R. G. 2007. Nefrotik Sindrom, Version 1.1 (www.clinicalguidelines.scot).
4. Ngastiyah, 2005, Perawatan Anak Sakit. Edisi 2, EGC, Jakarta.
5. Novak & Broom. 1999. Ingall and Salerno’s Maternal and Child Health Nursing, Edisi 9 Vol 2,
Mosby: St. Louis.
6. Siburian, A. 2013. Analisis Praktik Klinik Keperawatan Anak Kesehatan Masyarakat Pada Pasien
Sindrom Nefrotik Di Lantai 3 Selatan RSUP Fatmawati. Jakarta.
7. Sukandar E, Sulaeman R. Sindroma nefrotik. Dalam :Soepoarman, Soekaton U, Waspadji S et al
(eds). Ilmu Penyakit Dalam. Jilid II. Jakarta: BalaiPenerbit FKUI; 1990. p. 282-305.
8.
Wong, Whaley. Clinical manual of pediatrics nursing. 4 th edition. Mosby: Year book. Inc.
1996.
1621
DIABETES MELLITUS AT PGI CIKINI HOSPITAL
Gemin Suekto1, Diana Laila Rahmatillah2, Aprilita Rinayanti Efi2, Stefanus Lukas2
1
Student of Pharmacist Professional Program Student,
Faculty Of Pharmacy UTA’45 Jakarta
2
Email: ge_boy2000@yahoo.com
ABSTRACT
Diabetes mellitus (DM) is a group of metabolic disorders characterized by hyperglycemia and
abnormalities in carbohydrate, fat, and protein metabolism. It results from defects in insulin
secretion, insulin sensitivity, or both. Chronic microvascular, macrovascular, and neuropathic
complications may ensue 4. More than 120 million people worldwide suffer diabetes and is expected
this number will rise so that 370 million people ahead of the year 2030. Diabetes mellitus is usually
irreversible, Although patients can still undergo the normal way of life in the end of disease
complications but this could lower life expectancy of DM 6. Diabetes mellitus is divided into two
types, namely: DM type 1, the body can not produce insulin that is a hormone necessary to convert
sugar, starch and other food to the form of the energy required to live day life. DM type 2, insulin
secretion of insulin resistance and abnormal characterized by impaired insulin secretion, insulin
resistance, liver by excessive production of glucose metabolism of fats and abnormal. The
presentation of cases, a man aged 41 years come with complaints tired, shortness of breath and
fever .Physical BP 110/80 mmHg examination, pulse 86 times per minute, the temperature was 38.3
° C, breathing 24 times per minute. Laboratory results obtained in the which the levels of
erythrocyte sedimentation rate, hematocrit, Neutrophils segments, and blood sugar Increased
levels. Of the doctor's diagnosis is known patients suffering from pneumonia and diabetes mellitus
type II.
Keywords: Diabetes Mellitus, Insulin, Hyperglycemia
1622
INTRODUCTION
Diabetes mellitus (DM) is a chronic metabolic disease which characterized by hyperglycemia
resulting from absolute deficiency of insulin or the insulin receptor resistance on. More than 120
million people worldwide suffer from diabetes and this number is expected to rise to 370 million
people by the year 2030. DM usually irreversible, even though the patient is still able to live a
normal way of life but late complications of diabetes disease can reduce life expectancy (Gale and
Anderson, 2005) 8.
According to the American Diabetes Association (ADA) (2005)12, the Indonesian Society of
Endocrinology (PERKENI) (2006)14, DM is a group of metabolic diseases with characteristic
hyperglycemia that occurs due to abnormal insulin secretion, insulin action or both. Meanwhile,
according to WHO (1980) 10 said that diabetes is something that cannot be explained in a clear and
concise answer but in general, it can be said as a collection of anatomical and chemical problems
that are the result of number of factors which obtained absolute or relative insulin deficiency and
malfunctioning of insulin.
Diabetes mellitus is divided into two types, namely:
1. Diabetes mellitus type 1
Type 1 diabetes is usually diagnosed in children and young adults, and it was previously known as
DM Juvenil. In type 1 diabetes, the body cannot produce insulin which is a hormone that is needed
to convert sugar, starches and other food to the form of the energy needed to live all day.
Diabetes mellitus type 1 is the result rather than the interaction of genetic, immunological factors
and causes destruction of pancreatic beta cells and insulin deficiency. It is also caused by
autoimmune destruction of beta cells due. This is evidenced when individuals with type 1 DM
phenotype has no immunological markers that indicate an autoimmune process against beta cells.
This causes the autoimmune process of beta cell mass dwindle so that income is also impaired
insulin.
2. Diabetes mellitus type 2
Insulin resistance and abnormal insulin secretion is the cause of the development of type 2 diabetes
is. Type 2 diabetes is characterized by impaired insulin secretion, insulin resistance, hepatic glucose
production by excessive and abnormal fat metabolism. In obese individuals, glucose tolerance was
1623
normal at the onset of diabetes without insulin resistance because the thought of beta cells
compensate by increasing insulin production. However, when insulin resistance and insulin hyper
achieving sustained as a result of the compensation process, the pancreas is not able to survive the
hyper state of insulin so that the blood sugar levels to rise.
Diabetes is caused by other factors (1-2% of all cases of diabetes), including endocrine disorders (eg
acromegaly, Cushing's syndrome), gestational diabetes mellitus (GDM), exocrine pancreas disease
(pancreatitis), and because drugs (glucocorticoids, pentamidine, niacin , and α-interferon).
CASE PRESENTATION
A patient Mr. AP 41-year-old admitted PGI Cikini on November 7, 2014 with complaints of fatigue,
shortness of breath and fever. Physical examination BP 110/80 mm Hg, pulse 86 times per minute,
temperature 38.3 ° C, breathing 24 times per minute. Previous medical history was DM type II.
CLINICAL EVALUATION
Mr. AP in Cefriaxone drug therapy with 2 x 1 gram, it aimed to fix the infection of pneumonia germs.
Ranitidine 25mg injection 2x1 Amp to anticipate the effects of paracetamol drug against gastric
patients, Novorapid 4 x 12 ® insulin for anti-diabetic, Paracetamol 500mg tab tab 3x1 aims to
analgesics and down the heat, OBH 3x1 tablespoons to cough. These drugs were in use above the
usual dose.
Results of Laboratory Monitoring Blood Sugar
On 7,8 and 9 November 2014 Monitoring of Blood Sugar:
Date
Hour
Reference value
Unit
Results
7 – 11- 2014
21.00
70 – 150
mg/dl
*539
8 – 11- 2014
06.00
70 – 150
mg/dl
*329
1624
8 – 11- 2014
12.00
70 – 150
mg/dl
*449
8 – 11- 2014
18.00
70 – 150
mg/dl
*210
8 – 11- 2014
24.00
70 – 150
mg/dl
*418
9 – 11- 2014
06.00
70 – 150
mg/dl
*269
9 – 11- 2014
12.00
70 – 150
mg/dl
*411
9 – 11- 2014
18.00
70 – 150
mg/dl
*254
9 – 11- 2014
24.00
70 – 150
mg/dl
-
DRUG RELATED PROBLEMS (DRP)
Insulin and OBH cough drugs containing ephedrine can cause drug interactions. The effect of insulin
on the opponent causing the patient's blood sugar levels remain too high. Symptoms of
hyperglycemia such as: excessive thirst, urine output many, weight loss, hunger, drowsiness, loss of
coordination.
The solution OBH cough drugs replaced with a cough drugs safe for diabetics as siladex syrup with
the content of bromhexine hcl , guafenisin, which is free sugar and alcohol.
CONCLUSION
Based on the result, it can be concluded that there was drug related problems about OBH cough
drugs can caused increasing of blood sugar level. Thus, the cough medicine can be replaced with a
safe of cough medicine for diabetics.
REFERENCE
1. American Diabetes Association.,2005, Types of Diabetes Melitus. http://www.diabetes.org/typediabetes.jsp. May 21st. 2009.
1625
2. Elin Yulinah Sukandar Apt. and Team., 2009, Pharmacotherapy ISO, Second Edition. Published:
PT.ISFI, Jakarta.
3. Baxter, K., 2008, Stockley’s Drug Interaction, Eighth Edition. London : Pharmaceutical Press.
4. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy Handbook: A Pathophysiologic Approach 7th
Edition, McGraw Hill, New York.
5. Drug
Digest,
Drug
Comparisons,
Alpha-glucosidase
Inhibitors
@
http://www.drugdigest.org/DD/Home/AllAboutDrugs
6. Gale, E.A., & Anderson, J.V. (2005). Diabetes Mellitus And Other Disorders Of Metabolism.
Tn:Kumar, P; Clark M (eds).Clinical Medicine (6th ed),Ph i l a d e l p h i a , El s e v i e r Sauders; pp.
1101-1132.
7. Harkness, Richard., 2013, Drug Interactions, translated by Goeswin Agoes and Mathilda B.
Widianto, Published: ITB, Bandung.
8. Mount Auburn Hospital - Alpha-glucosidase inhibitors for type 2 diabetes, 1995-2004,
Healthwise, Incorporated, P.O. Box 1989, Boise, ID 83701 @ http://12.31.13.175/
9. PERKENI. Consensus Management And Prevention Of Diabetes Mellitus Type 2 In Indonesia.
Jakarta: Indonesian Society of Endocrinology; 2006. p.1-10.
10. Power, A.C., 2008, Diabetes Mellitus, Harrison’s Principles of Internal Medicine, 17th Edition.
11. Price, A. S and Wilson, ML., 1995, The Concept of Clinical Pathophysiology of Disease Processes
4th Edition, EGC Medical Book Publishers, London.
12. WHO Expert Committee on Diabetes Mellitus. Second Report. Geneva: WHO, 1980.
13. www.diabetes.org . American Diabetes Association [updated 2010; cited 2011 Jan 25]. Available
from http://www.diabetes.org/diabetes-basics/type-2/?
14. www.who.int/en/ . World Health Organization [updated 2011; cited 2011 Jan 25]. Available
from http://www.who.int/topics/diabetes_mellitus/en/
1626
EVALUATION OF DRUG RELATED PROBLEMS IN STROKE
HEMORRHAGIC PATIENTS WITH CHRONIC KIDNEY DISEASE
COMPLICATIONS WHICH TREATED IN RSPAD GATOT SOEBROTO
STROKE UNIT
Boggy Rakhmawan Suryawijaya1, Diana Laila Rahmatillah2 , Aprilita Rinayanti Eff2
1
Student of Pharmacist Professional Program Student, Faculty Of Pharmacy UTA’ 45 Jakarta
2
Email: bogey.bogle.bog@gmail.com
ABSTRACT
Stroke hemorrhagic is caused by a rupture of brain blood vessels that causes bleeding into the brain
parenchyma, cerebrospinal chamber on brains, or both of them18. Mr. SY 45 years old entered
RSPAD Gatot Soebroto on October 15th 2014 with a diagnosis of Stroke hemorrhagic with Chronic
Kidney Disease Complications. The treatment which given for 9 days are, Captropil (oral), Adalat
Oros (oral), Amlodipine (oral), and Perdipine (I.V), Citicoline (I.V), Omeprazole (I.V), CaCO3 (oral),
Paracetamol (oral), Tramadol (I.V), Cefixime (oral), Asam folat (oral), Vitamin B12 (oral), Fluimucyl
(oral), Vitamin C (oral). Based on the results from Praktek Kerja Profesi Apoteker at RSPAD Gatot
Soebroto, in this case founded several drug related problem like the inappropriate drug selection,
duplicate drug theraphy, occurred the adverse drug reaction, and occurred the drug reaction and
contraindication.
Keywords: Drug Related Problem, Stroke Hemorrhagic, Chronic Kidney Disease, RSPAD Gatot
Soebroto
1627
INTRODUCTION
Stroke hemorrhagic is caused by a rupture of brain blood vessels that causes bleeding into the brain
parenchyma, cerebrospinal chamber on brains, or both of them 18. Bleeding in the brain tissues
causing disruption of the circulation on brain that is caused the brain don’t get more of blood, and
hematoma conformation that caused suppression on the brain. This process triggers an increasing
pressure in intracranial that resulting compression on the brainstem8.
Chronic Kidney Disease is a reduction in kidney function are persistent and irreversible16. The process
of kidney failure occurs within more than 3 months16. This disease cannot be recovered, which is be
marked by a progressive reduction renal function and lead to renal disease at end-stage, and finally
death16.
ETIOLOGY
The most common causes of brain hemorrhagic is Aneurysm Berry, Aneurysm fusiform ,
Aneurysm myocotic , Malformasi arteriovenous, and Rupture arteriol serebral9.
CKD can occur if there is an infection, hypertensive vascular disease, connective tissue disorders,
congenital and hereditary disorders21.
MANAGEMENT6,10,13,14
General management for stroke hemorrahagic is directed to the lungs function, heart, kidney,
electrolyte and fluid balance, nutrition, and hygiene14. While the specific management equated with
causative treatment is the prevention and treatment the complication, rehabilitation, and the
prevention stroke like a primary and secondary promotive action14.
Specific management14:
a.
Subarachnoid hemorrhage14
-
Anti vasospasm: Nimodipine
-
Neuroprotective
b.
Intracerebral hemorrhage14
-
Fixing the physiology of hemostasis (when there is a physiological disorder of hemostasis)
-
Prevent/overcome cerebral vasospasm due to bleeding
-
Nimodipine
1628
-
Neuroprotective
c.
Operative14
d.
The complication treatment 14
-
Anti-edema: manitol 20% solution
-
Antibiotic, anti-depressants, anti-convulsants: with the indication
-
Anti-deep vein thrombosis and pulmonary embolism
e.
The management of risk factors14
-
Anti-hypertensive
-
Anti-diabetic
-
Anti-dyslipidemia
f.
Non-pharmacological treatment14
-
Operative
-
Neurorestoration (at acute phase) and medical rehabilitation
-
Education
Pharmacologic therapies which given in CKD are anti-hypertension, blood sugar control (in the case
of diabetes mellitus), hyperphosphatemia, dyslipidemia, hyperkalemia correction, metabolic acidosis,
and renal replacement (with the indication)13. The non pharmacological therapies are given such as
arrangement of protein, calories, fat, and salt intake 13.
CASE PRESENTATION
Mr. SY 45 years old entered RSPAD Gatot Soebroto on October 15th 2014 with a diagnosis of Stroke
hemorrhagic with Chronic Kidney Disease Complications. The anamnesis is the patient suddenly
fainted and vomitted who obtained from the patient’s family. Data were collected in 9 days.
CLINICAL EVALUATION1,3
In this case, the patient was treated with Captropil (oral), Adalat OROS (oral), amlodipine (oral), and
Perdipine (IV) for the treatment of hypertension; Citicoline (I.V) for neuroprotective drugs;
Omeprazole (IV), CaCO3 (oral) for gastric ulcer; Paracetamol (oral), Tramadol (I.V) for analgesic and
1629
antipyretic; Cefixime (oral), for anti-infection, folic acid (oral), Vitamin B12 (oral) for anemia;
Fluimucyl (oral) for cough; Vitamin C (oral) for the scurvy prevention and treatment.
DOSES AND HOW TO USE THE DRUGS
Captopril 25 mg was given 3 x 1 orally (PNGT), Adalat Oros 30 mg was given 3 x 1 orally (PNGT),
Amlodipine 10 mg was given 1 x 1 orally (PNGT), Perdipine 0,5 mcg was given in I.V, Citicoline 1 gram
was given 2 x 1 in I.V, Omeprazole 40 mg was given 1 x 1 in I.V, CaCO3 was given 3 x 1 orally (PNGT),
Paracetamol 500 mg was given 3 x 1 orally (PNGT), Tramadol 50 mg was given 3 x 1 in I.V, Cefixime
200 mg was given 2 x 1 in I.V, Asam folat was given 3 x 1 orally (PNGT), Vitamin B12 was given 3 x 1
orally (PNGT), Fluimucyl was given 3 x 1 orally (PNGT), and Vitamin C was given 3 x 1 orally (PNGT).
VITAL SIGN EXAMINATION RESULTS
Type Of
Normal
Value
Examination
Blood Pressure
<130/80
(mmHg)
36-
Temperature (
16/10/
17/10
18/10
19/10/
20/10
21/10/
22/10/
23/10
24/10/
14
/14
/14
14
/14
14
14
/14
14
180/11
180/1
140/9
130/80
180/9
170/90
160/90
150/9
140/8
0
00
0
0
0
38
37
37,7
37
37
36,6
36
36,5
38
80
80
70
82
67
70
80
96
108
24
24
20
22
20
18
20
20
28
0
37±0,3˚c
60-
Pulse (x/minute)
80/Minut
e
12-
Respiratory Rate
(x/minute)
18/Minut
e
CLINICAL CHEMISTRY LABORATORY EXAMINATION RESULTS
Type of Examination
Normal Value
Uremia
20 - 50 mg/dL
22
67
Triglyceridese
0,5 - 1,5 mg/dL
2,0
1,9
Na
135 - 147 mmol/L
137
139
K
3,5 - 5,0 mmol/L
4,2
4,6
Cl
95 - 105 mmol/L
102
106
SGOT (AST)
< 35 U/L
16/10/2014 17/10/2014
14
1630
SGPT (ALT)
< 40 U/L
Aceton
Negative
15
Negative
HEMATOLOGICAL LABORATORY EXAMINATION RESULTS
Type Of Examination
Normal Value
16/10/2014 17/10/2014 21/10/2014
Routine Hematology
Hemoglobin
13 - 18 g/dL
13,8
12,3
11,7
Hematocrit
40 - 52%
38
37
36
Erythrocyte
4,3 - 6,0 million/μL
4,8
5,0
4,7
Leukocytes
4800 - 10800/μL
11760
12540
14370
150000 - 400000/μL
218000
232000
331000
Platelet
Counts Of:
# Basophil
0 - 1%
0
# Eosinophil
1 - 3%
5
# Stem
2 - 6%
3
# Segment
50 - 70%
67
# Lymphocytes
20 - 40%
20
2 - 8%
5
# Monocytes
MCV
80 - 96 fL
78
74
78
MCH
27 - 32 fL
29
25
25
MCHC
32 - 36 g/dL
37
33
32
RDW
11,5 - 14,5%
13,60
DRUG RELATED PROBLEMS12
1.
Inapproprate Drug Selection12
Due to the patient wears the NGT, the oral drug that was consumed should be crushed first and
then dissolved with water. This result will be the effect of the drug will not optimal or caused toxic
effects1,19.
1631
Pharmaceutical intervention: if the patient still used, then the oral drug that was consumed by the
patient be replaced with drug in other dosage forms (eg injection dosage) or at least if the drugs
crushed or destroyed, it will not cause a decrease in effect or cause toxicity13,23.
2.
Duplicate Drug Therapy12
The discovered of the use of Adalat Oros and Amlodipine, because both of this drugs was the same
class of drugs (Calcium Channel Blockers Dihydropyridine). If the two drugs were used together, it
will increase the toxicity effect of one of these drugs1,19.
Pharmaceutical intervention: it was recommended to stop one of the use of drugs or provide a
different drug administration interval13,23.
3. Occurred The Adverse Drug Reaction12
3.1.
Patients had a dyspepsia because of continously Tramadol use1,19.
Pharmaceutical intervention: tramadol should only be used when necessary (if the patient felt pain
with pain score 4-6) 13,23.
3.2.
Patients experiencing cough (not often) caused by the side effects of captopril1,19.
Pharmaceutical intervention: patient was given cough drugs (fluimucyl), but if the cough
experienced by the patient is back, the use of captopril should be replaced with another
hypertension drugs like Angiotensins Receptor Blocker groups such as valsartan13,23.
4.
Occurred The Drug Reaction And Contraindication12
4.1
Interaction between Adalat oros with calcium carbonate. The use of drugs known as
nifedipine along with CaCO3 can reduce the effects of nifedipine by pharmacodynamic antagonism.
Close monitoring is required on how to use if the two drugs are to be used simultaneously or the
need for blood pressure control.
Pharmaceutical intervention: the drug administration given a period at least 1-2 hours.
4.2
Interaction between amlodipine with calcium carbonate. The use of drugs known as
nifedipine along with CaCO3 can reduce the effects of nifedipine by by pharmacodynamic
antagonism. Close monitoring is required on how to use if the two drugs are to be used
simultaneously or the need for blood pressure control.
Pharmaceutical intervention: the drug administration given a period at least 1-2 hours.
1632
4.3
Interaction between adalat oros and amlodipine can increase the anti-hypertensive effect,
which may increase the effects of toxicity from one drugs. Recommending to do the monitoring, or
the election of the drug to be retained and which drug would be dismissed its use (not discontinued
immediately, but should gradually).
Pharmaceutical intervention: it was recommended to stop one of the use of drugs or provide a
different drug administration interval.
CONCLUSION
Based on the results from clearkship at RSPAD Gatot Soebroto, in this case founded several drug
related problems like the inappropriate drug selection, duplicate drug therapy, occurred the adverse
drug reaction, and occurred the drug reaction and contraindication.
REFERENCES
1. AHFS drug information 2004. McEvoy GK, ed. Methotrexate. Bethesda, MD: American Society of
Health-System Pharmacists; 2003:1082-9).
2. BNF. 2009. British National Formulary. BMJ Group. UK.
3. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung Seto.
4. Corwin, elizabeth J. 2009. BUKU SAKU PATOFISIOLOGI, Ed. 3. Jakarta : EGC
5. Depatemen Kesehatan. 2008. Pelayanan Informasi Obat. Jakarta.
6. Dewanto, george Sp.S, dr. Wita J, Sp.S, dr. Budi Riyanto, Sp.S, & dr. Yuda Turana, Sp.S. 2009.
PANDUAN PRAKTIS DIAGNOSIS AND TATA LAKSANA PENYAKIT SARAF. Jakarta : EGC
7. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A Pathophysiologic Approach 7th Edition,
McGraw Hill, New York.
8. Ginsberg, Lionel, 2008, Lecture Notes: neurologi, Edisi kedelapan, Erlangga, Indonesia.
9. Gofir, A. 2009. Manajemen Stroke; Evidence Base medicine.Pustaka Cendekia Press.Yogyakarta.
10. Hartwig MS. Penyakit serebral. Dalam: Price SA, Wilson LM, editors. Patofisiologi: konsep klinis
proses-proses penyakit. Edisi 6. volume 2. Jakarta: EGC;2005.
11. Junaidi, I. 2004. Panduan praktis pencegahan and pengobatan stroke. Jakarta: PT. Bhuana Ilmu
Populers.
12. Kemenkesri. 2011. Pedoman Visite Apoteker. Jakarta.
1633
13. Koda-Kimble et al., 2009, Applied Therapeutics: The Clinical Use of Drug 9th Edition, Lippincott
Williams & Wilkins, USA.
14. Komaruddin, Boenjamin. 2012. Penanganan Penyakit Kidney Kronik. RSPAD Gatot Soebroto
Ditkesad. Jakarta.
15. Komaruddin, Boenjamin. 2012. Penanganan Stroke Hemoragik. RSPAD Gatot Soebroto Ditkesad.
Jakarta.
16. Lacy, F.C., Armstrong L.L., Goldman, M.P., Lance L.L.et al, 2010, Drug Information
Handbook,Lexi-Comp, American Pharmacist Association.
17. Levin, A., at all. 2 0 0 8 . Guidelines for the management of chronic kidney disease. CMAJ .
179(11):1154-1162.
18. Lumbantobing. 1994. Stroke. Jakarta : EGC
19. MIMS. 2011. 118th edition Annual Indonesia.
20. Muttaqin, Arif. 2008. Asuhan Keperawatan Klien dengan Gangguan Sistem Persarafan. Jakarta :
Salemba Medika.
21. Price, Sylvia A and Lorraine M Wilson. 1995. Patofisiologi Konsep Kllinis Proses-proses Penyakit.
Edisi 4. Jakarta: EGC.
22. Suyono, Slamet. 2001. Buku Ajar Ilmu Penyakit Dalam. Edisi 3. Jilid I II. Jakarta: Balai Penerbit
FKUI.
23. Walker, R., & Edwards, C. 2003.Clinical Pharmacy and Therapeutics, 3 rd. Edition Churchill
Livingstone. Philadelphia.
1634
DRUG INTERACTIONS AND THE SELECTION OF MISSING
RIGHT FOR MASSIVE ASCITES TREATMENT At PGI CIKINI
HOSPITAL
Sri Hasvira Syamsul Bachri1, Diana Laila Rahmatillah2, Aprilita Rinayanti Efi2, Stefanus Lukas2
1
Student of pharmacist Professional Program Student, Faculty Of Pharmacy UTA’45 Jakarta
2
Lecturerof Faculty Of Pharmacy UTA’45 Jakarta
Email: srihasvirasb@yahoo.co.id
ABSTRACT
Ascites is the accumulation of fluid (liquid pale yellow and clear) in the abdominal cavity /
peritonial7. Abdominal cavity located below the chest cavity, separated from it by diaphragma7.
Ascites fluid can have many sources such as heart disease, cancer, congestive heart failure or failed
kidney7. The most common cause of ascites is advanced liver disease or sirosis6. Approximately 80%
of cases, is caused by sirosis ascites6. Patient Ny. LSK, aged 36 years, entered PGI Cikini Hospital on
28 November, 2014 with a diagnosis Massive Ascites. The theraphy treatment which given for 7 day
are, Alinamin-F (vitamin B1 B2 combination), Ascardia (aspirin), Folic Acid, Lactulax (lactulose), Lasix
(furosemide), Neurobion Forte (Vitamin B1, B6, B12), Ottozol (pantoprazole), Sulcolon
(Sulphasalazine), Ultracet (tramadol combination with paracetamol). Drug Related Problem,
unwanted drug reactions, inappropriate drug choices, did not receive the drug, and drug
interactions (folic acid and sulcolon, lasix and ascardia as well as aspirin and pantoprazole).
Keyword : Drug Interaction, Massive Ascites, PGI Cikini Hospital
1635
INTRODUCTION
Ascites can appear at any age group, including the womb4. In children, ascites is usually caused
by liver and kidney disease4. Ascites is the accumulation of fluid in the cavity peritoneum4. The word
comes from the Greek ascites and Askos which means a bag or abdomen4. Ascites is one important
complication in patients with cirrhosis of the liver4. In the 10 years since the diagnosis is established,
approximately 50% of patients experience complications such as cirrhosis asites4. Several studies
conducted in adult patients suggests that the presence of ascites in cirrhosis cases are a sign of poor
prognosis with a survival rate two years after ascites raised by 50%4.
Ascites is the accumulation of fluid in the cavity abdomen pathological2,3. Male healthy adults do not
have or are slightly intraperitoneal fluid, but the women are as much as 20mL depending on
menstruation cycles2,3. Approximately 80% of cases are caused by cirrohosis ascites2,3. Some other
causes of ascites are congestive heart failure and kidney failure, inflammation, infection, and
nefrosis2,3.
CASE PRESENTATION
Patients aged 36 years Ny.LSK enter PGI Cikini Hospital on 28 November 2014. Patients presented
with symptoms after 1 week ago PGI CIKINI hospitalized with UTI disease, after returning home he
complained of abdomen ache and increasingly enlarged, bloating, hard defecate, sometimes black
defecate, nausea and abdomen pain.
From the laboratory results on 28th November 2014 showed an increased number of blood glucose
as 243 mg/dL (70-150 mg/dL). In hematological examination showed erythrocyte sedimentation rate
(ESR) which is as high as 50 mm/h (0-20 mm/h), a decrease in the amount of hemoglobin 10,0 g/dL
(12,0 to 14,0 g/dL), a decrease in the amount of hematocrit 36% (37-43%), the increase in
reticulocytes 17 per mil (5-15 per mil). On examination of liver function showed improvement
bilirubin 0,3 mg/dL (0,1-0,2 mg/dL), a decrease in the amount of albumin at 2,8 g / dL (3,4 to 4,8
g/dL), increase in globulin 4,9 g/dL (1,3 to 3,7 g/dL), increased ALT 103 U/L (0-50 U/L), increased AST
119 U/L (0-50 U/L). On examination showed neutrophil leukocyte count was lower rod 1% (2-6%). In
hemostasis examination showed clotting time (Lee-White) were low at 9-10 minutes (10-16
minutes). On examination of the APTT (Activated Partial Thromboplastine Time) showed decreased
patient APTT is 24,0 seconds (26,4 to 37,5 seconds). On 29th November 2014 the urine and
1636
parasitological examination, examination ascites fluid and ascites fluid obtained yellowish, the
sediment examination showed an increase of 26 bacteria / LPB (<24/LPB). On 30th November clinical
chemistry examination showed an increase in blood glucose at 10:00 is 239 mg/dL (70-150 mg/dL),
HDL (High Density Lipoprotein) decreased 44 mg/dL (> 45 mg/dL), LDL (Low Density Lipoprotein)
showed an increase in 137 mg/dL (<130 mg/dL).
In this case, the therapy used Alinamin-f (vitamin B1, B2) 10 1x1 mL ampoules as B1 deficiency,
ascardia (aspirin) 80 mg 1x1 tablets/day to reduce the risk of death and myocardial infarction, folic
acid 1 mg 1x2 tablets/day for the megaloblastic anemia caused folic acid deficiency, lactulax
(lactulose) syrup 15 mg (60mL) 2x1 hr/day for chronic constipation and portal systemic
encephalopathy, Lasix (furosemide) 10 mg/mL (2 mL) 1x1 ampoules/day is used for the treatment of
hypertension and edema, Neurobion forte 1x1 tablets 5000 mg/day for the deficiency of vitamin B1,
B6, B12, ottozol (pantoprazole) 40 mg 1x1 ampoules/day for gastric ulcer/duodenal ulcer, sulcolon
(Sulphasalazine) 500 mg 3x1 tablets/day for arthritis arttitis and as antibiotics, ultracet (tramadol
and paracetamol) 37,5 mg tablets 2x1 as acute pain medication.
CLINICAL EVALUATION
1.1 Drug Related Problem 1:
1.1.1
Failure to receive medication : found.
In this case, it was seen from the results of laboratory patient which increased in blood glucose but
the patient did not receive the drug DM and an increase in High Density Lipoprotein cholesterol and
Low Density Lipoprotein but the patient did not receive cholesterol drugs.
Pharmacist intervention : the laboratory resulted indicating positive patient an increase in blood
glucose and cholesterol from the start of treatment, it should be given cholesterol and DM drugs.
1.2
Drug Related Problem 2:
1.2.1
Improper Drug Selection : found.
Sulphasalazine used as antibiotics that may decrease the absorption of folate and changed in the
hydrolysis or reduction folate5.
Pharmacist intervention : the use of Sulphasalazine sulcolon containing antibiotic ceftriaxone can be
replaced with a dose of 2 x 1 g daily which used for abdomen infection1.
1637
1.2.2
Provision ultracet drug is indicated for short-term therapy and is acute pain to severe
pain, and counter-indication liver dysfunction5.
Pharmacist intervention : the use of ultracet patient should not be given because ultracet contain
paracetamol which is used as an analgesic but has side effects that can disrupt the function of the
liver and a patient has a liver disorder. Probably can be replaced with another analgesic classes such
as Tramal (tramadol) with a dose of 2 x 100 mg1,5.
1.3
3.3.1 Drug Interactions: found.
Ascardia (aspirin) and ottozol (pantoprazole) where proton pum inhibitors increased gastric pH so as
to principal and reduces the activity of the effects of ascardia5.
Pharmacist Intervention : because patients experience a disruption in the stomach so it is
recommended the use of drugs that can increase stomach acid that needed5.
3.3.2 Folic acid and sulcolon (Sulphasalazine) decreased absorption of folic acid and changes in the
hydrolysis or reduction folate2.
Pharmacist Intervention : monitor patient taking sulcolon containing Sulphasalazine because it can
increase the dietary folate5.
3.3.3 Lasix (furosemide) and ascardia (aspirin) where the response loop diuretics may be impaired in
patient with cirrhosis and ascites5.
Pharmacist intervention : the use ascardia containing aspirin to note and use with caution5.
CONCLUSION
Based on the results, it can be concluded that the patient suffered from massive ascites due to
cirrhosis of the liver, it based on laboratory results performed. During the therapy which found the
Drug Related Problems such as patient did not receive the drug, the drug options were less precise
and drug interactions.
REFERENCES
1. Anderson, Philip, et.al. 2002. Handbook of Clinical Drug Data 10rd Edition. United States of
America: The McGraw-Hill Companies
1638
2.
Fredman,
l.
Scott.
2010.
Clinical
Hepatology
:
Principles
and
Practice
of Hepatobiliary Disease Volume 1.London: Springer
3. j. Isselbacher, Kurt. 1999. Harrison's principles Of internal medicine / United Kingdom language
editioneditor,
Kurt
j.
Isselbacher
[et
al];
Indonesia
-
language
edition Editor, Ahmad h. Asdie ed. 13. Jakarta: EGC.
4. j. Med. Assoc. On 2013. Pathophysiology and diagnosis developed ascites in children. Jakarta: 63:
32-6
5. Medscape. Drugs Interaction. 2014
6. Reis, CE. 1998. Internal Medicine; Ascites; www.medstudents.com.
7. Price SA and Wilson LM. 1995. Pathophysiology : concepts of clinical Disease processes, 4th
Edition. Jakarta.
1639
Retention of Urine BPH (Benign Prostate Hyperplasia)
Treatment in PGI CikiniHospital Jakarta
MasnidaSitumorang1, Diana Laila Rahmatillah2, Aprilita Rinayanti3
1
Student of Pharmacist Professional Program, Faculty of Pharmacist UTA’45 Jakarta
2
Lecturer Faculty of Pharmacist UTA’45 Jakarta
Email: masnidasitumorang@yahoo.com
ABSTRACT
BPH (Benign Prostate Hyperplasia) is an enlargement of the prostate which occurs progressively
because of hormonal influences that causes the urinary outflow tract obstruction and typically occur
in men age more than 50 years1. BPH (Benign Prostate Hyperplasia) able cause retention of urine
and hematuria1.
Patient Mr. MYS 63 years old entered PGI Cikini Hospital on 31st August 2014 with diagnosis
retention of urine ec BPH (Benign Prostate Hyperplasia). Treatment therapy was Tramadol capsules,
vitamin K, Transamin (tranexamat acid) 500 mg tablets, Harnal (tamsolusin) tablets, Ceftriaxone 1 g
vial, Cernevit flc, Torasic (ketorolac) 30 mg ampoule, Urocholin (bethanecol) tablets, Lasix
(furosemide) 20 mg inj, Rimdopump (omeprazole) 20 mg inj, Kalnex (tranexamat acid) 500 mg
ampoule, and Rimstar (rifampicin) tablets. Based on the results it can be concluded the existence of
DRP (drug related problems) such as drug used without indication and improper Drug Selection.
Keywords: Retention of urineecBPH, Internal disease and PGI Cikini Hospital
1640
1.
INTRODUCTION
Benign prostate enlargement, or known as BPH commonly occurs in men who are aging1. The term
BPH or benign prostatic hyperplasia actually term histopathologic, which there are hyperplasia of
stromal cells and epithelial cells of the prostate gland1. Gland growth is very dependent on the
testosterone hormone, which is in the cells of the prostate gland, this hormone will be converted
into an active metabolite Dihydrotestosterone (DHT) by the enzyme 5a-reductase. This
Dihydrotestosterone directly trigger m-RNA in the cells of the prostate gland to synthesize protein
growth factors which spur growth and proliferation of cells the prostate gland. The elderly several
men enlarged benign prostate cells. This situation experienced by 50% of men 60 years old and ±
80% of men 80 years old. Enlargement of the prostate gland result in disruption the flow of urine
causing micturition disorder1.
Clinical persentation2
Retention of urine ecBPH (Benign Prostate Hyperplasia) can be found obviously by the
symptoms of hesitancy, beam enlargement of urinating lower, discontinuous, not dissatisfied while
finished urination, feeling to urinate after urinating and discharge residual urinating at the end of
urination. Abnormal urinary frequency, such as frequent micturition, difficult to hold urine and pain
when urinating. Sometimes it may occurs hematuria and pain during ejaculation.
Examination Support3
a)
The laboratory
Urine analysis and microscopic examination of urine is important to see the leucocytes cell,
bacterial and infection. There is other etiologies hematuria should be taken into account, such as
malignancy in the urinary tract, a urinary tract infection stones.
b)
Radiological examination
Inspection is usually done is Plain abdominal film, pielografi, intravenously, the ultrasound
and cystocopy. With the aim to estimate the volume of BPH, determine the degree of bladder
dysfunction of and residual urine volume of and look for other pathologies disorder, both related
and unrelated with BPH.
1641
Management4
The treatment of BPH are as below:
a. Observation
Typically do in patients with mild complaint. Advice provided by are with reduce to drink
after dinner to reduce nocturia, avoid the drugs decongestan (parasimpalitic), reduce to drink coffee
and does not allowed to drink alcohol in order not too frequent micturition.
b. Medical
Patients are usually given a degree of conservative treatment example by administering
inhibitors of alpha adrenoceptor such as: alfarosin, prazosin and terazosin. The advantage is that a
positive effect on patient complaints but does not affect the prostate benign. Reduce the prostate
volume by decreasing levels of testosterone /dehidrotestosteron (DHT) which with of finasteride 5
alpha reductase which prevent change of testosterone to causing decrease in the size prostate
dehidrotestosteron.
c. Suprapubic of prostatectomy transmilad prostatectomy (TMP)
Is one of the methods remove the gland by the abdominal into the bladder, can are using to
all sizes of nodes.
2.
CASE PRESENTATION
Patient Mr. MYS 63 years old entered PGI Cikini Hospital on 31 August2014. Patient
presented with ± 4 days difficult micturating, urine was red and patient previously suffered prostate
enlargement. From the result of the laboratory, on hematology examination indicated the value of
erythrocyte sedimentation rate (ESR) was high at 24mm / hour, the increase in the number of
reticulocytes 49 per mile (5-15 per mile). The increase in the number of neutrophils segment was
80% (50-70%) and monocytes10 (2-8%).total of PSA was 10.42 ng / ml (<= 4 ng / ml). Impairment of
hemoglobin (Hb) was 9.4 g / dL (13-16 g / dL), erythrocytes 3.29 10 ^ 3 / uL (4.5-5.5 10 ^ 3 / mL),
hematocrit 28% (40-48%), neutrophils rod 0% (2-6%), lymphocytes 8% (20-40%). Clinical chemistry
examination indicated a decrease in the amount of Ca ions (calcium) 8,5mg/dL (8.8 to 10.3 mg/dL).
In the urine and parasitology examination indicated red urine color (yellow), turbid (clear). There
was value in the urine leukocytes caterace Trace/15 cell / ml (negative), nitrite positive (negative),
1642
blood 3+/300 cell/ml (negative), protein 3+/300 mg/dL (negative), glucose Trace/100 mg/dL
(negative), erythrocyte 2526 / LBP (0-3 / LBP). Examination unit anatomy and physiology, as
micsroscopic show pieces of tissue ± 1/15 cc, spongy was brown. Microscopically consist of keeping
the pieces fibromuscular tissue and acini benign. Conclusion: benign prostate tissue. In this case the
patient was treated with Ceftriaxone 1 g vial, Lasix (furosemide) 20 mg inj, Vitamin K, Kalnex
(tranexamat acid) 500 mg ampoule, tramadol 30 mg tab, Rimdopump (omeprazole) 20 mg inj,
Torasic (Keterolac) 30 mg ampoule, Harnal (Tamsolusin) tablets and Urocholin (Bethanecol) tablets,
Cernevitflc, Rimstar (Rifampicin) tablets.
3. CLINICAL EVALUATION
Drug use without indication: was found. The use of Rimstar (Rifampicin) tablet was less
precise because of the laboratory examination was not one showed that the patient positively
affected by tuberculosis.
Intervention of Pharmacist: the use ofRimstar (Rifampicin) should be discontinued.
Improper Drug Selection: was found. The use of Ceftriaxone 1 g vial was less precise,
because the side effects of the antibiotic cephalosporin might cause the bleeding, whereas the
patients themselves has had hematuria, it will be aggravated the bleeding of the patient5.
Intervention of Pharmacist: Ceftriaxone 1 g vial changed with antibiotic from another groups, such
as class of quinolon (ciprofloxacin inj).
4. CONCLUSION
Based on the results, it can be concluded that the patient suffered from retention of urine caused by
BPH (Benign Prostate Hyperplasia). The presence of DRP (Drug Related Problems) such as Drug Use
Without Indication wasuse Rimstar (Rifampicin) tablets was less precise because of the laboratory
examination were no one which shows that the patient positively affected by tuberculosis. Improper
Drug Selection such as in use of Ceftriaxone 1 g vial was less precise, because the side effects of
1643
cephalosporinantibiotic might cause the bleeding, whereas patients themselves has had hematuria,
it will be aggravated the bleeding of the patient.
REFERENCES
1. Purnomo BB, Dasar-dasarUrologi, EdisiKedua. CV SagungSeto, Jakarta, 2007, hal 153-156.
2. Tanagho E.A., Mc Annich J.W., Smith’s General Urology 16th ed, The McGraw Hill Companies
2004, hal 367-374
3. Walsh P. ., Retik A.B., Vaughan E.D., Wein A.J., ampbell’s Urology 8th ed., WB Saunders,
Philadephia 2002, hal 1297-1433
4. IkatanAhliUrologi Indonesia, PanduanPenatalaksanaan Benign Prostate Hyperplasia (BPH), IAUI
2003
5. Zelenitsky SA, Ariano RE, Harding GK, et al. Antibiotic pharmacodynamics in surgical prophylaxis:
an association between intraoperative antibiotic concentrations and efficacy. Antimicrob Agents
Chemother. 2002; 46:3026–30.
1644
Treatment of The Dyspepsia Patient
At the PGI Cikini Hospital
Fitria Aptika1, Diana Laila Rahmatillah2 , Aprilita Rinayanti Efi2, Stefanus Lukas2
1
2
Email: Fitriaaptika@yahoo.com
ABSTRACT
Dyspepsia is a common term used for a collection of symptoms or complaints of pain or discomfort
on the solar plexus, nausea, vomiting, saltpeter, quick sense of satiety, and the stomach feels full or
bloated stomach 2. These complaints can be alternately perceived patient or vary both in terms of
the type of complaint or quality 2. Patient W.W 47 years old woman was hospitalized in the ward of
disease in PGI Cikini Hospital on November, 05 2014. Therapy treatment for treated i.e., the drug is
golangan H2 rantin blockers that serves to prevent the occurrence of hyper sereksi stomach acid, it
was used to remedy Episan protecting gastric mucosa, Domperidone is used to prevent the onset of
nausea and vomiting, Catopril 12.5 mg given to lower blood pressure in patients, Panadol is used to
relieve pain in headache and toothache, as well as lowering fever, pain and Ceftriaxone for the
infection caused by pathogenic bacteria on the top line. Presentation cases, W. W 47 yearold
woman was hospitalized in the internal medicine ward. The patient was diagnosed with the disease
dyspepsia. Evaluation of the clinic, that the existence of the DRPs (Drug Related Problems) were not
receiving medication that patient experiencing a decrease in calcium but the patient did not receive
the drug, supposedly from the early treatment given the remedy of ca gluconase. Not receiving
medication that patient experiencing a decrease in patient not receiving but hemaglobin drugs,
patient need to be given therapy such as folic acid, EPO (erythropoietin), Iron salts to combat
anemia that occurs in patient. Drug interactions i.e. captopril with food intake was high enough or
high potassium. This can cause high level potassium in the blood.
Keywords: Dyspepsia, disease In, PGI Cikini Hospital.
1645
INTRODUCTION
Adult population in Western countries influenced by dyspepsia ranged between 14-38% 1. However,
approximately 13-18% have spontaneous resolution over the past one year, with a stable prevalence
over time 1. Based on research on the general population found that 15-30% of adults have
experienced dyspepsia in a couple of day 1. Countries in the West (Europe) have a prevalence of
about 7-41%, but only 10-20% will seek medical1. Figures for the incidence of dyspepsia was
estimated at 1-8% 1. Whereas in Indonesia had not obtained certain epidemiological data 1.
According to the data of 2007, Indonesia Health profile of dyspepsia has been ranked the 10th most
disease categories for inpatients in the hospital in 2006, with the number of patients or about
34.029 are 1.59% 1.
Dyspepsia is there one or more symptoms of dyspepsia for 3 months with onset at least 6 months in
advance, as the full flavor or nausea in the upper abdomen, quick satiety, bloating, pain in the
epigastrium, burning feeling in epigastrium, and there is no evidence of structural or organic disease
(after endoscope channels cerna upper part) 5.
Dyspepsia may be an early symptom of the disease is critical, for example peptik, kholelitiasis ulcer
or gastric carcinoma, but often also in sufferers not found damage to organs 6. Due to the
disturbance of mind, exhausted because of too much work and financial problems can also cause
dyspepsia complaint 6.
Based on whether there is a cause and a symptom of the dyspepsia is divided over the organic
functional dyspepsia and dyspepsia 4. It says organic causes of dyspepsia in dyspepsia is obvious, for
example the presence of gastric carcinoma, peptikum ulcer, kholelithiasis, which can be found easily
4
. Functional dyspepsia and it is said when the cause is unknown or not found an abnormality on
examination of conventional, or Gastroenterology found the presence of organic damage and
systemic diseases 4.
Basic pathophysiology of functional dyspepsia are very complex and uncertain 4. Some things that
are considered to cause, among others, dismotilitas the stomach, gastric acid, h. pylori, psychic, and
use of medicines 4. Psychic disorders, and environmental factors can give rise to functional
dyspepsia 4. Stress can alter gastric acid secretion, gastrointestinal motility and vascularity 4. At
dyspepsia organic (ulcer) the role of stress and personal type remains controversial, although some
research can connect high serum pepsinogen and ulcer peptikum 4. The classic view of the
1646
pathogenesis of ulcer, where there are factors that increase spending on sour, things that degrade
the mucous defenses psychology, stress and h. pylori weakens the mucous defenses 4.
CASE PRESENTATION
W. W 47 year old, woman was hospitalized in the ward of disease in RS PGI Cikini on November, 05
2014. Patient hospitalized with complaints of nausea and vomited 3 times since 2 days before
entering the hospital and appetite decreased since 1 week before entering a hospital.
From the results of laboratory examination in clinical chemistry, showed the value of triglycerides
1.2 mg/dL (0.6-1.1 mg/dL), calcium low of 7.3 mg/dL (8.8-10 mg/dL), whereas complete blood
screening on HB low i.e. 7,5 gr/dL (14-18 g/dL), under normal Hematokrit 22% (37-43).
In this case the patient during treatment was treated with doses i.e., amp 2x1 50 mg, rantin episan
3x1 sdm, domperidone 10 mg 3x1 tablet, 12.5 mg tablet 2x1 catopril, panadol 500 mg 2x1 tablets,
and ceftriaxone 1gr 2x1 vial.
CLINICAL EVALUATION
1.
DRPs 1: not receiving the drug (failure toreceive medication):
In this case as seen from the results laboraturium patients experience a decrease in calcium but the
patient did not receive the drug.
Pharmacis interventions: in presence of laboraturium examination results decreased calcium
(hypocalcemia), thus triggered nausea and muntah4. From the beginning of treatment should be
given medication ca. gluconase 4.
2.
DRPs 2: did not receive medication (medication toreceive Failure):
In this case as seen from the results laboraturium patients experience a decrease in patients not
receiving but hemaglobin drug.
Pharmacis interventions: patients to be given therapy such as folic acid, EPO (erythropoietin), iron
salts to combat anemia that occurs in patients.
1647
CONCLUSION
Based on the results it can be drawn the conclusion that the existence of the DRPs (Drug Related
Problems) were not receiving medication that patients experiencing a decrease in calcium but the
patient did not receive the drug, supposedly from the early treatment given the remedy of ca
gluconase. Not receiving medication that patients experiencing a decrease in patients not receiving
but hemaglobin drugs, patients need to be given therapy such as folic acid, EPO (erythropoietin),
iron salts to combat anemia that occurs in patients. Drug interactions i.e. captopril with food intake
is high enough or high potassium. This can cause high level potassium in the blood.
REFERENCES
1. Andre. Y., Machmud, r. a., Widya 2013. Dietary relationship with incidence of depression in
patients with Functional Dyspepsia. FK UNAND Health Journals.
2. BPOM. 2008. National drug Informatorium Indonesia (IONI). Jakarta: Sagung Seto.
3. Drugs.com. Dugs Interaction. 2014
4. Ginayah, m., Sanusi, h. 2011. Hiperkalsemia. Continuing Medical Education Of IDI. Falkutas Of
Medicine University Of Hassanudin. Vol 38.
5. Julita, C, t. 2003. Differences in Depression in patients Functional Dyspepsia and organic. Health
Journal USU.
6. Nur Huda Satria Kusuma, I.G. Arinton, Hilma Paramita. 2011. the correlation Score Dyspepsia And
Dyspepsia in patients Anxiety Score Outpatient Clinic In the provincial hospital's Prof. Dr. Margono
Soekarjo Purwokerto. Mandala of Health. Vol 5.
7. Susanti, A, Briawan, D, Uripi, v. 2011. Risk Factors Of Dyspepsia In Students Of Bogor Agricultural
University (IPB). Indonesia medical journal, vol. 2.
1648
DRUG RELATED PROBLEMS
ACITES TRANSUDATIVE PATIENT
ISLAMIC CEMPAKA PUTIH HOSPITAL JAKARTA (RSIJ)
Rahmat Yunus1, Diana Laila Rahmatillah2 , Aprilita Rinayanti Efi2, Ihsanil Husna3
1
2
3
Doctor at Cempaka Putih Jakarta Islamic Hospital
Email:Rahmat17hazard@gmail.com
ABSTRACT
Acites is accumulation of serous fluid usually fluid which is pale yellow and clear fluid in the
abdominal cavity (peritoneal) 2. The abdominal cavity is located below the chest cavity 2. Liquid
asites many found on the patient such as liver disease, cancer, congestive heart failure, and kidney
failure 2. Massive asites is the highest degree asites or difficult cured due to massive asites
prognosisnya bad, with a survival rate of over 1 year and less than 50% 2.
Patient Mr. SH, aged 56 years, admitedto RSIJ on November 26, 2014 with Massive Asites diagnosis.
Therapy treatment for treating was. Spironolakton, Propanolol, Tramadol, Vitamin K, Lasix
(Furosemid), and Albumin. Based on the results of the practice of the Clerk's ward the RSIJ, then it
can be concluded that the DRPs (Drug Related Problem) that was needed additional drug therapy
and drug interactions (furosemid and propranolol, and propranolol and spironolakton).
Key words: Transudative, Acites, RSIJ Cempaka.
1649
INTRODUCTION
Acites derives from the Greek askos, meaning pouch or bag 2. Acites is overwrite patoligis fluid in the
abdominal cavity 2. Adult male healthy have no or little intraperitoneal fluid, but in females there as
many as 20 ml depending on menstrual cycle 2. Approximately 80% of cases of ascites due to
cirrhosis of the estimated 3. Some other causes of ascites are congestive heart failure and kidney
failure, inflammatory, infectious, nefrosis etc. 3.
Complementary examination includes inspection of liquid asites check the color count, protein,
bacterial cells and the malignancy 4. Asites is usually yellowish in cirrhosis, redness of the malignancy
and murky on the infection 4. Next USG abdomen to measure the size of the liver (cirrhosis small),
signs of pulmonary hypertension and pulmonary vein and vein width hepatica 4. Useful also to find
focal abnormalities (redirect allegations of violence diseminata) and for the diagnosis of ovarian
tumor intraabdomen tumor such as 6. As well as other biochemical tests are blood tests and liver
function tests to look for signs of cirrhosis hepatis (the levels of albumin decreased,
hiperbilirubinemia, increase in liver enzymes, thrombocytopenia and others 6. Examination of the
tumor markers if there is suspicion of malignancy (especially α-fetoprotein for hepatocellular
carcinoma, CA 125 for ovarian cancer 6.
CASE PRESENTATION
Patient Mr. SH, age 56 old at RSIJ on November 26, 2014. Patient come to the enlarged stomach
complaints already 1 week, shortness of breath, stomach bloating, no talking lust meal.
From the results of laboratory examination at Hematology, demonstrate the value of 7.3 g/dL
Hemoglobin (13.2-17.3 g/dL), Hematokrit 23% (40-52% , Erythrocytes 2.42 ˆ 6/10: L (4.40-5.90 €
6/10: L).
Clinical chemistry examination shows an increase in the value of albumin decreased 2,4 g/dL (3.4-4.8
g/dL), SGOT is 148 U/L (10-34 U/L), SGPT 93 U/L (9-43 U/L). Whereas on examination, there was a
decline in the value of electrolyte sodium (Na) 132 mEq/L (135-147 mEq/L). Third day performed
hemoglobin result 9.5 g/dL (13.2-17.3 g/dL). The four include hemoglobin Hematology examinations
done 10.4 g/dL (13.2-17.3 g/dL), 31% (hematokrit 40-52% , erythrocytes 3.42 10 ˆ 6/: L (4.40-5.90 €
6/10: L), as well as examination of the albumin of 2.2 g/dL (3.4-4.8 g/dL).
In this case, the patient was treated with the use of Lasix (furosemide) which was used as a diuretic
drug used to cope with the udem in the patient. The use of Spironolakton was used as a diuretic
1650
drug. The use of Propranolol was used to overcome the shortness of breath in patients. Use of
Tramadol was used to relieve pain in patients. Granting of Albumin was used to normalize the levels
of albumin in the body under normal.Hypoalbuminemia was one cause of udem. Vitamin K given to
prevent bleeding.
In this case the patient was treated by use of Lasix (furosemide) with a dose of 2 x 1 ampules a day,
with a dose of Spironolakton 100 mg 2 x a day, with a dose of 2 x Propranolol 80 mg doses of
Albumin was used then 1 x 100 cc a day, used with a dose of Vitamin K 2 x 1 tablet a day, Tramadol
was used at the time of laparotomy biopsy post-op with a dose of 2 x 100 mg.
CLINICAL EVALUATION
1.
DRPs 1: Needs additional drug therapy
By looking at the condition of the patients need additional drug therapy where the patient
laboratory data seen from a 10-day treatment value of Hb is still below normal values 5.
The patient needs to be given pharmaceutical interference therapy such as folic acid, EPO
(erythropoietin), iron salts to combat anemia that occurs in these patients 5.
2.
DRPs 2: Drug interactions
Use of propranolol and furosemide together can lower blood pressure and slow down Your heart
rate. This can cause dizziness, or feeling like you are fainting, weakness, fainting, rapid heart beat or
irregular, or loss of control of blood glucose. Use of propranolol and spironolactone together can
lower blood pressure and slow down Your heart rate. This can cause dizziness, or feeling like you are
fainting, weakness, fainting, rapid heart beat or irregular, or loss of blood glucose control 1.
Pharmasist intervention avoid drug interactions that occur then we recommended of monitoring
serum potassium levels, blood pressure, and blood glucose is recommended. Patient should be
advised to seek medical help if they experience dizziness, weakness, fainting, rapid heart beat or
irregular, or loss of blood glucose control 1.
CONCLUSION
Based on the results of it can be drawn the conclusion that the patient suffers from a Transudative
due to asites cirrhosis of the liver. In addition there was the DRPs (Drug Related Problems) during
therapy treatment which found the DRPs (Drug Related Problems) included additional drug therapy
and drug interactions.
1651
REFERENCES
1. Anderson, Philip, et.al. 2002. Handbook of Clinical Drug Data 10rdEdition. United States of
America: The McGraw-Hill Companies
2. Cipolle, Robert J, et al. 2004. Pharmaceutical Care Practice Second Edition. USA: The Mc. GrawHill Companies Inc.
3. Fredman, l. Scott. 2010. Clinical Hepatology: Principles and Practice of Hepatobiliary Disease
Volume 1. London: Springer
4. Sutedjo, v., 2007. Pocket Book To Know The Disease Through The Laboratory Examination Result.
Jakarta: Aksara Works Birata
5. Debra Johnson. 1999. Women and Anemia. Health Journal
6. Moore KP, et al. 2006. Guidelines of The Management of Ascites In Cirrhosis. Report on The
Concensus Conference of The International Ascites Club
1652
EVALUATION OF DRUG RELATED PROBLEMS IN THE
TREATMENT OF PATIENT WITH CKD (Chronic Kidney
Disease) AT THE PGI CIKINI HOSPITAL
Ardianti Miranda Sari1, Diana Laila Ramatillah2, Aprilita Rimayanti Efi2, Stefanus Lukas2
1
Student of Pharmacist Professional Program Student, Faculty of Pharmacy
UTA’45 Jakarta
2
Lecture of Faculty of Pharmacy UTA’45 Jakarta
Email: ardiantimirandasari@gmail.com
ABSTRACT
Chronic kidney disease or end-stage renal disease (ESRD) is malfunctioning kidneys chronically being
progressive and irreversible4. The body's ability to maintain metabolism and electrolyte and fluid
balance failed, causing uremia retention of urea and other nitrogen waste in the blood4.Kidney
failure occurs if the function was declared a second kidney is impaired to the point when they are
not able to exercise the functions regulatory and exscretory to retain homeostasis4. Two common
causes of kidney disease are diabetes and high blood pressure4. Genetic factors are also highly
influential4.
Case presentation: Mrs. JG 63 years old being treated at JG Ward K PGI Cikini Hospital. The patient
was diagnosed with the disease CKD.Clinical Evaluation: Drug related problems that occur in these
patients is unwanted drug interactions of CaCO3 and Nifedipine, CaCO3 and Captoril.
Keywords: CKD, Drug Related Problems, PGI Cikini Hospital.
1653
1. Introduction
Chronic kidney disease is the loss of kidney function progressively in a period of a few months or a
few years3. This disease is a problem in the field of Nephrology with fairly high incident rate 3. The
symptoms of worsening kidney function are unspecific, and might also be found malaise and
decreased appetite3. Chronic kidney disease is a public health problem wordwide3. Where is
gradually occurring decrease in kidney function over time and are usually settled3. Suffering from
end-stage kidney disease and will continue to increase if we do not do prevention and management
as well3. As for the disease that often affects kidney damage including diseases of high blood
pressure (hypertension), Diabetes Mellitus, blockage of the urinary tract (stones, tumors,
strictures/constriction), autoimmune Disorders, such as systemic lupus erythematosus, suffering
from cancer, kidney Disorders, in which case the development of numerous cysts on the kidney
organ itself (polycystic kidney disease) and destruction of the cells in the kidneys filter either by
infection or inflammation due to the impact of hight blood disease3. The term medical degree are
known as glomerulonephritis3.
2. Case Presentation
Mrs. JG 63 years old, female, hospitalized in the ward K PGI Cikini Hospital inpatients on 08
December 2014 with complaints of chest pain and headaches, patients have a history of past
illnesses of kidneys and DM. on 08 December 2014 the Hematology examinations done demonstrate
visible presence of abnormality of blood creep rate value 60 mm/h (0-20), leukocytes 13.9 10 ^ 3: L
(5.0-10.0 10 ^ 3: L)and look under normal hemoglobin values of 8.8 g/dL (-16.0 13.0 g/dL),
erythrocytes 3.06 10 ^ 6: L hematocrit, and 26% (40-48%). Examination of kidney faal visible
elevated levels Uremia 177 mg/dL (10-50 mg/dL) occurs in patients with renal failure and
triglycerides 10.3 mg/dL (0.6-1.1 mg/dL) showed a decrease in kidney function.
For blood sugar checks shows abnormal values at 10: 00 a.m. 112 mg/Dl (70-150 mg/dL), at 11: 00
a.m. 118 mg/dL (70-150 mg/dL) and at 18: 00 109 mg/dL (70-150 mg/dL). The laboratory results
from patients at diagnosis have CKD.
In this case therapy patients with Cefixime is indicated for treatment of uncomplicated urinary tract
infections caused by micro-organisms Escherichia coli and Proteus mirabilis. Captopril is used for the
treatment of hypertension that can not be addressed with a combination of other treatment and
1654
nifedipine is also given as additional therapy in hypertension. The use of folic acid given in Mrs. JG
because failing kidneys on patients occur uremia. The use of CaCO3 and Onandsetron is used to
simptomatis therapy in patients with CKD, such as nausea and vomiting. CKD can occur in patients
increased levels of urea which can lead to the occurrence of the mucous cell reduction and increase
secretion of acid1.
3. Clinical Evaluation
Drug Related Problems
1. Interaction between CaCO3 and nifedipine
Reduce the effects of CaCO3 Nifedipine antagonism by pharmacodynamic2. Pharmacist intervention:
Recommend the use of CaCO3 stopped because CaCO3 inhibits the effects of nifedipine.
2. Interaction between CaCO3 and kaptopril
Reduce the effects of CaCO3 Captopril with an unspecified interaction mechanism2.
Pharmacist intervention: Recommend the use of CaCO3 stopped because CaCO3 inhibit the effects
of the catopril.
4. Conclusion
Based on the result of the practice of the lerk's clinic on the Hospital’s Wards K PGI ikini Hospital
then it can be drawn the conclusion that the patient experienced disease CKD (Chronic Kidney
Disease). Besides DRP (Drug Related Problems) unwanted drug interactions of CaCO3 and Nifedipine,
CaCO3 and Captoril.
References
1. Anderson, Philip, et.al. 2002. Handbook of Clinical Drug Data 10rdEdition. United States of
America : The McGraw-Hill Companies
2. Medscape. Dugs Interaction. 2014
3. Suhardjono, Lydia A, Kapojos EJ, Sidabutar RP. 2001. Gagal Kidney Kronik. Buku AjarIlmu Penyakit
Dalam Jilid II Edisi 3. Jakarta: FKUI.
4. Suwitra, K. Penyakit Kidney Kronik. Hal. 581. Dalam : Aru W Sudoyo, Bambang S., Idrus Alwi, M.
Simadibrata K. and Siti Setiati(Eds). 2006. Buku Ajar Ilmu Penyakit Dalam. Pusat Penerbitan
Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia. Jakarta.
1655
THE CASE STUDY KIDNEY STONES (UROLITHIASIS) AT THE
PGI CIKINI Hospital
Robiansyah Panongah Pako1, Diana Laila Ramatillah2, Aprilita Rimayanti Efi2, Stefanus Lukas2
1
Student of Pharmacist Professional Program Student, Faculty Of Pharmacy
UTA’45 Jakarta
2
Email: robiansyah15@yahoo.com
ABSTRACT
A kidney stone is the presence of stones in the urinary tract, from the kidneys, ureters, urinary
bladder into the urethra4. The exact cause of urinary tract Stones that form is not yet known,
because of the many factors that entangled2. Urinary stone disease spread around the globe with a
difference in developing countries found a stone jarwhile in developed countries are more plentiful
upper urinary tract stone (kidney and ureter), this difference affected the nutritional status and
mobility of daily activities3. The average prevalence worldwide is 1-12% of the population suffer
from urinary tract stones. the factors that facilitate the occurrence of urinary tract stones include:
Hereditary, age, gender, geography, water intake, diet, work3.
Case presentation; Mrs. 53 years old CS treated at Cikini Hospital K ward. The patient was diagnosed
with the disease right urethral stones.
Keywords: Urolithiasis, Urethral Stone right, PGI Cikini Hospital.
1656
1. Introduction
Stones in the urinary tract or bladder stones are often called; urinary stone is the presence of stones
in the urinary tract, from the kidneys, ureters, urinary bladder into the urethra2. The exact cause of
urinary tract stones that form is not yet known, because of the many factors that entangled2. On the
nucleation process of hydrogen, sodium, uric acid and uric crystals of hydroxyapatite forms the core
of calcium ions and oxalate is then glue (adhesion) in the nucleus to form a mixture of stone 2. This
process is called heterogeneous nucleation2. Urinary tract stones in general contain elements of
calcium oxalate or calcium phosphate, uric acid, magnesium ammonium phosphate (MAP), Xanthin,
and cystine2. Urinary tract stones have a basic component of calcium about 75% in the form of
calcium oxalate or calcium phosphate, oxalate and phosphate mixture2. Identification of urinary
tract Stones can be done with the analysis of stone, so that the type and composition of the stones
can be known2. Many found the jar of a stone while in the developed countries more plentiful upper
urinary stones (kidney and ureter), this difference affected the nutritional status and mobility of
daily activities2. The average prevalence worldwide is 1-12% of the population suffer from urinary
tract stones2.
Urinary tract stones can cause complications in the form of obstruction and urinary tract infections2.
The manifestation of urinary tract obstruction on the bottom is the retention of urine or other
micturition complaints whereas in upper urinary tract stones can lead to hidroureter or
hidrinefrosis2. The stone is left inside the urinary tract may cause infection, kidney abscess,
pionefrosis, urosepsis and permanent kidney damage (kidney failure)2. Therapy for kidney stones is
the ESWL (Extracorporeal Shock Wave Lithotripsy) is a non-invasive therapy, because it does not
require surgery or insertion tool into the patient's body2. True to its name, Extracorporeal means
outside the body, whilst the Lithotripsy means destruction of rocks, literally meaning the destruction
of ESWL ureteral stones using shock wave (shock wave) that transmitted from outside the body2.
Mrs. CS is a 53 year old woman was hospitalized in the ward K, Patient hospitalised PGI Cikini on
November 30, 2014 with major lower back pain complaintpropagates to the stomach. On the results
of examination of complete blood counts on November 21, 2014, the value of the rate of blood 19
mm f/h (0-20 mm/hour , Normal Erythrocytes 3.33 x 10 ˆ 6/: L (4.00-4.50 x 10 ˆ 6/: L , Hemoglobin
1657
10.4 g/dl (12.0-14.0) Hematocrit 30% (37-43) Neutrophil stem 0%(2-6%) and 16% Lymphocytes (2040%) under normal Neutrophil segment, 71% (50-70%) Monocytes 9% (2-8%) Reticulocyte 42/MI (515) 4% Eosinophils (1-3%) and Eosinophils 5%(1-3%) above normal, examination of the rate of
deposition of blood to measure creep speed erythrocytes (red blood cells) and describe the
composition of the plasma as well as the comparison between erythrocytes (red blood cells) and
plasma. The rate of deposition of blood can be used as a means of monitoring the success of the
therapy, travel sickness. By a doctor for the preparation of ESWL performed Hematology back on 2
December 2014, hemoglobin 9.2 grams/dl (12.0-14.0 grams/dl) Hematocrit 27% (37-43%) was below
normal. Leukocytes, Platelets normally.
In
the
case
of
patients
with
therapy
Bicnat
wich
was
used
in
the
treatment
ofhyperphosphatemiapatients conditions. Hyperphosphatemia on patients with kidney failure
occurs as a result of release of phosphate from the cell due to the condition of acidosis and diathesis
was often the case. Bicnat working with bind phosphate in the digestive tract thereby reducing
phosphate absorption. PCT in usefor pain at the suffering on patients.
Vitamin K for the treatment and prevention of bleeding and tranexamic acid containing
Transamin/tranexamic. acids used for bleeding after kidney hemorrhage & abnornal ESWL, work by
inhibiting fibrinolysis. Tranexamic acid aminokaproat acid analog, was a work by way of block place
the bonds on the lysine which usually interact with plasmin, inhibits plasminogen activator to
competitively.
Cefoperazol was indicated for the treatment of infections caused by urinary tract infection
microorganisms without the complications caused by Escherichia coli and Proteus mirabilis.
DRPs Adverse drug reaction (adverse drug reactions)
The patient complained of a bloated feeling in the abdomen and Bowel dilute this reaction in
because effect from any user cefoperazol and the transamine represents side effects on the
gastrointestinal tract1.
Pharmacist intervention: provision of information to patient for side effects of the drug.
1658
4. Conclusion
Based on the result of the practice of the Clerk's clinic on the hospital's Wards K PGI Cikini then can
be drawn the conclusion that the patient experienced stone disease kidney stones/rock urethra.
Besides DRP (Drug Related Problem) included adverse drug reactions which use along Cefoperazol
and Transamine may cause gastrointestinal disorders.
References
1. Medscape. Dugs Information. 2014
2. Pahira, J and Pevzner. 2008. Urinary Stone Disease. Penn Clinical Manual of Urologi.
3. Rahardjo D, Hamid. 1997-2002. Perkembangan penatalaksanaan batu kidney di RSCM.
4. Sja’bani. 2006. Ilmu penyakit dalam. Jilid I Edisi 4. Pusat Penerbitan Departemen Ilmu Penyakit
Dalam Fakultas Kedokteran. Jakarta
1659
DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT
FOR OBSTRUCTIVE JAUNDICE PATIENT IN PGI CIKINI HOSPITAL
Mitra Wynne Timburas1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2, Stefanus Lukas2
1
Student of Pharmacist Program, Faculty of Pharmacy UTA’45 Jakarta
2
Lecturer of Faculty of Pharmacy UTA'45Jakarta
Email: mitra22wy@gmail.com
ABSTRACT
Jaundice is the yellow color of skin, eye sclera or mucous membranes due to accumulation of bile
pigments in blood and their deposition in body tissues. It commonly caused by gallstones, or
tumours of the bile duct and liver disorders. Case presentation : Mr. SS, 68 years old, came to PGI
Cikini hospital on august 7th 2014, with complaints headache, nausea, abdominal pain, and
weakness. Patients diagnosed with Obstructive Jaundice. Clinical evaluation: Based on the clinical
evaluation at the ward of K in PGI Cikini it could be concluded that was DRPs (Drug related
problems) such as drug use without indication, improper drug selection and drug interactions.
Key words : Drug Related Problems, Obstructive jaundice, PGI Cikini Hospital
1660
1.
INTRODUCTION
Jaundice is derived from the French word jaune, means yellow2. It should be examined under a
bright light during the day, to see eye sclera. Jaundice can be divided into two groups: haemolytic
jaundice and obstructive jaundice 4. Ikterus caused by bile duct obstruction (occurs when a gallstone
or cancer choledochal duct cover) or liver cell damage (occurs in hepatitis), the rate of bilirubin is
normal, but it can not pass from the blood into the intestine6.
According to Bonheur (2012)2, Jaundice is classified into three categories, depending on which part
of the physiological mechanism the pathology affects. The three categories are:
a.
Pre-hepaticular Pre-hepatic jaundice is caused by anything that results in an increased rate
of hemolysis (breakdown of red blood cells), resulting in diseases known as hemolytic disorders
which can elevate the bilirubin levels. Hemolytic disorders can be caused by parasite for example eg
Bebesia sp., And Anaplasma sp.
b.
Hepatocellular (hepatic) jaundice can be caused by acute or chronic hepatitis,
hepatotoxicity, cirrhosis, and drug-induced hepatitis which here is impairment of excretion of
conjugated bilirubin into the bile.
c.
The mechanism of post-hepatic jaundice is a decrease in the secretion of conjugated
bilirubin resulting conjugated hyperbilirubinemia. Conjugated bilirubin is soluble in water, so it is
excreted into the urine (bilirubinuria) via the kidneys, but urobilinogen be reduced so the color looks
pale stool. Factors causing impaired secretion of bilirubin can be functional as well as factors
choledocus duct obstruction caused by cholelithiasis, parasitic infestations, liver tumors, and
inflammation resulting in fibrosis. Obstructive jaundice included in hepatic post.
2. CASE PRESENTATION
Mr. SS, 68 years old, came to PGI Cikini hospital on august 7th 2014, with complaints headache,
nausea, abdominal pain, and weakness. Based on the laboratory tests, Mr. SS was diagnosed
obtsructive jaundice. Three years ago he had been in PGI Cikini hospital with the same diagnosis and
performed surgery to overcome blockages in the biliary system. The bilirubin levels was elevated
(hyperbilirubinemia) for total bilirubin 3.8 mg / dL (0.1 to 1.0 mg / dL) and indirect 1.0 mg / dL (0.1
to 0.8 mg / dL). Then the alkaline phosphatase increased to 3 times from the normal value was 308
U / L (30-125 U / L) and gamma glutamyl transpeptidase examination (GGT) with up to 4 times
1661
increase from the normal value is 414 U / L (0-50 U / L), albumin levels was decreased to 2.2 g / dL
(3.4 to 4.8 g / dL). Tumor markers such as CA 19-9 was increasing with the value of 87.2 U / mL (<37
U / mL). The patient's blood clotting time (aPTT) elevated to 39.3 seconds (11 to 14.2 seconds) with
a control aPTT value 30.8 seconds. Ensuring the presence of obstructive apart with clinical chemistry
examination, Radiological examinations were performed on Mr. SS was Ultrasonography (USG) and
Magnetic resonance Cholangio-Pancreatography (MCRP). Conclusions from MCRP and USG showed
a dam in the biliary system due to the presence of stones in the distal duct occurs choledocus and an
enlarged spleen (splenomegaly) and it caused an increase in hydrostatic vein.
3.
CLINICAL EVALUATION
3.1 Drug use without indication
Using heparin in patient may increase the risk of bleeding. APTT test results at the first day of
admission to hospital increased. D-dimer test was increasing with the value of 740 mg / L (0-500 mg
/ L but it didn’t indicate if patient had DVT (Deep Vein Thrombosis because hipernilirubinemia
showed false positive result in the examination d- dimer5.
Pharmacists interventions : Avoid the use of heparin. Give vitamin K and antifibrinolytic agents
(tranexamic acid) 4.
3.2 Improper drug selection
Lack of proper drug selection in patient with providing antibiotic therapy sefuroxim, culture and
resistance test was indicated that patient resistant to Sefuroxim then you should use another
antibiotic selection and in accorandce with the patient's condition.
Pharmacist Interventions: Use alternative antibiotics such as aminoglycosides antibiotics group
and class Fluoroquinolon1.
3.3 Drug interactions
Drug interactions found such as: sefuroxim and heparin can cause decreasing of prothrombin
activity so if it was possible, use alternative antibiotic classes. Heparin and ketorolac may increase
1662
the anticoagulant effect. Ranitidine and sefuroxim, which may decrease the effects of ranitidine
sefuroxim to increase gastric pH, the same thing also happens in omeprazole and sefuroxim7.
Pharmacist Interventions: Change sefuroxim with other antibiotics (aminoglycosides /
Fluoroquinolones) and Avoid to use Heparin3,4.
CONCLUSION
Using heparin in patient based on the D-dimer test were actually false positive while patient
experienced a long period of blood clots. To prevent infection before surgery, patient was given
Sefuroxim antibiotic dissected while the result of culture and resistance test existed, patient
resistanted to Sefuroxim. Found drug interactions between Sefuroxim and Heparin (increasing effect
of heparin), heparin and Ketorolac (increasing the anticoagulation effect), Ranitidine and sefuroxim
(ranitidine Sefuroxim lowering effect by increasing the pH of the stomach), Omeprazole and
sefuroxim (Omeprazole Sefuroxime lowering effect by increasing the pH of the stomach).
REFERENCES
1. ASHP Therapeutic Guidelines. Clinical Practices Guidelines for Antimicrobial Prophylaxis in Surgery.
http://www.ashp.org/surgical-guidelines/pdf.
2. Bonheur,
J,L.
2012.
Biliary
Obstruction.
Diunduh
dari
http://emedicine.medscape.com/articles/187001.
3. Hepler, C. D., Segal, R., 2003, Preventing Medication Errors and Improving Drug
Therapy
Outcomes, A Management Systems Approach, CRC Press LLC, Boca Raton, Florida.
4. Mukarami, J and Shimizu, Y. 2012. Hepatic Manifestations in Hematological Disorders.
International Journal of Hepatology Volume 2013 (2013), Article ID 484903.
5. Official Publication of The Rocky Mountain State Society of American Medical Technologist. DDimer Issue. Rocky Mountain Health Enquirer Vol.13 Spring2014 Issue1.
6. Samsuhidajat R, De Jong W. 2004. Buku Ajar Ilmu Bedah Edisi 2. Jakarta : EGC. Hlm 198-200
7. Stockley, I.H, 2008, Stockley’s Drug InteractionEdisi kedelapan, Great Britain Pharmaceutical Press.
1663
HIPERGLICEMIA IN PATIENT DIABETIC MELITUS TIPE II AT
ISLAMIC CEMPAKA PUTIH JAKARTA HOSPITAL (RSIJ)
Hasnawati1, Diana Laila.R2, Aprilita Rinayanti2
1
2
Email : Pakhsddarmawan79.bds@gmail.com
ABSTRACT
Diabetic Mellitus (DM) is a metabolic disease with characteristic hyperglycemia that occurs due to
insulin secretion, insulin action, or both of them. Hiperglicemia in diabetic is in connection with longterm damage, failure of multiple organs, especially the kidney eye, nerve, heart and blood vessels3.
Patient Mrs. WL 55 years old admitted to RSIJ , on 8 October 2014 with a diagnosis of diabetic
mellitus type 2, patient had a complain of nausea, vomiting, heartburn and no appetite. For
hospitalized patient got on therapy with glunerorm (gliquidone), simarc two (warfarin), simvastatin
(simvastatin), metformin (metformin), digoxin (digoxin), nitrokaf (glyceryl trinitrate), clopidogrel
(clopidogrel), furosemide (furosemide), magalat (magadrat simethicone), mucosta (rebamipide),
prazotec (lansoprazole), rantin (ranitidine HCl), onandcetron (onandcetron HCl). Based on the result
it can be deduced that any form of improper DRP (Drug Related Problems) form of improper
(prazotec), improper frequency (prazotec) and the presence of drug interactions (simarc with
clopidogrel; digoxin with metformin; simarc with prazotec; digoxin with prazotec; simvastatin with
prazotec; prazotec with clopidogrel; simarc with simvastatin).
Keywords: Diabetic Mellitus, Hiperglicemia, RSIJ
1664
INTRODUCTION
Drug is very important role in health care. Treatment and prevention of various diseases can not
remove it from the action with drugtherapy or farmakotherapy1,2. Various options are currently
available drug, that required careful consideration in choosing a remedy for a disease. No less
important, the drug should always be used correctly in order to provide clinical benefit optimal
clinical benefit3,4. Too many types of drug available it can also provide a separate problem in
practice, especially regarding how to choose and use the medicine properly and safely. Improper use
of drugs, ineffective, unsafe and uneconomical or more popular, with the term irrational, at present
there own problem in health care, both in developed countries and in developing countries5. This
problem often encountered in health care units, for example as in Hospitals, healt centers, private
practice, and society. The use of drugs that are not appropriate where the risks that may occur is not
balance with the benefit of the drug administration6,7.
By Morinda, the use of drug in health services in Indonesia is still a very big problem due to the use
of non rational polypharmacy, with the development of polypharmacy is the greater the likelihood
of a drugs, for example a patient to get three to five drug even more for each piece of the recipe,
usage of excessive antibiotic (43%), a short consultation period on average only three minutes away
and the lack of compliance in patient taking the drug8.
According to the American Diabetic Association (ADA) in 2010, Diabetic melitus is a group of
metabolic diseases with charasteristics hyperglycemia happenes because abnormalities in insulin
secretion, insulin action, or both. They are two types of Diabetic are type One and type Two9,10.
Diabetic Mellitus Type One is also called insulin dependent diabetic (IDDM), Diabetic Mellitus Type
Two is also called insulin dependent not (NIDDM), occurs most often in adults, especially in obese
individuals7,8.
To select the appropriate medication to the patient, should be based on scientific consideration
include consideration of effectiveness, safety, suitability, practicality, and cost. It also should
consider the kinetic and dynamic drug9.
CASE PERSENTATION
Patient Mrs. WL 55 years old age, admitted to RSIJ on 08 October 2014. Patient complained with
heart burn, nausea, vomiting, and no appetite.
1665
CLINICAL EVALUATION10
In this case, patient treated with glunerorm where glunerorm (gliquidone) sulfonylurea class of
drugs used to lower blood sugar levels, in combination with metformin (metformin) biguanide class
used for type two diabetic mellitus for patient who do not depend on insulin Simarc 2 (warfarin)
used as an anticoagulant. To prevent thrombus given clopidogrel (clopidogrel) as antiplatelet,
simvastatin (simvastatin) was used as a cholesterol drug, digoxin (digoxin) ACEI group to prevent
heart attacks, nitrokaf R (glyceryl trinitrate) used for the prevention and treatment of angina
pectoris, furosemide (furosemide) is used for hypertension and to prevent the occurrence of edema,
medicines for peptic ulcers elseis magalat (magadrat simethicone) antacid group, mucosta
(rebamipide) PPI group that was always combined with prazotec (lansoprazole), Rantin (Ranitidine
HCl) class of H2 blocker, onandcetron (onandcetron HCl) was used to prevent nausea and vomiting.
DOSAGE AND USING10
In this case patient treated with glunerorm (Gliquidone) 1 x 1 for three days used orally, simarc 2
(warfarin) dosage of 10 mg / 1 ml 1 x 1/2 day for five days is used orally, simvastatin (simvastatin)
dosage 10 1 x 1 mg daily for five days used orally, metformin (metformin) at a dosage of 500 mg 2 x
1 daily for four days used orally, digoxin (digoxin) at a dosage of 500 mg 1 x 1 daily for five days used
orally, nitrokaf R (glyceryl trinitrate) at a dosage of 500 mg 2x1 daily for five days used orally,
clopidogrel (clopoidogrel) at a dosage of 75 mg 1x1 for four days used orally, furosemide
(furosemide) 40 mg 1 x ½ daily for four days used orally, magalat (magadrat simethicone) with a
dosage of 3x1 a day for three days is used orally, Mucosta (rebamipide) at a dosage of 3 x 1 daily for
four taken orally, prazotec (lansoprazole) at a dosage of 30 mg 2 x 1 daily for four days used orally,
Rantin (ranitidine HCl) at a dosage of 2 x 1 daily for four days used by injection, onandcetron
(onandcetron) at a dosage of 1 x 1 daily for four days used by injection.
LABORATORY RESULT
Result of laboratory test on patient Mrs. WL which showed abnormalities at GDS 525 mg/dl (70200), was indication the presence of hyperglycemia, triglyceridese 1.4 mg/dl (> 1.4), was indication
the presence of renal failure, sodium 128 mEq/L (135- 147), was indication the presence of
hyponatremia, potassium 2.6 mEq/L (3.5-5.0) was indication the presence of hypocalemia, cloride
91 mEq/L (94-111) was indication a disturbance of balance in the body of the patient, SGOT 30 U/L
(0-35), SGPT (alanine aminotransferase) 34 U/L (0-35).
1666
1. DRP 1: Required additional drug
By looking at the condition of the patient did not need the addition of a drug or condition in which
the patient must add more medicine, because treatment already given in accorandce with the
therapy.
2. DRP 2: Drug Interactions
Simarc with clopidogrel may increasing the risk of bleeding. Digoxin with metformin which may
increasing the effects of metformin, which may lead to a life-threatening condition called lactic
acidosis, this can be weakness, increasing sleepiness, slow heart rate, muscle pain, shortness of
breath, stomach pain, feeling dizzy and faint . Simarc with prazotec combination of these drugs may
increasing the risk of bleeding. Digoxin with prazotec combination of these drugs may increasing the
effects of digoxin, which prazotec causes elevated levels of blood. Simvastatin with prazotec
combination of these drugs can increasing blood level and effect of simvastatin, may increasing the
risk of side effect such as liver damage11
3. DRP 3: Failed to receive the drug
In this case found the existence failures in the administration of drug or other words or frequency
administration of the drug that is given to the patient is not in accorandce with the recommendation
of a doctor, that prazotec should be taken 30 minutes before meals.
CONCLUSION
Based on the result of clinical work practice in internal medicine in RSIJ. It can be concluded that the
presence of DRP (Drug Related Problems) in the form of improper and frequency of drug and drug
interaction (simarc and clopidogrel; digoxin and metformin; simarc and prazotec; digoxin and
prazotec; simvastatin and prazotec; prazotec and clopidogrel; simarc and simvastatin).
REFERENCES
1. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung Seto
2. Syamsuddin, Dr. M. Biomed, Apt. 2011. Interaksi Obat Konsep Dasar And Klinis. Jakarta :
Universitas Indonesia Press
3. Mansjoer, A, dkk. 2007. Kapita Selekta Kedokteran Jilid kedua. Jakarta : Media Aesculapius FKUI
1667
4. Harsono,. 2003. Kapita Selekta Neurulogi Edisi Kedua, Yogyakarta : Gadjah Mada University Press
5. Priyanto, Drs. M. Biomed, Apt. 2009. Farmakoterapi and Terminologi Medis. Jakarta : Leskonfi
6. Anonim. 2005. Stocley’s Drug Interactions. The Pharmaceutical Press
7. Sutedjo, AY. 2007. Buku Saku Mengenai Penyakit Melalui Hasil Pemeriksaan Laboratorium.
Yogyakarta : Amara Books
8. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford
9. Karmel TL. Buku Ajar Ilmu Penyakit Dalam Jilid II. Edisi IV. Jakarta : Departemen Ilmu Penyakit
Dalam FK UI.
10. Kamil H, Ihsan, dkk. Data Obat di Indonesia. Edisi 10. Jakarta: Grafidian Medipress.
1668
EVALUATION OF DRUG RELATED PROBLEMS IN DIABETES
MELLITUS DISEASE AND CELLULITIS IN HOSPITAL CENTER
OF ARMY (RSPAD) GATOT SOEBROTO JAKARTA
Samir1, Diana Laila Rahmatillah2, Aprilita Rinayanti Efi2
1
Student of Pharmacist Professional Program Student
Faculty Of Pharmacy UTA’ 45 Jakarta
2
Email: mr_syamer@yahoo.com
ABSTRACT
Diabetes mellitus is a chronic disorder characterized by hyperglycemia due to insulin
deficiency that function allows glucose to enter the cells metabolized as an energy source. Insulin
hormone deficiency can be caused by the destruction of pancreatic beta cells that do not produce
insulin and decreased receptor sensitivity, resulting increase in blood sugar. Cellulitis is an acute
inflammation primarily affects the dermis tissue and subcutaneous with symptoms of fever and
malaise, followed by signs of inflammation are swelling, pain and florid. Patient Mrs. SW, aged 45
years, entered the Emergency Room of Hospital Gatot Subroto Army Center on December 10, 2014
with a diagnosis of diabetes mellitus type II uncontrolled and cellulitis. Pharmacological therapy
given profenid suppository, Novorapid, ampicillin-sulbactam, domperidone, omeprazole, sodium
diclofenac, antacid syrup, Lantus, ramipril, ketorolac, metronidazole, ultracet and clindamycin.
Results of clinical studies found a Drug Related Problems that interaction between ketoprofen with
diclofenak sodium, ketoprofen with ketorolac, antacids with ramipril. Ketorolac, ketoprofen, sodium
diclofenak with ramipril. Novorapid, Lantus with ramipril. There are side effects of adverse drug is
sodium diclofenac, ketorolac, and ketoprofen. The use of klindamycin under therapeutic doses.
Keywords: Diabetes Mellitus, Cellulitis, Gatot Subroto Army Hospital in Jakarta
1669
INTRODUCTION
Diabetes mellitus (DM) is one of Communicable diseases in the world and especially in
Indonesia. The Results of Basic Health Research in 2007 found that the proportion of the cause of
death due to diabetes in the age group 45-54 years old in urban areas was ranked 2nd, that is
14.7%, and the rural areas of this disease is ranked 6th, that is 5, 8%. These findings prove that
diabetes mellitus is a public health issue very serious and takes appropriate care for the sufferer.
Diabetes mellitus (DM) or diabetes is a chronic disorder characterized by hyperglycemia (blood
glucose is too high) and especially regarding the metabolism of hydrate charcoal (glucose) in the
body. The cause is deficiency of insulin hormone that functions allows glucose get into the cells to
metabolized (burned) and used as an energy source. Insulin hormone deficiency can be caused by
the destruction of pancreatic beta cells that do not produce insulin (type 1 diabetes) and decreased
receptor sensitivity to insulin resistance which increases resulting in increased blood sugar (diabetes
mellitus type 2).
Cellulitis is an acute inflammation primarily affects the dermis tissue and subcutaneous. isk
factors for this infection is local trauma (skin tears), open sores on the skin or disruption veins or
lymph vessels. The disease is usually preceded by trauma, because it is a place in the lower leg.
Prodormal cellulitis symptoms are fever and malaise, followed by signs of inflammation are swelling,
pain and florid. Cellulitis is usually caused by positive gram microbe and rarely cause bacteremia ,
research on the 272 cellulitis patients , only 4% of the results of blood tissue encountered
pathogens. Cellulitis gram negative can arise in patients with immune yield.
CASE PRESENTATION
Patient Mrs. SW, aged 45 years old, entered the Emergency Room of Hospital Gatot Subroto
Army Center on December 10, 2014, with the main complaints about pain in the genital bumps since
2 weeks before admission, complaints accompanied by swelling, florid, fatigue conditions, reduced
food intake, there was no itching vaginal discharge and odorless. Current medical history was
diabetes mellitus type II. Previously, she had a history of breast cysts and never had surgery.
Patients diagnosed type II diabetes mellitus uncontrolled and cellulitis.
CLINICAL EVALUATION
Laboratory Examination Results
11 December 2014
1670
Type Examination
Reference Values
result
Hematology
Complete Hematologic
Hemoglobin
12 – 16 g/dL
13,5
Hematocrit
37 – 47%
40
Erythrocytes
4.3 – 6.0 million/μ L
5,7
Leukocytes
4,800 – 10, 800/ μL
18460*
150,000 – 400,000/ μL
512000*
Platelets
calculate type
Basophils
0–1%
0
Eosinophils
1–3%
0*
Stems
2–6%
4
50 – 70%
77*
20 – 40 %
11*
2–8%
8
MCV
80 – 96 fL
71*
MCH
27 – 32 pg
24*
MCHC
32 – 36 g/dL
34
RDW
11,5 – 14,5 %
12,90
Neutrophils
Segment
Lymphocytes
Monocytes
clinical chemistry
glucose curve Daily
<184
182
Blood glucose once
<140 mg/dL
143*
HbA1c
5,7 – 6,4 %
10,4*
Uremia
20 – 50 mg/dL
22
Triglyceridese
0.5 – 1,5 mg/dL
1,0
-/negative
-/negative
glucose at 11
acetone
12 December 2014
1671
Type Examination
Reference Values
result
Blood glucose once
<140 mg/dL
225*
Acetone
-/negative
+/positive*
Type Examination
Reference Values
result
Blood glucose once
<140 mg/dL
237*
Uremia
20 – 50 mg/dL
36
Triglyceridese
0.5 – 1,5 mg/dL
0,7
potassium
3,5 – 5,0 mmol/L
4.8
chloride
95 – 105 mmol/L
98
Acetone
-/negative
-/Negative
Reference Values
result
<184
323*
<100 mg/dL
332*
<140 mg/dL
365*
Type Examination
Reference Values
result
Blood glucose once
<140 mg/dL
319*
Acetone
-/negative
-/Negative
Reference Values
result
14 December 2014
15 December 2014
Type Examination
glucose curve Daily
glucose at 11
daily glucose curve
glucose at 7
Blood glucose once
16 December 2014
17 December 2014
Type Examination
1672
Blood glucose once
<140 mg/dL
230*
Sodium
135 – 147 mmol/L
135
potassium
3,5 – 5,0 mmol/L
5,2*
chloride
95 – 105 mmol/L
98
Acetone
-/negative
-/Negative
Reference Values
result
<100 mg/dL
127*
<140 mg/dL
93
18 December 2014
Type Examination
daily glucose curve
glucose at 7
Blood glucose once
List of Drug Therapy
11/12
Name of drug
Profenid
novorapid
Dosage
1 supp
prn
3x5
UI
ampicilin
4 x 1,5
sulbactam
g
Domperidon
Omeprazol
Na. Diclofenac
Antasida Syr
Lantus
Ramipril
3x10
mg
1 x 20
mg
2 x 50
mg
3 x 1C
1x5
UI
1 x 2,5
mg
Route
6
12/12
1
1
2
2
8
4
Supp
x
sc
x
x
x
iv
x
x
x
Oral
x
x
2
2
8
4
x
x
x
x
x
x
x
x
sc
x
1
2
2
8
4
x
6
12
18
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
24
x
x
x
x
6
14/12
1
x
x
Oral
Oral
1
x
Oral
Oral
6
13/12
1
x
x
x
x
x
x
x
x
x
x
x
x
1673
15/12
Name of drug
Profenid
novorapid
Dosage
1 supp
prn
3x8
UI
ampicilin
4 x 1,5
sulbactam
g
Domperidon
Omeprazol
Na. Diclofenac
Antasida Syr
Lantus
Ramipril
Ramipril
novorapid
Lantus
Ketorolac
Lantus
Novorapid
metronidazole
Ultracet
Klindamicin
3x10
mg
1 x 20
mg
2 x 50
mg
3 x 1C
1x8
UI
1 x 2,5
mg
1x5
mg
3 x 10
UI
1 x 10
UI
Route
3 x 12
UI
3 x 500
mg
3x1
tab
2 x 300
mg
2
2
8
4
6
17/12
1
1
2
2
8
4
x
sc
x
x
increase dose 3 x 10 UI
x
x
x
iv
x
Oral
stop
Oral
x
Oral
x
sc
Oral
x
1
2
2
8
4
x
x
x
x
x
x
x
x
x
x
change Ketorolac
x
x
x
sc
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
sc
oral
24
x
x
sc
oral
18
x
iv
12
Oral
sc
6
x
x
x
x
6
18/12
1
x
x
Oral
mg
UI
1
Supp
3 x 30
1 x 12
6
16/12
1
x
x
x
x
x
x
x
x
x
1674
Vital sign
Physical
11/12
12/12
13/12
14/12
15/12
16/12
17/12
18/12
Blood pressure
116/80
130/90
143/90
124/77
140/92
120/81
140/90
160/90
Body temperature
36,3
36
36
36
36
36
36
36
Pulse
110
90
80
82
80
81
90
80
Respiratory rate
20
20
18
18
20
18
20
18
examination
DISCUSSION
The case studies were conducted on December 11- December 18, 2014 obtained a
complete hematology laboratory test results, counts, and clinical chemistry have increased above
the reference value, among others: leukocytes, platelets, neutrophils, Segment, Mean corpuscular
volume (MCV), blood glucose when, HbA1C . It found a decrease in the levels and mean corpuscular
hemoglobin esinophil (MCH). Increased levels of leukocytes usually indicates infection resistance
and stress state. Increasing the value of platelets is usually caused due to inflammation, increased
neutrophils caused by bacterial and parasitic infections, disorders of metabolites, and bleeding.
Increasing the value of MCV seen in liver disease, alcoholism, antimetabolic therapy, folate
deficiency / vitamin B12, and valproate therapy, also called macrocytic anemia. an increase in blood
glucose levels when, positive urine containing glucose and HbA1c increased indicate diabetes, MCH
decline indicates microcytic anemia.
Patient with a diagnosis of diabetes mellitus type II uncontrolled vaginal complications
sellulitis is given pharmacological therapy: rofenid suppositories (ketoprofen), Novorapid, ampicillinsulbactam, domperidone, omeprazole, sodium diclofenac, antacid syrup, Lantus, ramipril, ketorolac,
metronidazole, ultracet and clindamycin.
Profenid use as antiinflammatory only given when the patientexperienced pain again in the
vagina so that not every day is given. Domperidone 3 x 1 is given when the patient experienced
nausea and stopped state after the condition of nausea becomebetter. Use of Sodium diclofenak 2
x 50 mg as antiinflammatory since 11/12 and 16/12 discontinued and replaced with ketorolac
intravenously. Reason stopped diclofenac sodium for patient experiencing pain in the stomach state
which is a side effect of the drug. Since the beginning of the treatment patient were also given an
1675
antacid syrup 3 x 1 tablespoon and 1 x 20 mg omeprazole because the patient has a history of
gastritis. 1 x 2.5 mg ramipril started on 14/12 due to the patient's blood pressure since 2 days earlier
stage 1 hypertension and normal after administration of ramipril. 5/12 blood pressure back up
(stage 1) so that the dose of ramipril increased 1 x 5 mg. Novorapid 3 x 5 UI and Lantus 1 x 6 UI was
given since the beginning of treatment and the dose increased according by value of glucose levels.
5/12 blood pressure back up (stage 1) so that the dose of ramipril increased 1 x 5 mg. Novorapid 3 x
5 UI and Lantus 1 x 6 UI was given since the beginning of treatment and the dose increased
according by value of glucose levels while. The results of blood and tissue examination 17/12
acquired resistance is not visible growth of bacteria, and not done a test of resistance. 17/12 was
given 3 x 500 mg metronidazole and clindamycin 18/12 was given 2 x 300 mg orally for an abscess in
the prevention of vaginal and skin infections.
The use of ampicillin-sulbactam for urinary tract infections, skin infections
and skin
structure. Metronidazole as antimicrobial for anaerobic bacteria and protozoa, and clindamycin for
gram-positive bacteria and staphylococci are resistant to penicillin. Profenid suppositories,
diclofenak sodium, ketorolac, antipyretic and analgesic ultacet as antiinfalamasi, Novorapid and
Lantus for diabetes with uncontrolled blood glucose levels. omeprazole and antacids for peptic
ulcers and ulcer-related non-steroidal anti-inflammatory drugs. Ramipril as antihypertensive drugs.
Vital sign the patient's blood pressure did not show real improvement effect, but just
increased blood pressure hypertension stage II category is 150/90 mmHg despite dose of ramipril
increased from 1 x 2.5 mg to 1 x 5 mg. This condition can be due to a drug interaction between
sodium diclofenac, ketoprofen, ketorolac and provided with ramipril. The drug can reduce the
effects of ramipril by antagonism pharmacodynamic drug with reduced renal prostaglandin
synthesis vasodilatation, and thus affect the homeostasis of fluid and can reduce the
antihypertensive effect. ain in the stomach often perceived by the patient. The condition is likely
due to the side effects of ketoprofen, ketorolac, sodium diklofenac that can stop the formation of
prostacyclin (PGI2) are powerless to protect the gastric mucosa and inhibits acid production, so that
thereby responsible for the side effects of irritation of the stomach and intestines. Inhibition of
gastric mucosal protection allows the patient more susceptible to pain with a history of gastritis.
The use of antibiotics since the beginning of treatment and in combination with other
antibiotics because of the results of laboratory tissue to explain the unknown type of bacteria that
1676
infect so that a combination with other antibiotics to prevent antibiotic resistance with
monotherapy. The use of antibiotics is also based combination therapy to obtain a synergistic effect
in the treatment of cellulitis infection.
1.
Drug Interactions
a.
Ketoprofen with ketorolac and diclofenac sodium ketoprofen has a synergistic effect that
can increase the toxicity of each drug.
Pharmacist Intervention: Should one of these drugs was stopped because the drug was
contraindicated therefore not recommended for combination unless there is no alternative and the
benefit outweigh the risks.
b.
Ketoprofen with ketorolac or ketoprofen with diclofenac sodium may increase the
anticoagulant, so that necessary measures to avoid the occurrence of bleeding. In addition, these
drugs can also cause increase in serum potassium.
Pharmacist Intervention: Recommended one of these medications were discontinued or provide a
time interval of each drug administration with special monitoring.
c.
Rampiril may increase the effect novorapid and lantus
Pharmacist Intervention: although this interaction is benefit to diabetics, should be strict
monitoring of blood glucose levels to avoid the occurrence of severe hypoglycemia.
d.
Sodium diclofenac, ketoprofen, and ketorolac may reduce the effects of ramipril drug by
antagonism pharmacodynamic. NSAIDs reduce prostaglandin synthesis renal vasodilation, and thus
affect the homeostasis of fluid and can reduce the antihypertensive effect.
Pharmacist Intervention : This drug has the potential for harmful interactions. Use with caution and
monitor blood pressure closely. If there is no other alternative or the benefits outweigh the risks can
be given interval timing of of each drug.
e.
Antacids may increase the effect of rampiril
Pharmacist Intervention: blood pressure monitoring should be done to avoid the occurrence of
severe hypertension and given interval timing of of each drug.
2.
Drug Side Effects
Sodium diclofenac, ketorolac, ketoprofen can cause gastrointestinal irritation, ulcers, until the
bleeding so that aggravate the condition of gastritis patient.
1677
Pharmacist Intervention: to reduce these side effects, the lowest effective dose should be given to
the shortest possible duration of treatment.
3.
Improrer Dose
Clindamycin oral dose for adults is 150-300 mg every 6 hours and can be increased to 450 mg every
6 hours. in this case only given a dose of 300 mg every 12 hours or the dose is too small.
Pharmacist Intervention: Low doses can cause drug resistance so we need a dose adjustment in
accorandce with therapeutic doses.
CONCLUSION
Based on the results of clinical studies at the Central Hospital of the Army (Army Hospital)
Gatot Subroto can be concluded that there was Drug Related Problems (DRP) that was the
interaction between ketoprofen with diclofenak sodium, ketoprofen with ketorolac, antacids with
ramipril. Ketorolac, ketoprofen, sodium diclofenak with ramipril. The using of clindamycin drug
under therapeutic doses.
REFERENCES
1. Depkes, RI, 2008. Riset Kesehatan Dasar. Baand Penelitian and Pengembangan Kesehatan.
Departemen Kesehatan RI. Jakarta
2. Tjay. T,H., and Rahardja,K, 2007. Obat-Obat Penting : Khasiat Penggunaan and Efek-efek
samping. Edisi VI. Jakarta : Elex Media Komputerindo.
3. Djuanda, adhi, 2008. Ilmu Penyakit Kulit and Kelamin. Seventh edition . Fakultas Kedokteran
Universitas Indonesia. Jakarta
4. Swartz MN. 2004. Cellulitis. N Eng J Med. 350; 904-12
5. Kementerian Kesehatan, RI, 2011. Pedoman Interpretasi Data Klinis. Jakarta.
6. BPOM, RI, 2008. Informatorium Obat Nasional Indonesia. Koperpom. Jakarta
7. Medscape. 2014. Multi-Drug Interaction Checker.
8. World Health Organization, 2001. WHO global strategy for containment of antimicrobial
resistence. Switzerland.
1678
DRUG RELATED PROBLEMSTHERAPY FOR IMPAIRMENT OF
CONCIOUSNESS IN PATIENT WITH EPILEPSY AND
TUBERCULOUS MENINGITIS SUSPECTED
IMMUNOCOMPROMISED
Cindra Dewi Talib1 , Diana Laila Ramatillah2, Aprilita Rinayanti Efi2
1
Student of Pharmacist Professional Program, Faculty of Pharmacy
2
Lecturer of Faculty of Pharmacy
Tujuh Belas Agustus 1945 University, Jakarta, Indonesia
E-mail : Cindradewi_thalib@yahoo.com
Tlp : +62-87889958514
ABSTRACT
Epilepsy is an oldest neurological disease, found in all ages and can cause impairment and
mortality1. Allegedly there are about 50 million people with epilepsy in the world1. Active epilepsy
population is estimated to be between 4 to 10/1000 inhabitants per year, in developing countries is
estimated 6 to 10/1000 inhabitants per year1. Meningitis is one of the causes of death of children
and adults in many countries in the world2. Bacterial meningitis is always a threat to global health2.
Data from WHO in 2009 estimated the number of cases of meningitis and other neurological
approximately 500.000 cases with Case Fatality Rate (CFR) 10% worldwide2.
Case Presentation: Male patient with initials Mr. S.S, 22 years old, weight 45 kg, entered the Gatot
Soebroto Hospital, diagnosed Impairment of consciousness and epilepsy, tuberculous meningitis,
and suspected immunocompromised.
Clinical Evaluation: Basically, there wereseveral interventions made during the development of the
patient. The first one was advising which was to minimize the hepatotoxic effects of antiepileptic
drugs, suggesting corticosteroid therapy (Dexamethasone) in accorandce with the recommended
dosage, and minimizing the undesirable effects of antiepileptic drugs interactions5,6,7,9.
Keywords : Epilepsy, Seizures, Tuberculous Meningitis, Gatot Soebroto Army Hospital Center.
1679
1.
Introduction
Epilepsy is a brain disorder manifestations with various etiologies, but with typical symptoms, such
as periodic attacks caused by excessive release of cortical neurons electrical charge3. Singular attack
can not be used as a reason to uphold a diagnosis of epilepsy4.
Epilepsy declare a periodically recurring attacks with or without seizures6. The attack caused by
overloaded cortical neurons and is characterized by changes in the electrical activity as measured by
the Electro-ensefalogram (EEG)6. Seizures stated severity of smooth muscle contraction
uncontrolled6. Trigger factor epilepsy include fatigue, lack of sleep, hormonal, psychological stress,
alcohol10.
Meningitis is an inflammation reaction of one or all of the membrane / membranes (meninges) that
encloses the brain tissue or spinal cord, causing changes in the cerebrospinal fluid (exudate) of pus
or serous8. Which is usually caused by bacterial, viral and fungal organisms8. Tuberculous meningitis
is an inflammation reaction of the lining of the brain caused by basil tubercles8.
Immunocompromised patients are patients who are stricken with reactivation TB germs or a new
infection5.
2.
Case Presentation
Male patient with initials Mr. SS, 22 years old, weight 45 kgs, entered the Gatot Soebroto Army
Hospital Center on 10 December 2014 at: 00:46 am with a diagnosis: Impairment of consciousness
and epilepsy, tuberculous meningitis and suspected immunocompromised. Patient presents with a
decline in awareness since 5 hours before hospital admission, fever since 3 days before admission,
arms rigid, and could not speak, denied pain, and no nausea, vomiting and cough, drastic weight loss
also denied.
Patient already taking antiepileptic drugs and often do control to the neurologist. History of allergy
was denied, but the patient has a family history of disease that the patient's father had experienced
seizures as a child. Patient also experienced the ineffectiveness of cerebral tissue perfusion with
somnolent consciousness level.
At the time of admission the patient immediately given intravenous RL 20 dpm, milk Entrasol per
NGT 200 cc, Phenytoin 100 mg Intra Venous slowly, Dexamethasone Drips 3 x 50 mg,
Dexamethasone IV Injection 4 x 5 mg, Ceftriaxone IV Injection 2 x 2000 mg, Citicoline IV Injection 2 x
1680
1000 mg, Ranitidine IV Injection 2 x 1 ampoule, Depakote 250 mg 3 x 1 tablet, Carbamazepine 200
mg 3 x 1 tablet, and blender 1800 cal of food per 24 hours per NGT.
Then haematological test that included hemoglobin, leukocyte and differential count, hematocrit,
platelets, peripheral blood smear, liver function tests (ALT / AST), check electrolytes (Sodium,
Potassium, Calcium, Magnesium), urea, triglyceridese and albumin, CT Scan of the head, thorax
photos, AGD test,. The assessment found that abnormally high values of AST 51 U/L (normal
value<35 U/L), alanine aminotransferase 72 U/L (normal value<40 U/L), leukocyte count 13,090/µL
blood (reference value 4800-10800/µL) and also from the results of a CT scan of the head are both
hersisfer cerebral vasogenic edema.
3.
Clinical Evaluation
Anti-epileptic drugs was aimed to prevent seizures by delivering an effective dose of one or more
antiepileptic5. This therapy was to see that people with epilepsy can live a normal life and achieve
optimal quality of life for persons with mental possess5.
Epilepsy therapy that has been given at the time of the patient treated in the emergency unit is
Infusion RL 20 dpm, Intra Venous Phenytoin 100 mg given slowly to cope with seizures, Depakote
250 mg 3 x 1 tablet per NGT, Carbamazepine 200 mg 3 x 1 tablet per NGT . This therapy is a first-line
therapy for patients with epilepsy with tonic-clonic seizures6.
The additional diagnosis was tuberculous meningitis, the patient was given symptomatic treatment
such as IV injection of 4 x 5 mg Dexamethasone to prevent cerebral edema and as a supportive
therapy of meningitis, Ceftriaxone IV injection 2 x 2000 mg for severe infections, Citicoline 2 x 1000
mg in the treatment of loss of consciousness because of acute cerebral infarction, neurological
disorders or brain damage, Ranitidine IV Injection 2 x 1 ampoule to prevent stress ulcers.
4. Drug Related Problem (DRP)
4.1.DRP I : The dose was too low
Based on the British National Formulary No. 51, giving Dexametasone IV injection for the treatment
of meningitis treatment supporters, was given in a dose of 10 mg every 6 hours for 4 days 5,7.
However, patient was treated with Dexamethasone IV injection dose of 4 x 5 mg and already more
than 4 days. This can lead to a lack of effective treatment in doses that do not fit.
Pharmacist Intervention: suggest to the doctor to stop Dexamethasone therapy in tappering off
(gradually) 5,7,11.
1681
4.2. DRP II : Drug reactions were not desired
The use of anti-epileptic drugs can cause hepatotoxicity5,6,7, so it needed to be given
hepatoprotective to protect the liver of patient. It was also evident from patient’s high SGOT / SGPT
values.
Pharmacist Intervention: suggest to the doctor to prescribe HP Pro5,6,10.
4.3. DRP III : Drug Interactions
Drug interaction with a significant effect between:

Phenytoin and Carbamazepine
Phenytoin Carbamazepine lowering serum levels due to induction of enzymes that speed up
metabolism Carbamazepine. The effect may not be visible. Need to be monitored serum
concentrations in the blood of both drugs11.
Pharmacist Intervention: Suggest to the doctor to provide spacing for drug delivery is approximately
2 hours, controlling the levels of phenytoin in blood because phenytoin toxicity can also cause
seizures4,7,11.

Phenytoin with Depakote (Valproate Sodium)
The possibility of an increase in the effects of phenytoin, and decrease the effects of Depakote
causing phenytoin toxicity.
Need to be monitored serum concentrations in the blood of both drugs.
Monitoring the levels of free drug (phenytoin) in the blood to avoid toxicity11.
Pharmacist Intervention: Suggest to the doctor to provide spacing for drug administration is
approximately twohours, controlling the levels of phenytoin in blood because phenytoin toxicity can
also cause seizures4,7,11.

Dexamethasone with Phenytoin
The effects of steroids may be reduced at the start of giving Phenytoin. This is because phenytoin
may be induce enzymes to speed up the metabolism of steroids by the enzyme 6-BetaHydroxylated. However, dexametason also can lower serum levels by increasing the clearance
Phenytoin Phenytoin in the liver. Should be given range to give the both of drugs11.
2 hours, controlling the levels of phenytoin in blood because phenytoin toxicity can also cause
seizures4,7,11.
1682

Carbamazepine with Depakote (Valproate Sodium)
The interaction of these two drugs led to decrease the effects of Depakote making it possible to lose
control of convulsions or seizures. Monitoring of serum levels of both drugs and seizures or
convulsions that occur in patients during the first months after administration or the discontinuation
one of drugs obove. Dose adjustment is also needed11.
2 hours5,7,11.
5. Conclusion
After discussions with the Physician in charge of patient care, drugs used were in accorandce with
the Standards of Medical Services in the Gatot Soebroto Army Hospital and the Association
Standards of Medical Care Specialist Doctor Nerve Indonesia (PERDOSSI 2014) for Epilepsy disease
and tuberculous meningitis. From the analysis of drug-related problems (Drug Related Problems)
can be deduced the presence of drug administration at a dose that was too low, unwanted drug
reactions and drug interactions with drugs had an adverse effect on the patient's condition if not
treated properly.
REFERENCES
1. WHO.
Epilepsi.
WHO
Fact
Sheet
October
2012
:
number
999.
Available
at
:
http://www.who.int/mediacentre/factsheet/fs999/en/. Downloaded on 15 February 2014.
2. WHO.
Meningitis.
Number
of
Meningitis
Epidemics.
2014.
Available
at
:
http://www.who.int/gho/epidemic_diseases/meningitis/epidemic_districts/en/. Downloaded on 15
February 2014.
3. Mardjono and Sidharta. 2008. Neurologi Klinis Dasar. Cetakan ke-12. Jakarta : Dian Rakyat.
4. Harsono. 2007. Klasifikasi Bangkitan Epilepsi and Penjelasannya dalam Epilepsi. (Ed. II).
Yogyakarta : Gajah Mada University Press. Page : 26-35
5. Baand Pengawas Obat and Makanan Repubik Indonesia. 2008. Informatorium Obat Nasional
Indonesia. Jakarta : BPOM RI, KOPERPOM, andCV Sagung Seto.
6. Sukandar, Elin Yulinah, Dkk. 2008. ISO FARMAKOTERAPI. (Ed. I). Jakarta : PT. ISFI Penerbitan.
7. British Medical Association and the Royal Pharmaceutical Society of Great Britain. 2009. British
National Formulary 57. Britain : United Kingdom Pharmacist.
1683
8. Muttaqin, Arif. 2011. Buku Ajar Asuhan Keperawatan Klien dengan Gangguan Sistem Persarafan.
Jakarta : Salemba Medika.
9. Direktorat Bina Farmasi Komunitas and Klinik, Departemen Kesehatan Republik Indonesia. 2009.
Pedoman Pemantauan Terapi Obat. Jakarta : Depkes RI.
10. Persatuan Dokter Spesialis Saraf Indonesia. 2014. Pedoman Tatalaksana Epilepsi. Jakarta :
PERDOSSI.
11. Tatro DS (ed). 2004. Drug Interaction Facts 2004. Facts and Comparisons, St. Louis, MO.
12. Tim Penyusun Tenaga Medik. 2014. Standar Pelayanan Medik di RSPAD GATOT SOEBROTO
DITKESAD. Jakarta : RSPAD Gatot Soebroto.
1684
EVALUATION OF MEDICINE AND THERAPY FOR
HEBEPHRENIC SCHIZOPHRENIA WITH TRAUMATIC BRAIN
INJURY
Arestya Otari1, Diana Laila Ramatillah2, Aprilita Rinayanti Efi2
1
Student of Pharmacist Professional Program, Faculty of Pharmacy
2
Tujuh Belas Agustus 1945 University, Jakarta, Indonesia
E-mail: arestyaotari@rocketmail.com
ABSTRACT
Schizophrenia is a mental illness and medical condition which affects human brain function,
influencing normal cognitive, emotional, and behavioral funCtion5.Hebephrenic schizophrenia is the
most serious type, in which sufferers experience mental regression to a childlike state, remaining in
silence and refusing to communicate with others4.
The patient, age 47-year-old woman, wight 150 cm and 35 kg in weight, has been hospitalized for
one month with a diagnosis of hebephrenic schizophrenia with traumatic brain injury1. She became
ill for the first time after divorcing from her husband. She received treatment of two 2-mg tablets of
risperidone and 2-mg tablets of trihexyphenidyl twice every twelve hours, morning and evening, as
well as 25 mg of clozapine once every 24 hours.
Clozapine and risperidol together can have a heightened anti-dopamine effect which can cause
Neuroleptic Malignant Syndrome, which have the potential to interact and increase lingering
sedative effects.
Keywords: schizophrenia, hebephrenic schizophrenia, NMS
1685
Introduction
Schizophrenia can occur in anyone: data from the American Psychiatric Association (APA) from 1995
indicates that 1% of the world's population suffers from schizophrenia2. 75% of sufferers begin
showing symptoms between the ages of 16 and 25 Adolescents and young adults are at high risk
because their life at that stage is full of stressors2. Their condition often goes unrecognized by
friends and family because it's considered to be simply a phase of adaptation or discovering
oneself2.
Schizophrenia is a mental illness and medical condition that affects human brain function,
specifically cognitive, emotional and behavioral functions4. As a psychosis, it is most characterized
by loss of affective feeling or emotional response and withdrawal from normal interpersonal
relations4. It is often accompanied by delusions (false beliefs) and hallucinations (perceptions
without the stimulation of the senses)4. Its cause is neurobiological, for example an imabalance of
dopamine, a chemical cell in the brain. In patients, a decline in transtiretin or pre-albumin, a bearer
of the hormone thyroxine, which causes problems in the cerebro-spinal pathway4.
Hebephrenic schizophrenia is the most serious type, in which experiences a mental regression to a
child-like state. Patients only stay in one place and don't communicate with anyone4.
Organic mental disturbances are are mental disturbances and behavior caused by the presence of
organic brain syndromes or brain dysfunction from a variety of causes, for example infection, brain
trauma, and systemic illnesses that affect metabolism and hormonal function, and mental
disturbances and behavior as a result of psychoactive drugs, which disrupt social function or work4.
Various annesti syndromes and hallucinations, organic suspicion syndrome, organic affective
syndrome, organic personality syndrome, intoxication and withdrawal 4.
Case Presentation
The patient a 47-year-old, 35 kg, 150 cm woman, was admitted to the hospital at 11:00 on
November 21, 2014, with a diagnosis of hebephrenic schizophrenia with mental disturbance as a
result of traumatic brain injury1.
1686
The patient has a history of serious alcoholism. She first became ill at the age of 30 when she
divorced her husband1. She was easily angered and asked for an analgesic to help with a headache,
refused to bathe or eat, often talked to herself and ran away1. The triggering factor was being
divorced by her husband, her work and social functions were so disrupted that she couldn't be
engaged in conversation1. In general, she appeared old, undernourished, and messy1.
At the time of being admitted the patient was immediately given 2 2-mg tablets of risperidone and 2
2-mg tablets of trihexyphenidyl twice every 12 hours, morning and evening, as well as 25 mg of
clozapin every 24 hours1. Clozapin was administered for one week before being substituted with
donepezil at a dosage of one 2.5-mg tablet every 24 hours in the afternoon1. On December 6th she
suffered a fall and was given mefanamic acid and ciprofloxacin1.
A hematological examnation was conducted, encompassing hemoglobin, leukocyte and blood count,
hematocrits, thrombocytes, peripheral blood smear, heart function test (SGPT/SGOT), electrolyte
test (sodium, potassium, calcium, magnesium), urine, triglyceridese and albumen, a CT scan, and
chest X-ray. The result of the tests was abnormal levels of hemoglobin, 11.3 (reference 12-16 g/dL),
and thrombocytes, 40200/uL (150,000-400,000/uL), and the result of the CT scan showed
intraventicular lesions III causing obstructive hydrocephalus and left mastoiditis1.
Clinical Evaluation
Antipsychotics are a class of psychotropic drugs. Psychotropik medicines affect psychic function,
behavior and experience3. Antipsychotics work to control hallucinations, delusions, and changes in
mindset that occur in schizophrenia3.
3.1 DRP 1 (Drug Related Problems)
During treatment the patient was given various antipsychotics, among others risperidone, clozapine,
and trihexyphenidyl. There were drug interactions, among others:
1687
Risperidone in combination with trihexyphenidyl can increase the phramacodynamic effect of
trihexyphenidyl. At the same time, clozapine in combination with with risperidone can increase its
antidopamine effect, giving rise to Neuroleptic Malignant Syndrome which has the potential to
interact and induce an extended sedative effect. Clozapine in combination with trihexyphenidyl also
increases the pharmacodynamic effect of trihexyphenidyl.
Inteference of the Pharmacy
If one drug increases the effect of another, together they could decrease the desired effect of the
therapy. For this reason, adjustment of dosage and spacing of the administration of the various
drugs is necessary6.
3.2 DRP 2(Drug Related Problems)
Clozapine causes Neuroleptic Malignant Syndrome, an idiosyncratic reaction that doesn't depend on
initial blood levels. NMS can occur with only one does of neuroleptics, usually developing within the
first four weeks after beginning treatment. It mainly develops 24-72 hours after the administration
of neuroleptics, Autonomic dysregulation symptoms include tachycardia, fever, and a rise in blood
pressure. Extrapyramidal symptoms include tremors while sleeping, dystonia, and dyskinesia. NMS
affects laboratory results, increasing levels of triglyceridese and causing leukocytosis,
thrombocytosis, and dehydration3.
Interference of the Doctor
The use of clozapine was halted and replaced with donezepil1.
Interference of the Pharmacy
Clozapine caused NMS, resulting in the administration of donezepil3.
Conclusion
From this case it be can be concluded that schizophrenia can befall anyone, and hebephrenic
schizophrenia is a considerably serious variant. This illness is often discovered late by family and
acquaintances because it's considered to be a normal aspect of development. In the administration
1688
of antipsychotics first at the lowest possible dosage, then gradually increasing to a higher dosage
(tapering off), it is necessary to monitor the interaction of each drug in order to avoid causing
Neuroleptic Malignant Syndrome, which can result in a fatal administration of medicine. If drugs
interact, it is best if their administration is spaced or dosage is reduced in order to achive the desired
therapeutic effect.
REFERENCES
1. Constituent Medical Personnel Team. 2014. Medical Treatment Standards in RSPAD GATOT
SUEBROTO DIKESAD. Jakarta: RSPAD Gatot Suebroto.
2. Yosep Iyus. 2013. Keperawatan Jiwa. edisi ke-3. Bandung: Refika Aditama. Hal 59-75.
3. Maslim, r: Pedoman Penggolongan And Diagnosis Gangguan Jiwa Di Indonesia, Edisi 3, Direktorat
Kesehatan Jiwa Departemen Kesehatan RI.Jakarta.2002. Hal 46-51
4. Hawari Daandg. 2003 . Schezophrenia Dalam Pendekatan Holistik Pada Gangguan Jiwa, Penerbit
FKUI. Jakarta .
5. Kaplan & Sadock: “Schezophrenia” Dalam Sinopsis Psikiatri Jilid 1, Edisi 7, Penerbit Bina Rupa
Aksara .Jakarta .1997. Hal 685-729
6. Saragi Sahat. 2012. Panduan Penggunaan Obat. Rosemata Publiser. Jakarta.
1689
TREATMENT OF THE CHRONIC KIDNEY DISEASE (CKD)
PATIENT IN THE PGI HOSPITAL CIKINI JAKARTA
Nancy Tangkelangi1, Diana Laila Rahmatillah2, Aprilita Rinayanti Efi2, Stefanus Lukas2
1
Student of Pharmacist Professional Program Student, Faculty Of Pharmacy UTA’45 Jakarta
2
Email: tangkelangi.nancy@yahoo.com
ABSTRACT
Renal failure is usually divided into two broad categories namely chronic and acute1. Chronic renal
failure is a progressive development of renal failure and slow (usually lasting several years), whereas
acute renal failure occurs within a few days or a few weeks1. In both cases, the kidneys lose their
ability to maintain the volume and composition of body fluids in a state of normal food intake.
Although functional disability were similar in both types of terminal renal failure, but acute renal
failure have a typical illustration and will be discussed separately1. Mrs.MS patients, aged 66 years,
entered PGI Cikini Hospital on September 7, 2014 with a diagnosis of CKD (Chronic Kidney Disease).
Therapy treatment for hospitalized was rindopump inj, onandcetron 8mg inj, glucodex, folic acid
tablets, gliquidon tab, lactulax syr, Hp. pro stamp, PCT 500mg tabs. Based on the results, it can be
deduced that the presence of DRP (Drug Related Problems) form patient was onandsetron treanng
for patient drug with hepatic impairment which one maximum dose at 8 mg daily, so the decrease
in drug onandsetron in patient should be lowered of 16mg daily to 8 mg daily3.
Keywords: Chronic Kidney Disease Haemodialisis and PGI Cikini Hospital.
1690
INTRODUCTION
Chronic kidney disease is a pathophysiological process with diverse etiologies, resulting in a
progressive decline in renal function and generally end up with kidney failure. Furthermore, renal
failure is a clinical condition characterized by an irreversible decline in kidney function, to the degree
that requires renal replacement therapy which remains, in the form of dialysis or kidney
transplantation2.
Chronic renal failure or end stage renal disease (ERSD) is a progressive disorder of renal function and
the irreversible metabolism and ability tubules maintain fluid and electrolyte balance, causing
uremia, chronic renal failure or end stage renal disease (ERSD) is a progressive renal dysfunction and
the irreversible metabolism and ability tubules maintain fluid and electrolyte balance, causing
uremia4.
Chronic renal failure (CRF) is damage to renal physiology is almost always can not be recovered, and
can be caused by various things. The term uremia has been used as the name of this state for more
than a century, although now we realize that the symptoms of chronic renal failure was not entirely
due to the retention of urea in the blood4.
Chronic renal failure occurs after a variety of diseases that damage the kidney nephron mass. Most
of this disease is a disease of the renal parenchyma diffuse and bilateral, despite the obstructive
lesions of the urinary tract can also lead to chronic renal failure. At first, some kidney disease
primarily affects glomerular (glomerulonephritis), whereas other species mainly attack tubuls kidney
(pyelonephritis or polycystic kidney disease) or may also interfere with blood perfusion of the renal
parenchyma (Nephrosclerosis). However, when the disease process is not inhibited, then in all cases
the entire nephron eventually destroyed and replaced by scar tissue1.
The criteria for chronic kidney disease are1:
1 Kidney damage that occurred during the 3 months or more, such as abnormalities of structure or
function of the kidney, with or without decreased glomerular filtration rate (LGF), by:
- Pathological abnormalities.
1691
- A sign of kidney damage, including abnormalities in the composition of the blood or urine, or
abnormalities in imaging examination.
2. GFR <60 ml / min / 1.73 m2 were going for 3 months or more, with or without kidney damage.
Chronic renal failure was defined as a progressive decline in renal function were reversible and not
caused by different types of diseases. Underlying disease difficult to recognize when it has severe
kidney failure. When the glomerular filtration rate (GFR) falls below 25-30% of the normal rate, the
kidneys may become unable to excrete the remains of nitrogen, adjust the
volume and electrolyte, and secretes hormones.
CASE PRESENTATION
Patients aged 66 years Mrs.MS entered PGI Cikini Hospital on September 7, 2014. Patient present
with pain of the right lower abdomen accompanied by severe nausea and vomiting.
CLINICAL EVALUATION
Inj rindopump use to treat stomach pain, nausea Onandcetron for folic acid to patients. Lactulax
used to laksativa and Hp.pro to supplement the liver as well as the PCT for analgesic and antipiretic.
DOSAGE AND USE3
No.
Drugs
Giving method
Dose
Indications
1.
Rindopump Inj
IV
2 X 1 amp daily
Antibiotic
2.
Onandcetron 8mg
IV
2 X 1 amp daily
Vomiting Sick
Inj
3.
Glucodex
PO
1 x 80 mg daily
Antidiabetic
4.
Asam Folat tab
PO
1 X 2 tab daily
Suplement
5
Gliquidon tab
PO
1 x 1/2 tab daily
Antidiabetic
6
Lactulax syr
PO
1 X 1 C daily
Laksantiva
7
Hp. Pro cap
PO
2 X 1 cap daily
Liver supplement
8
PCT 500mg tab
PO
3 X 1 tab daily
Analgetic and
Antipiretic
CLNICAL LABORATORY VALUES
Type of
Result
Unit
Normal value
1692
examination
Hemoglobin
*9,1
g/dL
13,0-16,0
Hematocrit
44
%
40-48
Leukocytes
9,1
10^3 µL
5,0-10,0
Platelets
259
10^3 µL
150-450
Reticulocyte
*18
µg/L
5 – 15
Type of
Result
Unit
Normal value
Freezing period
10 - 11
minutes
10,0 – 16,0
APTT
32,6
second
26,4 – 37,5
PT
12,5
second
11,0 – 14,2
Fibrinogen
225
mg/dL
180 – 350
Total Protein
7,3
g/dL
6,0 – 8,0
Albumin
3,5
g/dL
3,4 – 4,8
Globulin
*3,8
g/dL
1,3 – 3,7
Urea
*101
mg/dL
10 – 50
Triglyceridese
*3,0
mg/dL
0,6 – 1,1
Sodium
*156
mmol/L
135 - 147
Potassium
3,5
mEq/l
3,5 – 5,0
examination
GUIDELINE PAIN
1693
MANAJEMEN TREATMENT CKD (CHRONIC KIDNEY DISEASE)
DRUG RELATED PROBLEM
The dose was too large (Over Dosage): Where for patient who treated in hospital. Cikini patient was
receiving onandsetron drug 16mg daily, while according to the literature, the dose for patient with
hepatic impairment is a maximal dose of 8 mg daily3. Thus lowering the dose of the drug
onandsetron in patient should be lowered from 16mg daily to 8 mg daily3.
Pharmaceutical
Interventions
:
doses
of
the
drug
onandsetron
at
8mg
daily
3.
CONCLUSION
Based on the result, it can be deduced that the presence of DRP (Drug Related Problems) form of
the dose is too large (Over Dosage): The use of onandsetron in patient with hepatic impairment
maximum dose is 8 mg per day. Thus decrease drug onandsetron in patient should be lowered from
16mg daily to 8 mg daily3.
1694
REFERENCES
1. A. Price, Sylvia & M. Wilson, Lorraine. 2005. Edisi 6. Vol.2. Gagal Kidney Kronik. Patofisiologi
Konsep Klinis Proses-proses Penyakit. Jakarta: EGC .
2. Aru W Sudoyo, dkk. 2009. Jilid 3. Edisi V. Penyakit Kidney Kronik. Buku Ajar Ilmu Penyakit Dalam.
Jakarta : Interna Publishing.
3. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford.
4. Smeltzer, Suazanne C. 2001. Edisi 8. Volume 2. Gagal Kidney Kronik. Buku Ajar Keperawatan
Medikal-Bedah Brunner & Suddarth. Jakarta: EGC.
5. Sibuea, W Herdin, dkk. 2005. Penanggulangan Gagal Kidney Kronik. Ilmu Penyakit Dalam.
Jakarta : AsdiMahasatya.
6. Jay H. Stein, MD. 2001. Panduan Klinik Ilmu Penyakit Dalam.Jakarta : EGC.
1695
DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT
FOR CEREBROVASCULAR DISEASE PATIENT IN PGI CIKINI
HOSPITAL
Marisca Theresia Thomas1, Diana Laila Ramatillah2, Stefanus Lukas2
1
Student of Pharmacist Professional Program Student, Faculty of Pharmacy UTA'45Jakarta
2
Email : makikozweet@rocketmail.com
ABSTRACT
Cerebral Vascular Disease or Stroke (CVD) is a loss of brain function caused by the cessation of blood
supply to the brain1. Stroke is also a brain disorder both functionally and structurally caused by
pathological state of cerebral vessels or of the entire vascular system of the brain2.
Case Presentation: Mrs. SZ 65 years old came to PGI Cikini Hospital with complaints of slurred
speech, restlessness and weakness.Three days before hospitalized, the patient greenness vomiting
and migraine headache. At that time, the patientgot fever and cough with thick white mucus.
Patient was suspected for decreasing of cognitionthat caused by CVD.
Clinical Evaluation: During the treatment, patient received 9kinds of drugs : Ceftriaxone, Soholin
(Citicoline),
Aspilet
(Acetylsalicylic
acid),
Simvastatin,
Omeprazole,
Cilostazol,
Toplexyl
(Oxomemazine, Guaifenesin), Captopril and Albumin.
Towards profile treatment of Mrs. SZ,there wereDRPs (Drug Related Problems) such asFailure to
receive medication, Untreated indication and Drug interactions.
Keywords: Cerebral Vascular Disease, Drug Related Problems, PGI Cikini Hospital
1696
1.
Introduction
Cerebral Vascular Disease or Stroke (CVD) is a loss of brain function caused by the cessation of blood
supply to the brain1. Stroke is also a brain disorder both functionally and structurally caused by
pathological state of cerebral vessels or of the entire vascular system of the brain2. Stroke usually is
caused by one of the four case: (1) thrombosis (blood clots in the blood vessels of the brain or neck),
(2) cerebral embolism (a blood clot or other material brought to the brain from other parts of the
body), (3) ischemia (decreased blood flow to areas of the brain) and (4) cerebral hemorrhagic
(rupture of cerebral blood vessels and bleeding into the brain tissue or the space around the brain)1.
2.
Case Presentation
Mrs. SZ 65 years old came to PGI Cikini Hospital with complaints of slurred speech, restlessness and
weakness. Three days before hospitalized, the patient greenness vomiting and migraine headache.
At that time the patientgot fever and cough with thick white mucus. Patient was suspected of
decreasing cognitionthat caused by CVD. The patient also had a history of Hypertension and
Diabetictype II, it was also confirmed from the results of hematological examination. Results of
laboratory tests showed abnormal values, such as an increased erythrocyte sedimentation rate,
leukocytes and kinds of leukocyte. At the same time hemoglobin and hematocrit decreased. Besides
microbiological examination was also conducted to see which antibiotic that was resistant.
3.
Clinical Evaluation
3.1
Drug Related Problem 1(Failure to Receive Medication):
Patient failure / not receive medication that was Captopril 25 mg on August 31st 2014 because the
stock of drugs were empty.
Pharmacist Intervention: The procurement should more concern about drug supply so there was no
stock of drugs are empty.
3.2
Drug Related Problem 2 (Untreaetd Indication) :
There were indications that was not handled, the patient did not get the treatment for Diabetic type
II disease.
Pharmacist Intervention: Patient should be given treatment to decrease blood glucose because
patient had a history of Diabetictype II andblood glucose and test results showed abnormal values.
3.3
Drug Related Problem 3 (Drug Interactions) :
3.3.1
Omeprazole may increase the toxicity of Cilostazol metabolized by enzyme CYP2C193.
1697
Pharmacist Intervention: Set the interval between the first drug and the other one. Use alternative if
available, such as H2 Blocker (Famotidine)4.
3.3.2
Aspilet can be decreased of effect from Captopril through antagonist pharmacodynamic
interactions and can cause potentially risk3.
Pharmacist Intervention: Use alternative if available, such as Calcium Channel Blocker (Amlodipine)5.
3.3.3
Cilostazol and Aspilet, both of them can increase the toxicity through synergist
pharmacodynamic interaction and potentially bleeding, drug use should be monitored3.
Pharmacist Intervention: Use one of the drugs only. If had to use both medications, set the interval
between the first drug and the other one and it need to check Prothrombin Time and INR3.
4.
Conclusion
Towards profile treatment of Mrs. SZ,there wereDRPs (Drug Related Problems) such as such
asFailure to receive medicationCaptopril 25 mg on August 31st 2014, Untreated indication that was
treatment for Diabetic type II and Drug interactions between Omeprazole with Cilostazol, Captopril
with Aspilet and Aspilet with Cilostazol.
References
1. Smeltzer & Bare, 2001. Buku Ajar Keperawatan Medical Bedah Brunner & Suddarth (Edisi 8).
Jakarta: EGC.
2. Doengoes, E., Marilynn., Moorhouse, F., Mary., and Geissler, C., Alice, 2000. Rencana Asuhan
Keperawatan: Pedoman untuk perencanaan and pendokumentsianperawatan pasien (Nursing care
plan: guidelines for planning and documenting patient care)(3th Edition). Jakarta: EGC.
3. British National Formulary. 2009. BMJ Group UK.
4. Stockley, I.H, 2008.Stockley’s Drug Interaction(8th Edition), Great Britain : Pharmaceutical Press.
5. Talbert, R. L., 2008. Cardiovascular Disorders In: Pharmacotherapy A Pathophisiologic Approach
(7th Edition). Eds Dipiro J. T. San Fransisco; McGrow-Hill Companies, Inc.
1698
EVALUATION OF DRUG RELATED PROBLEMS (DRP) AT
VOMITING TREATMENT IN PATIENT WITH HEMORRHAGIC
STROKE IN PGI CIKINI HOSPITAL, CENTRAL JAKARTA
Tiarim L.D Nainggolan S.Farm1, Diana Laila Rahmatillah2, Aprilita Rinayanti3
1
Student of Pharmacist Program, Faculty of Pharmacist UTA’45
Jakarta
2
Lecture Faculty of Pharmacist UTA’45
E-mail : Tiarimbalang@gmail.com
ABSTRACT
Stroke is a disease caused by an acute deficit of cerebral vascular disorder that occurs suddenly and
can lead to disability or death1. Stroke or interruption of blood flow in the brain is also known as a
brain attack (brain attack), a cause of disability (disability, invalidity)1. hemorrhagic strokes require
quick handling due to its neurotoxic elements of degradation of blood that can contaminate and
destroy nearby tissue rupture of blood vessels in the brain2. Nausea and vomiting are symptoms of
the underlying disease and not a specific disease6.
Case Presentation : Male patient with initial Mrs. DN, 81 years old. entered hospital on September
07 2014 with complaint of vomiting to overcrowd, impaired pulmonary oxygenation and electrolyte
disorders caused by vomiting.
Clinical Evaluation: During the treatment of patient treated with Depakote, Folic Acid, Vitamin B
complex, lansoprazole, Placta, Xarelto, Sangobion, NaCl caps, Azitromicyn, Primperan, Simvastatin,
Ranitidine ampoule, Onandsentron, Ventolin Inhalation + Flixotide + bisolvon 10 drops +
Diphenhydramine . Based on the clinical outcomes of patient it can be concluded the DRP (Drug
Related Problems) was the indication that was not addressed in the treatment which was to the
pasient.
Keywords: Stroke, vomiting, Brain attack
1699
4.
Introduction
Stroke is a disease caused by an acute deficit of cerebral vascular disorder that occurs suddenly and
can lead to disability or death1. In general, strokes are used as synonyms: Cerebral Vascular Disease
(CVD) and a Doctor of Education core curriculum in Indonesia (KIPDI) termed stroke as a disease
caused by circulatory disorders of the brain (GPOD)1. Stroke or interruption of blood flow in the
brain is also known as a brain attack, which is a cause of disability (invalidity)1. Classification of
Hemorrhagic Stroke, According to WHO in the International Statistical Classification of Diseases and
Related Health problems 10th Revision, hemorrhagic stroke divided into: a. Bleeding Intraserebri
(PIS), b. Subarachnoid hemorrhage (PSA), c. Subarachnoid haemorrhage2.
Vomiting is a symptom not a disease. These symptoms are such as discharge of the contents of the
stomach and intestines through the mouth by force6. Vomiting is a protective reflex of the body
because it can protect against accidentally ingested toxins6. Additionally, vomiting an attempt
removing toxins from the body and can reduce the pressure due to blockage or organ enlargement
that causes suppression of the digestive tract. Impact and complications of vomiting itself : body
dehydration, this will has implications of hypovolemic dehydration of the body, dry skin / cracking,
loss of consciousness, Metabolic Acidosis due to lack of H + in the stomach, Tooth decay due to acid
eroded stomach, Weak stomach, impaired vision and hearing5.
5.
Case Presentation
Mrs. DN 81 years old who was treated in hospital wards K in PGI Cikini. The patient had a history of
previous stroke, came to the hospital on September 7, 2014, the patient came with a limp because
of a condition that causes severe vomiting spasms, impaired pulmonary oxygenation and electrolyte
disturbances. Patient had no history of allergy to the drug. Vital examination conducted blood
presure 130/100, 36.70 body temperature, pulse 80 / minute, and respiratory rate 18 times /
minute.
6.
Clinical Evaluation
Based on clinical data and results of laboratory tests in the diagnosis Mrs.DN body electrolyte
deficiency due to severe vomiting experienced by the patient, it seen from the data of clinical
laboratory tests Sodium (Na) 122 mmol / L, potassium (K) 3.2 meg / L, calcium (Ca) 8.1 mg / dL.
Clinical laboratory tests have been carried out based on the results of the examination of
hemoglobin 10.1 g / dL, leukocytes 18.3 10 ^ 3, Retikuosit 39 per mil, Sodium (Na) 122 mmol / L,
1700
potassium (K) 3.2 meg / L, calcium (Ca) 8.1 mg / dL. From the results of the aerobic germs Breeding
Microbiology Sputum materials, procedures and culture of resistance from the results obtained
antibiotic sensitive (S) is ampicillin - sulbactam 20 µg, 15 ug Tigecyline, and Sulpham / TriMet 23.75 /
1.25 µg.
a.
In this case, patient received treatment therapy using Depakote 125 mg twice-daily dosing,
indications of Depakote was an anti-seizure, and can be given as a sedative for seizures. but it seen
from the medical records of patients not experiencing restless during hospital visits so that the
provision was not necessary Depakote during therapy, in addition to the side effects of Depakote is
nausea and vomiting, while the patient came to the hospital with complaints of severe nausea and
vomiting4.
Intervention of pharmacist : Therapy Depakote (sodium divalproat) should be stopped as it will be
worsen the patient's condition4.
b.
Drug Related Problem 2 :
In the case of Mrs. DN, patient received antibiotic treatment therapy Azithromycin, from breeding
Microbiology laboratory results obtained aerobic germs that are resistant to azithromycin.
Intervention of phamacist : better use of antibiotics in the treatment of antibiotic tigecycline
treatment using 15μg according to the sensitivity of the tissue culture3.
7.
Conclusion
After a review of therapeutic treatment of patient, it can be concluded that the therapeutic
treatment of patients Mrs. DN was not rational for giving Depakote (sodium divalproat) were less
needed by the patient during treatment and antibiotics were not in accorandce with the laboratory
results also in getting that patients resistant to antibiotics azithromycin group.
REFERENCES
1. Jennie MN, Yudiarto LY. Pengelolaan mutakhir stroke: Patofisiologi stroke. Semarang: Baand
Penerbit Universitas Diponegoro. Semarang; 1992.
2. Noerjanto M. Management of acute stroke: Masalah-masalah dalam diagnosis stroke akut.
Semarang: Baand Penerbit UNDIP; 2002.
3. Anonim,. 2009. Martindale 36 th. London Se1 7JN, UK
1701
4. Anonim, 2009 BNF 57. London, SE1 7JN, UK
5. Muttaqin, Arif. 2008. Buku Ajar Asuhan Keperawatan Klien Dengan Gangguan Sistem Pernafasan.
Jakarta : Salemba Medika
6. Mohamed H. Rahman, jane Beattie. 2004. Post operative Nause and Vomiting. The
pharmaceutical Journal.27
1702
DRPs OF SCHEIZOPRENIA DRUGS AT ARMY GATOT SOEBROTO
HOSPITAL JAKARTA
Nurhayati1, Diana Laila Rahmatillah2, Aprilita Rinayanti2
1
Student of Pharmacist Program, Faculty of Pharmacist UTA’45
Jakarta
2
Lecture Faculty of Pharmacist UTA’45
ABSTRACT
Skizoprenia represent one of the soul trouble which is its attack possible arise acutely. Every patient
which suspected to suffer skizoprenia have to be checked by psikiater after removed by possibility
of[is existence of disparity of organik1. Patient is SY, aged 40th years came to Amino treatment of
RSPAD Gatot Soebroto soul sent by family, with angry sigh, destroy goods, angry, can communicate.
Patient got anpispikotik therapy. Conclusion of existence of interaction medicinize risperidon and
clozapine which do not so significance.
Keywords: DRPs, Schezophrenia, clinical management, hospital practice
1703
INTRODUCTION.
Various theory is including genentik factor considered to be cause, acute psikosis patient
possible whoop it up behaviour and intrude, the possible preceded by symptom early (prodmoral) in
the form of secession from social relation, real trouble in role function for example as wage earner,
comporting is bizzare, real trouble in x'self hygiene and dress, blunt effect, leveling off or is not
compatible, talking digress, showing bizzare idea, existence of illusion and is other of etc1.
When patient very whoop it up and jumpy so that bother environment or enandger their self and
also others hence patient need take care of. Skizoprenia is chronic disease which need conservancy
therapy to prevent cause1. continuous Conservancy therapy use low dose antipsikotic needed,
because therapy which by snatches cannot prevent relapsing.
CLINICAL EVALUATION
Patient got risperidon, clozapine as atipikal antipsikotik, trihexypenidil, serolin, piracetam, voltadex,
clopidogrel as antiplatelet because finding of at result of MRI d show chronik infarc in right occipital
lobus cortical, do not see haematom marking and also SOLE intracranial, right mastoiditis atensi.
DOSE and ADMINISTRATION
Dose Should be
0.5–6 mg
Indication
Antipsikotic
25 mg daily-bid initial
Dose
Administr
Regimen
ation
2 mgx2/d
PO
Risperidon
25 mg x
PO
Clozapine
2 mg x 2/d
PO
Trihexypenidil
10 mg x 1/d
PO
Serolin
75 mg x 1/d
PO
Clopidogrel
800 mg x 2/d
PO
Piracetam
12,5 mg x2/d
PO
Voltadex
Name of drug
1/night
2–5 mg PO daily-qid
75 mg/d
Antipsikotic
Antiplatelet
(result MRI)
1704
LABORATORIUM RESULTS
25th OCT
NORMAL VELUE
ROUTINE HEMATOLOGI
14,5
13-18 g/dL
Haemoglobin
43
40-52 %
Hematocrit
4,8
4.3-6 juta/
Erythrocyte
28.100*
4800-10.800 /
Leukocyte s
281.000
150.000-400.000/
Trombosytes
89
80-96 fL
MCV
30
27-32 pg
MCH
34
32-36 g/dl
MCHC
13,70
11,5-14,5%
RDW
Diff Count
0
0-1%
Basofil
1
1-3%
Eosinofil
3
2-6%
Rod
66
50-70%
Segmen
25
20-40%
lymphocytes
5
2-8%
Monocytes
CLINIC CHEMISTRY
1,06
<1.5 mg/dL
Bilirubin total
100
<0.3
AST
88
<1.1
ALT
109
<200
Cholestrol total
83
<160
Trigliserida
34
>35
Cholestrol HDL
58
<100
Cholestrol LDL
22
20-50
Uremia
0,6
0,5-1,5
Triglycerides
1705
6,0
3,4-7,0
Sour blood vessel
94
<140
Blood time glucose
DRUG INTERACTION
There were interaction medicinize between clozapine and risperidon which can improve
Pharmacology effect from clozapin with significance 4th onset delayed, severity major2.
Intervention of Pharmacy was monitoring clozapin serum rate and adjustment of clozapin dose2.
CONCLUSION.
Pursuant to result of practice pharmacist in Amino Treatment room of Soul RSPAD Gatot Soebroto
Ditkesad, can be concluded that found the existence of interaction medicinize between clozapine
and risperidon which can improve pharmacology effect from clozapin with significance 4th onset
delayed, severity major. Intervention of Pharmacy was monitoring clozapin serum rate and
adjustment of clozapin dose.
REFFERENCES
1. Depkes RI. 2010.Pedomann Pengobatan Dasar di Puskesmas.Jakarta.
2. Tatro, David S. 2012.Drug Interactions Fact.Walters Kluwers Health, Inc.
3. Gomella, Leonard A dkk.2009. linician’s Pocket Drug Refence.Mc Graw Hill Medical.
New York.
4. BPOM.2008.Informasi Obat Nasional Indonesia (IONI). Jakarta:Sagung Seto.
1706
EVALUATION OF DRUG RELATED PROBLEM IN TREATMENT
OF APPENDICITIS PATIENT
Siska Mislu1, Diana Laila Rahmatillah2, Aprilita Rinayanti2
1
Student of Pharmacist Professional Program, Faculty of Pharmacist UTA’45 Jakarta
2
Lecture Faculty of Pharmacist UTA’45 Jakarta
Email : sismil_89@yahoo.com
ABSTRACT
Appendicitis is an inflammation that arises suddenly in the apendiks and it is the one of the cases of
acute abdominal most frequently encountered1. Appendix referred to as appendix1. Appendicitis is
often confused the term apendiks, because the appendix is actually the cecum1. Acute Appendicitis
a bacterial- inflammation caused by various factors1. The disease can be informed of all ages both
men and women, but more often in men aged of 10 to 30 years 1. There are 12% male and 25% of
women who appendectomy surgery and gained 7% of them are acute appendicitis2. From the
research of more than 10 years, 1987 to 1997, the average age of patients undergoing
appendectomy was 31.3 years and 22 years with the middle value ratio of male: female = 1.2 to 1.3:
12.
Case Presentation : Ms. OP 24-year-old admitted to the ward K. Patient was diagnosed with Chronic
Appendicitis. Clinical Evaluation: Drug-related problems that occured in this patient was drug
reactions to the use of the same drugs that Sumagesic (Acetaminophen) 600 mg tablets and
Farmadol (Acetaminophen) 500 mg infusion. Choose the drugs that were less precise in the use of
drugs torasic (ketorolac). Drug interactions between the use of Ceftriaxone-Heparin, Torasic
(Ketorolac)-Heparin and Omeprazole-Ondasentron.
Keywords: Appendicitis, Drug Related Problems, Acetaminophen.
1707
INTRODUCTION
Appendicitis is the most common cause of acute inflammation in the lower right quadrant of the
abdominal cavity, the most common cause for emergency abdominal surgery 3. Appendicitis can be
found at all ages, only in children less than one year are rarely reported4. The highest incidence in
the age group 20-30 years , after it declined4. The incidence in men and women are generally
comparable, except in the 20-30 year age incidence is higher men are multifactorial4. Appendicitis
etiology is caused by obstruction, ischemia, infection and hereditary factors5. Obstruction is often a
sign in the pathogenesis of appendicitis5. Various things can cause obstruction of the appendix
include stone (fecalith), food, mucus, parasites, tumors, endometriosis, foreign bodies, and
lymphoid hyperplasia5. From the results of laboratory examinations, it can be found leukocytosis5.
Urinalysis may be due to disorders of the urinary tract5. Other radiological examination that can help
with the diagnosis of appendicitis is the use of spiral CT scan5. In the examination can be found
enlarged apendiks with wall thickening, focal thickening of the cecal , apendikolit, air ekstralumen5.
CT scan is very useful in patients who have symptoms of appendicitis are not typical5.
Macroscopic picture of appendicitis appeared normal just about mucosal inflammation5. Apendiks
often purulent discharge from the exposed surface5. Management for appendicitis is surgery in the
form of removal of the apendiks (appendectomy)5. Appendectomy can be done openly or by
laparoscopy5. In patients who can not do surgery, may be given antibiotics intravenously5.
Antibiotics can also be given before surgery5. Giving antibiotics before surgery has been shown to
reduce postoperative wound infection in a prospective controlled sharing studie5. Antibiotics were
given antibiotics for a broad-spectrum gram-negative and anaerobic bacteria, with the aim to
eradicate the infection and prevent complications5.
CASE PRESENTATION
Ms. OP is a 24-year-old woman admitted to the ward K. Patients entered PGI Cikini Hospital on
December 4, 2014 with complaints of dizziness, nausea, vomiting, abdominal pain lower right and
dry lips. One day before admission the patient felt the chills once when he/she woke up in the
morning, patients experience nausea and vomiting. On December 4, 2014 hematological
1708
examination showed a high hemoglobin value is 14.2 (g / dL), the increased in leukocytes is 10.6 (10
^ 3 / mL), erythrocytes is 5.16 (10 ^ 6 / mL) , reticulocyte namely 18 (per mill) and examination of
the neutrophil leukocyte count showed an abnormal number is 1%. On December 5, 2014 clinical
chemistry examination showed increased SGOT at 39 U / L and ALT uyaitu 36 U/L. In addition,
examination of anatomical pathology unit to the conclusion that Ms. patients. OP disease Chronic
Appendicitis. On December 6, 2014 appendectomy surgery (surgical removal of the appendix).
In this case, patient treated with Ceftriaxone 1 g vial is used as an antibiotic before and after
surgery, sumagesic (acetaminophen) 600 mg tablets, it administered before surgery and used to
relieve pain suffered by the patient, the use farmadol (acetaminophen) 500 mg intravenously before
and after surgery as an antipyretic, use onandsentron 4 mg injection before and after the operation
aims to reduce or eliminate nausea and vomiting that complained of by the patient. The reason of
giving of heparin to prevent blood clotting occurs after surgery, the use of torasic (ketorolac) 30 mg
injection after surgery aims to relieve pain suffered by the patient, kalnex (tranexamic acid) 500 mg
injection is used to prevent bleeding after surgery, the use of OMZ (omeprazole) 20 mg injection of a
sense of bloating in the stomach which has been complained of by the patient.
CLINICAL EVALUATION
DRP 1 : Adverse Drug Reactions
Drug reactions are undesirable, because the use of the same drug indications within the same usage
(farmadol and sumagesic), where the drug is metabolized by liver enzymes ALT and AST can cause
patients improve.
Intervention of pharmacist : Sumagesic for analgesia replaced with analgesic class of NSAIDs, in
order to avoid an increase in SGPT and SGOT5,6.
DRP 2 : Improper Drug Selection
Use of Torasic (ketorolac) in this case was not quite right, because the use of postoperative
ketorolac maximum of two days. While in this case ketorolac used for five days8.
Intervention of pharmacist : Giving of ketorolac after the second postoperative day was replaced
with another drug.
DRP 3 : Drug Interactions
1.
Interactions Between Ceftriaxone and Heparin
1709
Ceftriaxone and heparin use, which will increase the level of ceftriaxone or anticoagulant effect of
heparin with7.
Intervention of pharmacist : Seek the other antibiotic, because cephalosporins can decrease the
activity prothombin7.
2.
Interaction Between Ketorolac and Heparin
Using of Torasic (Ketorolac) and heparin, both of which can increase the anticoagulant7.
Intervention of pharmacist : Used with caution and should be monitored closely.
3.
Interaction Between Omeprazole and Onandsentron
Use of OMZ (omeprazole) and ondasentron where Omeprazole will reduce the level or effect of
onandsentron by affecting metabolism in the liver enzyme CYP1A27.
Intervention of pharmacist : Should the use onandsentron and omeprazole was given in distance
less than two hours
CONCLUSION
Based on the result it can be concluded that the pasient disease was chronic appendicitis. In
addition the DRP (Drug Related Problems) included unwanted drug reactions that used Sumagesic
(acetaminophen) 600 mg tablets and Farmadol (acetaminophen) 500 mg infusion may cause SGOP
and SGPT increased. Choose the drug which was less precise in the use of Drug Torasic (Ketorolac).
Drug interactions between the use of Ceftriaxone-Heparin, Torasic (Ketorolac)-Heparin and
Omeprazole-Ondasentron.
REFERENCES
1. Arif, Mansjoer, dkk. 2000. Kapita Selekta Kedokteran, Edisi 3. Medica Aesculpalus, FKUI, Jakarta.
2. Bernard, Scott A. 2005. An Introduction to Enterprise A Medication. 2nd edition. Author House,
United States America.
3. Smeltzer, Suzanne C. and Bare, Brenda G, 2002. Buku Ajar Keperawatan Medikal Bedah Brunner
and Suddarth (Ed.8, Vol. 1,2 , Alih bahasa oleh Agung Waluyo…(dkk , EG , Jakarta.
4. Sjamsuhidajat, R. and De Jong W. 2005. Buku Ajar Ilmu Bedah. Jakarta: EGC
5. Sario, Stefanus. 2009. Hubungan Pengaruh Letak Serabut dengan Tipe Raandg pada Pasien yang
didiagnosa Apendisitis. FKUI, Jakarta
1710
6. Principles of analgesic use in the treatment of acute pain and cancer pain. American Pain Society.
3rd Edition, 1992
7. Medscape. Dugs Interaction . 2014
8. Ashley, Caroline and Currie, Aileen. 2009. The Renal Drug Handbook Third Edition. UK Renal
Pharmacy Group
1711
DRUG RELATED PROBLEMS IN ISCHEMIC STROKE AT
ROYAL PROGRESS HOSPITAL
Efriliana Sari1. Diana Laila R2. Aprilita Rinayanti Eff2
1
Pharmacist Professional Program Student, Faculty of Pharmacy UTA’45 Jakarta.
2
Lecturer Pharmacy in Pharmacy Faculty Universitas of 17 August 1945 Jakarta
(UTA’45 Jakarta
Email : efrilia_cantiq@yahoo.com
ABSTRACT
Ischemic stroke is a stroke that occurs when there is a blockage of a blood clot in a blood vessel in
the brain or the arteries to the brain (the brain is deprived of blood flow)4. Ischemic stroke can be
caused by thrombosis of intracranial or extracranial embolism5. Intracranial thrombosis caused by
atherosclerosis, where as extracranial embolism generally derived from extracranial arteries or from
the heart as a result of myocardial infarction, mitral stenosis, endocarditis, atrial fibrillation,
cardiomyopathy or heart failure congestive5.
Mr.ES is patient with age 37 years, came to the Royal Progress Hospital on November 30, 2014 with
a diagnosis of Ischemic Stroke. There were DRPs (Drug Related Problems) like drug interactions such
as Rindompump (Omeprazole) with folic acid, Taxilan (sucralfate) with phenytoin and allupurinol,
Aminophylin with ranitidine, and Ranitidine with Phenytoin injection in the therapy treatment for
hospitalized. This can be overcome by using both drugs within different time.
Keywords: Ischemic stroke, Neurology, Royal Progress Hospital
1712
INTRODUCTION
Ischemic stroke is a stroke that occurs when there is a blockage of a blood clot in a blood vessel in
the brain or the arteries to the brain (the brain is deprived of blood flow)4. Ischemic stroke risk
factors include age, gender, high blood pressure, heart disease, smoking, diabetes and high
cholesterol4. Ischemic stroke is a type of stroke are the most common4.
Ischemic stroke can be caused by thrombosis of intracranial or extracranial embolism5. Intracranial
thrombosis caused by atherosclerosis, whereas extracranial embolism generally derived from
extracranial arteries or from the heart as a result of myocardial infarction, mitral stenosis,
endocarditis, atrial fibrillation, cardiomyopathy or heart failure congestive5.
Ischemic stroke begins a series of phases that arise as a result of the ischemic cascade2. The exact
time of each phase is very heterogeneous and depend on many factors such as the size of infarction,
ischemic onset and duration, as well as the effectiveness reperfusi2. Ischemic phase begins with the
sudden cerebral hypoperfusion and followed the failure of cellular bioenergik, excitotoksik,
oxidative stress, damage to the blood brain barrier (SDO), microvascular injury, hemostatic
activation, inflammation and necrosis of neuronal, glial and endothelial cells2.
CASEPRESENTATION
Mr.ES is a 37-year-old man came to Royal Progress Hospital on November 30, 2014, with the state of
seizures, lethargy, apathy consciousness, can not speak, hemodynamic instability, bloody anus
(hemorrhoids). Patient had a history of previous post hemoroidectomi and cholesterol. Ct Scan
resulted reinforce the diagnosis of ischemic stroke for patient.
CLINICAL EVALUATION
In this case, patient was treated with ceftriaxone, ceftriaxon used for infection. The use of
antiplatelet namely Phytomenodion injection and tranexamat acid injection was used to prevent
bleeding in which the patient was bleeding. Giving Citicolin injection was used for acute conditions
on loss of consciousness. In addition, patients were also treated with injection Phenitoin reduce and
control the seizures that occur in patients. Giving calcium gluconate injection is used for the
maintenance of the functional integrity of the nerve, and the absorption of the amino acid binding in
1713
the patient's body. Aminophylin injection is used to assist the smooth running of oxygen to the
lungs. Kaen MG3, Aminofluid infusion, infusion of Ringer's lactate was used to supply amino acids,
electrolytes, carbohydrates and hiproteinemia for stroke patient. Allupurinol tablets used to lower
uric acid. Venaron used for hemorrhoid treatment. Candesartan tablets used for reducing patient.
Folic acid was used for the prevention of folic acid deficiency due to blood in his stool. Taxilan
(sucralfate), Rindompump (omeprazole) and ranitidine injection injection used for the treatment of
gastrointestinal.
DOSAGE AND METHOD OF USE
In this case initially patient entered ceftriaxon treated with a dose of 1 x 2 g was given by injection,
injection Phytomenodion with 3 x 1 daily dose was given by injection, Tranexamic acid injection at a
dose of 3 x 1 day given by injection, Phenytoin injection at a dose of 3 x 1 day given by injection,
Ranitidine injection with 2 x 1 daily dose was given by injection, folic acid at a dose of 1 x 1 day
orally, intravenous fluids Cast Ringer Lactat. The second day all the therapy on the first day
continued, added with tablets Candesartan therapy with a dose of 1 x 8mg a day orally, Allupurinol
with a dose of 1 x 100 mg per day orally, Taxilan with a dose of 3 x 15 ml orally, Calcium gluconas
injection at a dose of 2 x 1 administered daily injections, given the fluid also Ka-en MG3. The third
day all on the second day of therapy continued, added Citicolin injection therapy with 2 x 1 daily
dose was given by injection. The fourth day of the third day all therapy followed, added Venaron
tablets therapy with a dose of 3 x 2 tablets orally. The fifth day, all therapy on the fourth day
continued, added Rindompump injection therapy (omeprazole) with a dose of 2 x 1 flacon was given
by injection, injection Extrace 3 x 1 ampoule given by injection, Aminophylin injection in drip
infusion. Sixth day all on the fifth day of therapy followed that was stopped just Ranitidine injection
and Ka-en MG3. The seventh and eighth all on the sixth day of continued therapy added Aminofluid
infusion therapy 1000mg. Ninth day all continued therapy but Ca gluconat injection therapy,
Aminophylin injection and Aminofluid infusion was stopped.
CLINICAL LABORATORY DIAGNOSIS
Results of laboratory value for Mr. ES which showed abnormalities on Hemoglobin : 5.4 g / dL
(normal : 12-14 g / dL), 22170 leukocytes / mL (normal : 5000-10000 / mL), erythrocytes 1.8 1m / mL
1714
(normal : 4 , 5-5.5 1m / mL), hematocrit 15% (normal : 40-48%), the pH of 7.473 mmHg / (normal :
7.35 to 7.45 mm Hg / L), pCO2 28.7 mmHg / L (normal : 35.0 to 45.0 mm Hg / L), pO2 227.5 mmHg /
L (normal : 75-100 mmHg / L)
Drugs interactions :
a.
Rindompump (Omeprazole) interfere with the absorption of folic acid., Should be used in
the time apart.
b.
Sucralfate if given concurrently with phenytoin will reduce the effect of phenytoin,
phenytoin Should injected 2 hours before taking sucralfate or 6 hours after taking sucralfate.
c.
Sucralfate if given together with allupurinol will reducing effect of allupurinol, allupurinol
should be given one hour before or two hours after sucralfate
d.
Aminophylin if given together with ranitidine will increase aminophylin effect, you should
use the time apart.
e.
Ranitidine if given together with Phenytoin will boost the effects of phenytoin, you should
use the time apart.
CONCLUSION
Based on the results it can be concluded that the presence of DRPs (Drug Related Problems) form of
drug interactions was Rindompump (Omeprazole) interfere with the absorption of folic acid. Taxilan
(sucralfate) when was given concurrently with phenytoin will decrease the effects of phenytoin.
Taxilan (sucralfate) if given together with allupurinol will reducing effect of allupurinol Aminophylin
if given together with ranitidine will increase aminophylin effect. Ranitidine if given together with
Phenytoin will boost the effects of phenytoin. This can be overcome by using both drugs in separate
time when the administration of drugs , and it has been done in Royal Progress Hospital.
REFFERENCES
1. Baxter, K. Stockley’s Drug Interaction Eight Edition. London. 2008
2. Brouns R, De Deyn PP, 2009. The complexity of neurobiological processes in acute ischemic
stroke. Clin Neurol Neurosurg 111:483–95.
1715
3. Programs/2361 http://www.medcape.com/view .htm. Data access Desember, 14th 2014.
4. Juveska, 2007. Articles Medicine Neurology Non Hemorrhagic Stroke.
5. Saenger AK, Christenson RH, 2010. Stroke biomarkers: Progress and challenges for diagnosis,
prognosis, differentiation, and treatment. Clinical Chemistry 56(1): 21-33.
1716
DRUG RELATED PROBLEM IN THE TREATMENT OF
COMPLEX FEBRILE SEIZURE
Kiki Musda1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
Student of Pharmacist Professional Program Student, Faculty Of Pharmachy UTA’ 45 Jakarta
2
Lecturer of Faculty of Pharmachy UTA’ 45 Jakarta
Email :musda.kiki@yahoo.co.id
ABSTRACT
Febrile seizure is seizure that occur when body temperature is high (rectal temperature> 38 ° C) that
is caused by aekstraknium process7.Febrile seizure consist of two types, simple febrile seizures and
complex febrile seizures. Complex febrile seizures is seizure that lasts > 15 minutes, focal or partial
seizures, and reoccur more than once in a single day6,10.Patient An. Nfs, aged 1 year and 7 months
was seen in GatotSubroto Army Hospital on October 5, 2014. Measured body temperature is 39,40C
with the diagnosis of complex febrile seizures. Patient was treated with paracetamol suppositories,
paracetamol syrup, phenytoin injection, Stesolidrectal, phenobarbital injection, cefotaxime
injection, cefriaxon injection, IV FD D5 ¼, dexamethasone injection, mefenamic acid, rifampicin,
isoniazid, nebulisers, acyclovir and lytamin.Based on the result, it can be concluded that the DRP
(Drug Related Problems) is improper dosage regimen in the use of phenobarbital injection (the dose
is too high)6.
Keywords : Complex febrile seizures, child care, and phenobarbital injection.
1717
INTRODUCTION
A febrile seizure is a medical emergency that requires immediate assistance, early diagnosis and
appropriate management is needed to avoid a more severe defects caused by an often seizure6,9,11.
Febrile seizure is seizure that occur when body temperature were high (rectal temperature> 38 ° C)
that is caused by aekstraknium process. Febrile seizure consist of two types, simple febrile seizures
and complex febrile seizures. Complex febrile seizures is seizure that lasts > 15 minutes, focal or
partial seizures, and reoccur more than once in a single day6,11.
Seizures in children is a terrifying event for parents, the study found that the death rate of febrile
seizures was 0.46 to 0.74 percents. Impact of untreated febrile seizures is damage brain cells due to
lack of oxygen in the brain, spending more secretions and emergency risk for airway aspiration that
causes blockage of the airway. If not handled properly, can cause death9.
The incidence of seizures in children that frightening for parents, high levels of recurring events and
the presence of some diseases that accompany the children who have febrile seizures, became the
reason of the need for special attention to patients with febrile seizure cases, and required a wide
range of comprehensive management, especially in terms of treatment to optimize the success of
the treatment so that the incidence of febrile seizures can be decreased6.
CASE PRESENTATION
Patient An. Nfs, aged 1 year and 7 months was seen in GatotSubroto Army Hospital on October 5,
2014. Patient came with high fever since 5 days before admission, convulsions 3 hours before
admission gradually spread to the whole body, but it last for a moment. After seizure patient asleep
, then seizure occur again, until patient been taken to emergency departments (IGD). Measured
body temperature is 39,40C.
Previous medical history was febrile seizures and tuberculosis. History of treatment is paracetamol
and use of TB drugs in the continuation phase of TB treatment with alloy 2 OAT (INH-rifampin)6.
Diagnosis of the disease that accompanies after treatment in hospital is bronchopneumonia and
encefhalitis.
CLINICAL EVALUATION
Paracetamolsuppositoria 200 mg was given for fever treatment before going to the hospital6,10,11.
While during care, Stesolid (Diazepam rectal) 5 mg was given to treat seizures immediately, it was
given immediately when seizures occur because it’s very effective and can be given at home7. The
1718
dose for stesolid is 5 mg Stesolid for BB <10 kg, 10 mg for BB > 10 kg. Phenytoin was given
intravenously with an initial dose of 80 mg plus NaCl 0.9% up to 20 cc with iv bolus over 20 minutes
to treat seizure. Furthermore, given phenobarbital 40 mg in a few days to reduce the risk of
recurrence of seizure6,10. There was no evidence for using antipyretics to reduce the risk of febrile
seizures, but experts in Indonesia have agreed that the antipyretics can be given, Paracetamol
dosage used is 10-15 mg/kg/times given four times a day and not more than 5 times. For
paracetamol suppository given at temperatures above 38oC or in the event of seizure11.
Other diagnosis was encephalitis is brain tissue infections caused by herpes simplex virus. The
therapy that been given was acyclovir 80 mg every 8 hours given in an infusion of 100 ml of 0.9%
NaCl finished in minimum 1 hour for 14 days. Treatment for bronchopneumonia infection was
cefotaxime and continued with cefriaxone intravenously, which is an intravenous antibiotic that is
less recommended for oral intake. Antipyretic and analgesic were given to ensuring patients and
control the cough. Nebulized with 2 agonists and NaCl can be given to improve mucociliary
clearance6,11.
Patient has a history of TB treatment and therapy of isonizid and ripamfisin (Phase II) before. TB
treatment consists of two phases, namely the intensive phase for 2 months early with a blend of 3
OAT (INH-rifampin-pyrazinamide), and continued in the continuation phase (phase II) with alloy 2
OAT (INH-rifampin) to be given 6-12 months on a daily basis (daily) either in the intensive phase and
the continuation phase. Adequate nutrition is critical to the success of therapy of TB6,10.
LABORATORY EXAMINATION RESULTS
TYPE
EXAMINATION
RESULTS
Okt 7
NORMAL
Okt 8
VALUE
Okt 5
Okt 6
Routine hematology
11,0*
10.3*
9.3*
13– 18 g/Dl
hemoglobin
32*
31*
28*
40 – 52%
hematocrit
4.2*
4.1*
3.7
4.3 – 6.0 juta/μ L
erythrocyte
13900*
92000
5350
4.800 – 10. 800/ μ L
leukocytes
170000
113000*
595000*
150.000 – 400.000/Μl
hematology
1719
platelets
76*
76*
76*
80 – 96 fl
MCV
26*
25*
25*
27 – 32 pg
MCH
35
33
33*
32 – 36 g/dL
MCHC
CLINICAL
0.45
< 1.5 mg/dL
bilirubin
50*
< 35 U/L
SGOT (AST)
12
< 40 U/L
SGPT (ALT)
24
21
20 – 50 mg/dl
Urea
0,5
0.4
0,5 – 1,5 mg/L
Triglyceridese
290*
113
< 140 mg/dL
CHEMISTRY
Blood glucose (as)
139
127*
131*
132 – 145 mmol/L
Sodium (Na)
4,0
4.3
4,2
3,1 – 5,1mmol/L
Potassium (K)
103
96
101
96 – 111 mmol/L
*) Abnormal laboratory values
Dose Regimen
Phenobarbital dose given orally to reduce the risk of recurrence seizure. patient is given
phenobarbital injection at a dose of 40 mg for 6 days every 2 times a day and according to the
literature doses given at a dose of 3-4 mg should / kg per day in 1-2 doses due to the side effects of
phenobarbital cause behavioral disorders and learning difficulties for children 40-50%5,11,12.
Phenobarbital dose calculation: 8 kg x 3-4 mg = 24-32 mg
Dose of phenobarbital was given : 40 mg
Pharmacist Intervention :From the above calculation should have a minimum of phenobarbital dose
given at least 24 mg up to 40 mg (corresponding to the patient BB)6.
CONCLUSION
Based on the results of clinical work practice in child care of GatotSubroto Army Hospital, It can be
concluded that therapy in patient with compleks febrile seizure was appropriate however to note
1720
that phenobarbital, weight-adjusted patient to reduce side effect such as behavioral disorders and
learning difficulties6.
REFERENCES
1. American Academy of Pediatrics Steering Committee on Quality Improvement and Management,
Subcommittee on Febrile Seizures. Febrile seizures: clinical practice guideline for the long-term
management of the child with simple febrile seizures. Pediatrics. 2008;121(6):1281–1286
2. American Academy of Pediatrics Steering Committee on Quality Improvement and Management,
Subcommittee on Febrile Seizures. Febrile Seizures: Guideline for the Neurodiagnostic Evaluation of
the Child With a Simple Febrile Seizure. Pediatrics 2011;127;389 DOI: 10.1542/peds.2010-3318
3. BNF, 2009 The essential resource for clinical use of medicines in children
4. BNF 61, 2011 British National Formulary 61 March 2011
6. IDAI, 2006 Konsensus Penatalaksanaan Kejang Demam, Unit Kerja
Koordinasi Neurologi, IDAI
2006
7. IDAI, 2009.Pedoman Pelayanan Medis Ikatan Dokter Anak Indonesia, Baand Penerbit IDAI :
Jakarta.
8. ISFI , 2008 ISO FarmakoterapiCetakanPertama. ISBN : 978-979-18514-1-1 : 2008,2009
9. McGraw-Hill , 2006 Current Pediatric Diagnosis and Treatment 18thEdition The McGraw-Hill
Companies, New York.
10.
Lumbantobing, S.M. (2003). Penatalaksanaan Muthakhir Kejang Pada Anak. Jakarta : FKUI.
11.
RSPAD GatotSoebroto, 2012 StandarPelayananMedikKejangDemamKompleks.
12.
Strengell T, Uhari M, Tarkka R, et al. Antipyretic agents for preventing recurrences of febrile
seizures: randomized controlled trial. Arch Pediatr Adolesc Med. 2009;163(9):799–804.
13.
Tatro DS (ed). Drug Interaction Facts 2004. Facts and Comparisons, St. Louis, MO. 2004.
1721
OPEN FRACTURES WITH HEART AND DIABETES MELLITUS TYPE II IN
THE HOSPITAL WARD K PGI CIKINI
Hesty Baka1, Diana Laila Ramatillah2, Aprilita Rinayati2, and Stefanus Lukas2
1
2
bakahesty@yahoo.co.id
ABSTRACT
Fractures / open fracture is a fracture classification based in conjunction with the external
environment in which occurs the relationship with the external environment through the skin so
that it can occur that cause bacterial contamination and infection of skin wounds can be a bone
puncture coming out through the skin (From within) or because of broken objects from the outside
(from without)1.
The main cause of mortality and morbidity in patient with diabetes mellitus ( DM ) type 2 is coronary
heart disease ( CHD ) in which sufferers are two to four times more at risk of heart disease than nonDM and the mechanism of occurrence of CHD in type 2 diabetes mellitus is associated with the
presence of atherosclerosis which is influenced by various factor2.
Patient Mrs. Rmh aged of 72 years, got treatment in the hospital ward K PGI Cikini on 2 September
2014 with a diagnosis of fracture Open Cruris Sinistra with a history of diabetes mellitus and heart
disease.
Based on the assessment of the treatment of patient during the treatment , there are 4 DRPs ( Drug
Related Problems ) ie antibiotics claforan , albumin 25 %, Glucophage, no renal drug therapy and
drug interaction between Captopril and Glimepiride, Acetaminophen and Heparin, Diltiazem and
Onandcentron and Diltiazem and Metformin.
Keywords : Open fractures, heart disease, type II diabetes, PGI Cikini hospital
1722
INTRODUCTION
Open fracture is a fracture that has a relationship with the outside world through a wound in the
skin and soft tissues, it can be formed from the inside and outside. Specialized in open fractures, it
should be considered the andger of infection, either general or local infection infection in the bone
in question. Four important things you need is a prophylactic antibiotics, debridement of the wound
and fracture urgent, stabillisasi fracture, wound closure as soon as definitif3.
Coronary Heart Disease (CHD) is a heart disease which is mainly due to the narrowing of the
coronary arteries due to atherosclerosis or spasm or a combination keduanya4,
Diabetes Mellitus (DM) is a disease of Type II cells insensivitas hyperglycemia due to insulin . Insulin
levels may be slightly decreased or were within the normal range for insulin remains produced by
the beta cells of the pancreas , the diabetes mellitus type II is considered as a non insulin Dependent
Diabetes Mellitus (NIDDM)5 .
CASE PRESENTATION
Mrs. Rmh is a 72 -year -old woman weigh 75 kg and height 160 cm. She got treatment in the ward K.
Patient entered in the PGI Cikini Hospital on 2 September 2014. The patient was admitted with
complaints of left leg broken because of a fall. Open fractures was diagnosed of patient with a
history of disease cruris Sinistra Diabetes mellitus and heart disease.
LABORATORY DATA
Table 1. Laboratory Hematology
NORMAL
RESULT
EXAMINATION
UNIT
VALUE
06/09/2014
02/09/2014
05/09/2014
Morning/Night
LED
*116
*75
*54/*80
mm/hour
0-20
Hemoglobin
*10,3
*9,6
*9,7/*11
g/dl
12,0-14,0
HEMATOLOGY
Peripheral blood
1723
leukocytes
6,3
5,6
5,3/5,5
103/mL
6
5,0-10
erythrocyte
*3,93
*3,7
*3,72/4,13
10 /mL
4,0-4,5
hematocrit
*30
*29
*11/*32
%
37-43
Retikulosit
11
*18
*20/*17
permil
5,0-15
Basofil
1
1
1/1
%
0-1
Esinophil
3
*6
*7/*6
%
1,0-3
neutrophils Trunk
*0
*0
*0/*0
%
2,0-6
Neutrofil Segmen
54
55
*49/61
%
50-70
Limfosit
30
29
32/22
%
20-40
Monosit
*12
*9
*11/*10
%
2-8,0
Trombosit
203
225
229/222
103/mL
150-450
MCV
*76
*77
*78/*79
fL
81-92
MCH
*26,2
*25,9
*26,1/*26,6
pg
27-32
MCHC
34,3
33,7
33,6/34
g/dL
32-37
10-11
-
minute
10-16,0
Calculate Type
Lukosit
Hemostatis
Freezing time
APTT
-
APTT Patient
31,7
30,7
36,5/*40
Second
26,4-37,5
APTT Control
30,9
30,0
30,0/30,3
Second
26,4-37,5
PT Patient
*15
-
-
Second
11-14,2
PT Control
12,1
-
-
Second
11-14,2
INR
1.3
-
-
*695
-
-
mg/dL
180-350
(+) positive
-
-
-
-
Masa Protombin
(PT)
Fibrinogen
blood group
– Rhesus
1724
Table 2. Clinical Chemistry Laboratory
EXAMINATION
Result
02/09/2014 04/09/2014 05/09/2014 06/09/2014
UNIT
REFERENCE
VALUE
CLINICAL
CHEMISTRY
Protein Total
6,7
6,1
6,3
-
g/dL
6,0-8,0
Albumin
*2,8
*2,8
*3,2
-
g/dL
3,4-4,8
Globulin
*3,9
3,3
3,1
-
g/dL
1,3-3,7
SGOT
22
-
-
-
U/L
0-35
SGPT
33
-
-
-
U/L
0-35
Uremia
23
-
-
-
mg/dL
10-50,0
*1,2
-
-
-
mg/dL
0,6-1,1
-
-
-
-
-
136
-
-
141
mEq/L
135-147
*3,4
-
-
*3,2
mEq/L
3,5-5,0
*8,2
-
-
*8,2
mg/dL
8,8-10
*322
-
-
-
mg/dL
70-150
-
*267
mg/dL
70-150
-
*350
mg/dL
70-150
-
*245
mg/dL
70-150
-
*308
mg/dL
70-150
Kreatinin
Natrium. Kalium
Natrium (Na)
Blood
Pottasium(K)
Blood
Calcium(Ca)
When Blood
Sugar
Blood Sugar at
06:00
Blood Sugar at
11:00
Blood Sugar at
16:00
Blood Sugar at
11:00
-
-
-
-
*239
*225
*202
-
1725
Blood Sugar at
16:00
-
-
-
*179
mg/dL
70-150
CLINICAL EVALUATION
Use of injection claforan ( cefotaxime ) 1 g / vial given per 12 hours is used to treat infected for 6
days, because LEDs were based on the results of 116 mm / h, 75 mm / h , 54 mm / h, and 80 mm / h
there was an increase LEDs that indicate the presence of bacterial infection in patient. Cedocard
( Isosorbide dinitrate ) 5 mg / tablet given per 8 hours for 6 days was used to prevent heart attacks,
but it was also given Herbesser (Diltiazem) 100 mg / tablet was given per 24 hours for 6 days for
controlling angina and hypertension. Based on the results of clinical chemistry examination showed
that high blood glucose levels, giving Actos (Pioglitazone Hydrochloride) 30 mg / tablet was given
per 24 hours for 6 days, Amaryl (glimepiride) 3 mg / tablet given per 24- hour day 2 and day 3 only,
Glucophage ( metformin ) 850 mg / tablet was given 1 tablet a day to 3 only be used under on
glycemic control in patient with type 2 diabetes but the administration was not routinely ADO when
the patient blood glucose levels were still high .Farmadol (Paracetamol) 500 mg / tablet given per 8
hours in a day to 4 and 5 to reduce fever. Narfoz (Onandsetron) 4 mg / ampoule administered once
a day for 5 to treat nausea and side effects of drugs due to the use of analgesics and antibiotics.
Ketesse injection (Dexketoprofen Trometamol) 50 mg given 24 hours per day to 1.4, 5 and tablets
Ultracet (Tramadol 37.5 mg + paracetamol 325 mg) given per 8 hour ½ tablet on day 4, 5, 6, to
overcome pain and fever due to fracture. Captopril 25 mg / tablet given day 6 only 1 tablet to treat
hypertension. Heparin injections are given per 24 hours in the day to 3, 4, 5, 6, are used for the
prevention and treatment of venous thrombosis. Administration of albumin 25 % ( 100 cc ) per 24
hours at day 2 and 3 were used to overcome hipoalbumin which was based on the result of clinical
chemistry examination it showed the result whic was less than the reference value.
1.
DRPs (Drug Related Problems) I
In this case. the patient was bleeding and doctors gave antibiotic treatment to third -generation
cephalosporins are Claforan (cefotaxime) 1 g as an anti-infective. Claforan the treatment of choice
for patient fractures who are susceptible to bleeding6. The duration of treatment of at least 5 days,
1726
but the administration should be continued at least until 48-72 hours after disinfection was achieved
real.
Pharmacy Intervention is actually not the bones being treated for an infection, but the tissue around
the bone, so it was quite given antibiotics such as quinolones group Cravit (levofloxacin) 500 mg /
tablet and medicine for bone / bone growth accelerates as Calcium Supplements or preparation
which accelerates the absorption of Calcium like Kolkotriol7.
2.
DRPs (Drug Related Problems) II
Patient experiencing hipoalbumin, the doctor gave 25 % Albumin therapy, after re- examination of
albumin but examination results showed a very small increase (still experiencing hipoalbumin).
However, given the administration of albumin 25 % in just two days while the results of Albumin
levels still show a decrease (hipoalbumin).
Pharmaceutical interference was supposed to be giving 25 % Albumin is continued until a change in
the levels of albumin that can be seen from the results of the laboratory. Hipoalbumin can be
caused by kidney patient was not functioning properly, a protein produced by the liver is excreted
with urine. Impaired kidney function was reinforced by the results of measurements of
Triglycerides8.
3.
DRPs (Drug Related Problems) III
In this case the patient has a history of diabetes mellitus then given treatment with Glucophage
(metformin) for patient of normal weight. Therapy with Glucophage (metformin) was given only for
one day, but the results of further blood glucose levels showed an increase in blood glucose, but
treatment with Glucophage (metformin) was discontinued.
Pharmacy Intervention was supposed that therapy should be administered because the patient has
Hyperglycemia. Therapy in patient with diabetes mellitus should be given continuously until normal
blood glucose levels and should be examined at range blood glucose levels 9, 10.
4.
DRPs (Drug Related Problems) V
The severity of minor drug interactions :
1727
1)
Drug interactions between Acethaminophen with Heparin
Acetaminophen enhance the effect of heparin
Intervention should acethaminophen Pharmacy was not given because it was treated with Ultracet
medicine for fever and treat pain.
2)
Drug interactions between Diltiazem with Onandsetron.
Diltiazem enhances the effect of onandsetron.
Pharmacy Intervention was seen from granting Onandsetron for one day only, so you should set the
distance between Diltiazem taking medication taken night with drunk Onandsetron morning 11.
3)
Drug interactions between Diltiazem with metformin.
Ditiazem enhance the effect of metformin .Interference Pharmacy Metformin is seen from the
provision for one day only, so you should set the distance between the drug taking Diltiazem drunk
at night with metformin in the morning11.
CONCLUSION
Based on the results of clinical work practice in hospital wards K PGI Cikini it can be concluded that
found their DRPs (Drug Related Problems), but broadly it can be concluded that the therapy and
treatment of the patient was right, but there were some checks that need to be evaluated was the
examination triglyceridese. All therapeutic treatment which has the effect or adverse reactions can
be prevented by always monitoring and monitoring of patient during treatment, and always do
laboratory tests regularly and periodically in order to determine the condition of the patient, and
prevent worsening of the disease.
REFERENCES
1.
Salter RB. (2009) Treatment for open fractures. In : Textbook of disorders and injuries of the
musculoskeletal
system.
Third
ed.
Baltimore
:
The
Williams
&
WilkinsCo.Fromhttp://library.stikesnh.ac.id/files/disk1/5/elibrary%20stikes%20nani%20hasanuddin-rezwinhery-244-1-artikel9.pdf, 2 November 2014.
2.
Fadma Y, Fadil O, Detty E, Hubungan Berbagai Faktor Risiko Terhadap Kejadian Penyakit
Jantung Koroner Pada Penderita Diabets Mellitus Tipe 2 (diunduh 4 November 2014). Tersedia dari:
URL: HYPERLINK
1728
http://jurnal.fk.unand.ac.id/images/articles/vol3/no1/37-40.pdf.
3.
Sjamsuhidajat, Jong. (2007). Buku Ajar Ilmu Bedah. Ed. Revisi, EGC: Jakarta
4.
Majid A. Penyakit Jantung Koroner: Patofisiologi, Pencegahan, and Pengobatan Terkini
(diunduh
2
November
2014).
Tersedia
dari:
URL:
HYPERLINK
http://www.usu.ac.id/id/files/pidato/ppgb/2007/ppgb_2007_abdul_majid.pdf.
5.
Darmono, 2007, Penatalaksanaan Diabetes Melitus tipe II, Dexa Medica.
6.
Media Informasi Obat and Penyakit (diunduh 2 November 2014). Tersedia dari: URL:
HYPERLINK
http://medicastore.com/obat/1189/CLAFORAN_VIAL_1_G.html
7.
Pasaribu, Eskhol F, 2011; Obat Untuk Infeksi Tulang (di unduh 16 Desember 2014). Tersedia
dari: URL: HYPERLINK
https://id-id.facebook.com/Ikatan Apoteker Indonesia
8.
Sutedjo, AY, 2008, Buku Saku Mengenal Penyakit Melalui Hasil Laboratorium, Yogyakarta
9.
Saragi, Sahat, 2012, Panduan Penggunaan Obat Dilengkapi dengan Konsep Pharmaceutical
Care, Teori Konseling Obat, Teori Kepatuhan Minum Obat, Penerbit Rosemata Publisher, Jakarta
10.
BNF 61, 2011. Britsh National Formulary 61 March 2011
11.
www.healthline.com/druginteractions, di akses pada 04 Januari 2014, Jakarta
1729
DRUG RELATED PROBLEMS IN THE TREATMENT OF PATIENT
OF ENDOMETRIAL HYPERPLASIA WITH ENOMETRORRHAGIA
SUSPECT IDIOPATHIC THROMBOCYTOPENIA PURPURA (ITP)
IN PGI CIKINI HOSPITAL
Regina Cecilia Andawari1, Diana Laila Ramatillah2, Stefanus Lukas2
1
Student of Pharmacist Professional Program Student, Faculty of Pharmacy UTA’45 Jakarta
2
Email: reginazecil@ymail.com
ABSTRACT
Endometrial hyperplasia is the excessive growth of glandular and stromal vascularization is
accompanied by the formation of lymphocytes in the endometrium, this growth can affect some or
all layers of endometrium2. Idiopathic thrombocytopenia purpura (ITP) is a bleeding disease that is
obtained as a result of excessive platelet destructed characterized by thrombocytopenia (platelet
count <150,000 / mm3), purpura, picture of peripheral blood were generally normal, and no other
causes of thrombocytopenia4. Case Presentation: Patient Mrs. VS aged 45 years and 6 months, came
to the PGI Cikini Hospital with a chief complaint of bleeding from the genitals approximately 5
months. Patient had complain that the last 5 months, periods become longer up to 21 days,
bleeding gums, feel nauseous, arising bluish spots on the entire body, hard defecation and black.
Previously, the patient was treated at the SukmulSisma Medical Hospital and referred to the PGI
Cikini Hospital. PGI Cikini Hospital, patients diagnosed with endometrial hyperplasia with
menometrorrhagiasuspect idiopathic thrombocytopenia purpura. Treatment: At the time the
patient was admitted PGI Cikini Hospital, patient received 18 types of drugs such as Cefixime,
ceftazidime, Prednicort (6α-Methylprednisoline), Folic Acid, Neurosanbe 5000, Rocer (omeprazole),
Imuran (azathioprine), Mucosta (rebamipide), Actrapid (insulin), Mycostatin (nystatin), Cavit D3,
Cernevit, Fluconazole, INH, Transamin (tranexcamid acid), Lasix (furosemide), Novorapid (insulin
aspart), Lantus (insulin glargine) and acyclovir. From the profile treatment of Mrs VS, discovered the
existence of Drug Related Problems (DRP) including Drug Interaction, Failure to Receive Medication,
and Drug Use Without Indication.
Keywords: Endometrial Hyperplasia, Idiopathic Thrombocytopenia Purpura (ITP), Drug Related
Problems.
1730
Introduction
Endometrial hyperplasia is the excessive growth of glandular and stromal vascularization
accompanied by the formation of lymphocytes in the endometrium. This growth can affect some or
all layers of endometrium2. This type of bleeding is common during the reproductive and
premenopausal. Basic causes of bleeding in this situation is due to the absence of ovulation because
it is not the formation of the corpus luteum which leads to reduced secretion of progesterone, while
producing excessive estradiol cause stimulation of the endometrium continuously. Without
produces progesterone, the endometrium proliferates and endometrium becomes very much that
contain blood vessels without supported with sufficient stroma and become brittle, causing bleeding
endometrium3.
Idiopathic thrombocytopenia purpura (ITP) is a bleeding disease that is obtained as a result of
excessive platelet destructed, characterized by thrombocytopenia (platelet count <150,000 / mm3),
purpura, peripheral blood picture were generally normal, and no other causes of thrombocytopenia.
Classification of Idiopathic Thrombocytopenia Purpura is an acute and chronic. ITP is called chronic if
thrombocytopenia occurred during the 6 bulan4. The cause of ITP is an autoimmune disorder, so the
destruction of platelets in the reticuloendothelial system increases. This disorder usually
accompanies viral infection or immunization caused by the immune system response is not
appropriate (Inappropriate). Lately, ITP is also often referred to as immune thrombocytopenic
purpura (immune thrombocytopenia purpura). The diagnosis of ITP is largely made on the basis of
clinical features, with symptoms or signs of bleeding, accompanied by a decrease in platelet count
(thrombocytopenia)6.
Presentation Case
Patient Mrs. VS aged 45 years and 6 months, came to the PGI Cikini Hospital with a chief complaint
of bleeding in the genital approximately 5 months. Patient complain that the last 5 months, periods
become longer up to 21 days, bleeding gums, feel nauseous, arising bluish spots on the entire body,
hard defecation and black. Previously, patient already went to the SukmulSisma Medical Hospital
and referred to the PGI Cikini Hospital.
Clinical Evaluation
1.
Failed / Did not receive medication (Failure to receive medication)
1731
Patient were experiencing a medical problem that requires drug therapy but shecan not receive
treatment on the grounds of the state of the economy, psychology, sociology, or for reasons of
pharmaceutical5. It was found that some drug use that was not given every day that the patient did
not receive the drug Imuran on September 17, 2014, Mucosta on September 11, 2014, Mycostatin
on September 12, 2014, Rocer ampoule on September 11, 13, 14 and 18, 2014, Transamin on
September 13 and 14, 2014, and acyclovir tabs on 19th and 20th September, 2014.
Pharmacist Note: These drugs should still be given to obtain maximum therapy.
2.
The use of drugs without indication (Drug Use Without Indication)
The patient was givena isoniazid drug (INH), which was not in accorandce with the indication of the
patient.
Pharmacist Note: Patient should not be given the drug isoniazid (INH) because patient were not
identified with tuberculosis disease.
3.
Drug Interactions (Drug Interactions)
It was found that the presence of multiple drug interactions in patient.
a.
Using prednicort together with fluconazole may increase the effects of prednicort through
metabolic enzyme CYP3A4 in the liver1.
b.
Using prednicort together with isoniazid (INH) may increase the effects of prednicort
through metabolizing enzyme CYP3A4 in the liver1.
c.
Using cefixime together with furosemide may increase the toxicity effect pharmacodynamic
synergy. And can increase the risk of nephrotoxicity1.
d.
Using ceftazidime together with furosemide may increase the toxicity effect
pharmacodynamic synergy. And can increase the risk of nephrotoxicity1.
e.
Using isoniazid together with omeprazole may increase the effect of omeprazole through
CYPC219 by liver enzymes1.
Pharmacist Note: Provision of drugs like prednicort with fluconazole, there should be a distance.
Giving prednicort with isoniazid (INH), there should be a distance. Cefixime drug administration with
furosemide, there should be a distance. Ceftazidime with furosemide drug administration, there
should be a distance. Drug administration of omeprazole with isoniazid (INH), there should be a
distance.
1732
Conclusion
Based on the results, it can be concluded that it was discovered the existence of some of the DRP in
the treatment of patient Mrs. VS. Some of them were, the patient did not receive the drug on a daily
basis (Failure to Receive Medication), patient received INH drug which was not in accorandce with
the indication (Drug Use Without Indication), and the interaction between prednicort
andfluconazole, cefixime andfurozemide, ceftazidime andfurozemide and, omeprazole and INH
(Drug Interaction).
References
1. Medscape.com/druginteraction
2. Indahwati D, Aloysius Suryawan, UckeSastrawinata. 2007. HubunganKerapatanReseptorHormon
Estrogen
padaWanitaPerimenopauseterhadapKejadianTipeHiperplasia
Endometrium.
ArtikelPenelitianVol 6. No 2. Bagian/KSM ObstetriandGinekologiFakultasKedokteranUniversitas
Kristen Maranatha / RS Immanuel, Bandung.
3. Pramana, C. 2004. Kadar Estradiol Serum PadaWanitaUsiaReproduksiDenganPerdarahan Uterus
Disfungsi. BagianObstetriandGinekologiFakultasKedokteranUniversitasDiponegoro, Semarang.
4. Sakamoto, KM. 2000. Idiopathic Thrombocytopenic Purpura.Pediatri Rev 2000;21:95-103.
5. Saragi, S. 2012. PanduanPenggunaanObat. Rosemata Publisher. Jakarta
6. Setyoboedi,
B.
2004.
PurpuraTrombositopenikIdiopatikapadaAnak
(patofisiologi,
tatalaksanasertakontroversinya). Sari Pediatri, Vol. 6, No. 1.
1733
DRUG RELATED PROBLEMS THAT OCCURRED IN
PATIENT SEPSIS MACROVASCULAR DISEASE
COMPLICATIONS GENERAL HOSPITAL TREATMENT
ROOM CENTRAL OF THE ARMY (ARMY HOSPITAL)
GATOT SUBROTO
Abdullah1), Diana Laila Ramatillah2), Aprilita Rinayanti Eff2)
1)
Student of Pharmacist Program, Faculty of Pharmacy UTA’ 45 Jakarta
2)
Lecturer of Faculty of Pharmacy UTA’ 45 Jakarta
Tel: + 62819 - 1882 - 4488
Email: abdullah_alhafyz@yahoo.co.id
ABSTRACT
Sepsis is a systemic inflammatory response syndrome: clinical inflammatory response to
disturbances that cause infection or not infection1. Patient entered in the Emergency Room (ER) 8
October 2014, the diagnosis of sepsis patient ec furnier gangrene (scrotum), Haematemesis ec
gastropathy uremikum, CKD stage V on HD with anemia, metabolic acidosis, CHF fc II, type II
diabetes mellitus, hypertension, hepatitis B therapy received treatment for at GatotSubroto Army
Hospital namely, Lasix, D40%, Insulin (Novorapid, Humalog), Meropenem, Levofloxacin, Farmadol,
Omeprazole, Transamin, Vitamin K, Sodium Bicarbonate, Calcium Carbonate, Folic Acid, Vitamin B12,
Valsartan, Amlodipine, Transfusion Package Red Cells (PRC), Triofusin e 1000, Tramal, Ca Gluconate,
Metronidazole, Cefoperazone Sulbactam, Albumin transfusion, transfusion Fresh Frozen Plasma
(FFP), the result of monitoring drug therapy patient obtained their multiple DRPs (Drug Related
Problems), correlation between therapy with disease, Selection of appropriate medication, dosage
regimen, interactions and contraindications.
Keywords: Sepsis, Complications, Gatot Subroto Army Hospital
1734
Introduction
Sepsis presence of pathogenic microorganisms or their toxins in the blood and other tissues,
Systemic inflammatory response syndrome: clinical inflammatory response to disturbances that
cause infection or not infection1. Responses appear in the form of ≥ 2 the following conditions:
temperature > 38°C or < 36°C, frequency heart rate > 90 beats/min, respiratory frequency > 20
breaths/min, the white blood cells > 12000 cells/mL or < 4000 cells/mL or > 10% in the form of
immature1. Severe sepsis: sepsis associated with organ dysfunction, septic shock: sepsis with
hypotension simultaneously the presence of perfusion abnormalities1. Causinga frequent site of
infection sepsis (21-68% Respiratory tract, urinary Channels 14-18%, 14-22% Intra Abdominal
cavity): Sepsis by gram-negative bacteria (approximately 38% of the incidence of sepsis) Escherichia
coli and Pseudomonas aeruginosa is bacteria the most frequently isolated in sepsis, Gram-positive
(40%): Staphylococcus aureus, Streptococcus pneumoniae, Staphylococcus coagulase negative and,
Enterococcus. The cause of fungal sepsis (17%): Candida albicans frequently causes sepsis in hospital
patient1.
CLINICAL EVALUATION
While in hospital the patient was given medication therapy are: Lasix 18 ampoules / 24 hours up to
1,5cc / hour because Lasix is very effective to cope with edema administration IVFD to the effect
that faster with gradual dose. D40% 2 flacon / 3 hours up to 16 cc / hour as a replacement fluid and
energizing, glucose solution is administered in treatment with Calcium, Sodium Bicarbonate, and
Insulin for the emergency management of hyperkalemia. Triofusin e 1000 500 cc / 24 hours for
obtaining calories and electrolytes needed through total and partial parenteral nutrition in patient
with diabetes needs to be done to monitor blood sugar levels2.
Insulin 0,5 units / hour in NaCl 0,9% for patient undergoing surgery and require insulin infusion
intravenously for 12 hours or more, the speed of infusion of insulin if blood sugar < 4 mmol / liter is
given 0,5 units / hour for onward adjusted to the patient's clinical condition, after the patient began
to eat and drink, give insulin subcutaneously use multiples of 4 units of insulin applies if < 200 mg /
dL = 0 units, 201 - 250 mg / dL = 4 units, 251 - 300 mg / dL = 8 units, 301 - 350 mg / dL = 12 units, >
351 mg / dL = 16 units beyond2.
1735
Meropenem 1 gram 3 times daily in this case as empirical therapy, while awaiting culture results
come out, Meropenem be an option because of its broad spectrum for infection of gram-positive
and gram-negative, aerobic and anaerobic, tousesoshould be based on culture results, while for
patient impaired liver function and impaired renal function the dose and treatment regiment
adapted to the patient's clinical condition, Cefoperazone Sulbactam 2 times a day 1 gram for grampositive need for strong administration drip for 1 hour, 1 time a day Levofloxacin 500 mg is indicated
for patient who have urinary tract infections are caused by infection with gram-positive and gramnegative, and dose adjustment regiment not promising therapy for patient with impaired renal
function and liver function disorders, Metronidazole 500 mg 3 times also used for gynecological
surgery sepsis with major activity against anaerobic bacteria colonic2,3.
Omeprazole 40 mg 2 times a day as therapy uremikum gastropathy and gastric ulcers and reduction
during general anesthesia (acid aspiration prophylaxis) is given 40 mg in the afternoon and one day
prior to surgery and then 40 mg 2-6 hours before surgery, Inpepsa suspension effective in treating
ulcers stomach, protecting the mucosa from acid-pepsin in gastric ulcer timing of 2 gram 2 times a
day (morning and before bed at night) or 1 gram 4 times a day 1 hour before meals and before bed
at night, given for 4-6 weeks2.
Tramal 100 mg 3 times daily for pain, Farmadol given 3 times 1 gram to address moderate pain till
mild postoperative pain and fever, Ca Gluconate quickly can lead to vasodilation of blood vessels,
decrease in blood pressure, bradycardia and cardiac arrhythmias, and even can cause cardiac arrest
therefore IV administration either bolus or continuous need to monitor blood pressure and pulse of
this reaction is due to a decrease in potassium drastically in rapid decrease in potassium will result in
a decrease in contractile muscle cells, including heart muscle cells resulting in a decrease in pulse
and vasodilatation2,3.
Transamin injection of 500 mg 3 times a day is given to inhibit fibrinolysis so it can be useful to
prevent bleeding, is used in patient with mild renal function disorders at the recommended dose
reduction, whereas for patient with severe renal function impairment and avoid use in patient with
impaired function liver needs to be monitored, Vitamin K 3 times daily 10 mg is needed for the
production of blood clotting factors, for patient impaired liver function may have deficiencies
vitamin K 2,3.
1736
Sodium Bicarbonate 1 gram 3 times daily to cope with metabolic acidosis, in severe cases can be
administered by intravenous Sodium Bicarbonate, Calcium Carbonate 500 mg 3 times daily is used
as a phosphate binder in the treatment of hyperphosphatemia in renal failure complications2,3.
Folic Acid 15 mg 1 time a day is required for nucleoprotein synthesis and maintenance of normal
erythropoiesis, folic acid stimulates the production of red blood cells and white blood cells, Vitamin
B12 50 mg 3 times daily is important for growth, cell reproduction hematopoiesis, and nucleoprotein
synthesis and meilin, Vitamin B12 also plays a role in the formation of red blood cells through the
activity of folic acid coenzyme2.
Valsartan 160 mg 1 time a day for the treatment of hypertension that can be combined with other
antihypertensives, Valsartan may be given to patient with heart failure, patient with hemodialysis,
the patient is low in sodium, this group does not inhibit the breakdown of bradykinin that does not
cause a dry cough, Amlodipine1 time a day 10 mg as antihypertensive, how it works inhibits calcium
ion influx through the slow channel membran active cell, thereby affecting cardiac myocardial cells,
and vascular smooth muscle cells and reducethe ability of myocardial contraction, the formation
and propagation of electrical impulses in the heart, and systemic or coronary vascular tone,
Amlodipine did not reduce myocardial contractility and does not cause deterioration in heart failure
with a longer tenure so that it can be given once a day2,3.
PRC 500 cc of blood transfusion aims to improve the oxygenation of tissues and organs with a target
of 8 g / dL, transfusion Albumin to overcome the shortage of Albumin in the body, can lead to
instability Albumin shortage of water in the blood plasma, so that the blood volume is unstable and
undergo body hoarding fluid which is often characterized by swelling, Albumin also act as transport
in the body, including some elements of drugs and assist in the formation of a new body tissue,
addition of Albumin transfusion transfusion patient also in Fresh Frozen Plasma (FFP) contains all
plasma proteins that are fresh frozen plasma the goal is to reach 30% of normal clotting factor
concentrations2.
DOSAGE AND HOW TO USE
Lasix initial dose of 250 mg to 4 mg / min for 1 hour, the dose may be increased to 1 grams can be
repeated every 24 hours. D40% given 1-3 liters / day, Triofusin e 1000 500 cc for 24 hours, use
multiples of 4 units of insulin effect, if the blood glucose < 200 mg / dL = 0 unit, 201 - 250 mg / dL = 4
1737
units, 251 – 300 mg / dL = 8 units, 301 – 350 mg / dL = 12 units, > 351 mg / dL = 16 units onwards.
Meropenem 250 mg every 24 hours after the HD 500 mg every 8 hours, Cefoperazone Sulbactam
500 mg every 12 hours up to 1 gram a day, the initial dose after Hemodialysis Levofloxacin 500 mg
to 250 mg every subsequent 48 hours for 7 – 14 days, Metronidazole 500 mg every 8 hours,
Omeprazole 40 mg every 24 hours, Ranitidine 50 mg every 6-8 hours, Tramal 50 - 100 mg every 4 - 6
hours, Farmadol 1 g every 4 - 6 hours maximum 4 grams / day, Cagluconate 10 ml (2, 25 mmol) - 40
ml (40 mmol) of 10% / day, Transamin injection of 500 mg - 1 g every 8 hours, 10 mg Vitamin K
Injection for 24 hours2,3.
Valsartan 40 mg every 12 hours dose adjustment 80 - 160 mg every 12 hours, Amlodipine 5 mg - 10
mg every 24 hours, Inpepsa suspension 2 - 4 g every 12 hours for 4 - 6 weeks up to 8 grams, 500 mg
Sodium Bicarbonate rapid dehydration every 3-4 hours, later every 12 hours, Calcium Carbonate 500
mg every 8 hours, Paracetamol 500 mg - 1 grams every 4 - 6 hours maximum 4 grams, Folic Acid 5
mg every 24 hours depending on the disease Basically, Vitamin B12 50 - 150 mcg or more given
between meals every 8 hours2,3.
Blood transfusion Package Red Cells (PRC), Albumin transfusion, Transfusion of Fresh Frozen Plasma
(FFP)
LABORATORY RESULTS
Examination
Abnormal values
Normal value
Routine Hematology
Hemoglobin
7,8 *
13-18 g / dl
Hematocrit
23 *
40-52%
Erythrocyte
2,9 *
4,3 to 6,0 million / mL
14080 *
4800-10800μL
78 *
80-96fL
Leukosite
MCV
Coagulation
PT
13,4 *
10,2 to 12,2 seconds
APTT
48,4 *
29 to 40,2 seconds
Clinical Chemistry blood gas analysis
1738
pH
7,477 *
7,37 to 7,45
pCO2
23,2 *
33-44mmHg
pO2
42,7 *
71-104mmhg
Bicarbonate (HCO3)
17,3 *
22-29mmol / L
-4,6
(-2) -3mmol / L
82,7 *
94-98%
Albumin
24 *
3,8 to 5,1 g / dL
Urea
172 *
20-50mg / dl
Triglyceridese
11,6 *
0,5-1,5mg / dl
Calcium (Ca)
7,2 *
8,6-10,3mg / dl
GDS
179 *
<140mg / dl
Sodium (Na)
134 *
135-147mmol / L
Base excess (BE)
O2 saturation
Calculations Estimate Triglyceridese Clearance (CrCl) based on the Cockcroft-Gault4.
CrCl =
CrCl =
Weight (kg) x (140-age)
72 x (Cs) cr (mg %)
80 (kg) x (140-49)
72 x (11, 6 mg %)
CrCl
=
8, 71
mL/min
DRUG RELATED
PROBLEMS
(DRPs)
1.
Correlation between therapy with disease
There was a clinical condition was not treated, namely hepatitis B based on ISO book
Pharmacotherapy should be given hepatitis B vaccine therapy (HBIG).
Pharmacist Intervention: The dose of hepatitis B vaccine (HBIG) is usually 0,06 ml / kg IM
administered in a single dose for 14 days1.
2.
Selection of appropriate medication
1739
Selection of the drug was not safe for the patient's condition and dosing indispensable for these
patient (CKD stage V) because some drugs can not be in clean when hemodialysis.
Pharmacist Intervention: Patient with stage V renal failure need dose adjustments are based on
those calculations the dose should be decreased Triglyceridese Clearance Estimate of laboratory
values 5.
3.
Dose regimen
The dose, frequency and route of administration did not consider the effectiveness, safety, comfort,
and not in accorandce with the patient's condition? Meropenem 1 gram 3 times daily, Cefoperazone
Sulbactam 2 times daily 1 gram, 1 time a day Levofloxacin 500 mg, Valsartan 160 mg 1 time a day
Pharmacist Intervention: Use of drugs tailored to the patient's clinical condition; Meropenem for
ClCr < 10 mL / min to 250 mg for 24 hours, after hemodialysis given 500 mg every 8 hours,
Levofloxacin Cr 10-19 mL / min after hemodialysis therapy dose of 500 mg to 250 mg subsequently
every 4 hours for 7 - 14 days, Cefoperazone Sulbactam ClCr <15 mL / min therapeutic dose of 0,5
grams for 12 hours up to 1 gram / day, Valsartan as an antihypertensive drug, administered dose of
160 mg lowered to 40 mg 1 time / day in patient with Chronic Kidney Disease (CKD) on
Hemodialysis5.
4.
Interactions and contraindications
There were interactions between drugs with drug, Potassium Chloride + Valsartan need for dose
adjustment may increase potassium in the blood, Tramadol + Meropenem + Levofloxacin can affect
the central nervous system resulting in convulsions, Insulin + Sucralfate should be avoided or dose
adjustments of Insulin because of Sucralfate suspension containing carbohydrates so can interfere
with blood glucose levels, Calcium Carbonate + Sucralfate + Amlodipine, a Calcium Carbonate can
inhibit the action Sucralfate and Amlodipine, Lasix + Cefoperazone concurrent use can worsen
kidney function requires monitoring of renal function6.
Pharmacist Intervention: Potassium Chloride + Valsartan discontinued due to the use of potassium
normal laboratory values, Tramadol + Meropenem + Levofloxasin because this drug is needed in the
treatment of patient were advised to use Meropenem precedence because T½ of Meropenem
shorter that 1 hour of tramadol with T½ 6 hours, while for Levofloxasin given every 48 hours for
1740
patient with CKD condition that can be given after use of Tramadol, Insulin + Sucralfate improved
insulin dosage based on blood glucose levels. Calcium Carbonate + Sucralfate + Amlodipine,
Amlodipine use of precedence by chewing and swallowed to accelerate the absorption of Calcium
Carbonate inthe next administration and Sucralfate given within 1 hour after administration of
Calcium Carbonate, Lasix + Cefoperazone the use of Lasix precedence 30-60 minutes of use
Cefoperazone1,2,3,6,7.
CONCLUSION
Based on the assessment of the use of drugs were used, it can be concluded that, in patients with a
diagnosis of sepsis macrovascular disease complications, found the presence of some DRPs (Drug
Related Problems), correlation between therapy with disease, Selection of appropriate medication,
dosage regimen, interactions and contraindications.
REFERENCES
1. Yulinah Elin Sukandar. at all. 2008. “ISO Farmakoterapi”. ISFI Penerbitan. Jakart Barat.
2. Stiabudy Rianto. at all. 2008. “Informatorium Obat Nasional Indonesia”. Baand POM RI. Jakarta.
3. Hoan Tan Tjay and Rahardja Kirana. 2007. “Obat-Obat Penting”. Elex Media Komputindo
Kelompok Gramedia. Jakarta.
4. Sunil S. Jambhekar and Philip J Breen. 2009. Basic Pharmacokinetics. Pharmaceutical Press.
London and Chicago. UK/USA.
5. Caroline Ashley and Aileen Currie. 2009. The Renal Drug Handbook Third Edition. Radcliffe
Publishing Ltd18 Marcham Road, Abingdon, Oxon OX14 1AA. United Kingdom.
6. Medscape. Drug Interaction. 2014
7. Gunawan Sulistia Gan. at all. 2007, “Farmakologi And Terapi”. Departemen Farmakologi
andTerapeutik Fakultas Kedokteran - Universitas Indonesia. Jakarta
1741
EVALUATION OF DRUG RELATED PROBLEMS IN
TREATMENT HEMORRHAGIC STROKE
Dedy Firmansyah1, Diana Laila Ramatillah2), Aprilita Rinayanti Eff2)
1)
2)
Email: dodoy_f@rocketmail.com
Telp: +62813 8236 7040
ABSTRACT
Hemorrhagic stroke is the rupture of a blood vessel wall, causing bleeding in the brain2.
Hypertension triggered a major factor hemorrhagic stroke5. Administered drug therapy could
amount to much (polypharmacy) so that the handling of patients need more rigor6.Inaccuracy would
cause problems on the drug or drug related problems with the use of drugs (Drug Related
Problems)6.
Case Presentation: Patient Mr. BN, aged 48 years were treated in WardK PGI.Cikini
Hospital. Patient had complain limp hand and left foot, talk pleto, headache, constipation, decrease
of consciousness. CT - scan result hemorrhagic infarction in patientdiagnosed with the size of the
Cerebellum Dextra 3x2,5x3 cm ± 20cc . The patient had a history of diabetes mellitus and
hypertension. Test blood glucose levels obtained an average value of 191 mg/dL and LDL cholesterol
levels of 160 mg/dL. Diabetes Mellitus on the measurement of LDL cholesterol and blood glucose
exceeds the normal value.
ClinicEvaluation: Therapy treatment during care that tranexamic acid, Vitamin K,
Ranitidine Injection 5 mg, Vitamin B Complex, Folic Acid, Metformin 500 mg, Laxadine, Simvastatin
20 mg, glimepiride 1 mg, Captopril 25 mg, and Alprazolam 0,25 mcg. Drug related problems (DRP)
occurs in these patients because of the presence of unwanted drug reactions to the drug ranitidine
injection 50 mg with metformin 500 mg, oral antidiabetic between glimepiride 1 mg and metformin
500, and alprazolam 0.25 mcg and captopril 25 mg.
Keywords : Haemorrhagic Stroke, Drug Related Problems, PGI.CIKINI Hospital.
1742
INTRODUCTION
Stroke is a state of partial or complete loss of neurological function (focal neurologic
deficit or global) that occurs suddenly, lasts more than 24 hours or the cause of death, which was
solely caused by circulatory disorders of the brain due to reduced blood supply (ischemic stroke) or
spontaneous rupture of a blood vessel (hemorrhagic stroke)5.
About 14 of the 100 people suffered a hemorrhagic stroke. This condition mostly affects
older people, but can occur at any age6. There was two kinds of hemorrhagic stroke/bleeding were
intracerebral hemorrhage caused by bleeding in the brain and subarachnoid hemorrhage caused by
bleeding in the brain surface subakraniod space2. Symptoms of a stroke caused by bleeding in the
brain or intracerebral was weakness, numbness or tingling on one side of the body, difficulty
speaking or understanding, dizziness or blurred vision. These symptoms may be accompanied by
other symptoms such as sudden headache, altered consciousness, vomiting or stiff neck2.
Subakranoid stroke, the only symptoms that often occur suddenly was a severe headache2. It was
described as hit with a hammer, the only symptom that often occurs suddenly was a severe
headache2. Other symptoms that may occur is a loss of consciousness, seizures, nausea, vomiting,
sensitivity to light, stiff neck, confusion and fever2. These symptoms may be accompanied by
problems with speech and weakness on one side of the body2. Other causes that may cause
infarction or hemorrhage was dura sinus thrombosis, carotid artery dissection, vasculitis of the
central nervous system, intracranial large artery occlusive disease were progressive, migraine, drug
abuse (cocaine and anfetamin), haematological disorders (sickle cell anemia, polycythemia, and
leukemia)3. Enforcement diagnosis for stroke patients can usually be done with a CT-Scan
(Computerized Tomography Scan) and MRI (Magnetic Resonant Imaging)2. This was done if the
patient felt severe headaches or decreased consciousness2. CT-scan was performed to determine
the type of stroke, whether there was a blockage or bleeding2. Risk factors that may be the cause of
hemorrhagic stroke risk factors that can be changed such as hypertension, diabetes mellitus,
smoking, drug and alcohol abuse, increased hematocrit, asymptomatic carotid bruit, hyperurisemia
and dislidemia3.
CASE PERCENTATION
Patient Mr. BN was a male aged 48 years admitted to the Ward K, admission PGI.Cikini Hospital on
27 November 2014. The patient had complaints such as headaches, talk pleto, constipation, pain
1743
magh, the decrease of consciousness. The patient was a patient referrals from FMC Hospital, Bogor.
The patient previously had a CT-Scan of the head and unknow their perifokal edema with size
3x2,5x3 cm in the cerebellum dextra. Of FMC Hospital later the patient was referred to the PGI.Cikini
Hospital to be hospitalized. Patient previously had a history of diabetes mellitus and hypertension. A
history of the disease is certainly easier for doctors in diagnosing a patient illness.
On 27 november 2014, the patient's hematological examination showed hemoglobin
value was still high at 16.5 g/dL, leukocyte levels increased by 11.3 (
increased by 5.64 (
μL and erythrocytes
μL . Examination of blood glucose and cholesterol levels in the body of the
patient was done after the patient underwent treatment a few days. Test results obtained blood
glucose levels were still high with an average of 191 mg/dL and cholesterol checks werealso high at
160 mg/dL.
In this case, the patient was treated first in using the drug such as tranexamic acid and
vitamin K to overcome severe bleeding and captopril 25 mg as antihypertensive1. The use of folic
acid and vitamin B complex was done to address the occurrence of anemia due to bleeding1.
Therapies to treat blood glucose given the combination of metformin 500 mg as oral antidiabetic
and insulin actrapid injection 40 UI and glimepiride 1 mg given as a substitute for insulin actrapid
injection 40 UI for blood glucose test results provide significant decrease as expected. Simvastatin
20 mg selected for high LDL cholesterol1. Patient had gastric ulcers ranitidine injection that was
given to the effectiveness of the therapy and bowel obstruction given laxadin1. The amount of use of
medication that was used to make the patient feel anxious and disturbed sleep so for the therapy
given alprazolam 250 mcg1.
CLINICAL EVALUATION
DRPs : Drug Interactions
1. Interaction Ranitidine Injection 50 mg and Metformin 500 mg
Use of ranitidine and metformin, which was ranitidine may decrease the excretion of
metformin that will increase levels of plasma4.
Pharmacist intervention: Should be given within the administration of drugs, ranitidine
injection given every 6-8 hours (usually at night) whereas metformin can be used after eating1.
1744
2. Interaction Metformin 500 mg andGlimepiride 1mg
The use of a combination of metformin and glimepiride long term can lead to
hypotension4.
Pharmacist intervention: Recommended that blood glucose levels should be monitored so
that further action can be taken to use a single drug therapy4.
3. Interaction Alprazolam 0.25 mcg and Captopril 25 mg
The use of alprazolam and captopril will result in hypotension4.
Pharmacist intervention: Recommended the use of the drug should interval better
although captopril used before bed. But alprazolam should not be used for long-term considering
the effects of this drug dependency or should be done fisioterapi1.
CONCLUSION
In addition, there was a DRP (Drug Related Problems) includes interaction Ranitidine Injection 50 mg
and metformin 500 mg, Interaction Metformin 500 mg
and glimepiride 1 mg, Interaction
Alprazolam 0,25and Captopril 25 mg.
REFERENCES
1. Baand POM RI. 2008. InformatoriumObatNasional. Jakarta
2. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A Pathophysiologic Approach 7th Edition.
McGraw Hill. New York
3. Iskandar, J. 2002. PencegahanandPengobatan Stroke. Jakarta
4. Medscape. Drugs Interaction. 2004
5. Mutaqqin, Arief. 2008. Buku Ajar AsuhanKeperawatanKliendenganGangguanSistem Persarafan.
SelembaMedika: Jakarta
6. PERDOSSI, 2007. StandarPelayananMedik. Jakarta
1745
EVALUATION OF THE TREATMENT OF PATIENT WITH PULMONARY
TUBERCULOSIS (TB) BTA CATEGORY ONE AND SYNDROME DYSPEPSIA
AT PULMONARY DISEASE WARD GOVERNMENT GENERAL
PERSAHABATAN HOSPITAL
Wa ode Sriramadhan1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
Student of Pharmacist Program, Faculty of Pharmacy University of17 August 1945 Jakarta
Lecturer pharmacy in pharmacy Faculty University of 17 august 1945 Jakarta
(UTA’45 Jakarta
Email :oobbhhyy@gmail.com
ABSTRACT
Tuberculosis (TB) is an infectious disease caused by chronical bacteria Mycobakterium Tuberculosis
is transmitted through the air
germs into the air
(13)
(13).
When patient with TB coughs, sneezes or spits, they release TB
. Dyspepsia is a common term used for a syndrome or a collection of symptoms
or complaints of pain or discomfort on the nausea, bloating, vomiting, saltpeter, quick sense of
satiety, and the stomach feels full or begah
(6)
. patient TN. AD, aged 19 years, government general
persahabatan hospital which was signed on 12 December 2014 with a diagnosis of pulmonary
tuberculosis (TB) BTA after the laparoscopy category I and dipepsia syndrome. Therapy treatment
for 7 days treated that is NaCl Infusion, injection Ranitidine, Alinamin F, cetorolac injection , OAT
4FDC, Aspar K tablets, Multivitamins. Based on the results of the practice of the Registrar of clinics
on pulmonary disease Care Spaces rooms was over at Soka
government
general hospital
persahabatan then can be drawn the conclusion that the existence of the DRPS (Drug Related
Problems) regimens dose werenot in accorandce with the library and also hadindication withgiving a
drug.
Key words: Drug Related Problems (DRPs), Pulmonary Tuberculosis (TB) BTA, SyndromeDyspepsia.
1746
INTRODUCTION
Tuberculosis (TB) is a disease which iscaused by infection with Mycobacterium Tuberculosis
complex(10).Mycobacterium Tuberculosis rod-shaped, straight or slightly curved. These bacteria-sized
with of 0.3 – 0.6 mm long and 1-4 mm. Wall mycrobacterium is very complex, consisting of a layer of
fat is quite high (60%) (10).
Tuberculosis (TB) is a contagious disease with a relatively high incidence rate(10). Pulmonary
Tuberculosis (TB) was also reported as the cause of death is the third largest in the world after
cardiovascular diseases and diseases of the respiratory tract as well as an infectious disease the
number one in the world can cause death (9).
Clinical symptoms are cough, cough two weeks of blood, shortness of breath, chest pain, fever and
other (9). The world's Tuberculosis (TB) report by the WHO put Indonesia fourth most for sufferers of
Tuberculosis after China, India, and South Africa with the prevalence of Tuberculosis in Indonesia in
2013 is 297 per 100,000 population with new cases every year reaching 460,000 cases
(9)
. Thus, the
total cases to 2013 approximately 800,000-900,000 cases (13). In addition to the home environment
sanitation factors, the incidence of pulmonary Tuberculosis (TB) disease is also very concerned with
the behavior and the amount of family income because most patients with Tuberculosis (TB) is a
poor level of education is low
(9)
. For examination of pulmonary Tuberculosis (TB) were examined
specimens of sputum within 2 days that is during morning-during (SPS)(9). Based on the guidelines of
the national Tuberculosis program, the diagnosis of pulmonary Tuberculosis in adults is enforced
with Tuberculosis (TB) germs he met (BTA)(9). Whereas examination of the thoracic breed photos
and test sensitivity can be used as a support in diagnosis in accorandce with the indications and not
justified in diagnosing Tuberculosis (9).
Dyspepsia is a common term used for a collection of symptoms or syndrome/please come-han in
the form of pain or discomfort on the nausea, bloating, vomiting, saltpeter, quick sense of satiety,
and the stomach feel full (5).
Adult population in Western countries influenced by dyspepsia ranged from 14 to 38%. However,
approximately 13-18% have spontaneous resolution over the past one year, with a stable prevalence
over time (5). Dyspepsia affects 25% of the population of the United States each year and about 5%
of all patient go to the doctor for the primary services
(5)
. Whereas the United Kingdom has a
prevalence of dyspepsia about 21% and just two percent of the population of primary care
1747
physicians to consult them with the first new episode or dyspepsia and dyspepsia annually,
accounted for 40% of all consuls to the gastroenterologist. Survey on community estimates that only
around 35% of patients with dyspepsia who consulted a doctor, although its proportions will
increase as we get older (5).
CLINICAL EVALUATION
In the treatment of patient given Ranitidine injection 150 mg 2x1/12 hours for intravenous.
Ranitidine is a medication used to treat the dyspepsia syndrome. Alinamin F 2x1 oral administered
to meet ful fiil of vit. 12, B1 and NaCl 0.9% with cetorolac 500cc 1 amp 10 mg/12 hours for the
abdominal pains for IFVD wounds post laparoscopic, loss of body fluids, Aspar K 300 mg 3x1 tablets
used to help increase levels of potassium ions in the blood is lacking or hypokalemia, Multivitamins
tablet 3x1 supplements increase appetite as seen from the patient's nutritional condition, namely
poor nutrition. While the OATS 4FDC 1x2 tablets (Rifampin 150 mg, 400 mg, Pirazinamid 75 mg
Ethambutol, INH 275 mg) used for treatment each day in the intensive phase and to insert
pulmonary Tuberculosis (TB) on the BTA (1,2).
LABORATORY RESULTS
The results of laboratory examinations carried out by the patient AD. The value of abnormality point
out laboratory vaules in Leukocyte 10.81 000/mm3 (normal value: 5-10 000/mm3), 79.3% netrofil
(the normal rate: 50-70%) monocytes 9.8% (normal values: 2-8%) esinophil 9.7% (normal values: 24%) the hemoglobin of 13.0 g/dl (normal value: 14-18 g/dl), 40% (hematokrit normal value: 43-45%),
platelets 640 000/mm3 (normal value: 150-440 000/mm3), potassium 3.20 mmol/L (normal value:
3.5-5.5 mmol/L), triglycerides 0.6 (normal value: 0.8-1.5 mg/dL albumin, 2.1 g/dL (normal value: 3.45 g/dL, calcium 7, 00mg/dL (normal value: 8.4-10.2 mg/dL (1.8).
1.
Regimens Dose
In this case patient go the dose of Alinamin F which was incompatible with the doses which as
found in the literature.
Pharmacist Intervention
Administered Once daily 1 tablet a day after not 2 times a day (12).
1748
2.
Indications Without Giving Drugs
Laboratory results showed an abnormality that wasvalue of leukocytes, monocytes, netrofil, lisinofil,
which indicated the presence of infection should be treated with injection of the antibiotic of
Ceftriaxon (cephalosporins third generation). Ceftriaxon is a broad spectrum antibacterial indicated
for severe infection
(5)
. Views of the value of albumin occur causing loss hipoalbumin
recommendedfor patient was given nutritional therapy, by consuming fish Cork albumin
(12)
. Fish
Cork in addition contains albumin in large quantities, also has elements of zinc (zn) that play a role in
wound healing (12). Patient experiencing a decrease calcium that caused hypocalcemia so need to be
given in the form of hypocalcemia-enhancing drugs Vitamin D. Patient experienced a decline in
hemoglobin indicate anemia, but was not given medication anemia (12).
CONCLUSION
Based on the observations that have been made in the case of the patient then it can be inferred
that patient diagnosed with pulmonary Tuberculosis(TB) disease BTA category 1 and dipepsia
syndrome and patient experience some problems associated with the treatment, that was an
inappropriate dose regimens, and also had indication without giving drugs.
REFERENCES
1. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Sagung Seto : Jakarta.
2. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford.
3. Depkes,
2005.
Pharmaceutical
care
untukpenyakittuberkulosis.
DirjenBinaKefarmasianandAlatKesehatan. Jakarta.
4. Djojodibroto, Dr. R. Darmanto, Sp. P, FCCP. 2009. Respirologi (Respiratory Medicine). Jakarta :
EGC
5. Galileopharma. 2008, BNF edition 56, Alexandria University
6. Haapalahti M, Mykkanen H, Tikkanen S, Kokkonen J, 2004. Food habits in 10 – 11-year-old
children with functionalgastro-intestinal disorders. European Penderita Dispepsia Fungsional.
7. Herryanto, 2004, Riwayatpengobatanpenderita TB paruJurnalKesehatanvol 3, Bandung.
8. KEMENKES RI, 2011. PedomanInterpretasi Data Klinik.Kemenkes RI : Jakarta
1749
9. Made
dkk,
2013,
Hubunganpengetahuan,
sikapandMotivasitengakesehatandenganaktivitasnyadalampengendalianKasusTuberkulosis
di
KabupatenBuleleng. JurnalMegisterKedokteranKeluarga, Surakarta.
10. Manjoer, A, et al, 2000, Kapita selekta kedokteran, edisi 3, Jakarta, Medika aeusculapeus.
11. Pedoman Nasional Penanggulangan Tuberkulosis Edisi 2 Cetakan Kedua. Departemen
Kesehatan Republik Indonesia 2008.
12. Suzanne C. Smeltzer, Bare G. Brenda. 2002. BukuAjarKeperawatanMedikalBedah.EGC. Jakarta
13. WHO, 2014.What Is TB ?.World Health Organization
1750
EVALUATION OF DRUG RELATED PROBLEMS (DRPs)
TREATMENT OF CHOLELITHIASIS WITH DYSPEPSIA DISEASE
AT THE INTERNAL DISEASE WARD OF PGI CIKINI HOSPITAL
Sri Dwi Mei Karyanti1, Diana Laila Rahmatillah2, Aprilita Rinayanti Efi2
1
Student of Pharmacist Professional Program Student, Faculty of Pharmacy UTA’45 Jakarta
2
Email : srikaryanti6@gmail.com
ABSTRACT
Gallstone disease (cholelithiasis) is a chronic recurrent hepatobiliary disease1. The basic for which is
the impaired metabolism of cholesterol, bilirubin and bile acids, which is characterized by the
formation of gallstones in the hepatic bile duct, common bile duct, or gallbladder1. Dyspepsia is a
collection of symptoms or syndrome such as heartburn, nausea, bloating, vomiting, taste is full or
satiety, belching2. Case presentation : Patient Mrs. DIS 34 years old with a body weight 113 kg, she
has went to ward of internal disease in PGI Cikini Hospital on August 28, 2014 with a diagnosis of
cholelithiasis and dyspepsia disease. Patient diagnosed with upper abdominal ultrasound and blood
laboratory tests complete. Therapy treatment for during hospitalized is sharox (cefuroxime),
spasmomen (otilonium bromide), estazor (Ursodeoxycholic acid), inpepsa (sucralfate), folic acid,
pantozol (pantoprazole), torasic (ketorolac), dexamethasone, diphenhydramine, Neurobion 5000,
heparin drip, nexium (esomeprazole), dumin (paracetamol), meronem (meropenem), and inhalation
(Ventolin, Flixotide, bisolvon). Clinical Evaluation: basically, there were 3 interventions that have
been founded during the assessment of treatment the patient, drug interactions of sharox with
heparin, sharox with nexium, and torasic with dexamethasone. Besides that, discovered the
existence of the patient which did not receive the drug as needed was OBH. Non-compliance patient
in taking medicine like pantozol, folic acid, and Neurobion 5000. As well , there was an ineffective
drugs which were given from one class of drug was nexium and pantozol. There was DRP which was
necessary to watch out for in the treatment of patient. DRP can cause failure in patient treatment
and can cause lead to death.
Keywords: Cholelithiasis, Dyspepsia, and PGI Cikini Hospital.
1751
INTRODUCTION
Gallstone disease (cholelithiasis) is a chronic recurrent hepatobiliary disease1. The basic
for which is the impaired metabolism of cholesterol, bilirubin and bile acids, which is characterized
by the formation of gallstones in the hepatic bile duct, common bile duct, or gallbladder1. The
complaints on this disease may be dyspepsia sometimes accompanied intolerans to fatty foods. In
symptomatic, the main complaint is pain in the epigastric region, right upper quadrant or
precordium. The spread of pain can to middle back, scapula, or shoulder peak, accompanied by
nausea and vomiting. Risk factors in cholelithiasis were age, gender, pregnancy, genetic factors,
metabolic syndrome, and obesity1.
Dyspepsia is a collection of symptoms or syndrome of heartburn, nausea, bloating,
vomiting, taste is full or satiety, belching2. The etiology of peptic ulcer dyspepsia is, medications such
as NSAIDs, cholelithiasis, colesistis, pancreatitis, and systemic conditions such as diabetes mellitus ,
thyroid disease and pregnancy2 .
CASE PRESENTATION
Mrs. DIS is a 34 year old woman weighing 113 kg was treated in the internal disease
wards. Patient entered in the PGI Cikini Hospital on August 28 , 2014. The patient was admitted with
main complaint of heartburn in the upper right abdomen 2 hours before entering the hospital. The
history of medical patient now that since 2 hours before entering hospital, patient had experience of
heartburn in the upper right abdomen , vomiting 5 times , a cold sweat , yellow eyes , bloating ,
found gallstones . During treatment patient given drugs such as 1x1 suspension of inpepsa 15 ml,
spasmomen 40 mg 3x1tablet, estazor 2x250 mg capsule, nexium 2x40 mg tablet and already
recommended for surgery , but the patient is not willing. Past medical history of the patient was
gotten the anticoagulation, gallstones, asthma, and TIA (Trasient ischemic attack). Patient has
allergy to aspirin, antalgin, Decolgen, Ponstan, Panadol (paracetamol), and amoxicillin.
CLINICAL EVALUATION
The using of sharox (cefuroxime) as antibiotics. Spasmomen (otilonium bromide) as a pain
reliever in gastrointestinal disorders. Estazor (Ursodeoxycholic acid) was used to dissolve gallstones.
Nexium (esomeprazole) and pantozol
(pantoprazole) is a class of PPIs (Proton Pump
1752
Inhibitors) used to treat stomach pain and as a treatment of dyspepsia disease. Inpepsa (sucralfate)
was used for dyspepsia and also as unnausea and unvomiting. Torasic (ketorolac) was indicated for
pain. Dexamethasone and diphenhydramine was used to treatment of allergic and heparin as an
anticoagulant. Folic acid was used as a vitamin for maintaining health. Dumin was used for fever.
Meronem was used as an antibiotic and neurobion 5000 as neurotrophic vitamins . Flixotide and
Ventolin was used in the treatment of asthma. Bisolvon was used to relieve cough3.
Dosage and method of use the drug in a patient that was on the first day of treatment on
August 28, 2014, the patient was given the drug of spasmomen 40 mg 3x1 tablet, estazor 250 mg
2x1 capsule, nexium 40 mg 2x1 tablet, 1x1 inpepsa tablespoon, pantozol 1x1 through intravenous
injection ampoule and the drugs taken for 10 days until September 6, 2014. On the second day of
the date of August 29, 2014 given additional medication was antibiotics sharox 1 g 1x1 by
intravenous injection. Sharox antibiotics given to patient for 7 days until September 4, 2014. On
August 30, 2014 sharox enhanced antibiotic administration time interval becomes 2x750 mg and
given additional medication torasic 1 ampoule to treat pain in the patient, dexamethasone and
diphenhydramine was used each one ampoule as an un-allergy drug torasic. On September 1, 2014
patient got additional medication of drip 5000 U of heparin was given 1 ml in conjunction with the
infusion and drug administration time interval 2x1 ampoule pantozol given day. Heparin was given
for 6 days from the date of September 1 to September 6, 2014. On September 2, 2014 given
additional medication for 5000 Neurobion and folic acid each given 1 tablet for a day. Vitamins were
given 2 day until September 3, 2014. On September 3, 2014 the patient did not want to take
medication of folic acid, pantozol, and Neurobion 5000. On September 4, 2014 the patient has a
high fever with a temperature of 39◦C and given medication of dumin 1x1 tablet, and patient also
had asthma, cough and shortness of breath. Doctor gave inhalation ( Ventolin 1 ampoule + Flixotide
1 ampoule + 10 drops bisolvon ) which is administered 3 times daily for 3 days until September 6,
2014. The dose was increased to 7500 U of heparin per day which was given until September 6,
2014. On September 4, 2014 the patient did not want to inject drug pantozol. On September 5, 2014
the doctor prescribing of OBH, but the patient did not receive the medication prescribed. In
addition, there was a change of antibiotic that was used antibiotics morenem 1 g x 3 vials a day.
1753
Dumin was given 1 tablet 3 times a day and the patient did not want to accept pantozol injection.
Dated September 6, 2014, patient was given the same drug as before, except that the doctor did not
prescribe pantozol injection .
CLINICAL LABORATORY EXAMINATION RESULTS
The results of complete blood laboratory tests on the patient which showed that the value of
erythrocyte abnormalities 4,60x106/ mL (normal 4.00 to 4.50 x106/ mL), neutrophil rod 0% (normal
2-6%), neutrophils segment of 41 % (normal 50-70 %), lymphocytes 48% (normal 20-40%),
monocytes 9% (normal 2-8 %), direk bilirubin 0.3 mg/ dL (normal 0.1-0.2 mg/ dL), D-dimer 540 mg/
dL (normal 0-500 mg/dL), erythrocyte sedimentation rate 22 mm/h (normal 0-20mm/h). Upper
abdominal ultrasound examination results showed that in the gall bladder stones appear multiple
diameters from 0.78 to 1.95 cm.
DRP 1
Drug Interactions
Sharox (cefuroxime) and heparin will increase the effect of heparin by heparin (anticoagulation).
Possible serious or life threatening interaction. ephalosporins may decrease prothrombin activity 4.
Mechanism of cephalosporin can cause bleeding that is induction of vitamin K-responsive
hypoprothrombinemia, production of an acquired platelet defect, thrombocytopenia secondary,
immune thrombocytopenia, and inhibition of fibrin polymerization. Reported nearly 25 % of cases in
the United States die
result from bleeding after taking classes sefalosforin especially on
gastrointestinal5.
Doctor;s note: Check of APTT patient, erythrocyte sedimentation rate, and
D –dimer
Pharmacist’s intervention : the solution given in drug delivery interval of at least 2 hours and
perform monitoring through laboratory or clinical monitoring6.
Sharox (Cefuroxime) with nexium (esomeprazol) can occur a significant interaction.
Esomeprazole will decrease the level or effect of cefuroxime by increasing gastric pH4.
Doctor’s note: nexium given an empty stomach, but sharox given after eat3.
Pharmacist’s intervention: the solution given in drug delivery interval of at least 2 hours6.
1754
Torasic (ketorolac) and dexamethasone interact with mechanism of pharmacodynamic
synergism. Significant interaction possible, monitor closely. Increased risk of GI ulceration4. The
solution given in drug delivery interval of at least 2 hours6. Torasic drunk after eat3.
DRP 2
Adverse Drug Effects
Patient Mrs.DIS reported experiencing itchy eyes, nasal congestion after given drug torasic
(ketorolac) for the previous patient complained of pain in the right abdomen. After that, the doctor
gave dexamethasone injection of 1 ampoule to the patient but the patient reported increasingly
itchy eyes , nose increasingly clogged, flushed face, and lips itch. Administration of dexamethasone
did not help allergy patient then, patient was given diphenhydramine 1 ampoule IV .
Ketorolac is a non-selective NSAIDs ( inhibit cox-1 ) which has adverse reactions include urticaria,
angioedema, anaphylactic shock, and respiratory
exacerbation7. Reporting cases of anaphylactic
reactions have been reported after intramuscular injection of dexamethasone. Patient had
experiencing dizziness, pruritus, hypotension and dysphonia8. Incidence of anaphylactic reactions in
eye treatment using intravenous injection of dexamethasone in which patient experienced itching
and edema of the eyes until weeks9.
Doctor’s note: doctor gave dexamethasone for allergic patient. Then dexamethasone did not help
allergy patient which was given intravenous injection then difhenhidramin antihistamines was given.
Pharmacist’s intervension: Ideally ADRs should be prevented. Measures to prevent allergic drug
reactions include a careful history to determine host risk factors, avoiandce of cross-reactive drugs,
use of predictive tests when available, proper and prudent prescribing of drugs (especially
antibiotics) that were frequently associated with adverse reactions, use of oral drugs when possible,
and documentation of ADR in the patient’s medical record7.
DRP 3
Not receiving of drug therapy
On 5 September 2014 the patient had a cough and doctor prescribe Black Cough Drug
(OBH). However, no drug supplies, so that the drug was not administered to the patient.
Doctor’s note: treatment of cough with OBH replaced with bisolvon through inhalation .
1755
Pharmacist’s intervention: medication replacement can be provided upon treaties doctor .
DRP 4
Non Compliance
September 3, 2014, the patient did not want to take medication folic acid, pantozol, and
Neurobion 5000. On 4 September 2014 The patient did not want to accept pantozol injection.
Pharmacist’s intervention : therapeutic failure patient with chronic disease often a result of poor
adherence to drug therapy and therapy of non drug10.
DRP 5
Ineffective drug (irrational)
Doctor gave pantozol (pantoprazole) with nexium (esomeprazole) drug on the same day.
This was irrationality in drug delivery, where both drugs are one class of the same which is a proton
pump inhibitor. Both of these drugs have a way of working together that is binding K +/H+-ATPase
irreversibly thereby inhibiting the proton pump (H+) and further inhibits the secretion of HCl . The
solution was to stop one of the drugs11.
CONCLUSION
Based on the results of clinical work practice in the internal disease ward of PGI Cikini hospital, it can
be concluded that the presence of DRPs ( Drug Related Problems ) should watch out for in the
treatment of patient. DRP can cause failure patient in treatment can even lead to death. DRP in the
form of case studies that drug cefuroxime drug interactions with drugs esomeprazol and heparin ,
ketorolac with the drug dexamethasone . Interaction seriously need to watch out for and monitored
. Adverse reactions found in drug use ketorolac and dexamethasone for the need for an allergy test
in Mrs. DIS . Patient did not receive the required drug therapy and patient non compliance in taking
the drugs can lead to inefficiencies in the treatment of patient. There is irrational drug
administration in these patient where given two drugs of the same class 1 class is a pump proton
inhibitors .
REFERENCES
1. Vasiliy, et al. 2012. Concept of the Pathogenesis and Treatment of Cholelithiasis. Dalam: World
Journal of Hepatology. ISSN 1948-5182.
1756
2. Djojoningrat, D. 2006. Dispepsia Fungsional. Dalam: Sudoyo, A.W; Setiyohadi, B; Alwi, I;
Simadibrata, M; Setiati, S. (eds.). 2006. Buku Ajar Ilmu Penyakit Dalam. Jilid1. Edisi ke-4. Jakarta,
Pusat Penerbitan Departemen Ilmu Penyakit Dalam FKUI.
3. BPOM RI. 2008. IONI. Baand Pengawasan Obat and Makanan Republik Indonesia. Jakarta.
4. Medscape. 2014.Drug Interaction Checker. http://reference.medscape.com/drug. Diakses pada
tanggal 13 Oktober 2014.
5. Robert, F. 1990. Safety of Parenteral Third-Generation Cephalosporins. The American Journal of
Medicine Volume 88.
6. Syamsudin. 2013. Interaksi Obat Konsep Dasar and Klinis. UI-Press. Jakarta.
7. Solensky, R. 2010. Drug Allergy: An Updated Practice Parameter. American Academy of Allergy
Volume 105.
8. Figuredo.,et.al. 1997. Anaphylaxis to Dexamethasone. Allergy Net.
9. Achim.,et.al. 2014. Anaphylactic Reaction to Intravenous Corticosteroids in the Treatment of
Ocular
Toxoplasmosis:
a
case
report.
Journal
of
Medical
Case
Report.
http://
www.jmedicalcasereports.com.
10. Kementrian Kesehatan Republik Indonesia. 2011. Pedoman Interpretasi Data Klinik. Jakarta:
Bina Kefarmasian and ALKES.
11. Priyanto. 2009. Farmakoterapi & Terminologi Medis. Leskonfi. Depok.
1757
NON- Hemorrhagic STROKE At Islamic Cempaka Putih
Jakarta Hospital (RSIJCP)
Ade Irma Novita Sari1, Diana LailaRahmatillah2 ,AprilitaRinayanti Efi2, dr. Ihsanil2
Email: ade_swidd@yahoo.com
Pharmacist Professional Program Student
FacultyPharmacy Of 17 Agustus1945 JakartaUniversity
ABSTRACT
Stroke is a functional disorder of acute focal brain and globally more than 24 hours, is derived from
the interruption of cerebral blood flow and not caused by circulatory disorders of the brain at a
glance, brain tumors, stroke secondary to trauma or infection. Ischemic stroke is caused by focal
cerebral vascular occlusion causes a decline in the supply of oxygen and glucose to the brain that
undergo occlusion. Mr. TK 58 years old, was hospitalized at Islamic Cempaka Putih Jakarta
Hospitalon December 4, 2014 with a diagnosis non-hemorrhagic stroke. The treatment which was
given to this patient during hospitalized; clopidogrel, aspilet, injection vitamin C, injection nicholin
250 mg, pamol, episan syrup, omeprazole, and novorapid. Based on the results of clinical work
practice at the stroke center units at Islamic Cempaka Putih Jakarta Hospital, it can be deduced that
the presence of DRPs (Drug Related Problems) like drug interactions, failed to receive the drug, and
the indications that were not treated.
Keywords: Stroke, ischemic stroke
1758
INTRODUCTION
Stroke is a functional disorder of acute focal brain and globally more than 24 hours, is derived from
the interruption of cerebral blood flow and not caused by circulatory disorders of the brain at a
glance, brain tumors, stroke secondary to trauma or infection. Ischemic stroke is caused by focal
cerebral vascular occlusion causes a decline in the supply of oxygen and glucose to the brain that
undergo occlusion. The emergence of signs and symptoms of focal or global on the stroke is caused
by a decrease in cerebral blood flow. The occlusion can be thrombus, embolus, or thromboembolic
cause hypoxia to anoxia in one area of branching blood vessels in the brain. Any kind stroke will
cause acute neurological deficit, with signs and symptoms of stroke, namely, hemidefisit motoric,
sensory hemidefisit, loss of consciousness, paralysis of the facial nerve (VII) and hipoglosus (XII)
which contains the central, noble function disorders such as difficulty speaking (aphasia) and
impaired intellectual function (dementia), hemianopsia, and brain stem deficits. The stroke risk
factors:
Parameter
Potentially can be
Can not be controlled
controlled
Hypertension
Diabetes mellitus
Age
Heart disease
Hiperhomosisteinemia
Gender
Atrial fibrillation
Left ventricular
Hereditary
hypertrophy
Endocarditis
Race and ethnicity
Stenosis mitralis
Geography
Cardiac infarction
Smoke
Sickle cell anemia
Transient Ischemic Attack
(TIA)
Asymptomatic carotid
stenosis
1759
In ischemic stroke, reduce the blood flow to the brain causing hypoxemia regional areas of the brain
and cause a chain reactions that ended with the death of brain cells and the other supporting
elements. In general regional of brain area who has experiencing ischemic, consists of the core
(core) with the heaviest levels of ischemia and is located in the central. This area will be necrotic
area in a short time, if there is no reperfusion. Outside the ischemic core area there were penumbra
area of ischemic. Brain cells and supporting tissue is not dead but very reduced functions and cause
neurological deficits also. The ischemic level increasingly peripheral to the more light. Ischemic
penumbra region, on the outside can be surrounded by a hyperaemic areas as a result of collateral
blood flow (perfusion luxury area). Ischemic penumbra area that is the target of therapy of acute
ischemic stroke in order to reperfusion and make brain cells to function again. The reversibility
depends on the factors of time and if it does not happen reperfusion, penumbral region can be
deaths.
CASE STUDY
Mr. TK 58 years old, was hospitalized at Islamic Cempaka Putih Jakarta Hospitalon December 4,
2014. Patient came with complaint like exprience limp sensation, did not want to eat, hand and left
leg feels weak. Patient had impaired speech (slurred speech), the patient had fever ± 1 days. The
patient had a history of hypertension and diabetic mellitus ± 1 year.
CLINICAL EVALUATION
The use of clopidogrel and aspilet intended for blood thinners to prevent blood clots in the brain.
Vitamin C injection was used for the purpose of maintaining health and endurance the patient.
Nicholin 250 mg injection used to treat disorders of consciousness in patient. Pamol used to reduce
fever patients. Episan syrup was used to protect the ulcer from the effects of acid and pepsin.
Omeprazole is used as an inhibitor of gastric acid secretion. Novorapidflexpen used as therapy of
diabetic mellitus patient.
DOSAGE AND HOW TO USE THE DRUG
Patient treated with clopidogrel at a dose of 75 mg 1 x 1 administered orally. Aspilet (Acetylsalicylic
acid) at a dose of 80 mg 2 x 1 administered orally. Vitamin C is given 2 x 1 usage by injection route.
Nicholin at a dose of 250 mg 2 x 1 is given by injection route. Pamol given for extra treatment to
reduce fever. Episan syrup given orally with doses 3 x 1. Omeprazole 40 mg 1 x 1 administered
1760
orally. Novorapidflexpen given every 6 hours with its multiple doses per unit of 2 U of each blood
sugar checks if there is a rise in blood sugar.
CLINICAL CHEMISTRY LABORATORY EXAMINATION RESULT
On the result of laboratory tests on the first day of admission found some abnormal results include
hemoglobin 11.73 g / dL (normal values from 13.2 to 17.3), hematocrit 36% (normal values 40-52),
platelets 528 thousand / mL (normal value 150-440), MCV / VER 77 fL (normal value 80-100), MCH /
HER 25 pg (normal values 26-34), sodium 134 mEq / L (normal value 135-147), and blood sugar
when 151 mg / dL (normal values 70-200).
Result of laboratory tests on the second day onwards glucose examination every 6 hours as follows:
Date of
05.00
examination
11.00
GD
17.00
GD
11 pm
GD
GD
5/12/14
-
172 mg/dL
160 mg/dL
228 mg/dL
6/12/14
212 mg/dL
278 mg/dL
187 mg/dL
246 mg/dL
7/12/14
213 mg/dL
174 mg/dL
191 mg/dL
219 mg/dL
8/12/14
193 mg/dL
268 mg/dL
217 mg/dL
231 mg/dL
9/12/14
254 mg/dL
289 mg/dL
270 mg/dL
286 mg/dl
10/12/14
460 mg/dL
405 mg/dL
-
-
On the third day urine analysis complete laboratory examination, and found to have an abnormal
result of which, the clarity of urine (normally clear), leukocytes 20-30 / LPB (normal 0-5),
erythrocytes> 100 / LPB (normal value 3), bacteria 1+ (negative normal value), Protein 2+ (negative
normal value <30 mg / dL), glucose 1+ (negative normal value <100 mg / dL), Nitrite + (negative
normal value), and leukocyte esterase 1+ (negative normal value). From the result of urine analysis
complete laboratory that it can be concluded that the presence of bleeding in the urine.
1.
DRP 1: Drug interactions
There was a drug interaction between aspilet and omeprazole, concurrent use of PPIs may reduce
the bioavailability class of aspirin and other salicylate. Aspilet and clopidogrel, concurrent use of
1761
both drugs can cause bleeding in the GI. Pharmaceutical interventions: giving the interval for giving
medicine and gastrointestinal prophylaxis given additional medication such as PPI group. Clopidogrel
and omeprazole, concurrent use of PPIs may reduce the effectiveness of the group of clopidogrel in
preventing heart attacks and strokes. Pharmacist intervention: to replace with other drugs such as
antacids, H2 antagonist like ranitidine or famotidine.
2.
DRP 2 : Failed to receive the drug
The patient had a previous history of hypertension but when treated patients are not getting a drug
to treat the hypertension, so the patient blood pressure is unstable for each day. Pharmacist
Intervention:to be given antihypertensive drugs.
3.
DRP 3: The indications that were not treated
The patient had a history of hypertension but when treated patients are not getting the
hypertension drug. Pharmacist Intervention: to be given antihypertensive drugs.
CONCLUSION
Based on the result, it can be deduced that the presence of DRPs (Drug Related Problems) from drug
interactions such asaspilet the PPI omeprazole with group interaction may decrease the
bioavailability of aspirin, clopidogrelaspilet with the interaction concurrent use of both drugs can
cause bleeding in the GI, and clopidogrel with omeprazole with group interaction using PPIs may
reduce the effectiveness of clopidogrel. Failed to receive drugs and indications that were not
treated, the patient did not get antihypertensive drugs to cope with the hypertension.
REFFERENCES
1. Baxter, Karen, BSc, MSc, MRPharms. 2009. Stockley’s Drug Interaction. London. Pharmaceutical
Press.
2. Bruno A, Kaelin DL, Yilmaz EY. 2000. The subacute stroke patient: hours 6 to 72 after stroke onset.
In Cohen SN.Management of Ischemic Stroke.McGraw-Hill. PP 53-87.
3. Cohen SN. 2000. The subacute stroke patient: Preventing recurrent stroke. In Cohen
SN.Management of Ischemic Stroke.McGraw Hill. PP 89-109.
4. De Freitas GR, Christoph DDH, Bogousslavsky J. 2009. Topographic classification of ischemic stroke.
In Fisher M.(ed). Handbook of Clinical Neurology, Vol.93.(3rd series).Elsevier BV.
1762
5. Hacke W, Kaste M, Bogousslavsky J, Brainin M, Chamorro A, Lees K et al..2003. Ischemic Stroke
Prophylaxis and Treatment – European Stroke Initiative Recommendation.
6. Lacy, F.C., Armstrong L.L., Goldman, M.P., Lance L.L.et al, 2010, Drug Information Handbook,LexiComp, American Pharmacist Association.
7. Misbach,J. 2007. PanandganUmumMengenai Stroke.Dalam: Rasyid, A. And Soertidewi,L (eds).
Unit Stroke.Manajemen Stroke SecaraKomprehensif. Hal 1-9. BalaiPenerbitUniversitas Indonesia.
Jakarta.
8. WHO. MONICA. 1986. Manual Version 1 : 1.
9. Zullo A, Hassan C, Campo SM, Morini S. 2007. Bleeding peptic ulcer in the elderly: risk factors and
prevention strategies.Drug Aging. 24 (10): 815-28.
1763
EVALUATION OF TREATMENT ON BREAST CANCER
PATIENT (Ca mammae) AT PGI CIKINI HOSPITAL,
JAKARTA
Suraya Adas Mukaddas1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2, Stefanus Lukas2
1
2
Email: adasmukaddas@gmail.com
ABSTRACT
Breast cancer is a group of abnormal cells in the breast that continues to grow(6). Eventually these
cells to form lumps in the breast. If the cancerous lump was not removed or controlled, cancer cells
can spread (metastasis) to other body parts. Patient Mrs.. ER Age 47 Years, admitted PGI Cikini
Hospital, Central Jakarta on November 6, 2014, 60 kg, while in tow body 150 cm, with a diagnosis of
breast cancer (Ca mammae). Patient undergoing chemotherapy protocols for treatment, while
chemotherapy protocol given that Gemcikal 1400 mg + 0.9% NaCl 500 cc (days 1 and 8) and Brexel
130 mg + 500 cc of 0.9% NaCl iv drip (day 1), Nasea 0.3 mg iv, Dexamethasom 20 mg iv, Ranitidine
50 mg iv, 0.9% NaCl Infusion 100 cc. After the chemotherapy protocol patient treated Nasea 1 x 0.1
mg orally for 5 days, Ranitidine 2 x 150 mg orally for 5 days, Medixon 2 x 4 mg orally for 5 days,
Folavit 2 x 400 mg for 5 days. Based on the results of clinical work practice at PGI Cikini Hospital it
can be concluded that there were no DRP (Drug Related Problems).
Keywords: Breast Cancer, Chemotherapy, PGI Cikini Hospital
1764
INTRODUCTION
Breast cancer is a group of abnormal cells in the breast that continues to grow(6). Eventually these
cells to form in the breast bejolan. If the cancerous lump was not removed or controlled, cancer
cells can spread (metastasis) to other body parts. Metastases may occur in lymph nodes (lymph)
armpit or above the shoulder blades. In addition, cancer cells can be lodged in the bones, lungs,
liver, skin, and subcutaneous(1).
Breast cancer is a disease that occurs in case of genetic damage to the DNA of breast epithelial cells.
There are many types of breast cancer. Genetic changes found in the epithelial cells, spreading to
ductal or lobular tissue. The level of growth of cancer depends on the effects of estrogen and
progesterone. Cancer can be invasive (infiltrating) and noninvasive (in situ). Breast cancer can
develop invasive or infiltrating ductal wall and surrounding tissue, so far that many cancers are
invasive ductal carcinomas occur. Ductal carcinoma derived from the lactiferous ducts and shaped
like tentacles that invade surrounding breast structure. The tumor is usually unilateral, can not be
described, solid, non-mobile, and nontender. Lobular carcinoma of the breast lobe origin. Usually
bilateral and not palpable. Nipple carcinoma (Paget's disease) is derived from the nipple. Usually
occurs with invasive ductal carcinoma. Bleeding, bloody, and the case hardening nipple(2). Breast
cancer can invade surrounding tissues that have tentacles. Invasive growth pattern can produce
irregular tumor that could terapa palpation. At the time of developing tumors, occur in the
surrounding fibrosis and shortening Cooper's ligaments. When Cooper's ligaments shorten, resulting
in a peau d'orange occurrence (colored skin orange) skin changes and edema associated with breast
cancer. If breast cancer attacks the lymphatic ducts, tumors can develop in the lymph nodes, spleen
axila usually attack nodes. Tumors can damage the lining of skin, causing ulceration. Metastatic
breast cancer is caused by blood and systems occupy lympa, led to the development of tumors in
bone, lungs, brain, and liver(1).
The etiology of breast cancer is not known specifically, but there are risk factors that can lead to
breast cancer, namely: a personal history of breast cancer, daughter and sister of women with
breast cancer, early Menarche (less than 12 years), nulliparous and advanced maternal age at birth
first child (> 30 years), menopause at an advanced age, history of benign breast disease, obesity
after menopause, oral contraceptives, hormone replacement therapy of estrogen or progesterone,
Lifestyle, high socioeconomic status(2).
1765
Clinical manifestations visible from the insidensius clinical symptoms, generally lethargic and no
tenderness, bound, and hard with irregular borders, the majority occur in the upper outer quadrant,
more often on the left breast, pain usually occurs at a late stage, some women do not showed
symptoms and do not have a lump that can be therapeutic but abnormal mammogram results,
dimpling or peau d'orange is a condition caused by obstruction of the lymphatic circulation in the
dermal layer, asymmetric and elevation affected breast, nipple retraction, breast slightly attached to
the wall chest, ulceration, and metastases(2).
CASE PRESENTATION
Patients Mrs. ER, age 47 years, weight 60 kg, height 150 cm into the PGI Cikini Hospital on
November 6, 2014, the complaints contained a lump in the left breast, and the patient had no
history of previous illness. Based on DPL examination, liver ultrasound, and CT Scan Thoracic
patients diagnosed by a doctor suffering from breast cancer.
CLINICAL EVALUATION
Patient undergoing chemotherapy protocols for treatment, while chemotherapy protocol provided
that Gemcikal 1400 mg + 0.9% NaCl 500 cc (days 1 and 8) and Brexel 130 mg + 500 cc of 0.9% NaCl iv
drip (day 1), Nasea 0.3 mg iv, Dexamethasom 20 mg iv, Ranitidine 50 mg iv, 0.9% NaCl Infusion 100
cc. after the patient treated with chemotherapy protocols Nasea 1 x 0.1 mg orally for 5 days,
Ranitidine 2 x 150 mg orally for 5 days, Medixon 2 x 4 mg orally for 5 days, Folavit 2 x 400 mg for 5
days.
RESULTS AND DISCUSSION
Based on the results of the ultrasound examination: cutis and subcutis widened almost all quadrants
of the left breast. Fibrogranduler layer looks bleak, looks structure hipoekeik irregular edges
spikulated subareolar area diameter of 2.1 x 1.2 x 1.2 cm. Macroscopic 1.5 x 1 x 1 cm solid white and
microscopic preparations derived from breast cells, showed malignant epithelial tumor composed of
solid, trabakular and tubular. Where the tumor has invaded the skin and cause focal ulceration.
Mitosis is found in moderate amounts and based on the results of laboratory tests of hematology,
the result of abnormal leukocyte high value of 16.6 x 10³ / mL with a reference value of 5.0 to 10.0 x
1766
10³ / mL, one of the enforcement of cancer is invasive Cardinoma NST (of no special type), which has
invaded the skin, Grade I. In Mrs. therapy management. ER for patient treated with chemotherapy
protocols brexel containing Docetaxel 20 mg or 80 mg of injection liquid in the vial with the solvent.
Its mechanism of action that inhibits microtubule depolymerization. Which is metabolized in the
liver, and in non-renal excretion mainly / feces. With the indication of treatment of breast cancer(4),
Gemcikal containing Gemcitabine Gemcitabine 200 mg or 1,000 mg of the lyophilized powder form
of preparation in the vial. Indications: breast cancer, non-small cell type lung, pancreas, ovary,
bladder. Mechanism of action: inhibits DNA synthesis. Metabolized to two active metabolites and
experience uracil deamination become inactive metabolites, mainly excreted through the kidneys(5),
following the protocol of chemotherapy patients treated with Ranitidine 2 x 150 mg orally for 5 days
given to prevent nausea and vomiting after chemotherapy(3), Medixon 2 x 4 mg orally for 5 days
containing metilprednisolone that drugs known as anti-inflammatory corticosteroid that works and
allergenic(5), Folavit 2 x 400 mg for 5 days that contain folic acid which folic acid (folic acid, folate,
folacin, vitamin B9, vitamin BC, pteroyl-L-glutamic acid, L-glutamate-pteroyl, pteroylmonoglutamic
acid) is a water soluble vitamin. Vitamin B9 is essential for various body functions ranging from
synthesis nukleotid to remetilasi homocysteine. This vitamin is particularly important in cell division
and growth period after chemotherapy(5).
CHEMOTHERAPY PROTOCOL
Drug
The Dose Given
Day
Gemcikal
1400 mg
1 and 8
Brexel
130 mg
1
No. Therapy
1
Infusion NaCL 0,9 % 1000 cc
2
injection Nasea 0,3 mg
3
injection dexamethason 20 mg I.v
4
injection Ranitidine 50 mg I.v
5
Brexel 130 mg + NaCL 0,9 % 500 cc drip i.v
Timing Of Drugs
8 hours
Bolus
Bolus slowly
Bolus
1 hours
1767
6
7
Gemcikal 1400 mg + NaCL 0,9 % 500 cc
8
15 minute
1 hours
15 minute
CONCLUSION
There were no DRP (Drug Related Problems) of the treatment received by these patient because of
the use of rational drug therapy.
REFERENCES
1. Prasanto H. 2007. Hypercoagulation in Chronic Kidney Disease. Naskah Lengkap. The 7th Jakarta
Nephrology & Hypertension Course. PERNEFRI
2. Peranda, Rizky. 2011. Fenomena Sindroma Kekentalan Darah (Sindroma Hughes).
3. Baand POM RI. 2008. Information Obat Nasional Indonesia. Jakarta
4. Saragi, Sahat. 2012. Panduan Penggunaan Obat Dilengkapi dengan Konsep Pharmaceutical Care,
Teori Konseling Obat, Teori Kepatuhan Minum Obat. Penerbit Rosemata Publisher. Jakarta
5. Stockley, I.H. (2008). Stockley’s Drug Interaction. Eight Edition. Great Britain: Pharmaceutical
Press.
6. Tapan, Erik. 2005. Kanker, Anti Oksiand and Terapi Komplementer. Elex Media Komputindo.
Jakarta.
1768
CASE REPORT TYPHOID FEVER AT PGI CIKINI HOSPITAL,
JAKARTA
Lenah1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2, Stefanus Lukas2
1
2
Email : lenahpink@yahoo.com
ABSTRACT
Typhoid fever is an acute infectious disease that is usually found in the digestive tract, with
symptoms of fever more than one week, disorders of the digestive tract and disorders of
consciousness(2). Typhoid fever also called paratyphoid fever, enteric fever, typhoid and typhus
abdominalis. Typhoid fever is caused by Salmonella typhi bacteria. Patient Mr. OS, aged 55 years,
entered PGI Cikini Hospital, Central Jakarta on November 8, 2014 with a diagnosis of typhoid fever.
Therapy treatment for hospitalized ie ciprofloxacin and paracetamol. Based on the results of clinical
work practice in wards “K” PGI ikini Hospital, entral Jakarta, it can be deduced that there were no
DRP (Drug Related Problems).
Keywords: Typhoid fever, PGI Cikini Hospital
1769
INTRODUCTION
Typhoid fever is an acute infectious disease that is usually found in the digestive tract with
symptoms of fever more than one week, digestive tract disorders and disorders of consciousness (2).
Typhoid fever also called paratyphoid fever, enteric fever, typhoid and typhus abdominalis. Typhoid
fever is caused by Salmonella typhi bacteria. These organisms enter through food and drink that has
been contaminated with feces or urine of people infected with Salmonella(8).
Typhoid fever has atypical clinical symptoms and vary from mild to severe. Complaints and
symptoms of patients during the first week of acute infectious disease resembling in general, such
as fever, headache, anorexia, nausea, vomiting, diarrhea and constipation. Increased body
temperature every day, usually decreases in the morning and rising in the afternoon and evening(7).
In patients with typhoid fever can be found dry lips and chapped (rhagaden), the surface of the
tongue is dirty, white and yellowish at the edge of hyperemia with disorders of the gastrointestinal
tract such as diarrhea and constipation(3).
Typhoid fever is a disease transmission in "faeco - Oral" and is widely available in the community
with hygiene and poor sanitation. Typhi salmonella bacteria enter the body through the mouth with
food / drink contaminated(5). After the run through the stomach acid, bacteria penetrate the
intestinal mucosa and enter the bloodstream through the lymphatic flow. Subsequently, the
bacteria spread throughout the body. In the reticuloendothelial system (liver, spleen, etc.), bacteria
multiply and enter the blood circulation back (second bakteriemi)(2,5,6). and spread throughout the
body, especially to the small intestine lymphoid glands, causing ulceration of the mucosa oval above
Payeri plaque. The main process is in the terminal ileum. When severe, the entire ileum can be
affected and may occur perferasi or bleeding(5).
Germs endotoxin stimulates release of endogenous pyrogen formation(5,6). These substances
affect the temperature regulation center in the hypothalamus and cause symptoms of fever.
Although it may difagositosis, bacteria can multiply in macrophages because of constraints oxidative
metabolism. Germs can be settled/hide at one place in the body of the patient, and this can lead to
relapse or sufferers (carrier)(5).
CASE PRESENTATION
1770
Patients aged 55 years Tn.OS admission PGI Cikini, Central Jakarta on November 8, 2014. Patients
present with high fever fever ± 1 week SMRs felt up and down, especially in the afternoon, the fever
like fever, the patient had to buy drugs in pharmacies but complaints not reduced. The patient also
complained of headaches such as tingling, nausea, vomiting, muscle aches, diarrhea defecation 3
days ago.
CLINICAL EVALUATION
The use of ciprofloxacin antibiotic intended as a result of salmonella infection thypi. Paracetamol
was used with the aim to reduce the fever that occurs in patient.
Patient treated with a dose of 400 mg ciprofloxacin with 2 x 1 is given by injection for 6 days and
then continued at a dose of 500 mg ciprofloxacin x 1 administered orally for 7 days. Paracetamol at
a dose of 500 mg 2 x 1 administered orally.
On the results of laboratory tests on the first day of admission found some abnormal results include
LED 35 mm / h (normal value 0-10), hemoglobin 14.7 g / dL (normal value 13.0-16.0), hematocrit
41% (normal value 40 -48 , leukocytes 4.5 103μL (normal values 5.0-10.0), erythrocytes 4.76 106 /
mL (normal value 4:50 to 5:50), Eosinophils 0% (normal value 1-3), Neutrophils rod 0% (2- 6),
Monocytes 19% (normal value 2-8), SGOT H65 U / L (normal value 0-50), SGPT H71 U / L (normal
value 0-50). Liver enzymes (SGOT, SGPT) often increases with inflammation picture to acute
hepatitis. But will return to normal after recovery.
On the results of laboratory tests on the second day of admission found some abnormal results
including hematocrit 39% (normal values 40-48 , leukocytes 3.8 103μL (normal values 5.0-10.0).
On the results of laboratory tests on the third day of admission found some abnormal results among
leukocytes 3.8 103μL (normal values 5.0-10.0). to distinguish between patients with typhoid fever or
not, but their relative leukopenia and limpositosis can be a strong presumption tifoid fever
diagnosis(4).
1771
RESULTS INVESTIGATION
On the results of laboratory tests including S. Paratyphi Widal test O (Negative), S. Paratyphi AO
(Negative), S. Paratyphi BO (Negative), S. Paratyphi CO (Negative), S. thypi (Negative), S. Paratyphi
AH (Negative), S. Paratyphi BH (Negative), S. Paratyphi CH (Negative).
CONCLUSION
Based on the results of clinical work practice in wards “K” PGI ikini Hospital, Jakarta, it can be
deduced that the host OS of patients diagnosed with typhoid fever. In the therapeutic treatment of
patients found no DRP (Drug Related Problems).
REFERENCES
1. Depkes RI. 2008. “Informatorium Obat Nasional Indonesia”. Dirjen Pengawasan Obat and
Makanan. Jakarta.
2.
Hassan, Rusepno, 1985. Buku Kuliah Ilmu Kesehatan Anak Jilid 2. Bagian Ilmu Kesehatan
Anak Fakultas Kedokteran Universitas Indonesia : Jakarta.
3.
Herawati, M.H.,And L. Ghanie.2009. Hubungan Faktor Determinan Dengan Kejadian Demam
Tifoid Di Indonesia Tahun 2007. Media Peneliti And Pengembang Kesehatan.Volume XIX Nomor 4:
hal 165-173.
4.
Ismoedijanto, Dkk.2004. Metode Diagnostik Demam Tifoid Pada Anak. Divisi Tropik And
Penyakit Infeksi/SMF Ilmu Kesehatan Anak FK UNAIR/RSU Dr. Soetomo Surabaya, Hal 36.
5.
Kaspan
MF,
Soegijanto
S.
Demam
Tifoid
In:Pedoman
Diagnosis
and
Terapi. Surabaya:Bagian/SMF Ilmu Kesehatan Anak FK Unair/RSUD Dr.Soetomo. 2004; 264-7.
6.
Mansjoer A. Kapita Selekta Kedokteran Edisi III Jilid 2. Jakarta:Media Aesculapius FK UI.
2000; 432-3.
7.
Widodo, Djoko. 2007. “Demam Tifoid” Dalam Buku Ajar Ilmu Penyakit Dalam Jilid III, Edisi V
(Editor:Aru W. Sudoyo). Jakarta : Pusat Penerbit Departemen Ilmu Penyakit Dalam FKUI, Hal 27972805.
8.
Widoyono,
2011.
Penyakit
Tropis.
Epidemiologi,
Penularan,
Pencegahan,
and
Pemberantasannya. Edisi kedua. Erlangga : Jakarta.
1772
DRUG RELATED PROBLEMS (DRPs) ASSOCIATED WITH THE
TREATMENT OF PATIENT WITH STROKE HEMORAGIK IN PGI CIKINI
HOSPITAL
Anika Fazha1, Diana Laila Ramatillah2, Aprilita Rinayanti Efi3, Stefanus Lukas4
1
Student Of Pharmacist Program, Faculty of Pharmacy UTA'45 Jakarta
2
Lecturer Of Faculty Of Pharmacy UTA'45 Jakarta
Email: Anikafazha@gmail.com
ABSTRACT
A stroke is a certain form of cardiovascular disease that affects the blood supply to the brain, so
disruptions in brain function caused by a blockage or rupture of blood vessels1. Stroke hemoragik is
a brain blood vessels rupture causing discharge of blood to brain tissue parenkim, serebrospinalis
liquid space around the brain or a combination of both2. The cause of bleeding disorders otal fibers
through suppression of the brain and also by the hematon is causing ischemia on surrounding
tissues2. Increased intracranial pressure will in turn cause herniation of brain tissue and suppress
brain stem2. Risk factors for occurrence of stroke Hemoragik, the description, the other old age,
hypertension, Heart disease, diabetes Mellitus, hiperkolesterolemia, smoking and brain blood vessel
disorders3. The presentation of this case, a man of 46 years came with complaints of dizziness,
headaches, weakness. Physical examination blood pressure 164/100 mmHg, and the patient's blood
pressure is not controlled. Obtained results of laboratory where blood creep rate levels, Hemoglobin
and leukocytes, Triglycerides was increasing, and Increased cholesterol levels. Known diagnosis of
patient suffering a stroke hemoragik.
Keywords: hemoragik Stroke, hypertension, risk factors
1773
1. Introduction
A stroke is a certain form of cardiovascular disease that affects the blood supply to the brain, so
disruptions in brain function caused by a blockage or rupture of blood vessels1. Stroke hemoragik is
a brain blood vessels rupture causing discharge of blood to brain tissue parenkim, serebrospinalis
liquid space around the brain or a combination of both2. The cause of bleeding disorders otal fibers
through suppression of the brain and also by the hematon is causing ischemia on surrounding
tissues2. Increased intracranial pressure will in turn cause herniation of brain tissue and suppress
brain stem2. According to WHO estimates, a total of 20.5 million people in the world were infected
by a stroke in 2011 and the amount of 5.5 million persons had died. High blood disease or
hypertension, contributed 17.5 million cases of stroke in the world6. In Indonesia the disease was
occupying the third position after a heart and cancer where as much as 28.5% of the sufferers died
and the rest suffered partial or total paralysis. Only 15% can be recovered from the stroke and
disability6. Investigation by the pathophysiology of stroke consists of Ischemic and Hemoragik, of
which hemoragik comprised of subarachonoid bleeding occur due to the blood vessels around the
brain rupture surface, so ekstravasasi blood to the subarachnoid space layer maningen can take
place quickly, which causes extremely high mortality in the first month of bleeding5. Intraserebral
bleeding occur due to vascular injury induced by hypertension and the rupture of one of the many
small arteries that penetrate deep into the brain tissue5. Risk factors for occurrence of stroke
Hemoragik, the description, the other old age, hypertension, heart disease, diabetes mellitus,
hiperkolesterolemia, smoking and brain blood vessel disorders3. The main symptoms of the Onset of
bleeding hemoragik stroke is abrupt, especially when performing the activity and can be preceded
by a prodromal symptoms increase in blood pressure, headaches, nausea, vomiting, and a decrease
in the weight of consclousness until coma accompanied hemiplegia/hemiparese and can be
accompanied by seizures4.
Mr. Cs Patient aged 46 years of the PGI Cikini hospital admitted on 16 November 2014. Incoming
patient with complaints of dizziness, headache, Weak, blood pressure 164/100 mmHg. Previous
illness history was hypertension. On 17 November 2014 conducted laboratory examination where
the value can be increased blood creep rate of 23 mm/h, Hemoglobin increased 16.1 g/dL,
1774
Leukocytes increased 11.010^3/µL, Eosinophils decreases to 0% , Neutrophils rods decreases to 0%,
Neutrophils segment increased by 82%, Lymphocytes decreased 7%, Monocytes increased 11%,
Triglycerides 3.7 mg/dL, Potassium (K) decreased 3.0 mEq/L, Total cholesterol increased 201 mg/dL,
LDL Cholesterol Increased 147 mg/dL.
In this case patient got Kalnex 500 mg 3 x 1 tablets, which was aimed to stop the bleeding condition.
Citicolin 500 mg injection 2 x 1 amp, to reduce damage to brain tissue. Rocer injection 2 x 1, used to
overcome peptic ulcers experienced by patient, 1 x 20 mg Simvastatin aims to reduce the patient
cholesterol, Amlodipin 1 x 5 mg aims to reduce blood pressure, Epiven 3 x 100 mg, used for
neuropathic pain the patient felt, 1 x 8 mg Candesartan, is used to lower blood pressure. Provita
plus 1 x 1 is used to increase the durability of the body, 1 x 500 mg Paracetamol is used to reduce
pain in headache. Ceftriaxone 1 x 1 gr, to treat infections of the skin and tissue. Sumagesic 1 x 600
mg is used for curing pain head trauma lightly, and. 1 x 50 mg of zoloft, used to post trauma
experienced by the patient, Cefspan 2 x 100 mg used to treat urinary tract infections, Levofloxacin
500 mg, 1 x used for urinary tract infections. Infuse RL 20 drops/minute aims to restore the body's
fluid balance.
3.1. DRPs 1: : The dose was too big (Over Dosage)
3.1.1: The use of the drug simvastatin in this case 1 x 20 mg a day less precisely where these patient
experienced the initial dose should be where hiperkolesterolemia should be given 5-10 mg in a
single dose of9.
Pharmacist intervention: recommended the use of antikolesterol drugs and given the lowest dose
of 5 mg a day at hiperkolesterol9.
3.1.2: The use of Levofloxacin in patient this 1 x 500 mg less exactly where these patients experience
an infection of the urinary tract which dose should be given 250 mg a day9.
Pharmacist intervention: recommended the use of levofloxacin drug for urinary tract infections were
given 250 mg a day9.
3.2. DRPs 2: Drug interactions
3.2.1: Amlodipin and Simvastatin
Combining Simvastatin with Amlodipin can increase levels of simvastatin, this may increase the risk
of side effects such as liver damage, potential to increase the risk of myopathy/rhabdomyolysis7.
1775
Pharmacist intervention: Need dose adjustments or more often in monitoring. Limit the dose of
Simvastatin is not more than 20 mg/day when used simultaneously7.
3.2.2: Rocer and Simvastatin
Using Rocer and Simvastatin may increase blood levels and the effect of Simvastatin. This may
increase side effects such as liver damage10.
Pharmacist intervention: the need for adjustment of the dosage and more often in monitoring10.
4. Conclusion
Based on the results then it can be drawn the conclusion that the patient suffered a Stroke
Hemoragik. In addition there was the DRPs (Drug Related Problems) included drug Doses too large
(Over Dosage) , namely the use of the drug Simvastatin 20 mg and 500 mg Levofloxacin Drug Use,
drug interactions (Drug Intercation) use of Simvastatin with Amlodipin, Rocer and Simvastatin.
References
1. Lawrence m. Brass, a Yale University School of Medicine: Heart Book. Chapter 18: a Stroke (pgs
215-234)
2. Christopher G. Goetz Cerebrovascular Diseases. In: Goetz: Textbook of Clinical Neurology, 3rd ed.
Philadelphia: Saunders. 2007.
3. The Stroke Association Stroke Counsil. Stroke. 37: 1583-1633
4. Mardjono m. 2006. Mechanism of Vascular Disorders of Nerves in the Basic Clinical Neurology,
Eleventh Edition. Dian Rakyat. 270-93.
5.
CU
Rumantir.
patterns
of
Stroke
sufferer
In
Lab/Nerve
Pathology
Faculty
FPU
KedokteranUniversitas Padjadjaran Bandung's Hasan Sadikin hospital in the period 1984-1985.
Laporan Penelitian Experiential Learning Research Specialist Fields Of Neurological Disease. 1986.
6. Hartwig p. Cerebral Disease in: Price SA, Wilson LM, editors. Patofisiolofi: clinical concepts of
disease processes. Edition of 6. Volume 2. Jakarta: EGC; 2005.
7. Lloyd JD, Adams R, Carnethon M, Simone G, Ferguson B, Flegal k. 2009.Heart disease and stroke
statistics-2009 Update: A report from the American Heart Association Statistics Committee and
stroke statistics subcommittee. Circulation. 119: e21-e181.
8. Medscape.com, Drug interaction, 2014.
1776
9. RI Department of health, Directorate General of food and drug Supervision, national drug
Informatorium Indonesia.2008
10. Drugs. Com. Drug interaction. 2014
1777
SCHEZOPHRENIA PARANOID IN RSPAD GATOT SOEBROTO
Ayu Puspita Sari1,Diana Laila Rahmatillah2 , Aprilita Rinayanti Eff2
1
2
Email:Ayuzilullah@gmail.com
INTRODUCTION
Schizofrenia is a disease caused by interference arrangement of neurons in the human
brain,schizofrenia is a brain disease caused by the imbalance in dopamine, which is one of the
chemicals in the brain cell. The most common psychotic mental disorders characterized by the loss
of the feeling of affective or emotional responses and withdraw from normal interpersonal
relationships. Often followed by delusions (false beliefs) and hallucinations (perception without any
stimuli five senses 3
ETIOLOGY
Generally there are two kinds of diseases commonly called crazy, namely neurosa and
psychosis,Schizofrenia including psychosis. The cause is as yet known with certainty, but it is
mentioned heredity could be one cause. Even, genetic factors seem to be very dominant. According
to the study, when the father-mother's brother suffered from schizofrenia, then the child has a
potential of 3% for schizofrenia. If there is one sibling who suffers, then the child could potentially
suffer from schizofrenia by 5% -10% 4.
So what about the twin brother? If the twins are not identical, then the potential 5% -10%, while the
potential for identical twins with schizofrenia by 25% -45%. Meanwhile, if the schizofrenic is one of
the two parents, the child has the potential of 15% -20%. Schizofrenia can strike men and women.
Most women who develop the disease are those aged 20 to early 30s. While the group of male sex
earlier, the late teens to early 20s years.1
1778
MANAGEMENT
Modality therapy
1. Therapy cognition
In general, therapy cognitive therapy includes several techniques with the aim of:
a. Increasing activity is expected
b. Lowering the undesirable behavior
c. Improving recreation
d. Promote and provide opportunities in social skills
Techniques in cognitive therapy
a. Restructuring Techniques Cognition
At the start by expanding the awareness of self and observe the feelings and thoughts that may
arise.
b. This technique of facts
c. This technique of alternative
d. Dekatastropik
e. Reframing
f. Thought stopping
g. patterning
h. token economy
i. role play
j. Social skills training
2. Family Therapy
Creating a situation where family members can see the andger to the client and its activities, can
provide a sense of security, a sense of self-owned clients.
3. Therapeutic environment
This therapy aims to develop self-esteem, develop the ability to relate to others, helping people
learn to trust that govern aspects lain. Therapeutic physical environment: physical environment
remains, semi-permanent physical environment, physical lingkingan not tetap.Example therapy
restrain the patient's physical environment in.
4. Therapy psikoreligius
1779
Aimis to provide a sense of security, safety and freedom from guilt / sin, but it also can increase the
degree and his dignity
5. Group therapy
Aims to train self-understanding, channeling emotions, forming socialization and increase
motivation for the advancement of psychological (cognitive, affective) .5
Somatic Therapy
Somatic therapy, therapy aims to change maladaptive behavior is behavior that adapif by taking
action in the form fisik.Contohnya ECT treatment, psychopharmacology.
ECT induces a grand mal seizure artificially by passing an electric current through the effect troda
mounted on one or both temple, the Indication;
a. Patients with major depressive block, do not respond to antidepressants or who can not take
medicine.
b. Patients with bipolar disorder who do not respond to medication
c. Acutely suicidal patients who received no treatment long enough to achieve a therapeutic effect
d. When side effects of ECT are less than anticipated side effects associated denagn drug therapy,
such as elderly patients, patients with heart block and during gestation.4
Case Presentation
Mr.Dt 22-year-old man who was treated in poly RSAD soul. Patient diagnosed with paranoid
schizofrenia. Patient entering the ER nurse escorted by Army Hospital on 8th December 2014.
Patients were hanged himself with a reason for being unable to achieve what is in goal during school.
After the patient moody, filmed and rarely do the activity. Patient are very aloof.
As for drug therapy given to Mr. DT include clozapine, risperidone, THP. Risperidone beneficial in
reducing the incidence of nocturnal enuresis in patients with schizophrenia. Dose clozapine in
treatment with an initial dose of 12.5 mg once daily or 2 times a day can be increased to reduce the
risk of suicide in patient.
CLINICAL EVALUATION
3.1 (DRP)1
1780
Risperidone combination with benzodiazepines cause respiratory depression and hypotension,
especially the early weeks of therapy. Where increase the effect of risperidone. Serum
concentrations of clozapine may be increased by CYP1A2 inhibitors include: ciprofloxasin,
fluvoxamin, ketoconazole, norfloxacin, ofloxacin and roficoxib. Clozapine increase the effects of
amphetamine, selective beta blockers, dextromethorphan, fluoxetine, lidocaine, mirtazapine,
nevazodon, paroxetin, risperidone, ritonavir, TCA,
Pharmacist Intervention: Addition of THP serves as antidoum to overcome the side effects
ekstrapiramidal.1
3.2 (DRP)2
Haloperidol frequent cause of Parkinson's syndrome.
Pharmacist Intervention: Cope with trihexyphenidyl tablets 3-4x2 mg / day, SA 0.5-0.75 mg / hari3.
CONCLUSION
After the assessment of the patient's treatment, it can be concluded that the combination of drugs
clozepin, risperidone, and THP was combination of drugs that are often used in medical therapy in
patient with Paranoid Schizofrenia. Drugs used to treat schizofrenia are called antipsychotics.
Antipsychotics work control hallucinations, delusions and thought pattern changes that occur in
schizofrenia. In the case of Mr. DT patient showed significant improvement with the combination of
these three drugs.
REFERENCES
1. Hawari, Daandg H. Pendekatan Holistik Pada Gangguan Jiwa. Jakarta : Fakultas Kedokteran
Universitas Indonesia; 2007
2. Profil Pasien Rawat Inap Jiwa RSUD dr Moch Ansari Saleh Banjarmasin
3. Rachmawati, Pola Penggunaan Obat Antipsikotik and Antidepresan Pasien Rawat Inap di RSUD dr
Moch Ansari Saleh Banjarmasin, 2007
4. Schizophrenia. http://www.merck.com diakses tanggal 16 Desember 2014
5. Schizophrenia. http://www.emedicine.com diakses tanggal 16 Desember 2014
6. Maslim R. 2003. Diagnosis Gangguan Jiwa: Ringkasan Ringkas dari PPDGJ-III. Jakarta: PT. Nuh Jaya.
7. Kaplan, Sadock, Grebb. 1997. Sinopsis Psikiatri Ilmu Pengetahuan Perilaku Psikiatri Klinis Jilid Satu.
Jakarta: Binarupa Aksara.
1781
EVALUATION OF DRUG RELATED PROBLEMS IN DISPEPSIA IN
WARD MEDICINE IN RS.PGI CIKINI
Ekad Tawakal1, Diana Laila Rahmatillah2, Aprilita Rinayanti Eff3, Stefanus Lukas4
1
2
Email: Ekadetawakal@gmail.com
ABSTRACT
Dyspepsia is a common disease and often occur in internal medicine wards at PGI Cikini Hospital.
Dyspepsia is a collection of complaints or clinical symptoms consist of discomfort or pain, full of
flavor and heat in the upper abdomen persistent or relapsing complaints of pain and heartburn 4.
Case presentation: Ms 23-year-old woman admitted to the internal medicine ward. Patients
diagnosed with dyspepsia.
Clinical evaluation: basically, no one intervention that was found during the assessment of
treatment of patients, which is about drug interactions Inpepsa (Sucralfate) with Renatac
(Ranitidine), and Sharox (Sefurikxim) and renatac (Ranitidine).
Keywords: Dyspepsia, Gastrointestinal tract, pain.
1782
INTRODUCTION
Dyspepsia syndrome, better known as the general public although ulcer disease is not appropriate,
because the stomach is derived from the Dutch language, which means stomach
5.
Complaints that
appear on ulcer disease does not always come from the stomach. The prevalence of this disease
vary, most research shows that nearly 25% of adults have symptoms of dyspepsia at some time in
their lives.
A survey found that about 30% of patients who went to a general practitioner due to a
gastrointestinal disorders, especially dyspepsia and 40-50% of patients who come to a specialist due
to a digestive disorders, especially dyspepsia6.
Changes in the pattern of irregular eating, drugs that are not clear, substances such as nicotine and
alcohol as well as the presence of psychiatric conditions of stress, food intake will be limited so that
the stomach is empty, void stomach can lead to erosion of the stomach caused by friction between
the walls of the stomach , this condition can lead to increased production of HCL which will
stimulate the acid conditions of the stomach, so that the stimulus in the medulla oblongata carry
impulses vomiting that can not be accepted by the digestive tract perfectly. This is what causes
vomiting.
CASE PRESENTATION
Ms 23-year-old woman admitted to the internal medicine ward. Patients diagnosed with dyspepsia.
Patient entered in the PGI Cikini Hospital on June 5, 2014. The patient feels dizzy, nausea, vomiting,
and weakness of the week before admission. Upon admission, the patient feels dizzy, weakness,
nausea, and poor appetite. Has conducted laboratory tests that occur penigkatan erythrocyte
sedimentation rate, decreased hematocrit, and decreased neutrophils.
3. CLINIC EVALUATION
3.1 (DRP)1
Inpepsa (Sucralfate) and Renatac (Ranitidine) is a combination that is often used in the treatment of
peptic ulcers and duodenal ulcers. Concurrent use of both drugs can cause interaction. Inpepsa can
reduce the absorption or bioavailability of Renatac (Ranitidine) so that the drug must be given
within about 2 hours of administration.
1783
3.2 (DRP)2
Concomitant use Sharox (Sefurokxim) and Renatac (Ranitidine) can cause significant intraction,
which Renatac (Ranitidine) will reduce the effect of Sharox to increase gastric pH.
Pharmacist Intervention: Advise the patient to use the distance separating the two drugs, for
Renatac in consumption before meals while sharox consumed after a meal. To avoid interactions,
needs to be monitoring the use of both drugs.
CONCLUSION
After the assessment of the patient's treatment, it can be concluded that Inpepsa (Sucralfate) and
Renatac (Ranitidine) is a combination that is often used in the treatment of peptic ulcers and
duodenal ulcers. Concurrent use of both drugs may reduce the absorption or bioavailability of
Renatac (Ranitidine) so that the drug must be given within about 2 hours of administration.
Concomitant use Sharox (Sefurokxim) and Renatac (Ranitidine) may decrease the effects of Sharox
by increasing gastric pH, so Renatac consumed before a meal, while for Sharox consumed after
meals and after gastric ulcer drug use because otherwise it dyspepsia patients can not be addressed
properly
REFERENCES
1. Baxter, K. Stockley’s Drug Interaction Eight Edition. London. 2008
2. Hutagalung Poltak, Sirait Amir, Nadeax Moxa. 100 Tahun RS PGI Cikini, dengan Sentuhan Kasih.
Jakarta . 1997
3. ISFI,. “Iso Farmakoterapi” ISFI Jakarta.2012
4. Joint Formulary Commite. British National Formulary. London. 2009
5. Juliyanto, 2012.“Dispepsia”.http://endryjulianto.blogspot.com, diakses tanggal 16 desember 2014
6. Reeves J Charlene. Keperawatan Medikal Bedah. Jakarta. 2001
7. Syahputra, Wawan. 2013. “Dispepsia”. http://www.wawanssblogspot.com, diakses tanggal 10
April 2014
8. Staf Pengajar FK universitas Sriwijaya. Kumpulan Kuliah Farmakologi Ed. 2. EGC : Jakarta. 2009
9. Tjay Tan Hoan. Obat-Obat Penting. Elex Media Komputindo : Jakarta 2007
1784
DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT FOR
ISCHEMIC STROKE AND DIABETES MELLITUS TYPE II AT PGI CIKINI
HOSPITAL
Muchrip Tirtana1, Diana Laila Rahmatillah2, Aprilita Rinayanti Efi2, Stefanus Lukas2
1
Student of Pharmacist Professional Programming Student, Faculty Of Pharmacy UTA’ 45 Jakarta
2
Lecturers of Pharmacy Faculty UTA’45 Jakarta
Email: mtirtana@gmail.com
ABSTRACT
Stroke or cerebrovascular injury is loss of brain function caused by the cessation of blood supply to
part of the brain8. Stroke is classified to be two types, namely hemorrhagic stroke (primary
hemorrhagic strokes) and non-hemorrhagic stroke (ischemic strokes), Non-hemorrhagic stroke
(SNH) is a cerebral circulatory disorder that can appear secondary to pathological processes in the
vessels, such as thrombus, embolus, or basic vascular disease such as artero sclerosis and arteritis
disturbing cerebral blood flow so that the supply of nutrients and oxygen to the brain decrease
causing infraction7. Diabetes Mellitus (DM) type II is a hyperglycemia disease due to insulin
insensitivity. Because Insulin is still produced by the beta cells of pancreas, the diabetes mellitus
type II considered as Non-Insulin Dependent Diabetes Mellitus (NIDDM)1. Female patient 62 year
old, weighs 77 kg, and height 175 cm, was admitted to the hospital with complaints of dental pain
and want to do tooth extraction with the hope can be done of fitting dentures. The patient has ever
gotten ischemic stroke and diabetes mellitus type II. As visited the hospital with the aim of doing
tooth extraction, a doctor monitored therapy previously, namely ischemic stroke therapy and
diabetes mellitus. The result of hematological examination for the first time measurements on 16 th
of September 2014, showed the abnormality on several parameters, namely Trombosit, Globulin,
Urea, and Blood Potassium. The patient treated with Ciprofloxacin 500 mg tab, Metformin 500 mg
tab, Simvastatin 20 mg tab, Amlodinine Besylate 5 mg tab, Captopril 12,5 mg tab, Kalium Diklofenac
50 mg tab, Microlax Tube, and Transamin tab. Based on the result of clinical examination of the
patient revealed any DRPs (Drug Related Problems) is there are four drug interactions, were found
during the assessment of patient’s therapy, namely interaction of Amlodipine Besylate with
Simvastatin in which Amlodipine Besylate increase the effect of Simvastatin, Diclofenac with
Ciprofloxacin get potential interaction, Diclofenac with Captopril in which the effect of Captopril is
lowered by Diclofenac, Ciprofloxacin with Metformin in which Ciprofloxacin can increase or
decrease the effect of Metformin.
The keyword : Ischemic Stroke, Diabetes Mellitus, DRPs
1785
1.
PRELIMINARY
Stroke or Cerebrovascular injury is loss of brain function caused by the cessation of blood supply to
part of the brain8. According to WHO, stroke is clinical manifestation of cerebral function disorder,
both locally and globally, which takes place quickly and more than 24 hours or ends with death,
without finding the cause other than vascular disorder. The brain attack is a contemporary term for
stroke or cerebrovascular injury which refers to disorder of brain blood supply suddenly as the result
of partial or total vessels occlusion, or due to the rupture of brain blood vessels. Stroke is suddenly
interruption of cerebral circulation in one or more blood vessels which supply to the brain9. Stroke
interrupts or reduces the oxygen supply and generally cause serious damage or necrosis in the brain
tissue10.
Stroke is classified to be two types, namely hemorrhagic stoke (primary hemorrhagic strokes) and
non-hemorrhagic stroke (ischemic strokes) Non-hemorrhagic stroke (SNH) is cerebri circulatory
disorder that can appear secondary to pathological processes in the vessels, such as Thrombus,
embolus, or basic vascular disease such as artero sclerosis and arteritis disturbing cerebral blood
flow so that the supply of nutrients and oxygen to the brain decrease causing infraction7.
Diabetes mellitus (DM) Type II is a hyperglycemia disease due to insulin insensitivity. Because insulin
is still produced by the beta cells of pancreas, the diabetes mellitus type II considered as non insulin
Dependent Diabetes Mellitus (NIDDM)1.
Several factors are known to be able to affect Diabetes Mellitus type II1:
a.
Genetic Disorders
Diabetes can be decreased according to the genealogy of family history of diabetes, because the
gene that causes the body can not produce insulin properly.
b.
Age
Generally patients who have DM type II undergo the physiological changes drastically, DM type II
often appears after the age over 30 years and has excessive weight so that the body is not sensitive
to insulin.
c.
Stress Lifestyle
Chronic stress tends to make someone eats sweet food to increase the level of brain serotonin fat.
The serotonin has sedative effect for a while to relieve the stress. But, sugar and fat are harmful for
them who have risk of DM type II.
1786
d.
Wrong diet
The patients who have DM type II occur obesity (excessive fat) that can cause disruption of insulin
(resistance of insulin) Obesity is not as sweet food or high fat, but more due to the amount of too
much consumption. Approximately 80% of patients of DM type II are people who are classified as
obese.
2.
CASE PRESENTATION
Female patient 62 year old, weigh 77 kg, and height 175 cm, was admitted to the hospital with
complaints of dental pain and want to do tooth extraction with the hope can be done of fitting
dentures. The patient has ever got ischemic stroke and diabetes mellitus type II. As the patient’s
wishes to do tooth extraction made a doctor monitored therapy previously, namely ischemic stroke
therapy and diabetes mellitus type II.
The measurement result of patient’s blood pressure during the treatment was quite stable, the
changes of patient’s blood pressure did not get changes significantly. Even the breathing was quite
stable.
The result of hematological examination on 16th of September 2014, showed the abnormality
namely decreased of Hematocrit to 35 (%) which should 37-43 (%) It indicates the presence of
anemia, decreased of Neutrophils 0% may be caused the patient has an infection, and decreased of
Thrombosit under 150.000 is 147 (10 3/mL), indicates the existence of blood clotting barriers and
can potentially get a bleeding.
Based on the results of clinical chemistry examination on 21st Of September 2014 showed that the
abnormality of Potassium level to be 5,6 mEq/L which should not more than 5,6 mEq/L, this level
indicates hyperkalemia which may be caused the result of using drugs such as captopril, Amlodipine
Besylate, and potassium diclofenac. The increasing of urea 61(mg/dL) which should 10-50 (mg/dL)
indicates the occurrence of shock, a decreasing of blood volume to the kidney, bleeding, and
dehydration, the increasing of Urea level can be caused by using either hypertension drugs or the
age of patient. The increasing of globulin is also occurred where the normal level 1,3-3,7 (g/dL),
whereas the patient got 4,5 (g/dL) indicated that the occurrence of infection experienced by the
patient.
1787
3.
CLINICAL EVALUATION
The use of the antibiotics Ciprofloxacin 500 mg tabs be used for soft tissue infection, because the
patient did tooth extraction, opened soft tissue can cause infection. The combination Metformin
500 mg tabs in the morning and Simvastatin 20 mg tabs are given at night to get expected
interaction. Because obese patient Diabetes Mellitus, Simvastatin inhibits synthesis cholesterol in
the liver, by inhibiting enzyme HMG Coa reductase, whereas Metformin also can decrease the
weigh, triglyceride level, cholesterol, and total cholesterol, and also can increase LDL Cholesterol.
Thereby, the combination both of them are able to lower cholesterol level in the body. Amlodipine
Besylate 5 mg tabs is used for hypertension treatment by inhibiting the entry of calcium into the
smooth muscle of blood vessels, so that
reduce peripheral resistance. Captopril 12,5 mg tabs is
also used to prevent high blood pressure which works by inhibiting the enzyme peptidyl dipeptidase
that catalyzes the formation of angiotensin II and releases bradikin, so that the occurrence of
vasodilatation and decreased of aldosterone secretion which cause the occurrence of sodium and
water excretion and retention of potassium. Potassium diclofenac is used to relieve pain after
surgery, this drugs affects patient’s potassium level. Potassium diclofenac should be changed with
Ibuprofen, Mefenamic acid, Piroxicam, or the others AINS drugs which not appear the resistance of
potassium or sodium. Microlax tube is given to the patient because the patient gets constipation
during the treatment in the hospital, besides it also has a function to reduce potassium level in the
blood. Transamin tabs is given because the number of patient’s thrombosit dropped, it is feared to
get bleeding to the patient.
4.
DRPs (Drug Related Problems)
a.
DRPs (Drug Related Problems) I
The use of drugs that trigger the increasing of excessive potassium, such as Potassium diclofenac,
Captopril, and Amlodipine Besylate, where the use of those drugs can affect the level of potassium
in the blood of the patient. To avoid the high potassium level, the patient is stimulated to get
diarrhea, because potassium can be discharged through the digestive tract12.
The pharmacy records currently : avoid to eat some food which contain a lot of potassium, such as
banana, pineapple, and tempuyung leaves. Because the consumption of excessive potassium can
increase the concentration in the intracellular fluid13.
1788
b.
DRPs (Drug Related Problems) I Interaction of Drug5,6
1)
Interaction between Amlodipine Besylate and Simvastanstin.
Amlodipine besylate increase the effect of Simvastatin, so that it potentially increase the risk of
myopathy or rhabdomyolysis.
The pharmacy records : Simvastatin therapy dosage that be used not more than 20 mg/day 14.
2)
Interaction between Diclofenac and Ciprofloxacin
Diclofenac with Ciprofloxacin can cause potential interaction that be able to increase the risk of
central nervous system stimulation if Ciprofloxacin is given in large dosage.
The pharmacy records : the administration of drugs should not be given simultaneously, as it can
cause seizures15.
3)
Interaction between Diclofenac and Captopril
Diclofenac also can reduce the effect of Captopril through the antagonist interaction of
pharmacodynamic by reducing the renal prostaglandin vasodilatation synthesis, so that it affects
hemostatis fluid and can reduce the effect of antihypertensive.
The pharmacy records: given the distance giving medication at least 1 hour, if given together can
reduce the antihypertensive effect15.
4)
Interaction between Ciprofloxacin and Metformin
Ciprofloxacin can increase the effect of Metformin through the synergistic effect of
pharmacodynamic, so that can cause hypoglycemia or hyperglycemia.
The pharmacy records : the importance of monitoring sugar level in the blood and should know the
symptoms appeared if there is hypoglycemia and should know the symptoms appeared if there is
hyperglycemia.
5.
CONCLUSION
Based on the result of vital sign examination showed that patient’s blood pressure in normal
condition and also the respiratory tends to be stable. On clinical examination of patient showed the
cholesterol level, blood sugar is in normal condition, it occurred because the obedience of patient in
taking the drugs properly. Whereas the value of thrombosit, urea, and potassium in the blood of
patient are abnormal conditions derived from the use of drugs taken.
1789
REFERENCES
1. Feigin, V. (2007). Stroke. Jakarta: Bhuana Ilmu Populer Company
2. Darmono. (2007). Management of Diabetes Mellitus type II. Dexa Medika.
3. Saragi, Sahat, (2012). Guiandce of Drugs Using Completed with a Concept of Pharmaceutical Care,
Teory of Conseling of Drugs, Teory of Medication, Penerbit Adherence. Jakarta: Rosemata Publisher.
4. Sutedjo, AY. (2008). Handbook : How to Know a Disease through a Laboratory Result. Yogyakarta.
5. http://reference.medscape.com/drug-interactionchecker
6. www.rxlist.com/drug-interaction-checker
7. Price, SA and Wilson. (2006). Pathophysiology: Clinical Concept of Disease processes 6th Edition
Volume 1. Jakarta: EGC.
8. Smeltzer, Suzanne C. (2002). Textbook of Brunner & Suddarth Medical Surgery. Jakarta: E G C.
9. Chang, Ester. (2010). Pathophysiology: Application of Nursing Pratical. Jakarta: EGC.
10.
William, Lippicont. (2008). Nursing: Understanding of Various Diseases. Jakarta: Indeks.
11.
Gunawan, S.G et al. (2007). Pharmacology and Therapy 5th Edition. Jakarta: Balai Penerbit
FKUI.
12.
Larry, J., 2008, Merck Manual Home Health Handbook.
13.
Almatsier, S. (2006). Basic Priciples of Nutritional Science. Jakarta : Gramedia Pustaka
Utama.
14.
http://www.medicines.org.uk/emc/medicine/1201/SPC/
15.
https://www.medicines.org.uk/emc/medicine/24377
16.
http://www.drugs.com/drug-interactions/cipro-with-metformin-672-332-1573-0.html
1790
EVALUATION OF PATIENT OF HEMAPTOE SUSPECTED TBC
AT ISLAMIC HOSPITAL JAKARTA CEMPAKA PUTIH
Ayu Pravita Sari1, Diana Laila Rahmatillah2, Aprilita Rinayanti Efi2, Stefanus Lukas2
1
University Student of Pharmacist Professional Programming Student, Faculty Of Pharmacy UTA’ 45
Jakarta
2
Lecturers of Pharmacy Faculty UTA’45 Jakarta
ABSTRACT
Tuberculosis is an infectious disease which is caused by Mycobacterium tuberculosa, which mostly
(of 80%) attack the lungs1. This bacteria is rod-shaped and acid resistant by nature, also known as
acid fast bacili. The transmission of the disease happens when sufferers of TB positive acid fast bacili
cough or sneeze. At that time germs are spread out in the air in the form of droplets (sputum
sparks). Droplets containing germs can survive in the air at room temperature for several hours2. A
person can be infected once this droplets are inhaled. TB positive acid fast bacili is shown by
minimum 2 of 3 (anytime-morning-anytime) sputum specimens are positive acid fast bacili, or when
1 sputum specimen is positive supported with active TB roentgen result3.
A 66 year old patient, Mrs. J was admitted at Islamic Hospital Jakarta, Cempaka Putih on December
4th. It was due to coughing up blood for 2 days, losing appetite, nausea, vomiting, experiencing
shortness of breath. According to her medication history, she has been through TB treatments 3
years ago with therapy anti-TB drugs 1 x 4 for 6 months and streptomycin for 3 months. She was
treated with transamin inj 500 mg, Ranitidin inj 25 mg, domperidon tab 10 mg, ambroxol tab 30 mg,
salbutamol tab 2 mg, lansoprazole tab 30 mg, levofloxacin inj 500 mg, dexamethasone inj, and blood
transfusion. In this case, there was found DRPs (Drug Related Problems), duplication of medicine
and failed to receive medication.
Keywords
: Tuberculosis, Acid Fast Bacili, Islamic Hospital Jakarta Cempaka Putih
1791
INTRODUCTION
Tuberculosis is an infectious disease which is caused by tuberculosis germs (Mycobacterium
tuberculosa) which is transmitted through the air (droplets nuclei) as a patient with tuberculosis
coughs splashing saliva containing the bacteria is inhaled by others while breathing1. Mycobacterium
tuberculosa is rod-shaped and resistant to acid on staining. It is also called as Acid fast bacili. TB
germs die quickly if exposed to direct sunlight, but can survive several hours in the dark and humid
place. Hence, the tissues of this germs can be dormant (asleep) for a few years3.
SYMTOMPS
In adults the symptoms of TB are generally having coughs with sputum for 3 weeks or more, cough
up blood at least once. Other symptoms are experiencing shortness of breath, chest pain, feeling
weak, losing appetite, losing weight, feeling unwell (malaise), sweating at night without doing
activities, and having fever for more than a month4.
DIAGNOSIS
In order to get a precise diagnosis on TB, a series of action should be done. It should be stated with
anamnesa, physical examination, and further examination which may include an examination of
bacteria, radiology, and a tuberculin test. The determination of TB diagnosis based on sputum
examination is categorized into: 1) suffering TB with positive acid fast bacili with at least 2 or 3
(anytime-morning-anytime) sputum specimens are positive acid fast bacili or at the very least one
sputum specimen shows a positive result along with the chest x-ray picture showing active
tuberculosis; 2) suffering TB with negative acid fast bacili with negative acid fast bacili result on
sputum specimen examination and chest x-ray picture showing active tuberculosis; 3) suffering TB
Extra in which the disease not only covers lungs but also other parts of the body, such as brain
membrane, heart membrane, the membranes of the heart of lymph glands, bones, joints, skin,
intestines, kidneys, ureter, genitals, etc3.
TREATMENT
TB treatment is done in two stages: intensive and advanced. At intensive stage (the beginning),
patient is given medicine daily and needs to be monitored directly to prevent the occurrence of drug
immunity. If intensive treatment was given in a precise manner, generally the patient will not be
1792
infectious in 2 weeks. The majority of TB positive acid fast bacili patient convert into negative within
2 months. Duration of the medication is two months with anti-TB drugs (HRZE) given daily. At
advanced stage, the patient consumes less, but only in a longer time. Advanced stage is important to
be the time to kill persister (dormant) germs so as to prevent recurrence. The suration is 4 months,
anti-TB drugs (HR) given three times a week4.
Standard medication guides recommended by WHO and IUATLD (International Union Against
Tuberculosis and Lung Disease) are: a) Category 1: 2HRZE/4H3R3, 2HRZE/4HR, 2HRZE/6HE; b)
Category 2: 2HRZES/HRZE/5H3R3E3, 2HRZES/HRZE/5HRE; c)Category 3: 2HRZ/4H3R3, 2HRZ/4HR,
2HRZ/6HE.
Number 2 at the beginning as in “2HRZE” carries the meaning of 2 months consumption with daily
dose of the combination. Meanwhile, number at the end as in “4H3R3” indicates the usage. Here, it
means 3 times a week (within 4 months)4.
Implied anti-TB drugs (HRZE) is given at the end of intensive stage of treatment to the patient with
positive acid fast bacili category 1 or positive acid fast bacili category 2 in re-treatment. It is given
every day for a month. For patient weigh 33 – 50 kg, implied anti-TB drugs is combined with 1 tablet
of Isoniazid 300 mg, 1 caplet of Rifampisin 450 mg, 3 tablets of Pirazinamid 500 mg, and 3 tablets of
Etambutol 250 mg. Each package of one implied anti-TB drugs contains 30 blisters HRZE which are
packed in a small box.
CASE PRESENTATION
A 66 year old patient, Mrs. J was admitted at Islamic Hospital Jakarta, Cempaka Putih on December
4th. It was due to coughing up blood for 2 days, losing appetite, nausea, vomiting, experiencing
shortness of breath. According to her medication history, she has been through TB treatments 3
years ago with therapy anti-TB drugs 1 x 4 for 6 months and streptomycin for 3 months. The patient
came to the hospital with bring results roentgen of the thorax November 3th 2014 . Roentgen of the
thorax impression on November 3th 2014 is pulmonary tuberculosis long active aspect .
She was treated with transamin inj 500 mg with a dose of drip / 12 hours over two days , then third
day be replaced in the form of oral 3x1 tab , ranitidin 2x1 injection, domperidon tab 2x10 mg,
ambroxol tab 2x30 mg, salbutamol 2 mg 2x1/2 tab , lansoprazole 2x30 mg start given on fourth day
, levofloxacin inj 1x750 mg be provided only in third day , dexamethasone extra (corresponding need
) given on fourth day , and blood transfusions given twice on fourth day .
1793
THE RESULTS OF LAB
She conducted the examination of the lab on the first day , the second , and fourth .The results of
laboratory test mrs. J showed abnormality is hemoglobin in the first day 10.1 g/dL , in the second 9.7
g/dL , in the fourth day 10.1 g/dL ( normal = 11.7 -- 15.5 g/dL ) ; hematokrit in first day at 30 percent
, on second day of 29 percent , 32 percent in the fourth day ( normal = 35-47 % ) ; erythrocytes in
first day at 3,31 10^6/µL, in the second 3.24 10^6/µL , in the fourth day 3,55 10^6/µL ( normal =
3.80 - 5,20 10^6/µL ) ; in the fourth day of leukocytes 11,20 thousand/µL ( normal = 3.6 - 11
thousand/µL ) . On the fourth day of sputum examination at 8.25 AM (acid fast bacili I ) with a
negative result , at 9 PM (acid fast bacili II ) with a negative result , and on the fifth day at 8 AM (acid
fast bacili III ) with a negative result .
CLINICAL EVALUATION
In this case , she was treated with transamin to cough up bloody , domperidone given to reduce
nausea vomiting , ambroxol given as mukolitik, salbutamol given to reduce the shortness of breath
.The second day , salbutamol 2mg and ambroxol given 3x1 tab and 3x0,5 tab because the doctor
prescribe 3x1 tab and 3x0,5 tab , but nurses not according to giving the medications .Given as a
prophylactic levofloxacin on the respiratory tract infection, lansoprazole given because the patient
experienced in the fourth day after the injection levofloxacin 2x vomiting. Because the patient
experienced by levofloxacin vomiting after granting , doctors to reduce the provision of salbutamol 2
mg and ambroxol to be 2x30 mg and 2x0,5 tab .Blood transfusion done on the fourth day at 7 AM
and 8 PM
because the results of the lab of hemoglobin in the day first and second low.
Dexamethasone given because she was complained itching and bumps after given transfusion
blood.
In this case, there were found Drug Related Problems (DRPs) :
1.
Duplication of medicine
Given medicine of lansoprazole and ranitidin.
Recomendation : Should be given one medication.
2.
Failure to receive medication
Domperidon and lansoprazole given after meals.
Recomendation : Domperidon and Lansoprazole given 30 minutes before meals.
1794
CONCLUSION
Based on the results it can be drawn the conclusion that happened which was DRPs ( Drug Related
Problems ) there are duplication of medicines and failed to receive medication.
REFERENCES
1.
Widoyono.
(2008).
Penyakit
Tropis
:
Epidemiologi,
Penularan,
Pencegahan
&
Pemberantasannya. Jakarta : Penerbit Erlangga.
2.
Girsang M. (2002). Pengobatan Standar TBC, l.Cermin dunia kedokteran, volume 137. Kalbe
Farma
3.
Depkes RI. (2002). Pedoman pemberantasan penyalit saluran pernafasan akut. Jakarta :
Departemen Kesehatan RI.
4.
Depkes RI. (2005). Pharmaceutical care untuk penyakit tuberkulosis. Jakarta : Departemen
Kesehatan RI.
1795
EVALUATIONDRUG RELATED PROBLEM (DRP) OF AT THE RSUP
PERSAHABATAN HOSPITAL JAKARTA
Nurul Nabila1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
Email :bella.migorda@yahoo.co.id
ABSTRACT
According to the National Kidney Foundation (NKF) Kidney Disease Outcome Quality
intiative Guidelines updated in 2012, the definition of chronic kidney disease is kidney damage over
3 months, in the form of structural abnormalities of the kidneys, can or without a decrease in
glomerular filtration rate (GFR), which is characterized by abnormalities pathology, and the presence
of markers of kidney damage, can be either blood or urine laboratory abnormalities or radiological
abnormalities glomerular filtration rate less than 60 mL / min / 1,73m2 as long as more than 3
months, can be with or without kidney damage
(1).
Patient Ny. AZ. Age 64 yrs enter
RSUP.Persahabatan on 26 November 2014. Patient presented with shortness of breath, chest pain
like a heavy object struck and penetrated backward sometimes there disappears with rest, DM (+),
HT (+), edema (+) tingling in the hands of (+). Since March 2014 OS has been said to be HD but he did
not want to and enter inpatient several times, patient are given therapy Bicnat Lasix 2x20 mg 3 x
500 mg, Ranitidine inj 2 x 50 mg, Captopril 3 x 25 mg, Domperidom 3 x 10 mg (5) .inj 2 x 20
Keywords: CKD on HD, Diseases in, RSUP.Persahabatan
1796
INTRODUCTION
Kidneys are vital organs which very important in maintaining the stability of the
environment in the body. The kidneys regulate the body's fluid and electrolyte balance and
acid-base by filtering the blood through the kidneys, selective reabsorption of water,
electrolytes and non-electrolytes, and excrete the excess as urine. Kidney traversed by
about 1,200 ml of blood per minute, a volume equal to 20 to 25 percent of cardiac output
(5,000 ml per minute). Over 90% of the blood that enters the kidneys are in the cortex,
while the rest flowed into the medulla (7).
Chronic renal failure (chronic kidney disease) is a progressive loss of kidney function, which
occurs months to years with natural renal structural changes gradually with interstitial
fibrosis. CKD is categorized based on the level of kidney function, GFR (Glomerular filtration
rate / GFR), into stage 1 to stage 5, with increased numbers indicate an increase in the
severity of disease was defined as a decrease in GFR (9).
The development and progress of CKD can not be predicted, in patients with CKD stage
condition 1 or 2 are generally no symptoms and metabolite disorders commonly
experienced patients with CKD stages 3 to 5 are anemic, secondary hyperparathyroidism,
cardiovascular disorders, malnutrition and fluid and electrolyte abnormalities which are
marker of impaired kidney function. Uremic symptoms (fatigue, weakness, shortness of
breath / wheezing, mental disorders, vomiting, nausea and anorexia bleeding) generally
does not appear on stage 1 and 2, there was at the lowest stage 3 and 4, as well as in
patients with CKD stage 5 which also ordinary experience itching in the skin (6).
1797
CASE PRESENTATION
Patient is Ny. AZ64 years old entered RSUP.Persahabatan on 26 November 2014. Patient was
present with shortness of breath, chest pain like a heavy object struck and penetrated backward,
sometimes the pain disappeared when patient took a rest. DM (+), HT (+) patients were taking
insulin 16 minutes when GD ≥ 20 suda recurrent hypoglycemia (+ tingling in the hands of (+ ,
right eye glaucoma sdah 2 yrs, left eye has a cataract. Retivoapati DM sudh since ≥ 10 yrs
ago.Since March 2014 OS has been said to be HD but did not want to and get in hospitalization
several times. Patients entered the diagnosa of CKD stage V or end stage renal disease who
regularly have to perform hemodialysis. Patients treated with Captopril, Lasix injection,
Ranitidine injection, domperido then after patients HD patients treated with bicnat, vitamins
B12, folic acid, amlodipine, sucralfat syrp, Aminofluid 500cc / 24 hours, new diatab, cetirizine,
omeprazole, and NaCl 0.9 % 500 cc / 24 hours.
CLINICAL EVALUATION
On the first day until day 4 Laxsix injection 2 x 20 mg Bicnat 3 x 500 mg, Ranitidine injection 2 x
50 mg, Captopril 3 x 25 mg, Domperidon 3 x 10 mg and then after in HD patients was treated
with bicnat 3x100 mg, amlodipine 1x10 mg, 1x15 mg folic Acid, Vitamin B12 3x50 mg, cetirizine
2x10mg, new diatab 3x2mg, omeprazole 2x20m.
DOSE AND HOW TO USE
Dosage and how to use the drug in a patient was on the first day patients the drug IVFD
Aminofluid 500 cc / 24 hours to supply amino acids, electrolytes and water before and after
surgery in individuals with mild malnutrition due to hypoproteinemia or oral intake.Furosemid
injection (Lasix) 2x20 mg given as the antihypertensive to reduce edema in patient. Bicnat
3x500mg was given to lower levels of urea and triglyceridese (based on lab results) and also to
balance the acidity in the blood injection patient.Ranitidin 2x50mg with pathological
hypersecretory state or tough or as an alternative treatment to overcome short-term IV
administration in patient which was Ranitidine can not be given orally.Captopril 25 mg given
orally 3x25 mg for hypertension mild to moderate and severe hypertension can also slow the
progression of kidney disease that has been there, 3x10 mg Domperidon For nausea and
vomiting. After 4 days in hospital patient did the HD and then given therapy Folic Acid 1 x 15 mg
1798
was used in the treatment of anemic conditions that appear on the uremiacondition, Vit.B12 3 x
50 mg. Vitamin B12 in combination with folic acid is used to treat anemic normocytic,
normokrom which occurs in patients, amlodipine 1x10mg used as adjunctive therapy
combination, aimed to control the patient's blood pressure fluctuates largely due to the
condition of the kidneys in patients who have decline.Sucralfat syr 3 x 15 cc administered to
patient for the treatment of duodenal ulcer. The dose for adults is generally 2 teaspoons (10 ml),
4 times a day, when the stomach is empty. Doses were given no more than 8 mEq / kg daily. New
Diatab 3 x 2 mg.NaCL 0.9% Returns the electrolyte balance in the patient. Cetrizine 2x10mg
allergy Awarded for treatment of patient who experience an itching on sexual organs.
Omeprazole Omeprazole 2x20 cps are given orally to Tukat gastric and ulcers, omeprazole
therapy for patients already want to go home, so Ranitidine injection is stopped.
LABORATORY DATA RESULTS
Table 1. Results of Laborator
Type
check up
normal value
Examination
result
Leukocytes
8.59
5-10
Netrofil
67.8
50-70
Lymphocytes
21.7
25-40
Monocytes
4.2
2-4
Eosofil
1.0
4,8-10,8
Basofil
0.3
0-1
Erythrocyte
3.86
4,5-6,5
HB
10.2
13,0-18,0
Hematocrit
30
40-52
MCV
78.8
80-100
MCH
26.4
26-36
MCHC
33.6
32-36
RDW-CV
13.1
115-145
Platelet
214.000
150.000-440000
1799
pH
7.138
7.34-7.44
PCO2
27.8
35-45
PO2
80.2
85-95
HCO3
13.9
22-26
Table
TCO2
14.7
23-27
Laboratory Examination Results
Base Excess
-11.1
-2.5-2.5
Std HCO3
16.3
22-26
Saturation O2
95.0
96-97
GDS
210
<160
Total Protein
6.2
6-8
Albumin
2.5
3.4-5
Globulin
3.7
1.3-2.7
AST(SGOT)
9
0-37
ALT(SGPT)
7
0-47
Uremia
118
20-40
Triglyceridese
6.8
0.8-1.5
As.Urat
7.9
3-6
Prothombine time
-
Clinical
Chemistry
9.4-113
(PT)
INR
-
0.83-1.16
APTT OS
-
28-40
Type
2
Check Up Result
Normal Value
Examination
6/12/14
8/12/14
Na
139.0
-
135-145
Kalium
2.10
-
3,5-5,5
Calcium
-
8.10
20-40
Chloride
102.0
-
98-109
Magnesium
-
2.10
1.7-2.7
1800
Based on the results of clinical work practice in inpatient wards, it can be concluded that the
presence of DRPs (Drug Related Problems), namely:
1. The existence of drug interactions between:
a. Sucralfate between Ranitidine
Sucralfate drug absorption will be reduced when used in conjunction with Ranitidine(5).
Pharmaceutical interventions
Ranitidine drug use should be made at least 2 hours before or after administration of
Sucralfate(5).
b. Captopril between Furosemide
Captopril and furosemide Mechanism: synergistic properties. Significant interactions. Risk of
acute hypotension, hypokalemia and renal insufficiency should be monitored usage (5).
Pharmaceutical interventions
Handling is fluid status and weight of the patient should be carefully monitored in patients
receiving loop diuretics when concomitant use with ACE inhibitors and their use should be
monitored(5).
CONCLUSION
Based on the results of clinical it can be concluded that the presence of DRPs (Drug Related
Problems) were interaction Ranitidine with Sucralfate which was Sucralfat absorption will be
reduced when used in conjunction with Ranitidine. And adverse drug effects are captopril and
furosemide Mechanism:Significant interactions. Risk of acute hypotension, hypokalemia and
renal insufficiency should be monitored usage.
REFERENCES
1.Alam, syamsir and Hadibroto iwan, 2007. Gagal Kidney, Gramedia pustaka utama; jakarta
2. Baradero, Marry dkk, 2008. Klien Gangguan Kidney, Penerbit buku kedokteran EGC; jakarta
3. Baand POM RI, 2008.Information Obat Nasional Indonesia, Jakarta
4. http://www.medcape.com/view program/2361.htm
5. BNF 61, 2011.Britsh National Formulary. Pharmaceutical Press: London
1801
6. Baxter, karen, 2008. Stockley’s Drug Interaction. Pharmaceutical Press: London
8. Elin Yulinah, 2011, ISO Farmakoterapi 2, Penerbit: Ikatan Apoteker Indonesia, Jakart.
9. Sukandar, Enday. 2006. Gagal Kidney and Panduan Terapi Dialisis. Pusat
Informasi Ilmiah
Bagian Ilmu Penyakit Dalam FK.UNPAD. Bandung
10.UK Renal Pharmacy Group, 2009, Renal Drug Handbook Third Edition,Radcliffe publishing
Oxford. New York
CASE REPORT
1802
MANAGEMENT OF PATIENT IN HOSPITAL WITH
TUBERCULOSIS MENINGITIS AT HOSPITAL JAKARTA AT
PGI CIKINI
Anton Supriadi1, Diana Laila Ramatillah2, AprilitaRinayanti Eff2 ,
Drs. Stefanus Lukas2
1
Student of Pharmacist Professional Program, Faculty of Pharmacy UTA’45 Jakarta
2
Email: civasregall78@gmail.com
ABSTRACT
Meningitis is an inflammation of the protective membranes covering the brain and spinal
Medulla which is known as meninges (1). Inflammation of meninges can be caused by viral
infection, bacteria or other microorganisms and causes most often is due to drugs (2). Meningitis
can be life-threatening and is an emergency condition. Classification-based agent of meningitis
cause, i.e. bacterial meningitis, viral meningitis, meningitis, meningitis a parasitic and fungal
meningitis non infection. Tuberculosis meningitis is an inflammation of the brain membrane
caused by the bacteria Mycobacterium Tuberculosis, this disease is a form of complications
which often appear on Tuberculosis Pulmonary diseases (1.3). Patient EP 34 year age, male
gender, weight 52 kg, patient experience decreased consciousness, fever, cough, nausea,
vomiting, a history of previous illness the patient was diagnosed with Pulmonary Tuberculosis in
2010, family disease History's wife also was diagnosed with Pulmonary Tuberculosis. Patient was
suffering from Meningitis in EP diagnose Tuberculosis. Resulted of the checks conducted were
visible from cell count leukocytes and MRI results where the examination becomes a reference to
diagnose the disease that inflicted patients.Patients given the drug ceftriaxone and antibiotic
ciprofloxacin, Dexamethasone, Rocer, Citicholin, Largactil, Bcomplex, New Diatab, and for
management tuberculosis Isoniazid, Rifampin given, Ethambutol and Pyrazinamide.
Keywords: Meningitis, Mycobacterium Tuberculosis, MRI.
1803
INTRODUCTION
Tuberculosis is an infectious disease caused by a direct bacterium most of which attacked the
lungs. These bacteria including Bacillus gram positive, rod-shaped, the walls is a complex of
glycolipids as well as candle-lipid hard penetrated chemicals (5). Tuberculosis meningitis is the
result of the spread of the bacterial limfogen and hematogen Mycobacterium tuberculosis
primary infection of the lung (4).
Meningitis itself is divided into two according to the examination of the Cerebrospinal Fluid (CSF)
or also called Liquor Cerebrospinal is (LCS), namely: bacterial causes of meningitis purulent a with
besides the bacteria Mycobacterium tuberculosis, and meningitis bacterial causes of tuberculosis
with the serosa or viruses. Clinical signs and symptoms of meningitis are almost always the same
on every type, so the necessary knowledge and more action to determine the type of meningitis.
This relates to the handling of subsequent tailored to etiology. For tuberculosis meningitis
needed more specific therapy due tothe cause is not just bacteria that can be addressed with
broad spectrum antibiotics. The World Health Organization (WHO) in 2009 declared tuberculosis
meningitis occurred in 3.2% of cases of complications of primary tuberculosis infection, 83% are
caused by complications of primary infection in the lung (4).
CASES PRESENTATION
Mr. EP 34 year age, male gender, weight 52 kg, patient had experience decreased consciousness,
fever, cough, nausea, vomiting, a history of previous illness that the patient was diagnosed with
Pulmonary Tuberculosis in 2010, family disease History's wife also was diagnosed with
Pulmonary Tuberculosis. Patient suffering from Meningitis in EP diagnose Tuberculosis.
inspection results made can be seen in the number of leukocytes and cells of the MRI results
where the brain showed focal cerebral infection multiple, possibly by toxic or TB examination to
be a reference to diagnose the disease that inflicted on patient.Patient was given the drug
ceftriaxone and antibiotic ciprofloxacin combined to treat gram negative bacterial infection, antiinflammatory drugs as Dexamethasone, Rocer are used to protect the stomach, Citicholin to lose
consciousness due to brain trauma and improve blood circulation, nausea vomiting remedies as
1804
Largactil, Bcomplex to increase durability of the patient's body, New Diatab to treat diarrhea
caused by drug side effects, and for management tuberculosis Isoniazid given, Rifampin,
Ethambutol
and
Pirazinami
CLINICAL EVALUATION
Drug interactions occur between Rifampin and Isoniazid (INH), Rifampin can increase the
hepatotoxicity of Isoniazid (INH), but this combination does not cause in some sufferers, drug
side effects are also found on the treatment of these patient, but can be addressed immediately,
i.e. of the antibiotic ceftriaxone, ciprofloxacin gram negative gastric drug Rocer which have
adverse side effects diarrhea resolved by granting the drug NewDiatab (4.5).
PATIENT LABORATORY DATA
E X A M I N A T I O N
T H E
R E S U L T S
BLOOD CREEP RATE
12
L E U K O C Y T E S
1 4 , 8
E O S I N O P H I L S
m
/
h
THE REFERENCE VALUE
0
r
–
1
0
–
1
0
1 0 ^ 3 / u l
5
0
%
1
–
3
NEUTROPHIL STEM
0
%
2
–
6
NEUTROPHILS SEGMENT
8
%
5
0
–
7
0
L Y M P H O C Y T E S
9
%
2
0
–
4
0
4
THORAX EXAMINATION RESULTS:
Heart enlarged impression left waist protruding heart, apex embedded, not widened
mediastinum and aorta, trachea and hilar lung does not look good, infiltrate, diaphragm and
sinuses well. Cardiomegaly possibility of mitral, pulmo configuration does not appear to infiltrate.
THE MRI EXAMINATION RESULTS:
Brain showed focal cerebral infection multiple, possibly by toxic or TB
1805
CONCLUSION
Tuberculosis (TB) meningitis is the complication results from the spread of bacteria and
hematogenlimfogen Mycobacterium tuberculosis primary infection of the lung to meninges.
management using the antibiotic ciprofloxacin and ceftriaxone antibiotic with a spectrum that is
different but both have in common that is equally effective on gram negative bacteria,, antiinflammatory drugs as Dexamethasone, Rocer were used to protect the stomach, Citicholin to
lose consciousness due to brain trauma and improve blood circulation, nausea vomiting
remedies as Largactil, Bcomplex to increase durability of the patient's body, New Diatab to treat
diarrhea caused by drug side effects management for tuberculosis and given Isoniazid Rifampin,
Ethambutol, and Pyrazinamide.
Based on observations made on the patient Mr. EI at the Hospital of the PGI Cikini can be
inferred:
1. Drug interactions Occur between rifampin and INH with increasing anti-hepatotoxic INH, but
this combination does not cause anti-hepatotoxic on most sufferers.
2. There is a side effect of the medications given. But it has been in anticipation
3. Treatment of patients is rational.
REFERENCES
1. Ginsberg Difficult and recurrent meningitis. Journal of Neurology,
Neurosurgery and Psychiatry. 2004; 75: 16-21
2. AR Tunkel, Hartman BJ, Kaplan SL et al. Practice guidelines for the
management of bacterial meningitis. Clinical Infectious Diseases 2004; 39: (9)
1267-84
3. T Ducomble, K Tolksdorf, Karagiannis I, B Hauer, B Brodhun, W Haas, L
Fiebig. The burden of extrapulmonary tuberculosis and meningitis: an
investigation of national surveillance data, Germany 2002 to 2009. Euro
Surveill.2013; 18 (12) 20436.
4. a. IsrarYayan. Meningitis. Faculty of Medicine – University of Riau, Arifin
1806
Achmad General Hospital of Soweto.2008; 1-6.
5. tuberculosis Meningitis. http://www.mayoclinic.com/health/tuberculosis
Accessed September, 25th 2013.
6. Epidemiology tbc Indonesia. http://www.tbindonesia.or.id. Accessed
25th September, 2013.
7. Fenichel GM. Clinical Pediatric Neurology. 5th ed. Philadelphia: Elvesier
Saunders; 2005. p. 106-13.
8. the Tuberculosis Coalition for Technical Assistance. International Standards for
Tuberculosis Care (ISTC). 2nd ed. The Hague: Tuberculosis Coalition for
Technical Assistance, 2009.
9. Raviglione MC, O'Brien RJ. Tuberculosis. In: Longo DL, Kasper DL,
Jameson JL, Fauci AS, Hauser SL, Loscalzo j. Harrison's principles of internal
medicine. 18th edition. New York: McGraw Hill; 2012
1807
KIDNEY STONES IN PGI CIKINI HOSPITAL
Candra dwi putra1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
Email : candra12356@gmail.com
ABSTRACT
Drug Related Problems (DRP's) are unwanted incidences that happen to patients associated with
drug therapy1. Two or more drugs that are given at the same time may change its effect
indirectly. Drug interactions causing losses,3 kinds of shared interactions is major (highly
significant clinical), moderate (moderate clinical significant), minor (minimum clinical significant).
Based on the results from Praktek Kerja Profesi Apoteker at PGI Cikini hospital, This patient in
inpatient at PGI Cikini hospital get major drug interactions is Awarding tramal with ondasentron
and tramal with meropenem. This should be a concern and immediately treated for the effects of
inflicted could harm the lives of patients.
Keywords: DRP, drug interaction, kidney stones
1808
INTRODUCTION
A licensed holds a very important role in the improvement of the quality of health services
oriented to the patient (Patient Oriented). As a licensed, quality improvement of this service can
be made through a process of service pharmacy (Pharmaceutical care). Practice of
Pharmaceutical care is an integrated activity with the purpose to identify, prevent and solve the
problem of drugs and health related problems. One of these activities is to conduct a study on
drug related problems (DRP's) of any therapy that is taken into consideration and given to the
patient.
Study on Drug Related Problems (DRP's) is extremely complex and expansive, one form of drug
Related Problems are problems associated with drug interactions-drugs used in a therapeutic
(Drug Interaction). According to the Institute of Medicine report, the numbers of Genesis
(incidence) of drug interactions in the clinic is large enough. From the a source, it is known that
44,000 – 98,000 deaths occur every year due to various errors in clinical, and about 7,000 deaths
occur due to the side effects of treatment are performed (including as a result of drug
interactions)2.
The incidence of significant drug interactions in clinical difficult partly because first, the
documentation is still very rare. Second, often escaped from observations because less science
on doctor about mechanism and the possibility of drug interactions so the drug interactions to be
increased toxicity is often thought of as a idiosyncrasy reaction to one medication while a decline
in the effectiveness of the interaction is often thought to be due to the increase of the severity of
the disease in addition to too many interacting drugs so it is difficult to remember and the third
occurrence or the severity of the interaction is influenced by individual variations ( specific
population more sensitive for example elderly patient or patients who had severe, the distinction
between individual metabolic capacity), certain diseases (especially kidney failure or severe liver
disease), and other factors (large doses, the drug ingested together, giving the Chronicle).
Treatment with some drugs (poly pharmacy) and habitual physicians to easy the occurrence of
drug interaction. A survey reported in 1977 about poly pharmacy in sufferers being treated at the
hospital showed that the incidence of side effects in patients who got 32 0-5 kinds of drugs is
3.5%, while that gets 16-20 range medications is 54%. The increased in the side effects of drugs
1809
that are far in excess of an increasing number of drugs given together is expected due to the
occurrence of drug interactions are also increasing3.
Severity levels and given the interactions can be classified into 3 levels is the minor, moderate or
major. The severity of the minor, An interaction is included in the severity of the minor if the
interaction may occur but is considered a significant potential harm to patients in the event of
negligence. An example is the decrease in the absorption of ciprofloxacin by antacid when
dosage was given less than two hours after A moderate Severity 3 interaction within the
moderate severity if one of the potential hazards may occur in patients, and some type of
intervention/monitor is often necessary. The effect of moderate interaction might cause the
patient's clinical status changes, causing additional care, care in hospitals and or extension of the
length of stay in hospital. An example is the combination of Vancomycin and gentamicin
nefrotoksisity monitoring needs to be done. The severity of A major interaction is included in the
severity of major if there is a high probability of incidents that enandger patients including events
pertaining to the lives of patients and the occurrence of permanent damage. An example is the
development of arrhythmias that occur due to the granting of erythromycin and terfenadin.
ETIOLOGY
Based on the factors that affect the formation of etiology kidney stones that urine pH,
concentration of dissolved substances urine, urine stasis, a diet high in calcium and bone
dimeralisasi. Most of the stone contains calcium, while the rest contain amino magnesium or
struvit phosphate, uric acid or cystine. The mechanism of the formation of kidney stones or
urinary tract is not known for certain, but some books mention , the process of stone can be
caused first the existence of precipitation the salts dissolved in the urine, where if the urine is
saturated precipitation will occur. Second, have a core (nidus), for example there is infection of
the ulcer occurred later, where it became the core of the ulcer formation of stones, as the
sticking stone from particles the nucleus . the third, change of the pH or the presence of other
colloids in urine will neutralize the charge and cause the onset of precipitation4.
1810
CASE PERSENTATION
A woman aged 61 years in the diagnosis of renal colic suffered from kidney stones left. The
patient complained of lower back pain left side as long as 4 days ago and is a reference of the
RSU Depok Yudha Bhakti because of dengue fever. When in abdominal ultrasound, it turns out
there are hidronephrosis (+) and nephrolithiasis (+). Another complaint experience fever,
nausea,vomiting and coughing.
LABORATORY EXAMINATION VALUE
Date : 18 december 2014
Type of examination
Value
Normal Value
Blood sedimentation rate
106
0-20 mm/hour
Hemoglobin
9,8
13 - 16 n
Leukosite
18300
5-10 thousand mm3
Erytrosite
47000000
4-5 million mm3
Hematocyte
29
40-48 %
Retikulosite
6
5-15 %
Trombosite
294000
150 - 450 %
Urine complete
1811
Specific gravity
1010
1015-1025 gr/ml
Color
yellow
Yellow young
Nitrit
positif
Nothing
pH
6,0
4,6-7,4
Protein
Trace / 10 mg/dl
- / nothing
Glucose
negatif
- / nothing
Bilirubin
negatif
- / nothing
Urobirinogen
0,2
< 0,2
Keton
negatif
nothing
CLINICAL EVALUATION
The therapeutic use of medication during hospitalization in RS PGI Cikini is given antibiotics
cefoperazon as anti infection on a patient's urinary tract. drop paracetamol to reduce pain in the
left loin and fever patients. Anti spasmodic functioning Spasmium/ anti seizure the digestive
tract, ulcer peptic. Tramal contains tramadol HCL the indication of moderate to severe pain
before and after operation. Meropenem as Gram-negative antibiotic and positive that often
invade the urinary tract then Capsules pink-white given sleeping pills from a doctor before.
Metrodinazol serves as an anti trichomoniasis. OBH to cough patients. Blood pressure-lowering
as Bisoprolol because on day 5 experienced blood pressure increased to 160/80. A PCT addition
treatment tab fever patients. Onandcentron for emetic /anti nausea and vomiting infusion of NS
(100 ml NaCl replaces sodium chloride inside the body or also as resuscitation. All therapies are
going well but there are some finds drug interactions.
1. Drug Related Problems / DRP 's (drug interactions with drugs ) :
Onandsetron ↔ Tramadol
1812
Simultaneous use of 5-HT3 receptor antagonists with agents that have or increase activity
serotonergic like tramadol can serotonin syndrome risk may occur, which is a rare but serious
condition and potentially fatal. Allegedly the result of hyper stimulation brainstem 5-HT1A
receptor and 2A. According to the literature, the development of serotonin syndrome have been
reported with a co-receptor antagonists, 5-HT3, concurrent use of drugs especially during
serotonergic and also in high doses. Some reported cases be fatal. Serotonin syndrome
symptoms include mental status changes such as irritability, altered consciousness, confusion,
hallucinations, and coma, autonomic dysfunction such as tachycardia, diaphoresis, hyperthermia,
labile blood pressure, chills, and mydriasis; neuromuscular disorders such as tremor, rigidity, and
ataxia; and gastrointestinal symptoms such as abdominal cramps, nausea, vomiting, and
diarrhea5.
MONITORING CLOSELY of receptor antagonists: the use of 5-HT3 can decrease the analgesic
tramadol efficacy. The proposed mechanism is the antagonism of serotonin-mediated effects of
tramadol in the spinal level. In a randomized, double-blind study of 40 patients undergoing
lumbar Laminectomy, patients given onandsetron 4 mg on the induction of anesthesia needed
more tramadol postoperative compared patients given control saline (NaCl 0.9%) of fluid. Use of
tramadol per hour did not differ significantly with the two groups, except at the first
postoperative hours, probably due to the relatively short half-life of plasma onandsetron. 4 mg
dose of onandsetron 24 hours do not reduce incidence of post-operative nausea and vomiting6.
2. Drug Related Problems / DRP's (drug interactions with drugs):
Tramadol ↔ Meropenem
Tramadol may cause seizures, and combining it with other medications that can also cause
seizures such as meropenem may increase that risk. The interaction may be more likely if you are
elderly, undergoing alcohol or drug withdrawal, have a history of seizures, or have a condition
affecting the central nervous system such as a brain tumor or head trauma. You should avoid or
1813
limit the use of alcohol while being treated with these medications. Also avoid driving or
operating hazardous machinery until you know how the medications affect you7.
CONCLUSION
The use of tramal should be replaced with other opioid analgesic pain relievers as on his left
thigh as well as part of post-operative Kidney stone worked at 11 Dec 2014. Reasons changed
tramal because it has the level of severity of major interaction that is andgerous to the health of
patients and can cause permanent damage. Such as interaction tramadol and ondasentron can
happened serotonin syndrome symptoms are irritability, altered consciousness, confusion,
hallucinations, and coma, autonomic dysfunction such as tachycardia, diaphoresis, hyperthermia,
labile blood pressure, chills, and mid rise. neuromuscular disorders such as tremor, rigidity.
gastrointestinal symptoms such as abdominal cramps, nausea, vomiting, and diarrhea. While the
effects of interactions arising tramal and meropenem depressant and depressant. Patient should
be terminated if you have a history of seizures because it can andger the lives of patients.
REFERENCES
1. Cipolle, R.J., Strand, L.M., and Morley, P.C., 1998, Pharmaceutical Care Practice,
The McGraw-Hill Companies, New York
2. Almeida OP, Norman P, et.al. Succesful Mental Health Aging : Results
From a Longitudinal Study of Older Australian Men. The American Journal
of Geriatric Psychiatry. 2006; 14, 1, p.27.
3. Setiawati, A., Suyatna, F.D., and Gan, Sulistia. 2007. Farmakologi And Terapi.
Jakarta:Departemen Farmakologi and Terapeutik FKUI.
4. Bailie, G.R., Johnson, C.A., Mason, N.A., Peter, W.L.St. (2004). Medfacts Pocket
Guide of Drug Interaction. Second Edition. Middleton: Bone Care
International, Nephrology Pharmacy Associated, Inc. Halaman 1-6.
5. Cerner Multum, Inc. "Australian Product Information." O 0
1814
6. DeWitte JL, Schoenmaekers B, Sessler DI, DeLoof T "The analgesic efficacy of
impaired by concurrent administration of onandsetron." Anesth Analg
tramadol is
92 (2001): 1319-
21
7.Gardiner JS, Blough D, Drinkard CR, et al. "Tramadol and kejang: penelitian
surveilans
pada populasi managed care." Farmakoterapi 20 (2000): 1423-1431
1815
DRUG RELATED PROBLEMS ASSOCIATED NON
HEMORRHAGIC STROKE AT INSTALLATION OF INPATIENT
NUMFOR DR. MINTOHARDJO HOSPITAL
Alfia1, Aprilita Rinayanti Eff and Diana Laila R2.
1
Student of Pharmacist Program Faculty of Pharmacy UTA’45 Jakarta
2
Email : alfiafiaiskandar@yahoo.com
ABSTRACT
Non-hemorrhagic stroke is a disease that is often found in internal medicine wards in
Mintohardjo Hospital. Non-hemorrhagic stroke is defined as a stroke caused by a blood supply to
the brain is reduced or stopped due to thrombus formation or emboly in arteri cerebral. Mr.Hn
55 years old hospitalized in internal medicine wards. Patient on therapy patient was given RL
infusion, NaCl infusion, Amlodipine, Phenytoin, Folic Acid, Neurobion, Ambroxol, Ventolin
Nebulezer and Neulin. From the results of monitoring drug therapy,we found Drug Related
Problem that is improper drug selection.
Key words: Drug Realeted Problem, non hemorrhagic stroke, Mintohardjo hospital
1816
INTRODUCTION
Stroke is defined as a syndrome of Rapidly developing clinical symptoms and signs of focal, global
occasionally loss of cerebral function lasting more than 24 h or leading to death, with no
apparent cause other than of vascular origin. 1
Non-hemorrhagic stroke it self is a disease caused by a blood supply to the brain is reduced or
stopped due to thrombus formation or inhibit cerebral artery emboli. Usually cardiac source of
embolism, aortic arch, or the more proximal arterial lesions. 2
The management of stroke consists of pharmacological and non-pharmacological therapies. Nonpharmacological treatment of hemorrhagic stroke (clots) can be done by reperfusion and
neuroprotective. Reperfusion is restore blood flow to the brain so that the perfusion increased
adequately, drugs that can be given include: thrombolytic agents, platelet inhibitors and
anticoagulants. 2
Alteplase is recommended in the treatment of acute ischemic stroke if it can be administered
within 3 hours of symptom onset; it should be given by medical staff experienced in the
administration of thrombolytics and the treatment of acute stroke, preferably within a specialist
stroke center. Treatment with aspirin 300 mg once daily for 14 days should be initiated 24 hours
after thrombolysis (or as soon as possible within 48 hours of symptom onset in Patients not
receiving thrombolysis); Patients with aspirin hypersensitivity, or reviews those intolerant of
aspirin despite the addition of a proton pump inhibitor, should receive clopidogrel 75 mg once
daily (unlicensed use) as an alternative. 3
CASE PRESENTATION
Patient Mr. Hn, age 55 years old, admission Mintohardjo Hospital on 19 November 2014 with a
complaint weakness in the hands and left foot. Patient experienced weakness in the arm and left
leg, the patient's speech slurred speech, cough, hypertension, stroke two months ago because
there was bleeding and being in the treatment of pulmonary since 2 months ago. Based on the
history of the disease it can be determined goal of therapy in patients is to improve the flow of
blood to prevent blood clotting. The parameters measured were blood pressure, laboratory
values associated hematologic values, LDL (Low Density Lipoprotein) and other vital signs.
CLINICAL EVALUATION
1817
In this case the patient (Mr. Hn) is treated with RL infusion, NaCl infusion, Amlodipine, Phenytoin,
Folic Acid, Neurobion, Ambroxol, Ventoline Nebulezer, and given the addition of Neulin (citicolin)
for outpatient therapy. Indications of amlodipine is given to control the blood pressure,
Phenytoin as an anticonvulsant and folic acid for overcome the deficiency of folic acid clue to
side effect of Phenytoin, and Neurobion which serves as a supplement to neurotritis.4
Result of laboratory examination show that the value of eosinophils and neutrophils are
abnormal it is indicate that the patient experienced to infection, and the value of LDL (Low
Density Lipoprotein) showed abnormal indication that the patients. Suffered hyperlipidemia and
blockage of blood vessels that lead to non-hemorrhagic stroke.5
DISCUSSION
The patient was admitted to hospital on 19 November 2014 with a complaint weakness in the
hands and left feet and was diagnosed with non-hemorrhagic stroke. Based on the history of the
disease can be determined goal of drug therapy is to improve blood flow to prevent blood
clotting. The parameters measured were blood pressure, laboratory values associated
hematologic values, LDL (Low Density Lipoprotein) and other vital signs. Mr.Hn blood pressure
measurement on the first day was 180/120, pulse 84x / min and temperature of 36 0 c. Patient
was treated with amlodipine, Phenytoin, Folic Acid And Neurobion tablet, amlodipine 2 times
daily is indicated for the management of hypertension, Phenytoin 3 times daily for
anticonvulsant, Folic Acid once daily as for folic acid deficiency due to side effects Phenytoin and
Neurobion once daily as analgesic for the peripheral nerves. On the second the patient still
received the same drug. On third day patient received additional treatment that was ambroxol
tablet with Ventolin Nebulizer as eskpektoran to treat cough due to relapsed pulmonary TB and
on the last day patient received additional medication Neulin 2 times daily as post-stroke
therapy.4
Laboratory result show that abnormalisty of eosinophils, neutrophils and LDL. Increasing LDL can
causes non-hemorrhagic stroke.4
From the results of the monitoring of treatment we found Drug Related Problems that is
improper drug selection, buthe did not received drug of choice for overcome non hemorraghic
stroke alteplase short of breathness that the patient complain only is treated with ventolin
1818
nebulizer and ambroxol. On the third day the doctors diagnosed patient suffered pulmonary TB
of any such investigation laboratory of sputum examination. While the literature says patient
suffering from pulmonary TB should be treated with Isoniazid, Rifampicin, Piracinamid,
Ethambutol, and Streptomocin not with ambroxol.4
CONCLUSION
Based on observations during the monitoring of drug therapy in the Dr.Mintohardjo Hospital it
can be concluded that is DRP (Drug Related Problems) ie lack of proper drug selection.
REFERENCES
1. Stephen Tomlinson et al., 2008. Mechanisms of Disease: An Introduction to
Clinical Science Second Edition. New York. Cambridge University Press. Hal.191
2. And L. Longo, MD et al. 2005. Harrisonâ € ™ s manual of medicine 16th Edition. USA. The
McGraw-Hill Companies, Inc. P.58
3. Royal Pharmaceutical Society. 2011. British National Formulary 61. London.
BMJ Group of Great Britain. P.151
4. APHA. 2008-2009. Drug Information Handbook 17th Edition. USA. Lexi- Comp
5. Stevens, Christine Dorresteyn. 2010. Clinical Immunology And Serology: A
Laboratory Perspective 3rd Ed. Philadelphia. FA Davis Company. Page 7
1819
CASE REPORT : DRUG RELATED PROBLEMS IN TREATMENT
OF NON HAEMORRHAGIC STROKE DISEASE AT
MINTOHARDJO HOSPITAL
Mardiatul Husnaini1,Aprilita Rinayanti Eff and Diana Laila R2
1
2
Mardiatul_husnaini@yahoo.co.id
ABSTRACT
Non Haemorrhagic stroke is a brain tissue damage caused by lack of blood flow to the brain that
disrupt the need for blood and oxygen in brain tissue5. Hypertension is the increasing of blood
pressure, diastolic blood pressure above 90 mmHg, or systolic pressure above 140 mmHg8.
Patient Mr. SN, 42 years old, entered Mintohardjo Hospital on November 20, 2014 has a
diagnosed of non-hemorrhagic stroke (SNH) with a history of hypertension. He feels dizzy,
disturbance in the limb right and tingling on the right of cheek. The results of laboratory tests and
vital signs showed normal values. During hospitalized patient was treated with RL injection,
Citicolin injection, Neurobion injection, amlodipine, and gabapentin. Based on the results of
clinical practice in Mintohardjo Hospital it can be concluded that the presence of DRP (Drug
Related Problems) in the form improper drug selection.
KEYWORDS: Drug Related Problems, Non Haemorrhagic Stroke, Hypertension, Mintohardjo
Hospital
1820
INTRODUCTION
Non Haemorrhagic Stroke or stroke infarction is a clinical sign of dysfunction or brain tissue
damage caused by lack of blood flow to the brain that disrupt the blood and oxygen requirement
in the brain tissue5. Approximately 88% of all strokes are non Haemorrhagic stroke caused by the
formation of thrombus formation or emoboli which inhibit cerebral artery. Cerebral Aterosklosis
is a causative factor in many of the problems Non Haemorrhagic Stroke, although 30% of
unknown etiology5.
Ischemic stroke classification is divided into three types, namely: Stroke thrombotic, embolic
stroke and systemic hypoperfusion. Thrombotic stroke is the process of thrombus formation that
causes clotting. Embolic stroke is as blocked artery by a blood clot. Systemic Hipoperfusion is
reduced blood flow to all parts of the body due to a disturbance in heart rate5.
Hypertension is the increased blood pressure, diastolic blood pressure above 90 mmHg settle, or
systolic pressure above 140 mmHg settled. Hypertension due to increased peripheral vascular
smooth muscle tone, which causes an increase in resistance arterioles and reducing capacity of
the venous blood vessel system. Hypertension may occur as a result of another disease process,
more than 90 percent of patients suffering from essential hypertension, a disease in blood
pressure regulation of unknown cause. Environmental factors such as life stress, high-sodium
diet, obesity and smoking are factors predisposing to hypertension7.
CASE PRESENTATION
Patient Mr. SN 42 year old admitted to the island Noemfoor of Mintohardjo Hospital. Patient
Diagnosed with Non Haemorrhagic Stroke. Patient entered Mintohardjo Hospital on November
20, 2014. The patient had complained when he came to the hospital that were disturbance in the
limb tingling on the right cheek area, for 1 day before he was enteri the hospital. Complaints
occur suddenly when the patient want to catch the bird, the patient said that at the time of the
incident he felt dizzy, but the patient did not experience nausea, vomiting, blurred vision, and
speech disorders.
CLINICAL EVALUATION
In this case the patient was treated with an infusion of RL (Ringer Lactate) 14 MDGs, Ringer's
lactate administration aims to restore water and electrolyte balance in the body, injection of 500
1821
mg Citicolin aims to improve the nervous system by increasing the consumption of oxygen in the
brain and improve drug metabolism. Then injection neorobion 5000 for treating cerebrovascular
injury. 1x amlodipine 10 mg od.
DISCUSSION
Mr. SN had history of hypertension and based on the diagnosis show that he Stroke Non
Hemoragic (SNH). Chemical examination showed that increasing result of 10,500 leukocytes/µl
(normal 5000-10000/µl) and total cholesterol 248 mg/dl (normal < 200 mg/dl) and urea 75 mg/dl
(normal 17 - 43 mg/dl), and the patient blood pressure 160/120 (normal 120/80), pulse 88x/min
and temperature 36º C.
For overcome SNH disease, the patient was treated with infus of RL, Citicolin Injection 500 mg,
Neurobion Injection 5000 od, Amlodipine 10 mg, and Gabapentin 100 mg bid, RL administration
aims to restore water and electrolyte balance in the body. Citicolin Injection 500 mg od can
improve the consumption of oxygen in the brain and improve drug metabolism. Neurobion
Injection 5000 used for treating cerebrovascular injury. Amlodipine 10 mg, for hypertension.
Amlodipine works by inhibiting the movement of calcium into the cell membrane in systemic and
coronary vascular smooth muscle and acts directly as a peripheral arterial vasodilator that can
cause a decrease in vascular resistant infections as well as a decrease in blood pressure7.
Furthermore, the patient was given Gabapentin for relieve pain, especially neoropatic pain. On
the fourth day patient was given cholesterol-lowering drugs, simvastatin 20 mg, because patient
has elevated on total of cholesterol 248 m/ dl (normal < 200 mg/dl). On the last day he received
amlodipine for hypertension and simvastatin.
DRUG RELATED PROBLEM:
Improper drug selection
The patien experieneed non hemorrhagic stroke, but he did not receive the first lune drug for
treating the stroke is Alteplase.
CONCLUSION
Based on the monitoring of drug therapy in patient with SNH disease at Mintohardjo Hospital it
can be concluded that there is have Drug Releated Problem, that is improper drug selective.
1822
REFERENCES
1. Anwar, TB, 2004, p Dislipidemia as a risk factor for coronary heart EW p, http:
/librarary.usu.ac.id/download/fk/gizi.bahri3.fd p. Accessed November 2014.
2. National Agency of Drug and Food Control. 2008. The Indonesian national drug information.
Sagung seto. Jakarta.
3. BNF 61, 2001. Britsh National Formulary 61 March 2011
4. Cipolle, Robert J, et al. 2004. Pharmaceutical Care Practice Second Edition. USA: The Mc.GrawHill Companies Inc.
5. Corwin, E .j. 2009. Handbook Pathophysiology. Jakartab: EGC
6. ISFI, 2009. "ISO Indonesia Vol. 44 ". Noble Berlico Farma. Yogyakarta
7. MOH, 200, Pharmaceutical Care for hypertension, Directorate building a community
pharmacy,
clinical
pharmacy
Directorate
General
Development,
medical
devices.
http://emedicine.medscape.com
8. Joint National Committee on prevention, 2003. Evaluation and treatment of high blood
pressure
1823
CASE REPORT : DRUG RELATED PROBLEM OF ASSOCIATED OF TUBERCULOSIS (TB) STAGE II AT
MINTOHARDJO HOSPITAL.
Rezkyta Triana Tambing1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
Student of Pharmacist Program, Faculty of Pharmacy UTA'45 Jakarta
2
trianarezkyta@gmail.com
ABSTRACT
Tuberculosis (TB) is a disease caused by Mycobacterium tuberculosis. The bacteria usually attack
the lungs, but TB bacteria can attack any part of the body such as kidney, spine and brain. If not
treated properly, TB disease can be fatal1. Patient Mr. AH 69 years old, entered Mintohardjo
hospital on 25th september 2014 with the diagnosis of advences tuberculosis (TB) stage II. Patient
was treated for 9 days with an infusion of RL, Ceftriaxon injection, a Bisolvon (bromhexin HCl),
Isoniazid (INH), Rifampisin, Ethambutol, Sanfuliq (curcuma). Based on the result of monitoring
the using of drugs it can be concluded that there is drug related problems i.e. untreated
complaints nusea, vomiting and anemia.
Keywords : Drug Related Problem (DRP), Tuberculosis (TBC ), and Mintohardjo Hospital
1824
INTRODUCTION
Tuberculosis (TB) is a disease caused by infection Mycobacterium tuberculosis complex.
Mycobacterium tuberculosis shaped a straight rod or slightly curved not sporulated berkapsul or
not. This bacteria measuring wide 0.3-0.6 mm and long 1-4 mm. Mycrobacterium the wall very
complex, consisting of layers of fat substantial (60 %)2. Tuberculosis (TB) is one of an infectious
disease with incidence that is relatively high Pulmonary tuberculosis also reported as cause of
death third largest in the world after the disease of cardiovascular and diseases of the respiratory
tract and infectious diseases is number one in the world that can cause death3.
Clinical symptoms is coughing 2 sunday coughing up blood, asthma, chest pain, fever and etc 4.
Reports the globe by tuberculosis who made indonesia ranked fourth highest number of TB for
patients after China, India and South Africa with the prevalence of TB in Indonesia in 2013 is 297
per 100,000 people with a new case every year reached 460.000 cases. In this way total cases
until 2013 reached around 800.000-900.000 case1. Aside from the issue of sanitation home
environment, occurrences of a disease pulmonary tuberculosis also is very much related to
behavior and the number of the family income because most of TB sufferers are poor that low
education level5. For examination pulmonary tuberculosis examined specimens phlegm in the
two days that is when morning – of time (SPS). Based on a guide tb program national the
diagnosis of tuberculosis pulmonary in adults enforced with seen germs TB (BTA)4. While
examination thorax photo, culture and the sensibility can be used in a supporting diagnosis in
accorandce with the indication and is not tolerated in diagnosing TB4.
CASE PRESENTATION
Patient Mr. AH ,69 years old entered Mintohardjo hospital by the 25th of september 2014. The
patient came with complaint asphyxiate from early morning. Short of breathness more severe if
he did activity. Patient complained appetite reduced ,dry cough, nausea, and vomiting. Patient
had treated with TB drug stage II for 3 months before. Because he suffered TB with positif
infection of Mycobacterium tuberculosis.
1825
VITAL SIGN EXAMINATION
The date of the
Blood pressure
Pulse
Respiratory
examination
(120/80 mmHg)
(60-100x/minutes)
(14-18x/minutes)
Temperature
(36-37⁰
25/9/2014
120/90 mmHg
86 x / minutes
22 x /minutes
36 ⁰
26/9/2014
130/80 mmHg
88 x / minutes
26 x /minutes
36 ⁰
27/9/2014
130/90 mmHg
88 x / minutes
22 x/ minutes
36 ⁰
28/9/2014
120/80 mmHg
88 x / minutes
20 x/ minutes
36 ⁰
29/9/2014
120/90 mmHg
88 x / minutes
20 x/ minutes
36⁰
30/9/2014
120/90 mmHg
84 x / minutes
20 x/ minutes
36⁰
1/10/2014
120/70 mmHg
80 x / minutes
20 x/ minutes
36⁰
2/10/2014
110/80 mmHg
80 x / minutes
20 x/ minutes
36⁰
3/10/2014
110/80 mmHg
80 x / minutes
20 x/ minutes
36⁰
CLINICAL EVALUATION
Patient with is treated with TB drugs stage II (Rifampisin, Ethambutol, Isoniazid). RL infusion as an
electrolyte, ceftriaxon injection as an antibiotic for treat bacterial infection. Bisolvon tablets
(Bromhexine HCl) for diluting sputum. Sanfuliq (Curcuma) as a supplement to maintain a
function of the liver, for reduce shortness of breath oxygen (O2).
LINE CURING TO TBC6
Category II
A dose of times a day
The stage of
Duration of
Tablet
Kaplet
Tablet
Tablet
Tablet
Vial
treatment
treatment
Isoniazid
Rifampisin
Pirazinamid
Ethambutol
Ethambutol
Streptomisi
@300mg
@ 450 mg
@ 500 mg
@ 250 mg
@ 500 mg
n @ 1,5 gr
1
1
3
3
-
0,75 gr
The stage of
intensive
2 months
daily doses
1826
To
continued
1 month
1
1
3
3
-
-
5 months
2
1
-
1
2
-
Advanced
stage
(doses)
three times
a week
Bb = 33-50 kg
RESULT OF LABORATORY EXAMINATION 7,8
Results hematology on 24th September 2014 show that is increase value of leukocytes i.e.
11,000/ul (5.000-10.000 ul.) is and on 25th of september 2014 show a decrease of erythrocytes
value i.e. 4,01 million/ul (4,2-5,4 million/ul) and a decreasing hemoglobin velue i.e. 10.9 g/dl (1214 g/dl) that indicate patient axperince anemia. Result of blood gas test on 24th September 2014
show increasing pCO2 i.e. 60,4 mmhg (32-48 mmhg) and patient has diagnosed asthma and that
signifies namely hipoventilasi respiratory. The patient also experienced respiratory disorders and
loss of gastric acid that seen from the increasing value of HCO3 i.e. 38.9 mmol/L (21-28 mmol/l)
and accumulated of CO2 in the lungs that seen for the increasing of CtCO2 i.e. 40.8 mmol/L (2327 mmol/L ).
DOSAGE AND USING THE DRUGS9,10,11
In this case doctors gave any treatment that are an infusion of RL instead of the body fluids with
a dose of 14 drop per minutes intravenously for 7 days. Ceftriaxon injection as an antibiotic for
treating some bacterial infections with a dose of 2X1 in for 7 days. Bisolvon (Bromhexine HCl)
tablet diluting sputum with a dose of 3X1, Rifampicin, Isoniazid, Ethambutol for as anti
tuberculosis with a dose of Rifampisin 1X450 mg, Isoniazid 1X300 mg, Ethambutol 1X1000 mg.
Sanfuliq (Curcuma) given as a supplement to maintain the function of the heart with a dose of
2X1 orally. Oxygen (O2) given to the treatment of shortness of breath with a dose of 2 liters per
minutes for 5 days.
1827
DISCUSSION
Tuberculosis (TB) caused by bacteria (Mycobacterium tuberculosis) the most often affecting the
lungs. TB spreads from person to person through the air. Tuberculosis (TB) pulmonary is one
infectious disease with incidence relatively high. Pulmonary tuberculosis were also reported as
the cause of death of the third largest in the world after kasrdiovaskular disease and diseases of
the respiratory tract. Clinical symptoms is coughing 2 sunday coughing up blood asphyxiate,
chest pain, fever, etc.
In this case the patient has get TB drugs stage II for 3 months and will continue with further
therapy. The patient has come to the hospital with complaints shortness of breath since
morning. Especially when he has done the activity. Patients also complained of diminished
appetite, coughing up sputum dry, nausea, and vomiting. The examination of the vital sign on
respiratory show, above normal is over 18x/minutes. Laboratory reports show
increasing
leukocytes value that indicate presence of infection, and he received ceftriaxon. Ceftriaxion
injection is antibacterial broad spectrum that is indicated for severe infections. The patient
experienced a decline in the value of erythrocytes and hemoglobin indicated he has but not
handled. Increasing in pCO2, HCO3, BE and CtCO2 indicate that patient overcome patient treated
with (O2) oxygen, bisolvon (bromhexin HCl) as mucolytic diluting. For overcome, patient treated
TB drug stage II (rifampisin, ethambutol, isoniazid), because the use of rifampisin, ethambutol,
Isoniazid and in a long period of time caused liver damage (hepatotoksik) so that patients
therapy with sanfuliq (curcuma) to maintain the function of heart.
1.
a.
Untreated Complaine / Untreated disease
Patients need therapy B6 for overcome nausea and vomiting patient an reduce the
side effects of isoniazid (INH) but not.
b.
Patient suffered anemia but he did not receive sumpplement for increasing his
erythrocytes and hemoglobin.
2.
Drug Interaction
a.
Rifampicin with Isoniazid (INH)
Rifampisin can increase toxicity of isoniazid by enzim induces. Rifampisin improve the
1828
metabolism of isoniazid to for toxic metabolism.
b.
Isoniazid with foods
The absorption of isoniazid will be reduced when given after a meal (especially a scombroid
specis, tuna fish mackerel, salmon that is not fresh).
CONCLUSION
Based on the results of clinical practice in Mintohardjo hospital it can be concluded that the
existence of DRP (drug related problem) in form of untreated complaints, and drugs interaction.
REFERENCES
1. WHO, 2014. What Is TB ?.World Health Organization
2. PDPI, 2013. Guidelines for the diagnosis and management of tuberculosis. Jakarta
3. Made dkk, 2013, The relation of knowledge , attitude and tenga motivation of activity in
controlling health with the case of tuberculosis in the district buleleng .Megister the journal of
family medicine, Surakarta
4. Djojodibroto, Dr. R. Darmanto, Sp. P, FCCP, 2009. Respirology (Respiratory Medicine). Jakarta:
EGC.
5. Herryanto, 2004, the treatment of patients with pulmonary TB History Health Journal vol 3,
Bandung.
6. BPOM. , 2008. Indonesian National Medicine Information (ioni). Jakarta: Sagung Seto.
7. KEMENKES RI, 2011. Guidelines of interpretation of data clinic. Kemenkes RI : Jakarta
8. Afifah, 2009. A journal examination astrup / blood gas analysis. FIK UI. Jakarta
10. Depkes, 2005. Pharmaceutical care for tuberkulosis. Dirjen Bina Kefarmasian and Alat
Kesehatan. Jakarta.
1829
DRUG RELATED PROBLEM TOWARDS THE TUBERCULOSIS
AND DIABETES MELLITUS DISEASE ATTHE INTERNAL
WARD OFPULAU SANGEANG DR. MINTOHARDJO NAVY
HOSPITAL JAKARTA
Lince Muliati Layuk1, Aprilita Rinayanti Eff and Diana Laila R2
1
2
Email :Layuk20stella@gmail.com
ABSTRACT
Tuberculosis is caused by Mycrobacterium tuberculosis which often affects lungs. Tuberculosis
spreads from person to person through the air. When the person with tuberculosis coughs,
sneeze or spit, tuberculosis bacteria is released to the air1. A patientMr NS, 51 years old, entered
Dr. Mintoharjo Navy Hospital on 12 November 2014 with diagnosis of Tuberculosis first category.
Patient was treatedduringin seven days were RL infusion, Cefotaxin injection, Omeprazole
injection, Levofloxacin injection, Onandsetron injection, Metformin tablet, Neurobion 5000 mg
injection, Codein tablet, glimepirid, ranitidine injection, tuberculosis drug,FDC (INH, Rifampisin,
Pirazinamid, and Ethambutol). Based on the clinic practical at Mintoharjo Navy Hospital, it can be
concluded there is found drug related that isuntreatedcomplaint.
Key words: Drug Related Problem, Tuberculosis, Diabetes mellitus, Mintohardjo Hospital.
1830
INTRODUCTION
Tuberculosisis a disease caused by Mycro bacterium tuberculosis. Mycrobacterium tuberculosis
has shape straight stem or a little curve, unspored or uncapsuled. Its width is 0.3-0.6 mm and
length is 1-4 mm. Mycrobacterium wall is very complex, it consists of enough high fat layer
(60%)2.
Tuberculosis is one of infectious diseases with relative high rate. It is also reported the
third biggest death cause in the world after cardiovascular and repirastory tract. It is number one
disease infection in the world that can cause death3.
The clinical symptoms are coughing for two weeks, bleeding cough, breathless, pain in
chest, fever, etc4. Tuberculosis world report by WHO puts Indonesia in the fourth big rank for
country with many Tuberculosis suferers after China, India, and South Africa with the
Tuberculosis prevalence in Indonesia in 2013 was 297 per 100, 000 people with new case every
year reached 460.000 cases. Therefore, total case until 2013 reached 800,000-900,000casesI.
Besides house sanitation factor, tuberculosis is also caused by behavior and income rate because
most of its suferers are poor people with low education5. For checking tuberculosis, sputum is
examined for two days, which is calledSPS. Based on the tuberculosis national guide program,
TBC diagnosis for adult is conducted by finding Tuberculosis Bacteria (BTA)10. While from thorax
photo examination, prolific and sensitivity can be used to support diagnosis based on the
indications and it is not allowed in diagnosing Tuberculosis4.
CASE PERCENTAGE
Patient Mr. NS, 51 years old, entered Dr. Mintohardjo Navy Hospital on 12 November
2014. The patient came with complaint that weak of body for two weeks. He also felt dizzy when
sitting or spining, cough and white sputum. He hadalso low appetite and weight loss.
The patient had ever got treatmentforcough with sputum before. From sputum and Xray, the result was tuberculosis. He was ever given theraphy with tuberculosis drugfirst category
but it was only consumed for two days and discontinued until present. He hadalso diabetes
mellitus history.
1831
Date
Blood pressure
Pulse
Breath
Temperature
(120/80 mmHg)
(60-100x/minute)
(14-18x/minute)
(36-370C)
12/11/2014
110/60 mmHg
80x/minute
18x/minute
360C
13/11/2014
120/80 mmHg
80x/minute
18x/minute
360C
14/11/2014
120/70 mmHg
80x/minute
18x/minute
360C
15/11/2014
120/70 mmHg
88x/minute
18x/minute
37.60C
16/11/2014
110/90 mmHg
90x/minute
18x/minute
36.50C
17/11/2014
120/80 mmHg
88x/minute
18x/minute
37.50C
18/11/2014
100/80 mmHg
80x/minute
18x/minute
36.70C
CLINICAL EVALUATION
Patient was given therapy with tuberculosis drug, FDC first category (INH, rifampisin,
pirazinamid, etambutol),RL infusion is as electrolyte,Ondacentroninjection is to prevent from
nausea and vomit,Cefotaxim and levofloxacin injections are as antibiotics to cure some bacteria
infections. Omeprazol injection is to cure peptic ulcer and duodenum ulcer. Metformin and
glimepirid are to cure diabetes mellitus. Codein is to cure cough.
STAGES IN TREATMENT FOR TUBERCULOSIS10
First Category
Tuberculosis drug,
Composition
Usage
FDC tablet
4FDC
75 mg INH
Intensive stage/beginning and daily
150 mg Rifampisin
insertion
400 mg pirazinamid
275 mg Etambutol
2FDC
150 mg INH
Advance stages, 3 times a week
150 mg Rifampisin
1832
Weight
Intensive Stage
Advance stages
(Every day for 2 months)
(3 times a week for 4 months)
30-37 kg
2 tablets 4FDC
2 tablets 2FDC
38-54 kg
3 tablets 4FDC
3 tablets 2FDC
55-70 kg
4 tablets 4FDC
4 tablets 2FDC
>70 kg
5 tablets 4FDC
5 tablets 2FDC
LABORATORY EXAMINATION RESULT 7,8
Hematologhy examination result on the first day, showed they patient had an increase in
lecocyte from 21,200 / ul (5,000-10,000 ul) which signed the infection. On 12November 2014 the
erictrocyte decreased 3.91 millions/ul and also the hemoglobin decreased 10.7 g/dl (12-14 g/dl)
which signed anemia. The Increase result of 148 mg/dl (<110 mg/dl) signed that the patient
haddiabetesmellitus.On17th November 2014, when the patientin lower condition had blood
glucose rate 117 mg/dl.
DOSAGE AND DIRECTION9, 10, 11
In this case, medicine therapies was given by doctor were RL infusion as the substitution
for body liquid with dosage of 16 tpmintravenously for 7 days. Rainitidine injection is to cure
gastritis and the low of gastricacidwith dosage 2x1 for 3 days, then the therapy was continued by
administering ranitidine tablets. Onandcetron injection is to prevent nauseaand vomit with
dosage 3x4 mg. Cefotaximinjection as antibiotic is to cure some bacteria infections with dosage
2x1 with injection for 7 days. Omeprazol injection is to cure peptic and duodenum ulcers with
dosage 1x1 ampul. OAT FDC first category (INH, Rifampisin, Pirazinamid, Etambutol) with dosage
1x3 tablets. Metformin is to cure diabetes mellitus with dosage 2x850 mg. Codein is to cure
cough with dosage 3x20 mg. Glimepirid is to cure diabetes mellitus with dosage 1x2 mg.
Levofloxacin drip is as antibiotic with dosage 500 mg.
DISCUSSION
1833
Tuberculosis is caused by Mycobacterium tuberculosis bacteria that often affect lungs. It spreads
from person to person through the air. It is also one of the deadliest diseases with quite high
rate. It is also reported as the third biggest death cause in the world after cardiovascular and
respiratory tract deseases. The clinical symptoms are coughing for two weeks, bleeding cough,
breathless, pain in chest, fever, etc.
In this case, the patient had previously got tuberculosis drug first category but it was only
consumed for 2 days patient stop it.Patient came in weak condition since 2 weeks before. He felt
dizzy when sitting and rolling. The coughed was with white sputum. The patient had also
lowerapetite and weight loss. The result of Vital Sign Examinations showed that breath is a
normal of 18x per minute.The laboratory examination showed the increase of lecocyte which
means infection. So the patient was given Cefotaxim injection which is antibiotic that belongs to
the third generation of cephalosporins. It has wider spectrum activities to the positive and
negative grams. The decrease of eritrocyte and hemoglobin signs anemia, butpatient did not
give treatment for overcome his anemia,codein therapy for his cough that pushes the cough
source in medulla, tuberculosis drug first category therapy (INH, rifampisin, pirazinamid,
etambutol),for diabetes mellitus was given glimepirid and metformin.
DRUG RELATED PROBLEM 4.6
Untreated complaint/ disease:
a. Patient needed B6 therapy to reduce the side effect of Isoniazid (INH), but it was not given.
b. From the labolatory examination result shows the decrease of eritrocyte and hemoglobin that
sign anemia, but it was not handled. It was better to give a blood increase suplement.
CONCLUSION
Based on the pratice of clinical word in Mintohardjo
hospital, it can be concluded that there
is drug related problem, that is untreated in complaints.
REFERENCES
1. WHO, 2014. What Is TB ?.World Health Organization
1834
2. PDPI, 2013. Pedoman diagnosis andpenatalaksanaanTuberkulosis . Jakarta
3. Made
dkk,
2013,
Hubunganpengetahuan,
sikapandMotivasitengakesehatandenganaktivitasnyadalampengendalianKasusTuberkulosis
di
KabupatenBuleleng. JurnalMegisterKedokteranKeluarga, Surakarta
EGC
5. Herryanto, 2004, Riwayatpengobatanpenderita TB paruJurnalKesehatanvol 3 hal 1-6, Bandung.
6. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Sagung Seto : Jakarta
7. KEMENKES RI, 2011. PedomanInterpretasi Data Klinik .Kemenkes RI : Jakarta
8. Afifah, 2009. JurnalPemeriksaanAstrup / Analisa Gas Darah. FIK UI. Jakarta
10.
Depkes,
2005.
Pharmaceutical
care
untukpenyakittuberkulosis.
DirjenBinaKefarmasianandAlatKesehatan. Jakarta.
11.
Galileopharma. 2008, BNF edition 56, Alexandria University
1835
DRUG RELATED PRLOBLEM ASSOCIATED DYSPEPSIA SYNDROME
AND TUBERCOLOSIS AT MINTOHARDJO NAVY HOSPITAL
Novia Ratna Sari1, Aprilita Rinayanti Eff2 and Diana Laila Ramatillah2
1
2
noviaratnasari410@yahoo.com
ABSTRACT
Dyspepsia is a term which includes a group of symptoms that come from a problem in upper gut.
The many symptom is usually pain or discomfort in the upper abdomen, in addition, other
symptoms that may develop include bloating, nausea and vomiting. Tuberculosis is infections
disease. Caused by various strains of Mycobacteria, usually Mycobacteria tuberculosis.
Patient, Mr. S, 30 years old, weight 65 kg, entered in hospital on the 5 th October 2014 with
diagnose dyspepsia and tuberculosis. During treatment, the patient was treated with IVFD RL,
Onandcertron injection,Ranitidin injection, Sukralfatsyr, Tuberculosis drug 4 FDC, and vitamin B6.
Based on the result of clinical work practices Mintoharjo, it can be concluded that there is drug
related problem, adverse drug reaction and untreated disease.
Key words : Drug Related Problem, Dyspepsia, Tuberculosis, Dr. Mintohardjo Hospital
1836
INTRODUCTION
Dyspepsia is group of complaint or clinical symptoms which consist of discomfort or pain, full and
heat in the upper of abdomen that persists or relapsed. The term of dyspepsia itself began to
aggressively express since the end of 1980, describe the complaint or the collection of symptoms
(syndrome) which consist of pain, nausea, vomiting, bloating, early satiety, full, belching and
burning sensation radiating chest. The syndromes or the complaint can be caused or based by a
few diseases of course, including diseases in our stomach or known as gastric.
Tuberculosis is a disease that caused by complex mycobacterium tuberculosis infection.
Mycobacterium tuberculosis is straight or slightly curved, without spore or encapsulated.
Generally, Mycobacterium tuberculosis invades the lungs and the small portion of the body
organs. The bacteria can survive in moist and dark place. In the body tissues, bacteria can
dormant (sleep until few years) it arises based on its ability to multiply within phagocytic cells.
The main preparation of cell wall of Mycobacterium tuberculosis including gram positive bacilli,
rod- shaped cell wall contains complex lipidaglipida and candles.
TB ’s report by WHO in 2006 explained that Indonesia as the third largest connector in the world
after India and China with the number of cases about 529000 people per year. According to
Notoatmodjo(2003) besides the factor of home environment sanitation, the incidence of TB
disease also associated with the behavior and the amount of income for the majority of patients
because most of the patient is come from the poor where has very low educational level. The
checkup of pulmonary TB is checked by Three sputum specimens in 2 days namely in the
morning. According to the direction of National TB program, the Lung diagnosis for adult is found
TB Bacteria (BTA).
CASE PRESENTATION
A patient, Mr. S, 30 years old, weight 65 kg, entered in hospital on the 5th October 2014 with
diagnosed dyspepsia and tuberculosis. He came with complaints, got fever for 4 days before
come to the hospital, limp, nausea, dizzy, pain in epigastrium, cough with phlegm and narrow for
nearly a week. During treatment, the patient was treated with IVFD RL, Onandcertron injection,
Ranitidin injection, Sukralfatsyr,Tuberculosis drug 4 FDC, and vitamin B6.
1837
CLINICAL EVALUATION
In this case, the patient was treated with IVFD RL 20 drop perminute , Onandcentron injection to
overcome nausea, Ranitidine injection and Sukralfat syrup for overcome dyspepsia, Tuberculosis
drug 4FDC and vitamin B6 to overcome the effect Tuberculosis drug.
THE DOSAGE AND HOW TO USE IT1
In this case, the patient was treated with Onandcentrom 2mg/ml three times during 5 days,
ranitidine 50 mg, 2x1 for 4 days, Sukralfat syrup 3x1 at the dose 500mg/ml, 4FDC is a treatment
for Tuberculosis patient (75 mg INH, 150 mg Rifampisin, 400 mg Pirazinamid, 275 mg Etambutol)
1x4 tablet orally, and Vitamin B6 1x1 per day.
TREATMENT FOR TUBERCULOSIS2
1st Category
Weight
Incentive stage every day for 56 days
Advanced stage 3 times a week
for 3 days
INH, rifimpisin, etambutol, pirazinamid
Rifampisin, INH
30-37 kg
2 tablet 4 FDC
2 tablet 4 FDC
38-54 kg
3 tablet 4 FDC
3 tablet 4 FDC
55-70 kg
4 tablet 4 FDC
4 tablet 4 FDC
≥71 kg
5 tablet 4 FDC
5 tablet 4 FDC
2 st Category
Weight
Incentive stage every day for 56 days
for 3 days
INH, Rifimpisin, Etambutol, Pirazinamid,
Rifampisin, INH, Etambutol
and Injek Sereptomisin
30-37 kg
2 tablet 4 FDC
2 tablet 4 FDC
38-54 kg
3 tablet 4 FDC
3 tablet 4 FDC
55-70 kg
4 tablet 4 FDC
4 tablet 4 FDC
≥71 kg
5 tablet 4 FDC
5 tablet 4 FDC
1838
LABORATORY RESULTS5
Hematology 4000 u/l decline in which the normal values for leokosit i.e. 5,000-10,000 u/l,
erythrocytes patient 4.40 million / µl are normally 4.6-6.2 million/ µl, the values of hemoglobin
(HB) 11.7 g/dl normally 14-16 g/dl, and hematokrit 33% normal 42-48%, laboratory value show
that lever fungtion abnormally. Result of liver function SGOT 39 u/l which normal value i.e. < 35
u/l and SGPT 48 u/l are normally < 41 u/l can be seen happening increase.
DISCUSSION
Dyspepsia is a group of clinical symptoms or complaints of bad taste or pain, full flavor and heat
in the upper abdomen that settled or experiencing recurrence1. Tuberculosis is an infectious
disease directly caused by Mycrobacterium tuberculosis, most (80%) invade the lungs. The source
of transmission of TB sufferers are positive at the time of the BTA coughs or sneezes, sufferers
spread germs into the air in the form of droplets (a splash of phlegm), droplets containing germs
can survive in air at room temperature for a few hours, so that people can become infected if
droplets are inhaled into the respiratory tract2.
In this case Mr. S age 31 years, weight 65 kg comes to RS with complaints fever 4 days before
entering the hospital, limp, nausea, pain in the solar plexus, cough with phlegm almost a week,
the patient was diagnosed with dyspepsia and tuberculosis.
Results of laboratory examination show that leukocytes obtained 4000/ µl decline, erythrocytes
4.40 million / µl, the values of hemoglobin (HB) 11.7 g/dl, and his 33% hematokrit all experienced
a decline, due to the infection of Mycrobacterium tuberculosis. Patient experienced anemia due
to deficiency folic acid and vit B12 so he received folic acid and vit B12 so patient need folic acid
intake and vit.B12. On examination of the liver function show that SGOT and SGPT increase
above normal value 39 u/l and 48 u/l, due to the effects of the use of Tuberculosis drug, so that
patient also need hepatoprotector.
During treatment in hospital patient got IVFD RL 20 drop perminute, ranitidine injection may
reduce the secretion of stomach acid and sukralfat for dyspepsia, onandcentron for nausea, 4FDC
for tuberculosis treatment and vitamin B6 to overcome side effect of Tuberculosis drugs.
1839
1.
Untreated disease/ complaint4
Patient has anemia due to folic acid and vit B12 deficiency. The patient should be given intake
folic acid and vit.B12.
2.
Adverse Drug Reaction
Tuberculosis drug can cause liver malfunctioning, preferably patient is given the drug for
hepatoprotector.
CONCLUSION
Based on the results of clinic practice at Mintohardjo hospital can be concluded the existence of
the DRP (Drug Related Problem) that is. Untreated disease/complaint and adverse drug reaction.
REFERENCES
2. DEPKES RI, 2005. Pharmaceutical Care Untuk Penyakit Tuberculosis. Direktorat Bina Farmasi
Komunitas and Klinik. Jakarta
EGC.
4. Oehadian Amaylia, 2003. Aspek Hematologi Tuberculosis,Bandung : Fakultas Kedokteran
Universitas Padjadjaran
5. Sutedjo, AY. 2007. Buku Saku Mengenai Penyakit Melalui Hasil Pemeriksaan Laboratorium.
Yogyakarta : Amara Books
6. Tally NJ, Stanghellini V, dkk. 1991. Functional dyspepsia a classification with guildlines for
diagnosis and management. Hal 145
7. Djojodinigrat, D. 2006. Dispepsia fungsional. Jakarta
1840
CASE REPORT : DRUG RELATED PROBLEMS OF DEEP VENOUS
THROMBOSIS (DVT) DISEASE AT PGI CIKINI HOSPITAL
Hasnawati1, AprilitaRinaYanti Eff2 and Diana Laila R2
1
2
Email : hasnawati91@gmail.com
ABSTRACT
Deep venous thrombosis (DVT) is defined as a blood clot forms in a vein that is marked by the
presence of abnormalities in the blood vessel walls, changes in blood flow and the changes of
power frozen blood. Causing of venous thrombosis most common is the existence of a known
crack on blood vessels. Patient Mrs. RH, age 36 year old, entered the PGI Cikini hospital on
september 27, 2014 with a diagnosis of venous thrombosis in limbs left. Patient was treated for 7
days
with
biozim
(ceftazidim),
rocer (omeprazole),
nonflamin (Tinoridin),
tromboaspilet (asetilsalisilat acid), tramifen (Tramadol), neurosanbe, folic acid, vitamin B
complex, heparin, simarc (Warfarin) and NaCl 0.9% for soaking the feet that swollen. Based on
the results of clinical monitoring of using drug at PGI Cikini hospital it can be concluded there is
has the existence of the DRP (Drug Related Problem) that are using of drug a appropriate, patient
using of drug without indication and drug interaction.
Key words: Drug Related Problems (DRP), VenousThrombosis and PGI Cikini Hospital
1841
INTRODUCTION
Deep venous thrombosis (DVT) is a condition in which the veins thrombus is formed
on the lower limbs and especially in the inguinal area. Blood clots can inhibit blood from the
legs back to the heart. ¹ one factor the risk of thrombosis is due to a long imobilisation.2
In cases of venous thrombosis who have need of supervision and the proper treatment of
thrombosis and implementing the prevention of widespread thrombosis and emboli formation in
other areas, which can cause death. The incidence of venous thrombosis in general very difficult
investigation, so no report for sure. Many reports only suggests the data that
patients
3
hospitalized with various diagnosed.
Thrombosis is the largest cause of death in the united states. About 80 – 90 % of thrombosis can
cause is known.4,5 Deep Venous occurrence of thrombosis (DVT) in the United States more than 1
per 1000 and there are 200,000 new cases each year. The total number of occurrences of deep
venous thrombosis about 60% pulmonary emboli with risk of death about 30% in 30 days. 6,7
Thrombosis is the occurrence of a blood clot in the cardiovascular system, including arteries,
veins, heart and microcirculation room.3 Thrombus may occur at arterial or venous, arterial
thrombus
on
called
thrombus white because compositionally more
platelets
and fibrin thrombus in the vein, while the call of red thrombus due to occur in the flow of the
slow that causes red blood cells trapped in the tissue fibrin that is red.3
Venous thrombosis (DVT) is in a State of emergency that must be diagnosed and therapy as soon
as
possible. This
of the endless death
is
because often
leads to lung thrombus
and release the
heart
6,7
. Prevention of thrombosis in the venous (DVT) can be done by way
of administering anticoagulants, one of them with the use of heparin given through intravenous
lines. Heparin works indirectly on various parts of the system are intrinsic and extrinsic blood
clotting with affect activity of antithrombin III and his inhibiting factor IX, X, XI, XII.8
Initial therapy according to Morgan, shows that 50% of the cases of DVT were formed at the time
ofthe operation and 25% occur within 72 hours after surgery. Therefore, it is important to
start prophylaxis prior to induction of anesthesia in patients risk of medium to high risk. UFH
(Unfractionated Heparin) can be given before surgery in patients with high risk. Increasing risk of
1842
bleeding during surgery is not much evidence in some of the research that has been done.
Administering heparin for patients with venous thrombosis can length clotting time.9
CASE PRESENTATION
Patient Mrs. RH, age 36 years old enter the PGI Cikini hospital on 27th September 2014 with a
diagnosed of venous thrombosis in lower limb right foot. Patient come with complaints of pain,
swollen right foot. A now, patient has history swollen in the right
leg and pains since
approximately 1 week.
CLINICAL EVALUATION12
In
this
case
the
patient
of infections, Rocer (Omeprazole)
is
treated
for
peptic
with
Biozim (Ceftazidim)
for
the treatment
ulcers or duodenal ulcer, Nonflamin (Tinoridin)
for analgesic and antipyretic, Tromboaspilet (asetilsalisilat acid), Heparin, Simarc (Warfarin) for
blood thinning (prevention of thrombosis), Tramifen (Tramadol) for analgesic and antipyretic,
Neurosanbe and Vitamin B complex for Achy muscles, tingling (nervous disorders), anemia, and
folic acid for anemia and NaCl 0.9% for soaking the feet that swollen.
RESULTS OF LABORATORY
The result of the hematology on 27th September 2014 showed decreasing in values of
hematocrit 36 g/dL (37-43 g/dL), increasing Reticulocyte 18 permil (5-15permil), monocytes 10%
(2-8%) showed the presence of an infection, And increasing in the of value ie APTT 39,0 seconds
(26,4-37.5seconds) indicates the presence of blood clotting factors deficiency.
DOSES AND THREATMENT
Biozim (ceftazidime) injection 1 gr 3 time daily, rocer (Omeprazole) 20 mg 2 time daily, folic acid
0.4 mg once daily, nonflamin (Tinoridin) 50 mg 2 time daily, tramifen (Tramadol) once daily,
tromboaspilet (asetilsalisilat Acid) 80 mg once daily, neurosanbe once daily, vitamin B complex
once daily, 15.000 units of heparin, and simarc (Warfarin) 2 daily and NaCl 0.9 % 2 time daily.
1843
DISCUSSION
Venous thrombosis is caused by the presence of abnormalities in the blood vessel walls, changes
in blood flow and changes of bleeding deep venous thrombosis can occurs in patient of obesity,
infection, imobilization, pregnancy, use of contraceptives, operatif as well as a history of trauma
and increating of age. DVT is a cardiovascular disorder the third number after coronary artery
disease and stroke. Signs and symptoms of DVT include edema, pain and change of colour in
skin.13
In this case, the patient have has complaint with pain swollen right, since approximately 1 week.
Laboratory results showed decreasing in hematocrit value, neutrophils and increasing in
reticulocyte and monocytes, this abnormally value indicated the presence of an infection so
physician are also biozim (ceftazidim) infection as an antibiotic12. Patient has an increasing
APTT value ie 39,0 seconds (26,4-37,5 seconds) and patient was treated with heparin as
anticoagulant and tromboaspilet to prevent the occurrence of blood clotting, nonflamin
(tinoridin) is a nonsteroidal (NSAIDS) which has anti inflammatory and power analgesic and
tramifen (tramadol) is a powerful analgesic that works on receptors opiates that bind to stereo
specific in receptor in the central nervous system so that it stops the pain sensation and response
to pain. Neurosanbe and vitamin B complex are given to relieve muscles pain and tingling
(neuroses). Patient was given folic acid but in laboratory examination there is no showing that
the patient has anemia.
1.
Drug Interaction
Rocer (Omeprazole) and simarc (Warfarin) may increase the effects of simarc (Warfarin),
biozim (ceftazidime) may increase the effect of anticoagulant of simarc (Warfarin), heparin,
and tromboaspilet (asetilsalisilatAcid). Tromboaspilet (asetilsalisilat Acid) and folic acid can
reduce the effects of folic acid. Tramifen (Tramadol) can increase the anticoagulant effects of
simarc (Warfarin), heparin, and tromboaspilet. Tromboaspilet (asetilsalisilat Acid) and heparin
may increase the effects of heparin.
2.
Using of drug without indication
1844
Patient was treated with folic acid for handling the anemia, without support laboratory data.
3.
Patient do not receive appropriate drug dose
On 29 and 30 September 2014 patients received Rocer (Omeprazole) once daily, it should be
given 2 time daily and on September 28, patient received nonflamin (Tinoridin) once daily, it
should be given 3 time daily.
CONCLUSION
Based on the results of the practice of the Clerk's Ward in PGI Cikini hospital it can be concluded
there is drug related problem for this case ie drug interaction, using of drug without indication
and patient do not receive appropriate drug dose.
REFERENCES
1. Ismail . Trombosis Vena Dalam. Journal of the Indonesian Orthopaedic Ass. June 2000; 26 (I) :
23-38.
2. Karmel TL. Buku Ajar Ilmu Penyakit Dalam Jilid II. Edisi IV. Jakarta : Departemen Ilmu Penyakit
Dalam FK UI; 2006: 767-768
3. Karmel Tambunan : Thrombosis. KONAS PHTDI Semarang, September 2001.
4. Brick RL, Kaplan H. Syndrome of thrombosis and hypercoagubility. Medical clinics of North
America 1998 May; 3: 408-447
5. Hirsch J, Hoak J. Management of deep vein thrombosis and pulmonary embolism circulation.
1996; 93: 2212-45
6. Andrews KL, Gamble GL, et al. Vascular Diseases. In: Delisa JA, editor. PhysicalMedicine &
Rehabilitation Pr inciples and Practice, 4th Edition. Phyladelphia: LippincottWilliams & Wilkins;
2005. p. 787-806.
7. Kesteven P. Epidemiology of Venous Tr ombosis. In: Labropoulos N, Stansby G, editors.Venous
and Lymphatic Diseases. New York, NY 1001: Taylor & Francis Group; 2006. p. 143-51.
8. Kamil H, Ihsan, dkk. Data Obat di Indonesia. Edisi 10. Jakarta: Grafidian Medipress; 2002: 959960
1845
9. Morgan MA, Iyengar TD, Napiorkowski BE, Rubin SC, Mikuta JJ. The clinical course of deep vein
thrombosis in patients with gynecologic cancer. Gynecol Oncol 2002 (Jan);84(1):67–71.
10. Burns, A. 2009. Renal Drug Handbook third edition. UK.
11. BNF. 2009. British National Formulary. BMJ Group. UK.
13. Rani AA, Soegondo, Nazir AU et al. Panduan Pelayanan Medik Perhimpunan Dokter Spesialis
Penyakit Dalam Indonesia. Jakarta : Pusat Penerbitan Departemen Ilmu Penyakit Dalam Fakultas
Kedokteran Universitas Indonesia;2006.
1846
CASE REPORT : DRUG RELATED PROBLEMS (DRP) IN OSTEOMYELITIS DISEASE AT
MINTOHARDJO HOSPITAL JAKARTA
Sonandg Nauli1, Aprilita Rinayanti Eff and Diana Laila R2
1
2
Sonandg17.sn@gmail.com
ABSTRACT
Osteomyelitis is an inflammation that occurs in the bone marrow, usually caused by a bacterial or
mycobacterial pyrogenic. Osteomyelitis can be a chronic problem that will affect the quality of
life or result in loss of limb.
1
patient was hospitalized AL Dr. Mintohardjo 2 October 2014 to
conduct Hyperbaric oxygen therapy (HBO). Therapy treatment received while in hospital is
osteocal. From the results of the monitoring of drug therapy found a DRP (Drug Related Problem)
that is the untreated complaint.
Keywords: Drug Related Problem (DRP), Osteomyelitis, Mintohardjo Hospital
1847
INTRODUCTION
Osteomyelitis is an infection of bone marrow in long bones caused by Staphylococcus aureus and
sometimes Haemophylus influensae.2 Osteomyelitis can be classified according to its
pathogenesis direct/exogenous and hematogenous, and according to the course of their illness
as acute, sub-acute, and chronic. Each type is based on the length of time from onset of disease
(infection or injury). Acute osteomyelitis develops between two weeks after the onset of disease,
subacute osteomyelitis between one to several months and chronic osteomyelitis after a few
months. Hematogenous Osteomyelitis is an infection caused by bacteria spread through the
blood. Osteomyelitis direct/exogenously caused by direct contact tissue and bacteria during
trauma and surgery. 3
Hyperbaric oxygen therapy is that the patient must be in a high-pressure chambers and breathe
pure oxygen (100%) the air pressure is greater than normal atmospheric air, that is equal to 1
ATA (atmospheres absolute). High pressure oxygen delivery to therapy performed in the
chamber or KUBT (High Pressure Air Room). 4 HBO therapy can theoretically increase the amount
of oxygen dissolved form such that it would be more readily accepted by the network. HBO usage
will increase vascularization and tissue perfusion, so that will be able to supply the needs of the
injured tissue oxygen. This became the basis that this therapy is used to improve perfusion of the
tissue injuries suffered pifoksia, due to hypoxia in the tissue will cause the length of the wound
healing process. 5
CASE PRESENTATION
Patients Mr. Su, aged 31 years old, was hospitalized at Mintohardjo hospital on 02 October 2014
came with a complaint to perform HBO therapy (Hyperbaric oxygen).
CLINICAL EVALUATION
In the case the patient is treated with osteocal and HBO therapy (Hyperbaric oxygen). Osteocal is
given for overcome calcium deficiency, and if using of osteocal in the long term can lead to
hypercalcemia.6 On examination of the laboratory results obtained value of erythrocyte
sedimentation rate were above the normal neutrofil and normal range indicates that the patient
exposed to infection, abnormal neutrophil, monocytes indicated normal an increase in acute
infections.
1848
DISCUSSION
On the first day Mr. SU in this case the blood pressure 120/80, pulse 80X / min and temperature
of 36
0
c. Drugs given to Mr. SU is osteocal and KUBT therapy. Indications of a given drug is
Osteocal for to overcome calcium deficiency, and using use osteocal in the long term can lead to
hypercalcemia. This condition is characterized by nausea and vomiting, appetite and thirst are
constantly which could adversely affect renal function. High level of calcium in the urine can
cause kidney stones formation.
From the results of the monitoring of drug therapy there is DRP (Drug Related Problems) that is
untreaced complaint. Patients with chronic osteomyelitis infection must be tareated with
antibiotic and analgesic for overcome infection rednec his pain.
PHARMACEUTICAL INTERVENTIONS
Patient must be treated with antibiotic and analgesic.7
CONCLUSION
Based on the result clinical practice in Mintohardjo hospital it can be concludet that there is any
Drug Related Problem (DRP), that is untread complaints and untreated disease.
REFERENCES
1. Brunner and Suddarth. 2001. Medical Surgical Nursing 8th Edition Volume 2. New York: Book
Medical Publishers EGC
2. MOH, 1995 Health Data Center.
3. King R., 2004, Osteomyelitis, Medicine.com, Inc.
4. Mahdi, H et al. (2009). Diving and Hyperbaric Medical Sciences. Surabaya. Lakesla.
5. Guritno. M (2005) A Hyperbaric Oxygen Therapy in the Treatment of Diabetic Foot. The
Indonesian Orthopaedic Association. 50 th Continuing Orthopaedic Association, Mataram, March
4-5 2005.
6. APHA. 2008-2009. Drug Information Handbook 17 th Edition. USA. Lexi-Comp
7. Carek PJ, Dickerson LM, and Sack JL, 2001, Diagnosis and Management of Osteomyelitis,
American Academy of Family Physicians.
1849
CASE REPORT : DRUG RELATED PROBLEMS (DRPs)
ASSOCIATED HYPERTENSION DISEASE AT MINTOHARDJO
HOSPITAL JAKARTA
Winda1, Aprilita Rinayanti Eff and Diana Laila R2
1
2
ABSTRACT
Vertigo is the sensation of movement or sense of motion of the body or the surrounding
environment, can be accompanied by other symptoms, mainly due to the disruption of
autonomic networking tool body balance. Hypertension is the increased blood pressure, diastolic
blood pressure above 90 mmHg settle, or systolic pressure above 140 mmHg settled. Patient Mr.
H was admitted to hospital on 3 October 2014 with a diagnosis of vertigo and hypertension.
Therapy treatment for hospitalized ie RL 20 MDGs infusion, injection onandsetron, ranitidine
injection, Betahistine tab, dramamine tabs, tab captopril, sucralfate syrup, mefenamic acid tabs,
tab amlodipine and valsartan tab. Based on the monitoring of drug therapy in the treatment
room Noemfoor island in RS AL Dr. Mintohardjo we can concluded the existence of DRP (Drug
Related Problems) in the form of improper drug selection and drug interaction.
Keywords: Drug Related Problems (DRPs), Vertigo, Hypertension, and Mintohardjo Houspital
1850
INTRODUCTION
Vertigo is the sensation of movement or sense of motion of the body or the surrounding
environment, can be accompanied by other symptoms, mainly due to the disruption of
autonomic networking tool body balance. Vertigo is a condition in which a person feels dizzy with
spinning or rotating environment even though the body feels the person is not moving. Vertigo is
not the case due to hereditary factors, but there are several factors that cause vertigo as a
migraine attack, inflammation of the neck, motion sickness, bacterial infections of the ear and
lack of oxygen to the brain.1
Hypertension is the increased blood pressure, diastolic blood pressure above 90 mmHg settle, or
systolic pressure above 140 mmHg settled.2 hypertension due to increased peripheral vascular
smooth muscle tone, which causes an increase in resistance arterioles and reducing capacity of
the venous blood vessel system. Hypertension may occur as a result of another disease process,
more than 90% of patients suffering from essential hypertension, a disease in blood pressure
regulation of unknown cause. Environmental factors such as life stress, high-sodium diet, obesity
and smoking are factors predisposing to hypertension.3
CASE PRESENTATION
Patient Mr. H age of 25 years old entered RS AL Dr. Mintohardjo on 3 October 2014 with
complaints of dizziness spinning 2 days before entering the hospital, was diagnosed with vertigo
and hypertension. History now dizzy spins initially perceived exertion accompanied buzzing in the
ears and past medical history of hypertension.
CLINICAL EVALUATION
In these cases the patient was treated with an infusion of RL given to regulate the balance of
electrolytes in the body fluids, injection onandsetron to treat nausea and vomiting, ranitidine
injection as a treatment for mild stomach ulcers, Betahistine is indicated for the treatment of
vertigo, dizziness and balance disorders that occur in blood circulation disorders or Meniere's
syndrome, dramamine indicated for nausea, vomiting, vertigo, motion sickness, labyrinth
disorders, captopril is indicated to treat hypertension in patients, sucralfate syrup is indicated for
gastric ulcer, mefenamic acid for pain on the patient's complaints, Amlodipine is indicated for
1851
hypertension, angina prophylaxis, valsartan is indicated for the treatment of hypertension, heart
failure therapy in patients on ACE inhibitors intolerans, post myocardial infarction.
LABORATORY DATA
Type examination of
The Results
Unit
Normal Value
Leukocytes
13,200 *
/ UL
5000-10000
Erythrocyte
5:37
Million / mL
4.6-6.2
Hemoglobin (Hb)
16.3
g / dL
15.2-17.5
Hematocrit (Ht)
45
%
44-72
243,000
g / dL
150000-400000
87
mg / dL
70-110
179 *
mg / dL
60-170
Total cholesterol
165
mg / dL
114-203
HDL
27 *
mg / dL
> 40
LDL
102
mg / dL
<130
SGOT
17
U/L
<109
SGPT
39
U/L
<31
20
mg / dL
<42
1.1 *
mg / Dl
0-0.9
Hematology
Routine blood
Platelets
Clinical Chemistry
Blood Glucose
Fasting Blood Glucose
Fat
Triglycerides
Liver Function
Kidney Function
Urea
Triglyceridese
DISCUSSION
This case the patient hospitalized for the second time on 3 October 2014 with complaints of
dizziness spinning 2 days before entering the hospital, was diagnosed with vertigo and
1852
hypertension. At the time of admission, patient use treated with infusion of RL 20 MDGs to
regulate fluid balance of electrolytes in the body, and injection of 1 ampoule 20 onandsetron
MDGs to treat nausea and vomiting. One day later the patient is given an injection drug
ranitidine 2 times 1 ampoule as therapy for peptic ulcers, Betahistine 2 times 1 tablet indicated
for the treatment of vertigo, dizziness and balance disorders that occur in disorders of the
circulatory or Meniere's syndrome, dramamine 1 tablet 3 times indicated to nausea, vomiting,
vertigo, motion sickness, labyrinth disorders, captopril 2 ½ times for antihypertensive tablets, 3
times a day sucralfate 15ml syrup is indicated for gastric ulcer, mefenamic acid 500 mg 3 times to
cope with complaints of pain in patients. Treatment is continued until two days later
discontinued. Until the third day patient still treated with the same drug but captopril
administration discontinued and the patient was given a one time additional amlodipine 10 mg is
indicated for hypertension, angina prophylaxis, valsartan 1 times 10 mg is indicated for the
treatment of hypertension, heart failure therapy in patients on ACE intolerans inhibitors, postmyocardial infarction. Four days after admission the patient was discharged, with a take-home
medication is the same as when the third day of treatment but without sucralfate syrup.
On examination of the results of laboratory values above the upper limit of normal
leukocytes showed patients exposed to infection, triglycerides above the normal limit of the
patients showed hipertrigliseridemia, triglyceridese value exceeds the normal range indicates the
patient's renal function decline it is necessary for the identification of drug-related problems
(Drug Related Problems).
1.
Improper drug selection
In these case the patient suffered hypertension stage 2 but patient is treated with captopril only,
while from literature hypertension stage 2 must be treated whit combination therapy
2.
Drug interactions
Mefenamic acid and captopril when used together can decrease the effectiveness of captopril,
in lowering blood pressure.
Mefenamic acid and amlodipine when used together can decrease the effectiveness of
amlodipine, in lowering blood pressure.
1853
CONCLUSION
Based on the monitoring using of drug at Mintohardjo Hospital it can be concluded that
there is found. Drug Related Problem that is improper drug selection and drug intraction.
REFERENCES
1. Joesoef AA. Overview of vertigo. In: in Joesoef AA, Kusumastuti K (eds). Clinical Neurootologi:
vertigo. The study group vertigo Perdossi, 2002. 13-28.
2. Joint National Committee on prevention, evaluation and treatment of 2003. The high blood
pressure
3. Mycek, MJ (2001). Pharmacological Reviews Illustrated. Editor Huriawati
Hartanto. Second Edition. Jakarta: Widya Medical. Hal: 181-193.
4. Baxter, K. (ed). 2008. Stockley's Drug Interaction, Eight Edition. Pharmaceutical Press, London
and Chicago.
1854
CASE STUDY : DRUG RELATED PROBLEMS (DRP) IN ANGINA
PECTORIS DISEASE AT MINTOHARDJO HOSPITAL
Kusrina Sand1, Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
Email: Rin08sandjai@gmail.com
ABSTRACT
Angina Pectoris is a disease characterized by chest pain caused by coronary blood flow that not
sufficient to fulfiil oxygen demand in miocard1. Patient Mr WJ, age 72 years old came to
Mintohardjo Hospital with complaints of chest pain, cold sweat, nausea vomiting and
intermittent chest pains . The Patient had a history of hypertension and smoking. During patient
hospitalized, patient was given Clopidogrel, Enoxaparin, Cardioaspirin, Simvastatin, ISDN,
Diazepam, Laxadine syrup, Omeprazole, Sucralfate syrup, Concor, and Alloupurinol. From the
results of the monitoring of drug use it can be concluded there is found Drug Related Problems,
that are using drug without indication, adverse drug reactions, and drug interaction between
omeprazole with clopidogrel, enoxaparin with clopidogrel, enoxaparin with cardioaspirin,
cardioaspirin with clopidogrel, cardioaspirin with concor, and omeprazole with diazepam.
Keywords: Drug Related Problems (DRP), Angina Pectoris, Mintohardjo Hospital
1855
INTRODUCTION
Acute coronary syndrome (ACS) is one of the manifestation of coronary artery abnormalities still
a major health problem in the world. According to statistics of American Heart Association (AHA)
2008, in 2005 the number of patients who underwent medical treatment in the United States
due to the ACS nearly 1.5 million people to 1.1 million people (80%) showed a case of Angina
Pectoris Unstable or infarcation Myocardial Without ST Elevation (NSTEMI), while 20% of the
cases recorded suffer an Infarcation Myocardial with Elevation (STEMI)2.
Angina pectoris is a disease characterized by chest pain caused by coronary blood flow that not
sufficient to ful fiil oxygen demand in miocard. Imbalance between oxygen supply and its use can
result vascular smooth muscle spasme or obstruction of the blood vessels due to the lesions of
atherosclerosis1.
Treatment individuals with angina pectoris adjusted with the ultimate goal of therapy and
symptoms. Currently, treatment of angina pectoris reguler use of therapies that include uses
drugs known as nitrates, β-blockers, calcium antagonists and antiplatelet such as aspirin.
CASE PRESENTATION
Patient Mr WJ, age 72 years old, went to the Mintorahdjo hospital on
October 2, 2014.
The patient was admitted to the hospital with complaint of palpitations. Patient said on
september 10, 2014 he felt chest pain, cold sweats, nausea, vomiting, palpitations, chest pain
intermittent, the patient have a history of Hypertension and history of smoking. Patiet was
treatment with Enoxaparin, Clopidogrel, Cardioaspirin, Simvastatin, ISDN, Diazepam, Laxadine
syrup, Omeprazole, Sucralfat syrup, Concor and Allopurinol.
DOSAGE AND HOW TO USE THE DRUGS
Enoxaparin given for 3 day at the dose 2x0,6 ml, Clopidogrel 75 mg p.c once daily, Cardioaspirin
p. c once daily, Simvastatin 20 mg once daily, ISDN 5 mg three time daily, Diazepam 5 mg three
1856
time daily, Loxadien sirup once daily, Omeprazole injection twice daily, Sucralfat a.c three time
daily, Concor 2.5 mg once daily and Allopurinol 100 mg twice daily3,4 .
LABORATORY RESULTS
The results of laboratory tests showed that abnormality laboratory values in Erythrocytes 4,39
million/µL (normal value: 4.6-6.2 million/µL), Hemoglobin 12.5 q/dL (14-16 q/dL), CK 110,000
UI/L (normal value: 30 – 180 Μl/L , K-MB 14 U/L (normal value: > 10 U/L), LDL 175 Mg/dL (< 130
mg/dL)5.
DISCUSSION
Mr WJ came to the hospital with complaints of chest pain, cold sweats, nausea vomiting, chest
pain intermittent. Results of Laboratory examination show that abnormality in erythrocytes 4,39
million/µL (normal value: 4.6-6.2 million/µL), Hemoglobin 12.5 q/dL (14-16 q/dL), CK 110,000
UI/L (normal value: 30 – 180 Μl/L , K-MB 14 U/L (normal value: > 10 U/L), LDL 175 Mg/dL (< 130
mg/dL) and a negative value of Troponin. This is indicate that patient experience angina pectoris.
In this case Mr WJ has 72 years old and he receive 11 item of drug. Using of polipharmacy drug
can cause Drug Related Problem and Adverse Drug Reactions (ADR).
For handled the patient complaint, physician gave ISDN (Isosorbid dinitrate) for the treatment of
angina. ISDN is calcium channel blocker and calcium channel Activator (potassium-channel
activators) that has a vasodilatory effect.
In heart failure, vasodilators dilate arteries and
decrease peripheral vascular resistance and left ventricular systolic pressure resulting in
increasing cardiac output, or dilated veins that lead to increased venous capacity and reduced
venous return to the heart (ventricular diastolic pressure decreases). Enoxaparin injection for
blood thinners. Anticoagulant is given in NSTEMI conditim to inhibit the formation and activation
of Thrombin. Selection of anticoagulation need to consider the risk of ischemia and bleeding6.
Giving as cardioasprin and clopidogrel as antiplatelet for reduce the risk of infarction and heart
attack. Aspirin and Clopidrogel (CPG) are used for diseases of the heart and blood vessel in
coronary heart disease. Aspirin and CPG prevents platelet to form clot (clots) that causes
blockage of blood vessels. CPG is sometimes also used in atrial fibrillation with irregular heart
1857
rhythm. Gastrointestinal bleeding often occurs in the administration of cardiovascular drugs,
especially on antithrombotic drugs. Aspirin as COX-1 inhibitors, where as Clopidogrel and
ticlopidine has a different mechanism with aspirin. Clopidogrel metabolized by CYP450 enzymes
to produce the active metabolite. This active metabolite through irreversible bond through the
ADP receptors P2Y12 class of platelet glycoprotein GPIIb then activate/IIIa platelet aggregation
inhibiting complex. Using of Enoxaparin, Clopidogrel, and Cardioaspirin at the same time should
need to be done in order to know the INR examination of factors on blood thinners and
bookkeeping feared would happen on bleeding the same drug use. Omeprazole injection was
given for handly side effect of Cardioaspirin. Sucralfat can cause constipation so that the patient
receive Laxadine. Patient also treated ulcers but the side effect is constipation, that he is so given
laxadine for overcome the constipation. Also treated with ISDN and Concor (Bisoprolol) for
angina and hypertension. Allopurinol and Simvastatin was given for treating gout and
hypercholesterolemia. Diazepam as tranquiliaer 6.
1.
Drugs without Indication
In this case patient receive Allupurinol to treat hyperuricemia but laboratory show that patient
have normal value uric acid
2.
Adverse drug reactions6
In this case patient receive Enoxaparin, Clopidogrel and Cardioaspirin. The using of these drugs
can increase risk of bleeding and can peptic ulcer moreovere if given in patient with have history
of peptic ulcer.
3.
Drug interactions7
a.
Omeprazole with clopidogrel, where omeprazole may decrease effect of clopidogrel to
affect hepatic enzymes CYP2C19.
b.
Clopidogrel with Enoxaparin increase the risk of bleeding
c.
Cardioaspirin with Enoxaparin, where Enoxaarin may increase the effect cardioaspirin
and increase risk of bleeding
1858
d.
Cardioaspirin with clopidogrel may increase the risk of bleeding when given concurrently
with clopidogrel.
e.
Cardioaspirin and concor (Bisoprolol), cardioaspirin can reduce the effects of bisoprolol.
f.
Omeprazole and Diazepam, omeprazole may increase the effect of diazepam
CONCLUSION
Based on the results of clinical work practice at Mintohardjo Hospital it can be concluded that
the presence of the DRP (Drug Related Problem), that are form of using of drug without
indication, adverse drug reaction, and drug interaction.
REFERENCES
1. Sutedjo, AY. 2007. Buku Saku Mengenai Penyakit Melalui Hasil Pemeriksaan
Laboratorium. Yogyakarta : Amara Books
2. Undas, Anetta, Ilena. 2008. Hiperglicemia is Associated with Enhanced Thrombin Formation,
Platelet Activation and Fibrin Clot Resistance to Lysis in Patient is with Acute Coronary Sydrome
3. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung
Seto.
4. British National Formularium 52th Edition.2008. Lambeth High Street. London
SEI 7JN.UK.
5. Mycek,J Mary. 2001. Farmakologi Ulasan Bergambar , Edisi 2. Widya Medika.
Jakarta
6. Anonim. 2013. InHealth Gazette. Devisis Pelayanan obat
7. Medscape. Drug Interaction.2014
1859
CASE REPORT : DRUG RELATED PROBLEMS IN PATIENT
WITH BENIGN PROSTATIC HYPERPLASIA DISEASE AT DR.
Listia Alvira1, Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
Email : Listiaalvira@yahoo.com
ABSTRACT
Prostate hyperplasia or Benign Prostatic Hyperplasia (BPH) is the enlargement of the prostate
caused by excessive growth of epithelial tissue and fibromusculer of transition zone and
periurethral areas. Patient Mr PN, age 76 years old came to Mintohardjo hospital with complaint
can not micturition on 26/11/2014. The patient did not have a history of hypertension and did
not smoker. Patient was treated Vitamin K, Adona, Ceftriaxon, Vitamin C, Ketorolac, Kalnex,
Omeprazole by injection. Results of the monitoring of the use of medications we found DRP
(Drug Related Problem). That are untreated disease and drug interaction.
Keywords: Drug Related Problem, Benign Prostac Hyperplasia, Mintohardjo Hospital
1860
INTRODUCTION
Prostate hyperplasia or Benign Prostatic Hyperplasia (BPH) is the enlargement of the prostate
caused by excessive growth of epithelial tissue and fibromusculer of transition zone and
periurethral areas 1.
BPH or benign tumors of the prostate due to prostate cells that continue to experience growth.
Microscopic basis, changes in the prostate can be seen as someone aged 35 years. At the age of
60-69 years, enlarged prostate cause clinical complaint start at 50% of men. While at the age of
80 years, BPH occurs in nearly 100% of men. In 2000, the WHO noted there are about half a
million people who have experienced BPH worldwide 2.
BPH occurs at the age above 45 years in which testicular function suandg declined. Due to the
decrease in testicular function led to an imbalance of hormones testosterone and
dehidrotestosteron so as to spur growth/enlarged prostate. By maskrokospik can reach 60-100
grams and sometimes even greater to 200 gram or more 1.
Treatment of prostatic hyperplasia sufferer individuals adapted to the end goal of therapy and
symptoms. Currently, a regular prostate hyperplasia treatment using therapeutic observation,
therapeutic drug classes which include the medikamentosa inhibitor of α-adrenergic, an inhibitor
of the enzyme 5-alpha-reductase, fitotherapy, and surgical therapies such as Transurethral
resection of the Prostate (TURP), Transurethral Insision of the Prostate (TUIP) open
prostatectomy, and laser Prostatectomy with Nd-YAG, or Ho-YAG 3.
CASE PRESENTATION
Patient Mr PN, aged 76 years old, came Mintohardjo hospital On October 26, 2014. Patient
entered hospital with complaint could not micturition. Patient has underwent surgery with
Transurethral resection surgery methods of the Prostate (TURP) on October 26, 2014. Patient
was treated with Vitamin K injection, Adona injection, Ceftriaxon injection, Vitamin C injection,
Ketorolac injection, Kalnex injection, Omeprazole injection.
DOSAGE AND MODE OF USE
1861
Vitamin K injection 2 mg bid, Adona injection 2 ml/10 mg, Ceftriaxon bolus IV injection 1 g/day in
bolus, Vitamin C injection 1000 mg/day, Ketorolac injection 10-30 mg every 4-6 hours, Kalnex
injection 0.5-1 g 3 times a day, Omeprazole injection 40 mg/day 4,5.
LABORATORY EXAMINATION
Laboratory examination results (urine routine) indicates abnormal laboratory value of Leukocyte
esterase: 500/L (normal values: negative), Nitrite positive (normal values: negative), Albumin 25
(normal values: negative), Sediment microscopic Erythrocytes 20–25/LPB (normal values: 0 –
2/LPB), Sediment microscopic Leukocytes 8–10/LPB (normal values: 0 – 5/LPB), urine Bacteria ++
(value: normal negative) 6.
DISCUSSION
Patient Mr PN was hospitalised with complaint could not micturition. The laboratory examination
showed patient had abnormal Leukocyte esterase, Nitrite positive, the presence of Albumin,
sediment, Erythrocytes and Leukocytes that are suspected that the of having hemauria and
leukosituria, and urine turbidity examination show urine contained bacteria. From the results of
laboratory examination and patient complaint doctors was diagnosed patient experienced BPH
and perform sursery6.
After performing the operation, the patient treated the during 5 days. On the first day he is given
Ketorolac injections because the patient complained of pain in the wound of the former
operations, and also given Vitamin K injection, Kalnex injection, Adona injection as prophylaxis
to prevent the occurrence of post-operative bleeding 5.
On the second day of treatment, the patient gets an injection of ceftriaxon as antibiotics to
prevent the occurrence of infections, injections of Vitamin C is indicated to speed healing of
wounds on the former surgery, injection of Omeprazole to cope with the irritation in the
stomach as a result of the use of ketorolac that side effects can irritate the gastric side effects 5,7.
Then the next day the patient only receive ketorolac injection because the patient complain is
pain only and patient get ketorolac for bring to home5.
1862
1. Untreated complaint5.
In this case the patient has enlarged prostate but patient do not receive drug therapies such as
the inhibitor α-adrenergic.
2. Drug Interaction8.
The existence of drug interactions between ketorolac and Vitamin K, which Ketorolac can
decrease the effects of vitamin K.
CONCLUSION
Based on the results of the practice of the Clerk's clinic on of Mintohardjo hospital, it can be
concluded the that the existence of the DRP (Drug Related Problem) in the form of drug
interaction between Ketorolac and Vitamin K, and patients do not receive drug therapy for BPH
drug i.e. the inhibitor α-adrenergic.
REFERENCES
1. Surjadi K, dkk. 2006. Pola Distribusi Imunoekspresi P63 pada Hiperplasia
Prostat sebagai Indikator Keganasan. Fakultas Kedokteran. Universitas Kristen Maranatha
2. Anindyajati, Gina . National Institute of Diabetes and Digestive and Kidney
Disease
3. Sutedjo, AY. 2007. Buku Saku Mengenai Penyakit Melalui Hasil
Pemeriksaan Laboratorium. Yogyakarta : Amara Books. Hal : 157
4. Medscape. Drug Interaction.2014.
5. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta :
Sagung Seto. Hal : 381, 57
6. Arif, Mansjoer dkk.2000. Kapita Selekta kedokteran. Media Aesculapius.
Jakarta. Hal : 333
7. Gan gunawan, sulistia. 2007. Farmakologi and Terapi. Departemen
Farmakologi and Terapeutik. Fakultas Kedokteran Universitas indonesia. Jakarta. Hal : 777
8. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford. Hal : 576
1863
CASE REPORT: DRUG RELATED PROBLEM ON THERAPY
THE DISEASE TUBERCULOSIS (TB) AND HEMAPTUE
CATEGORY I ON THE WARD SANGEANG DISEASE IN
Syahrianti. S1, Aprilita RinaYanti Eff2 and Diana Laila R2
Lecturer of Faculty of Pharmacy UTA'45 Jakarta
Email: syahrianti88@gmail.com
ABSTRACT
Tuberculosis is an infectious disease caused by Mycobacterium tubercolosis, most (80%) invade
the lungs. Mycobacterium tubercolosis is Gram-positive bacilli, shaped rod on the wall of his cell
contains a complex of glikolipida as well as candle-lipida (wax) which is difficult to break down
substances chemistry1. Patient Mr. AJ, age 29 years old, came to mintoharjo hospital with a
diagnosis of tuberculosis (TB)first category the advanced stages. Patient was given treatment for
6 days that were, Ceftriaxon injection, Kalnex injection, Ranitidine injection, Adona injection,
vitamin K injection, Acran (Ranitidine tablets), Codein, Paracetamol, 4FDC tuberculosis drugs,
Sanfuliq (Curcuma). Based on the results of the clinical practices it can be conclnedthe existence
of the DRP (Drug Related Problem) that and drug interactions: between INH and Paracetamol,
patient has nousea and vomiting are not treated the patients complained of nausea as well but
he not recewe tretment. Clinical work in Mintoharjo Hospital it can be concluded that there is
any that are treated complain, drug duplication and drug interaction.
Key words: Drug related problems (DRP), Tuberculosis (TB), and the Mintohardjo Hospital
1864
INTRODUCTION
Tuberculosis is a disease of the lower respiratory tract infection that invades the tissues of the
lung or pulmonary parenkim tuberculosis Mycobakterium by basil, can be about almost all
organs (kidney, meninges, bones and lymph nodes) and the most diparu location, usually a
primary location2.
Clinical symptoms are cough, cough two weeks of blood, shortness of breath, chest pain, fever
and others3.Tuberculosis (TB) is a disease that has long been known and to date is still the
leading cause of death in the world. The prevalence of TB in Indonesia and other developing
countries is quite high.In 2006, new cases in Indonesia totaled > 600,000 and mostly suffered by
people who are in the productive age (15-55 years). The death toll due to infectious TB
amounted to about 300 people per day and happens > 100,000 deaths per year. It is challenges
for all parties to leading this infection. One of the important efforts to suppress the transmission
of TB in the community is to do a definitive early diagnosis4.
Home environment sanitation factors, the incidence of pulmonary TB disease is also very
concerned with the behavior and the amount of family income because most patients with TB is
a poor level that have low education4. Examination of sputum specimens of lung TB is examined
within two days of that during the morning-during (SPS). Based on the guidelines of the national
TB program, the diagnosis of pulmonary TB in adults is enforced with TB germs he met (BTA) 5,
while examining a photo of thoracic, culture and sensitivity test can be used as a support in
diagnosis in accorandce with the indications and not justified in diagnosing TB2.
PERCENTAGE OF THE KHASUS
Patient Mr. AJ, age 29 years entered Mintohardjo hospital on November 13, 2014. The Patient
complaints of cough blood, pain body, dizziness, lethargy, nausea, fever, no appetite and weight
loss. Patients recently exposed to tuberculosis during his life.
EXAMINATION OF VITAL SIGN
Date Of
Blood Pressure
Pulse
Breathing (14-
Temperature
Examination
(120/80 mmHg)
(60-100x/minute)
18/minute)
(36 -37 ⁰
13/11/2014
90/70 mmHg
80 x / minute
16 x / minute
37 ⁰
1865
14/11/2014
90/70 mmHg
86 x / minute
17 x / minute
39,5 ⁰
15/11/2014
95/70 mmHg
86 x / minute
16 x / minute
38,5⁰
16/11/2014
90/80 mmHg
86 x / minute
18x / minute
38,5 ⁰
17/11/2014
100/70 mmHg
86 x / minute
17 x / minute
38⁰
18/11/2014
90/80 mmHg
89x / minute
16 x / minute
37⁰
CLINIC EVALUATION6
Patient is treated with 4FDC (INH, Rifampin, Ethambutol, Pirazinamid). Infusion RL as the
electrolyte. Ceftriaxon injection as an antibiotic, to treat some bacterial infections. Codein is
given as antitussive and middle pain medicine, Sanfuliq (Curcuma) is given as a supplement to
maintain liver function, Ranitidine is given for dyspepsia, while the drug for bleeding is Adona,
Kalnex injection, injection of vitamin K and also given Paracetamol for fevers and chills.
LINE TREATMENT For TBC6
Category 1
OAT-FDC tablets
4FDC
Composition/Content
Usage
75 mg INH
Intensive stage/initial and daily
150 mg Rifampisin
inserts
400 mg Pirazinamid
275 mg Etambutol
2FDC
150 mg INH
150 mg Rifampisin
Weight
38-54 kg
INTENSIVE PHASE (every day for
The ADVANCED STAGES (3
2 months)
times seinggu for 4 months)
3 tablets 4FDC
3 tablets 2FDC
1866
THE RESULTS OF LABORATORY EXAMINATION7,9
Laboratory examination on november 13, showed the increased levels of leokosit i.e. 17,500/ul
(5,000-10,000/µl) indicated infection process or accute inflamation, haemoglobin decreased 8.2
g/dl (12-14 g/dl) indicates anemia and blood sediment at a rate of 80 mm/h (10 mm/hour)
indicates the presence of acute infections local.
DOSAGE AND METHOD OF USE6,8,10,12
In this case, patient is treated with infusion of RL as alternate the body fluids with dose 20 drop
each second for 6 days. Ceftriaxon injection as an antibiotic, to treated some bacterial infections
with a dose of 2x1 by Injection for 6 days. Vitamin K inj, Kalnex inj and Adona inj 2x1 ampules for
5 days. 4FDC 1x3 used for tuberculosis therapy. Sanfuliq (Curcuma) is given as a supplement to
maintain liver function with a dose of 2x1. Ranitidine 2x1 injection ampules and Acran (Ranitidine
tablets) 2x1 for 4 days is given as a cure dyspepsia. Codein 3x1 is given as an antitussive and
antinyeri 1x500mg, paracetamol as antipiretic for 6 days.
DISCUSSION
The main symptom of pulmonary TB is cough for more than 4 weeks, with or without sputum,
malaise, flu symptoms, a low degree of fever, anorexia, sweating at night, chest pain, coughing
up blood and anemia12.
Before the patient was to hospitalised he experienced coughing with blood by as much as 15
times and nosebleed in the evening after coming home to work, the patient come to hospital on
July 13, 2014 in sebtember with complaints of cough blood, body pain, dizziness, lethargy,
nausea, fever, no appetite and weight loss. Laboratory results showed an increase in the value of
leukocytes and blood that indicates deposition rate of infection so that it diterapi with injection
of the antibiotic is Ceftriaxon cephalosporins third generation. Ceftriaxon is a broad spectrum
antibacterial indicated for severe infection. Patients experience a decline in the value of
erythrocytes and hemoglobin indicating anemia, but is not addressed. Codein is given to relieve
coughs and pains-pain, paracetamol is used to lower her fever. TB therapy patients given the
4FDC category 1 Tuberculosis drugs (Isoniasid, Rifampin, Ethambutol and Pirasenamid) therapy
due to the use of Rifampin, Ethambutol, and INH in a long period of time resulted in liver damage
(anti-hepatotoxic) so patients diterapi with sanfuliq (curcuma) to maintain liver function.
1867
DRUG RELATED PROBLEM6,7,8,9,11,12
1. untreated Complains
a. Patient complaint of nausea, because side effect of INH but he dont receive B6 for overcome
his anemia.
b. laboratory results showed a decrease the value of erythrocytes and hemoglobin that indicated
anaemia but doctor do not give treatment for over come anaemia. Should be given blood
Enhancer supplements.
2. Drug duplication that is ranitidine injection and Acran (Ranitidin) tablet.
3. drug interactions
a. Isoniazid with Paracetamol
isoniasid will increase the effects of paracetamol that increased the anti-hepatotoxic if given
concurrently during the week when isoniasid dose 300 mg/day and paracetamol 500 mg/day
b. Isoniazid with food
Absorption of isoniazid will be reduced if taken with fish specis scombroid, tuna, mackerel,
salmon are not fresh.
CONCLUSION
Based on the results of Clinical work in Mintoharjo Hospital it can be concluded that there is any
that are treated complain, drug duplication and drug interaction.
REFERENCES
1. Depkes, 2005. Pharmaceutical care untuk penyakit tuberkulosis. Dirjen Bina Kefarmasian and
Alat Kesehatan. Jakarta. Halaman 12
2. Somantri, irman. 2007. Keperawatan Medikal Bedah Asuhan Keperawatan pada Pasien
dengan Gangguan Sistem Pernapasan . Salemba Medika: Jakarta. Halaman 59
3. Herryanto, 2004, Riwayat pengobatan penderita TB paru Jurnal Kesehatan vol 3, Bandung.
EGC. Halaman 88
1868
5. Leli,samtawati.dkk. 2012. Evaluasi Metode Fastplaquetbtm untuk Mendeteksi Mycobacterium
Tuberculosis pada Sputum di Beberapa Unit Pelayanan Kesehatan di jakarta-indonesia. The
Indonesian Association Againts Tuberculosis. Jakarta. Halaman 101
6. Sutedjo, AY, SKM. 2007. Mengenal Penyakit Melalui Hasil Pemeriksaan Laboratorium (Ed
Refisi). Yokyakarta: Amara Books (halaman 25 and 28)
7. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Sagung Seto : Jakarta.
8. KEMENKES RI, 2011. Pedoman Interpretasi Data Klinik . Kemenkes RI : Jakarta halaman 80
9. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford 142
10. Tarro, S David. 2006. Drug Interaction Facts. Facth & Comparisons. The primary sourse for
drug information 1169
11. Galileopharma. 2008, BNF edition 56, Alexandria University. Halaman 297
12. ISFI, 2009. “ISO Indonesia Vol. 44”. Berlico Mulia Farma. Yogyakarta halaman163
1869
CASE REPORT : DRUG RELATED PROBLEM IN PATIENT
WITH SPONDYLODISCITIS DISEASE AT PGI CIKINI
HOSPITAL
Dorence Thedora Marcus1, Aprilita Rinayanti Eff 2, Diana Laila2
1
Student of pharmacy Program, faculty of pharmacy UTA’45 Jakarta
2
Lecture pharmacy of pharmacy UTA’45 Jakarta
(University of 17 August 1945 Jakarta)
Email: Marcus_novia@yahoo.co.id
ABSTRACT
Spondylodiscitis is an infection in the discus and vertebrae adjacent due to the piogen infection,
Piogen infection is a condition in which the pathogenic organisms multiply and spread between
the tissues. This situation usually bring on reactions both of acute and chronic inflammation.
Patient Mrs Ys, aged of 40 years old entered in Cikini Hospital on September 30 2014 with a
diagnosis Spondylodyscitis. Therapy patient was treated for 9 days with is Farpain (ketorolak),
Lyrica (Pregabalin), Pirofel (Piroxicam), Myonep (Eperisone HCL), Medrol (Methylprednisoline),
Lanfix (Cefixime), Pantazol (Pantoprazol), Dulcolax (Bisacodyl). Based on the results of clinical
work practice Cikini Hospital it can be concluded that there is DRP (Drug Related Problem) be
drug interaction.
Keywords : Drug Releted Problems. Spondylodiscitis, PGI Cikini Hospital
1870
INTRODUCTION
Spondylodiscitis is an infection of the diskus and vertebrae adjacent to discus the caused by
piogen, piogen infection is a condition in which the pathogenic organisms multiply and spread
between the body tissues. Spondylodiscitis happen because there are viral or bacterial infection.
Swelling and inflammation on the spondylodiscitis can cause back pain 1.
Symptoms of this infection is not specific, including fever, local pain and neurological signs when
abnormalities structure form which exposed getting worse. looks normal in the early stages show
vertebral endplate are looks blurred and reduced discus height which lasted rapid. MRA is the
supporting investigation the recommended because it can detect edema in trabecular bone very
early before happen the destruction 2.
CASE PRESENTATION
Patient Mrs Ys, aged 40 years old entered Cikini Hospital on September
30 2014 with a diagnosis Spondylodyscitis. Patient had complain is low back pain for 7 years,
have history of peptic ulcer.
CLINICAL EVALUATION
This patient is treated with Farpain (ketorolak) for short-term treatment for moderate to severe
acute pain. Lyrica (Pregabalin) for the treatment of peripheral neuropathic pain. Pirofel
(Piroxicam) for the symptomatic treatment of (pain) in rheumatoid arthritis. Myonep (Eperisone
HCL) for the treatment of low back pain by treating musculoskeletal stiffness or muscle stiffness.
Medrol (Methylprednisoline) for the treatment of inflammatory and allergic disorders. Lanfix
(Cefixime) as an antibiotics.
Pantazol (pantoprazole) as an blocker reduce gastric acid and Dulcolax (Bisacodyl) as constipation
agent3.
DOSAGE AND HOW TO USE OF DRUG
Ketorolac tablet 10 mg given 2 x 1 day, pregabalin capsule 50 mg given 2 x 1 day,
piroxicam tablet 10 mg given 2 x 1 day, Eperisone HCL tablet 50 mg 2 x 1 day, Methylprednisoline
tablet 4 mg 2 x 1 day, cefixime capsule 200 mg 2 x 1 day, pantoprazole tablet 20 mg 2 x 1 day and
10 mg bisacodyl suppository 1 x 1 day 4.
1871
Results of hematological examination on the first day of October 2014 patient
Hospitalized showed increasing of erythrocyte sedimentation rate (12 of the normal values of 010 mm / h) that indicate the pasient experienced infection or inflammation disease, increasing
eosinophils (5 of normal values 1-3%) indicate a parasitic infection, decreasing of lymphocytes
(15% of normal values 20-4-) indicate a bacterial infection, increasing leukocytes (7 of normal
values 0-3) indicate patient of infection and bone marrow disorders and erythrocyte increasing
indicate that experienced and severe inflammation.
DISCUSSION
Patient Mrs Ys, aged of 40 years old entered Hospital with The main
complaints of back pain, fatigue and anxiety The patient has a history of back pain for 7 years, On
the first day the patient is given Lanfix for bacterial infections, Farpain inflammation drug for
moderate acute pain, Myonep for treatment musculoskeletal spasm, Pantazol for the reduction
of gastric acid secretion because patient has history of peptic ulcer for treatment of pain due to
Spodylodiscitis. The patient on the second day, the patient underwent laboratory examination is
hematology, clinical chemistry, urine ,parasitology and CT Scan. Patient had blood pressure
110/90 mmhg and result of CT Scan indicated that patient suggested for MRI examination.
MRI test results showed the patient infection of the lower lumbar spine and
emphasis on lumbar spine so that the patient had complaint of pain. Lyrica drug to cope
neuropathic, Medrol suppression of inflammatory and allergic . for over come the pain, patient
is treat with lyrica and medrol and Dulcolax supp for constipation. Furthermore from the thorax /
lung and lumbosacral photo, see that the patient experienced joint inflammation in the patient's
spine.
1.
DRP : Drug Interactions
Piroxicam and ketorolac are pharmacodynamic synergis and can increase toxicity. expecialy GI.
Never use combination of keterolac, piroxicam and Methylprednisoline 5.
CONCLUSION
1872
Based on the results of clinical practice PGI Cikini Hospital, it can be concluded that there is found
DRP (Drug Related Problems) that is interaction.
REFERENCES
1. Josipovic-Jelic, Z. 2008. "Spondylodiscitis". Bratislavske lekarske listy: 345–347
2. Anonim 2014,”spondylodiscitis https://www.scribd.com/doc/242921126/MAKALAHSpondilodisitis-pdf
3. Sandra M. Nettina, 2000, Taking care of your lower back and neck pain,: philadelphia
4. Baand POM RI, 2008. Informasi Obat Nasional Indonesia. Baand POM; Jakarta
5. Madescape http://reference.medscape.com/drug-interactionchecker
6. Anonim,2002 ‘spinal condition & treatment Http:/www. Back pain
7. Sugianto. 2001. Terapi manipulasi pada nyeri pinggang ; Jurnal Ikatan fisioterapi Indonesia.
Jakarta
8. Anonim 2012, http://www.scribd.com/doc/79740733/Nyeri-Punggung-Bawah-LBP-Low-BackPain#scribd
1873
CASE STUDY: DRUG RELATED PROBLEMS IN TREATMENT OF
DIABETES MELLITUS COMPLEX
Chusnul Hikmah Djibran1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
Student of Pharmacist Professional Program Student, FacultyOf Pharmachy UTA’ 45 Jakarta
2
Email : ime.djibran@yahoo.com
ABSTRACT
Diabetes mellitus DM is a metabolic disease with characteristic hyperglycemia due to abnormal
insulin secretion, insulin action or both2). According to the American Diabetes Association, (2014)
classification for diabetes mellitus based on the etiology is diabetes mellitus type 1, diabetes
mellitus type 2, gestational diabetes, pre-diabetes and diabetes types other8). Prolonged
hyperglycemia can be a andgerous metabolic state which one of them is Diabetic
Ketoacidosis(DKA). If DKA did not handle properly, the patient can be unconscious and coma6).
Patient, Mrs. Sr, 49 years old, entered Gatot Subroto Army Hospital on December 11, 2014.
Patient present with loss of consciousness since less or more 5 hours before entering the hospital
with a history of diabetes and a history of stop injecting insulin. Therapy treatment for
hospitalized is rehydration fluids, drips insulin therapy, ceftriaxone, omeprazole, aspilet,
simvastatin, furosemide, paracetamol, combivent inhalation, fluimucyl, simvastatin and citicolin.
Key words: Diabetes Mellitus,Diabetic Ketoacidosis, Army Hospital Gatot Soebroto
1874
INTRODUCTION
Diabetic Ketoacidosis is a result of severe insulin deficiency and accompanied by metabolic
disorders of protein, carbohydrates and fats. This condition is sometimes called "fast
acceleration" and is the most serious metabolic disturbances in insulin dependent diabetes1).
Diabetic ketoacidosis is due to lack of insulin or insufficient amount of insulin that is real, this
situation results in disturbances in the metabolism of carbohydrates, proteins and fats. There are
three important clinics picture in diabetic ketoacidosis ; dehydration, electrolyte loss and
acidosis7).
If the amount of insulin is reduced, the amount of glucose that enters to the cell will be reduced
as well. Besides, the production of glucose by the liver becomes unmanageable. Both of these
factors will result in hyperglicemia. In an effort to eliminate excess glucose from the body, the
kidneys will excrete glucose together water and electrolytes (such as sodium, and potassium)7).
CASE PRESENTATION
Patient, aged 49 years Mrs.Sr entered Gatot Subroto Army Hospital on October 11, 2014. Patient
come with loss of consciousness, since less or more 5 hours before admission. One day before,
the patient was vomiting more 5x / day.
Previous medical history was uncontrolled diabetes and ulcer surgery digit I. Previous treatment
history was patient stop taking insulin and claimed set of nutritional diet. Patient diagnosis
wasdiabetic ketoacidosis.
CLINIC EVALUATION
DAK (Diabetic Ketoacidosis) therapeutic principle is to treat dehydration, hyperglycemia, and
electrolyte imbalances, and overcoming existing co morbidities. The goal of therapy is to replace
the volume of circulating fluid and electrolyte imbalance correction4,5).
PatientMrs. Sr, was gotten rehydration fluids and electrolytes by providing loading infusion of
0.9% Nacl 2 line 40drops/ min on the right hand and left hand the patient until the next
maintenance 2000cc 20 drops / min. Initially fluid therapy directed to the addition of
intravascular and extra vascular fluid as well as the improvement of renal perfusion. Then the
1875
blood sugar control with insulin drips, Insulin therapy to inhibit cytogeneses done so as to reduce
metabolic acidosis. The objective of reducing the use of insulin cytogeneses, is reducing the
blood glucose levels as well as address the imbalance of electrolytes.Blood glucose levels should
be lowered slowly, continuously up to the limit specified2). Patient given 10 units of insulin
Novorapid next sc 2 units /hour in syringe pump, but this was discontinued after insulin
administration or GDS levels of patient is normal. In addition, patient received ceftriaxone 1 x 2 g
IV to prevent infection and given omeprazole injection of 1 x 40mg IV. Laboratory tests on the
patient included blood gas analysis, complete urine, hematological examination, blood glucose
when GDS, HbA1C, SGOT AST, alanine aminotransferase ALT, albumin, HDL, LDL, acetone and
triglyceridese.
In addition to the patient's diagnosis was loss of consciousness due to CVD or sepsis, sepsis and
CAP 2nd dd pulmonary TB infection, the patient also suffered a fracture in the left leg with
immobilization, so that the patient was given additional medication furosemide 1x40mg,
3x1000mg paracetamol for fever patient, Combivent inhalation every 8 hours , fluimucyl 3x1,
aspilet 1x30mg, and 1 x 20 mg simvastatin, thus patient was advised to do consultation the
Department of neurology and given additional medication citicolin 2 x 500 mg.
Before this, patient had a history of diabetes mellitus who was not controlled, the patient also
suffered amputations in the thumb of his right foot. The patient had 2 years to stop using insulin
and only have a diet.
LABORATORY EXAMINATION RESULT
Clinical Chemistry
Reference Value
11/12
12/12
13/12
7,37
7,518*
7,459
7,510*
pCO2
33-44 mmHg
25,8*
26,6*
25,3*
pO2
71-104 mmHg
91,7
63,3*
96,8
Bicarbonat (HCO3)
22-29 mmol/L
21,2*
18,3*
20,4*
Base Excess(BE)
(-2)-3 mmol/L
-0,3
-4,5
-0,4
94 - 98%
95
87,6*
98,3*
Blood Gas Analysis
Ph
Oxygen Saturation
1876
Clinical
12-Des
Reference Value
11-Des
Urea
20-50 mg/dL
57*
59*
Triglyceridese
0,5-1,5 mg/dL
1,9*
1,9*
Blood Glucose
< 140 mg/dL
505**
Sodium (Na)
135-147 mmol/L
126*
134*
133*
Potassium (K)
3,5-5,0 mmol/L
5
3,5
3,4*
Clorida (Cl)
95-105 mmol/L
84*
98
Negative
Positive
Chemistry
Aceton
Hematology
00.49
257*
Negative
05.59
07.17
82
Negative
Negative
Reference Value
11/12
12/12
Hemoglobin
12-16 g/dL
11,4*
10,5*
Hematocrit
37-47%
31*
30*
Erythrocyte
4,3-6,0 juta/µL
4,1*
3,6*
Leukocyte
4,800-10,800 /µL
20550*
16,400*
150,000-400,000 /µL
276.000
224
MCV
80-96 fL
76*
83
MCH
27-32 pg
28
29
MCHC
32-36 g/dL
37*
35
Routine
Hematologi
Platelets
Urinalysis
Reference Value
12/12/2014
Colour
Yellow
Yellow
Purity
Clear
Clear
4,5 - 8,0
6.0
1.010 -1.020
1.015
Complete urine
pH
Density
1877
Protein
Negative
positive 2
Glucosa
Negative
positive 3
Bilirubin
Negative
Negative
Nitrit
Negative
Negative
Ketones
Negative
Negative
Negative / positive 1
Negative
Erythrocyte
0-0-1
< 2 /LPB
Leukocyte
2-2-3
< 5 /LPB
Urobilionogen
*) Abnormal laboratory values
Basically therapy in the patient was in accorandce with the Standards of Medical Care
management of patient with Diabetes Ketoacidosis. But the dose of each drug given should be
considered with impaired kidney function, so it is necessary to take into account for patient dose
reduction, such as :
1.
Aspiletif CrCl> 10ml/menit, so dose adjusment is not necessary, but if CrCl value <
10ml/menit, so it is not recomended 9).
2.
Acetaminophen, reduced 50% of dose may be warranted in patient with severe renal
impairment ( r l ≤ 30ml/menit
3.
9,10)
.
Simvastatin, severe renal impairment ( r l ≤ 30ml/menit , 5mg qDay initially 9,10).
So, calculating triglyceridese clearance values of serum triglyceridese of patient based on the
value of 1.9 mg / dL
CrCl =
CrCl =
(140-Age)x Weight
x 0,85 so,
72 x SCr
(140-49)x 50
x 0,85 = 28,27ml/minuted.
72 x 1,9
1878
From the calculation of triglyceridese clearance values , it can be concluded for doses aspilet was
right , for paracetamol was need reducing 50% of dose to 3x500mg , and for simvastatin dose
reduction was also necessary because the r l value of the patient was ≤ 30ml / minute to 5 mg /
day . For the various drugs given patient, there were no significant interaction.
CONCLUSION
Based on the result of clinical practice in Gatot Subroto Army Hospital, it can be concluded that
the treatment of diabetic ketoacidosis given to the patient could have been right, just needs to
be given special attention, especially in patient dosing with impaired renal function state.
REFERENCES
1. English, P and Williams, G. (2003). Hyperglycaemic crises and lactic acidosis in diabetes
mellitus. Liverpool : Postgrad Med, Vol. 80
2. Join British Diabetes Societies. (2010). The Management of Diabetic Ketoacidosis in Adult.
London
3. Newton, Christopher A and Raskin, Phillip. (2004). Diabetic ketoacidosis in type 1 and type 2
diabetes mellitus: Clinical and biochemical differences. Archive of Internal Medicine, Vol. 164,
4. PERKENI. (2011). Petunjuk Praktis Pengelolaan DM Tipe 2. Jakarta.
5. RSPAD Gatot Soebroto (2012) Standar Pelayanan Medik Ketoasidos Diabetes
6. Sumantri S., (2009). Pendekatan Diagnostik and Tatalaksana Ketoasidosis Diabetikum. Internal
Medicine Department. Jakarta.
7. Wall, et.al. (2001). Hyperglycemic Crises in Patient With Diabetes Mellitus,
Clinical Diabetes, Spring.
8. WHO Department of Noncommunicable Disease Surveillance Geneva. (1999).
Definition, Diagnosis and Classification of Diabetes Mellitus and itsComplications. Report of a
WHO ConsultationPart 1: Diagnosis and Classification of Diabetes Mellitus.
9. Anonim. (2014).Medscape.Dosing uses and interaction.
10. British Medical Association and the Royal Pharmaceutical Society of Great Britain. 2009.
British National Formulary 57. Britain : United Kingdom Pharmacist
1879
CASE REPORT : EVALUATION OFDRUGRELATEDPROBLEMS IN
PATIENT MELENA AT MINTOHARDJO HOSPITAL
Tety Restiaty amparodo¹, Aprilita Rianayanti Efi², Diana Laila Rahmatillah²
1
2
Email:tetyrestiatyamparodo@ymail.com
ABSTRACT
Melena defined as black as tar dirt because of the blood that is changing shape¹. Bleeding can
occur
from the esophagus, stomach
ileumevenasendescoloncancausemelena
or duodenum. Butlesionsin the jejunum,
provided
thatthe
travel
time
through
the
astrointestinal tractlongenough. Approximately60mLis sufficienttocauseabowel movements with
blackstools. Acute blood loss greater than this amount can cause melena more than 7days.
Patient Mr. Maged of 67years entered RSAL Dr.Mintohardjo September 5, 2014 with a diagnosis
of Melena. Therapy treatment for 8 days, PRC transfusion (Packed RedCells), infusion of Ringer's
lactate,
Transamin
(tranexamic
acid),
Vitamin
K,
Sucralfate,
omeprazole,
Dexanta
(aluminumhydroxide, magnesiumhydroxide, simethicone), Sanprima F (Sulfametoxazole,
trimethoprim) and ketoconazole. Based on the results of treatment and drug therapy, it can be
concluded that there is a DRP(Drug Related Problems) form of drug interactions.
Keywords:Melena, RSALMintohardjo, Gastrointestinal
1880
1.
INTRODUCTION
Melena term usually describes bleeding from the esophagus, stomach or duodenum, butaslong
intestine trip, bleeding from yeyunum, ileum lesiOn the jejunum, ileum and colon asendes even
may cause melena. Required minimum of 60 Ml bleeding. Bleeding is more than this can give
melena to about 7days¹.
Melena black color caused by blood contact with hydrochloricacid to form hematin.The stool will
be shaped like tar (sticky) and cause a characteristic odor. Consistency is different tarry stools
that are black or dark after a person consumes iron, bismuthorlicorice, Similarly, red stools can
occur from consuming bitsor after intravenous injection sulfobromoftalein. Gastrointestinal
bleeding, even if only detected with a positive test for occult blood, shows the potential of
serious illness and should be investigated further².
2.
CASEPRESENTATION
Patient Mr.J, aged 67years entered RSAL Dr.Mintohardjo on September 5,2014 with a diagnosis
of Melena. Patient presented with defecation which was black with a liquid consistency, dizziness
when standing from a sitting position, the patient had a history of peptic ulcer disease.
3.
CLINICAL EVALUATION
In this case the patient was treated with an infusion of RLtorestore the body's electrolyte, PRC as
blood transfusion, Transamin and vitaminK injection to stop the bleeding, Sucralfate to coat th
egastric mucosa, Omeprazole to inhibit gastric acid secretion, Sanprima for teasanti bacterial,
and ketoconazoleas an antifungal³.
4.
TREATMENT AND DOSE
In this case
the patient received therapy :RL in fusion administered intravenously, PRC
transfusion of 500 mlintravenous,transamininjection given 3x1 da intravenously, vitamin K
injection given 3 x 1 intramusculary, sucralfate suspension was given3x1day tablespoon orally,
Omeprazole injection given2x1 intravenously. Omeprazole tablet given 2x20 mgday orally,
1881
Dexanta syrup3x1 tablespoon orally, SanprimaF caplets given 3x1orally, ketoconazoles tablets
given1x200mgoraly³.
5.
LABORATORYEXAMINATIONRESULTS
Results of laboratory tests on the firstday,in routine hematology decreased hematocrit
values:23% (references 42-48%), this is aims to help diagnose various diseases including anemia.
Decreased hematocrit of 30% indicates that the patients had moderate to severe anemia.
Morphological examination of peripheral blood was also done with the results: Anemia
normocytic normochromic Neutrophilia. Anemia normocytic the number of red blood cells are
abnormally low, but the size of normal cells, usually occurs after acute hemorrhage. While
Neutrophilia is increased beyond the normal amount neutrophil mostly the cause is a bacterial
infection. Blood sugar test astray, the results of the examination: 147mg/dl(reference <110
mg/dl) but not significantly increased, and tests renalfunction shows an increase in the amount
of urea , this increase indicates that patients with decreased renal function.
6.
DISCUSSION
Patient Mr.Maged 67 years, On 5September 2014 entered RSAL Dr.Mintohardjo , with melena
(defecation black and liquid consistency) and patient got dizziness when standing from sitting. On
the first day of treatment the patient was given an infusion of RL (20 MDGs) torestore the body's
electrolyte, vitamin K injection and Transamin to stop the bleeding, sucralfate to protect the
gastric mucosa, omeprazole to reduce gastric acid secretion. Patient was also given a transfusion
of 500ml PRC, PRC (Packed RedCells) is material for a blood transfusion which mostly consists of
red blood cells /erythrocytes, but still contains little remains of leukocytes and platelets. On day5
today 6 treated,patient still with infusion but got the addition of another drug: Sanprima F,
Dexanta syrup and tablets. Before endoscopy patients given antibiotics :Sanprima F tablets,
complaints reduced and patient did not defecate blood anymore, but the patient still felt weak.
On day 6 treatments, Endoscopic with esophagitis and the results suggested that fungal
medication given Ketoconazole 1tablet 3times daily. On day 7 treatments and medication
infusion was continued until the last day of the patients admitted to the day to 8 where in no
1882
further complaints of the patient, the problem is resolved infusion was stop and continued
therapy at home with take-homedrugs: Sucralfate, SanprimaF, Omeprazole and Ketoconazole.
7.
DRUGRELATEDPROBLEM
There was interaction between ketoconazole and sulfamethoxazole which increased
QTcinterval⁵ (associated with the ECG heart rate), so its use should be carefully monitor and
strictly necessary. Like wise between sulfamethoxazole (SanprimaF) with omeprazole, namely:
can enhance the effect sulfomethoxy through CYP2C9/10⁵.
8.
CONCLUSION
Based on the result of the practice in the inpatient unit Sangeang Islandin RSALM concluded that
there are DRP(Drug Related Problems) form of drug interactions.
REFERENCES
1. Bakta I Made, Suastika I Ketut,1999, Gawatdarurat di biandgpenyakitdalam, Jakarta;
EGC.
2. BaandPengawasObatandMakanan RI, 2008,InformatoriumObatNasional Indonesia, Jakarta;
Baand POM RI, KOPERPOM and CV AgungSeto.
3. Isselbacher J. kurt et al,2008, Prinsip-prinsipilmupenyakitdalamvol I, Jakarta.
4. BNF.2009.British National Formulary.BMJ Group.UK.
5. Madescapehttp://reference.medscape.com/drug-interactionchecker.
1883
CASE REPORT : DRUG RELATED PROBLEMS IN THE
TREATMENT OF DISEASES DISPEPS IT IN WARD MEDICINE
RS.PGI CIKINI
Andi Anhar Wahyuddin1, Aprilita Rinayanti Eff and Diana Laila R2
1
2
Andianhar91@gmail.com
ABSTRACT
Dyspepsia is a common disease and often occur in internal medicine wards at PGI Cikini Hospital.
Dispepsia is a collection of complaints or clinical symptoms that consists of discomfort or pain,
full of flavor and heat in the upper abdomen persistent or relapsing
of pain and
heartburn. 2 Patient Mrs. AP is a 32-year-old admitted to the internal medicine ward. Patient
diagnosed with Dyspepsia disease. Patient was treated with Paracetamol, Lasix, Onandsetron,
Pantozol, Polysilane. Based on the results of clinical work practice in Cikini hospital about drug
interactions Laxis (Furosemide) with Polysilane (Kalsium carbonate and magnesium hydroxide).
Keywords: Dyspepsia, pain, RS PGI Cikini
1884
INTRODUCTION
Dyspepsia syndrome more commonly known as kat masyara ulcer disease even though less
precise, because the ulcer is derived from the Dutch language, which means bloating. Complaint
which mun cul on a g ti ma disease do not always come from the stomach. The prevalence of this
disease vary, most research shows that nearly 25% of adults experience symptoms in spepsia at a
time in her life.10
A surve y mentioned, approximately 30% of patients who go to a general practitioner due to the
presence of gastrointestinal disorders chiefly ad i spepsia and 40-50% of patients the to
comecialis spes to be due to indigestion, especially dyspepsia. 2
Changes in the pattern of irregular eating, drugs that are not clear, substances such as nicotine
and alcohol as well as the presence of psychiatric conditions of stress, food intake will be limited
so that the stomach is empty, void stomach can lead to erosion of the stomach caused by friction
between the walls of the stomach , this condition can lead to increased production of HCL which
will stimulate the acid conditions of the stomach, so that the stimulus in the medulla
oblongata carry impulses vomiting so it can not be received by the digestive tract perfectly. This
is what causes vomiting. 2
CASE PRESENTATION
Patient Mrs. AP is a 32-year-old woman admitted to the internal medicine ward. Patient
diagnosed with dyspepsia. Patient entered in the PGI Cikini Hospital on September 21,
2014. Patient felt dizzy, nausea, vomiting, and weakness of the week before admission. Upon
entering the hospital, the patient felt dizzy, weakness, nausea, and poor appetite. Results of
laboratory such occurs enhancement erythrocyte sedimentation rate, decreased hematocrit,
and an increase in the neutrophils.
CLINICAL EVALUATION
In this case patient treated with Cefotaxim used to treat infections, Parasetamol used to treat
pain, fever, Laxis The use u ntuk reduce fluid in the body and throw it through the
urinary. Meropenem used
u
ntuk
overcome
infection
in
the
stomach, Ranitidin
for
1885
treatment ulcers gastric and duodenal ulcers, reflux, esophagitis, dispepsia chronic episodic.
Onandsetron to overcome vomiting, Pantozol to relieve symptoms and short-term treatment of
gastric disorders and reduction of gastric acid, Polysilane to relieve symptoms associated with
excess stomach acid , gastritis, gastric ulcer with symptoms such as nausea GEJ style, gastric
pain. 4
DISCUSSION
Patient Mrs. AP is a 32-year-old woman diagnosed with dyspepsia, entered in the PGI Cikini
Hospital on September 21, 2014. The complaint of dizziness, nausea, vomiting, and weakness of
the week before admission. Upon admission, the patient feels dizzy, weakness, nausea, and poor
appetite. Patient suffering from dyspepsia diagnosis
Dyspepsia is a collection of complaint or clinical symptoms consist of discomfort or pain, full of
flavor and heat in the upper abdomen persistent or relapsing pain and heartburn heat 2
Therapeutic treatment includes administration of Laxis (Furosemide) to cope with dyspepsia in
order to reduce fluid in, through the urinary Onandsetronto overcome vomiting, Pantozol to
relieve symptoms and short-term treatment of gastric disorders and reduction of gastric acid,
Polysilane to relieve symptoms associated with excess stomach acid, gastritis, peptic ulcers with
symptoms such as nausea, stomach pain. 4 The results of laboratory tests which occur
enhancement erythrocyte sedimentation rate, decreased hematocrit, and was an increase in
neutrophils.
Drug Related Problem 1
Furosemide and calcium carbonate can reduce levels of calcium carbonate by increasing renal
clearance, small or non-significant interaction. 1
Drug Related Problem 2
Furosemide and Magnesium hydroxide can reduce the level of magnesium hydroxide by
increasing renal clearance, small or non-significant interaction. 1
1886
CONCLUSION
Based on the results of clinical work practice in Cikini hospital about drug interactions Laxis
(Furosemide) with Polysilane (Kalsium carbonate and magnesium hydroxide).
REFERENCES
1. Baxter, K. Stockley's Drug intera ction Eight Edition. London. 200 8
2. Harahap, Y, 2009. Characteristics of patients with dyspepsia inpatient hospital Tahup 2007
Martha Physics field.
3. Poltak Hutagalung, Sirait Amir, Nadeax Moxa. 100 Years of RS PGI Cikini, with Sentuha n
Love. Jakarta. 1997
4. ISFI ,. "Iso Pharmacotherapy" ISFI Jakarta.2012
5. J oint Formulary Committee. British National Formulary. London. 2009
6. Juliyanto, 2012. "dyspepsia". http://endryjulianto.blogspot.com , accessed on May 9, 2014
7. Reeves J Charlene. Medical Surgical Nursing. Jakarta. 2001
8. Syahputra, Henry. 2013. "Dyspepsia". http://www.wawanssblogspot.com , accessed on 10 April
2014
9. Lecturer in the Faculty of Medicine University of Sriwijaya. Pharmacology Lecture Ed set. 2.
EGC: Jakarta. 2009
10. Taringan, C., 2003. The difference in depression in patients with functional dyspepsia and
organic
dyspepsia. Downloaded
20011.
dated
October
4 http:
//library.usu.ac.id.dowdload/fk/psikiatri-citra.pdf
11. Tjay Tan Hoan. Medications important. Elex Media Komputindo: Jakarta 2007
1887
CASE STUDY: DRUG RELATED PROBLEM IN
PATIENT WITH PULMONARY TBC, DYSPEPSIA SYNDROME AND
HYPERTENTION AT PERSAHABATAN HOSPITAL
Pajar Budi Lestari1, Aprilita Rinayanti Eff.2 and Diana Laila Rahmatillah2
1
Student of Pharmacist Program, Faculty of Pharmacy UTA ’45 Jakarta
2
Lecturer of Faculty of Pharmacy UTA ’45 Jakarta
Pajarbudilestari17@gmail.com
ABSCRACT
Tuberculosis (TBC or TB) is an infectious disease caused by Mycobacterium tuberculosis (Jackson,
Stephen. 2009).
Dyspepsia syndrome is an abdominal pain, bloating and nausea. The symptoms can occur with
gastric and duodenal ulceration and gastric cancer but most commonly it is of uncertain origin
(BNF 67, 2014). Acquired immunodeficiency syndrome (AIDS is defined as the most severe form
of a continuum of illnesses associated with human immunodeficiency virus (HIV) infection
(Smeltzer, S. C., Bare, B. G., Hinkle, J. L., & Cheever, K. H., 2010).
Patient mis M.I., 23 years old, was hospitalized at Persahabatan Hospital on October 8, 2014 with
diagnosis : Pulmonary TBC, Dyspepsia Syndrome and HIV AIDS. Patient was treated with
Fluimucyl, Rifampicin, Isonoazid, Pyrazinamid, Ethambutol, Onandsentron and Ranitidine. In this
case, there is found Drug Related Problems (DRPs) that is untreated complaints, dosage regimen
is too low, unappropriate drug selection and drug interactions.
Keyword : Drug Related Problem, Pulmonary TBC, Dyspepsia Syndrome, HIV
AIDS, Persahabatan Hospital
1888
I.
INTRODUCTION
Tuberculosis (TBC or TB) is an infectious disease caused by Mycobacterium tuberculosis (Jackson,
Stephen. 2009).
Dyspepsia syndrome is an abdominal pain, fullness, early satiety, bloating and nausea. The
symptoms can occur with gastric and duodenal ulceration and gastric cancer but most commonly
it is of uncertain origin (BNF 67, 2014).
Acquired immunodeficiency syndrome (AIDS is defined as the most severe form of a continuum
of illnesses associated with human immunodeficiency virus (HIV infection (Smeltzer, S. ., Bare,
B. G., Hinkle, J. L., & Cheever, K. H., 2010).
II.
CASE PRESENTATION
Patient mis M.I., 23 years old, was hospitalized at Persahabatan Hospital on October 8, 2014.
Patient came with complaint about shortness of breath since one week before admission, cough
with sputum ± 3 months, nausea, pain in heart burn and heat arising missing since ± 3 months
prior to admission hospital.
III.
CLINIC EVALUATION
In this case the patient was treated with Fluimucyl as anti mucolytics to reduce the viscosity of
sputum, Rifampicin for anti TB drug in combination with other anti TB therapy for early and
repeated, Isonoazid for the treatment of all forms of active tuberculosis caused by germs that are
sensitive, Pyrazinamide for therapy TB in combination with other anti TB which are bacteriside
which can kill germs in cell with acidic conditions, Ethambutol for TB combination therapy which
is bacterostatic to suppress the growth of TB bacteria, Onandsentron to treat nausea, Ranitidinee
to overcome stomach irritation.
1889
IV.
DOSAGE AND METHODE OF USAGE
No
1
Day
st
1 day
Therapy Treatment

Oxygen 3 lpm NK

IVFD NaCl 0.9% 500 cc /12 hour + Aminofluid
/24 hour
2
2nd day

Fluimucyl 3x200mg (PO)

Rifampicin 1x450 mg (PO)

Isoniazid 1x300 mg (PO)

Pyrazinamide 1x750 mg (PO)

Ethambutol 1x750 mg (PO)

Onandsentron 3x4 mg (iv)

Ranitidine 2x50 mg (iv)

Oxygen 3 lpm NK

/24 hour
3
3rd day








Oxygen 3 lpm NK

/24 hour



1890
th
4
4 day




Ranitidine 2x50 mg (iv).

Oxygen 3 lpm NK

/24 hour
5th day
5








Oxygen 3 lpm NK

/24 hour







Laboratory Data
No.
Parameter
Value
Normal Value
Hematologi
6-10-2014
11-10-2014
1891
1
Leukocytes
9070/mm3
3560/mm3 *
5000-10000/ mm3
2
Neutrophils
74.3% *
51.6%
50-70
3
Limphocytes
14.7% *
22.5% *
25-40
4
Monocyte
9.0% *
13.2% *
2-8
5
Eosinophil
1.7% *
12.4% *
2-4
6
Basophil
0.3%
0.3%
0-1
7
Erythrocytes
4.3 billion/uL
4,84 billion/uL
3,6-5,8
8
Hemoglobin
11 g/dL *
9.7d/dL *
12,0-16,0
9
Hematocrit
33% *
31% *
35-47
10
MCV
77.4 fL *
81.3 fL
80-100
11
MCH
25.6 pg *
25.5 pg *
26-34
12
MCHC
33 %
31.4% *
32-36
13
RDW-CV
13.6%
14
Platelet count
386000/mm3
316000/mm3
150000-440000
15
Blood Glucose
86
-
<180
11,5-14,5
No.
Parameter
Value
Normal Value
1.
Anti HIV
Reactive18.34
Reactive ≥ 0.25
Non Reactive < 0.25
2.
Procalsitonin
> 200ng/ml
Normal < 0.05
Local Infection ≥ 0.05 - < 0.5
Sepsis ≥ 0.5 - < 2
Severe Sepsis ≥ 2 - < 10
Septic Shock ≥ 10
DISCUSSION
1892
In the first day of hospitalized patient was diagnosed with pulmonary tuberculosis and was
treated with anti-tuberculosis drugs, but on the third day of treated patient also was diagnosed
with dyspepsia syndrome and HIV. Based on laboratory data, it was believed that the patient had
an infection showed from a low value of leukocytes, suffered from anemia which was showed
from the value of hemoglobin, MCH and MCHC which were low but the patient did not get a
blood enhancing drugs. The patient also suffering HIV who presentated from anti-HIV test result
is reactive 18.34, patient also has not received HIV drugs. During the treatment period patient
was treated with a solution of NaCl infusion to maintain osmolarity and acid base balance in the
body and added Aminofluid for maintenance of homeostasis in patient less oral fluid intake. The
patient was experiencing cough phlegm then she was given Fluimucyl as anti mucolytics to
reduce the viscosity of sputum. She was also given Rifampicin for treatment resistant
tuberculosis in combination with other anti tuberculosis therapy for early and repeated (BNF 67,
2014). Isoniazid was used therapy for all forms of active tuberculosis, caused by suspectible
bacteria and for prophylaxis of persons at high risk of getting an infection. Pyrazinamide for
treatment of tuberculosis in combination with other anti tuberculosis, bacteriside, could kill
germs that were in cell with acidic conditions. Ethambutol for tuberculosis combination therapy
with other drug, appropriate treatment regimen if resistance was suspected, bacterostatic, by
pressing the TB germ growth. Onandsentron for reducing nausea and vomiting. Ranitidine for the
treatment of gastric ulcer and duodenal ulcer, because patient complained of nausea and
abdominal pain. Drug Related Problem (DRPs) that are untreated complaints patient has
symptom anemia but do not receive the drug, the patient do not get Pyridoxine as a prophylactic
to prevent and cope with disturbances of peripheral neuritis caused by the consumption of
isoniazid. Ranitidine dose is too low which given only of 2x50 mg where as 3x50 mg (Burns, Aine.
2009). Unappropriate drug selection for onandsentron, because onandsentron is used as an anti
nausea due to the effect of chemotherapy, drug interaction between rifampicin with INH and INH
with pyrazinamide.
V.
1. Untreated comlpaints
1893
a.
The patient experience HIV but she do not get HIV drugs. It is recommended to give HIV
drugs.
b.
The patient experience anemia, but she do not get the blood enhancing drugs. It is
suggested for the doctor to give blood enhancing drugs and monitoring the result of blood
pressure and blood check.
c.
The patient did not get Pyridoxine, as a prophylactic therapy to prevent and cope with
disturbances of peripheral neuritis caused by the consumption of isoniazid (Jackson, Stephen.
2009)
2. Dose regimen is too low
Drug dose was too low, the prescription Ranitidinee 2x50 mg daily. While according to Dr. Aine
Burns ( Renal Drug Handbook, 2009) is 3x50 mg daily. It is suggested that the doctor to reevaluated the use of therapeutic doses of Ranitidinee and monitor the record nurses list therapy.
3. Unappropriate Drug Selection of drug
The patient was experiencing nausea and vomiting, the recipe given is onandsentron.
Onandsentron is an antiemetic used to treat nausea and vomiting from chemotherapy effect.
The patient should be given domperidone. It is suggested that the doctor review the accuracy in
drug and monitor the record nurses list therapy.
4. Drug Interactions
a.
Rifampicin with INH
Toxicity of INH can increase with Rifampicin through enzim induction. (Stockley, 2008)
b.
INH with Pyrazinamide
Additive hepatotoxicity ( Stockley, 2008)
It is recommended that nurses monitor routinely and check monitoring of liver function.
VI.
CONCLUSION
Based on the result of clinical work practice tuberculosis ward in Persahabatan Hospital, it is
concluded that there is Drug Related Problem (DRPs). There are untreated complaints, dosage
regimen is too low, unappropriate drug selection and drug interactions.
1894
REFERENCE
1. British National Formulary 67th Edition. London. Hlm. 44, 386 – 390
2. Burns, Aine. 2009. Renal Drug Handbook third edition. New York : Oxford. Hlm. 634
3. Jackson, Stephen H.D., Paul A.F. Jansen., & Arduino A. Mangoni. 2009. Prescribing for Erderly
Patient. London: Wiley-Blackwell. Hlm. 199
4. Smeltzer, S. C., Bare, B.G., Hinkle, J. L., & Cheever, K. H. 2010. Brunner & Suddarth’s: Textbook
of Medical Surgical Nursing 12th Edition. Philadelphia: Lippincott Williams & Wilkins. Hlm. 1
5. Stockley, Ivan H. 2008. Stockley’s Drug Interaction. London: Pharmaceutical Press. Hlm. 308,
310
1895
DRUG RELATED PROBLEM IN PATIENT WITH
HYPERTENSION HEART DESEASE (HHD) AND PARAPARESE
INFERIOR DISEASE AT MINTOHARJO HOSPITAL JAKARTA
Jefri Tri Widodo1, ,Aprilita Rinayanti Efi2 and Diana LailaRahmatillah2
1
Student of Pharmacist Professional Program Student, Faculty of Pharmacy UTA'45 Jakarta
2
Lecturer of Faculty of Pharmacy UTA'45 Jakarta
Email: dodojefry@yahoo.co.id
ABSTRACT
Paraparese inferior is paralysis caused by loss of motor functions of the nervous lumbar, sacral,
or
thoracic.
The
general
term
used
to
describe
paraparese
is
incomplete
(1).
paraplegia Hypertension Heart Disease (HHD) is an abnormality of the spectrum which is an
accumulation of blood pressure increase. HHD recovery can be achieved by administering
antihypertensive therapy at every stage and condition. Hypertension is a factor that causes the
greatest cause of CVD risk as HHD other CVD risk factors. The final phase of HHD is heart failure(2).
Patient Mr. ZN, age 56 year old, entered theMintoharjoHospitalon 25 November 2014 patient
was diagnosed Paraparase Inferior and Hypertension Heart Desease (HHD). Patient has treated
with Infusion RL, oxygen gas (O2),Neurodex, Mecobalamin, amlodipine, Cardace, Canderin,
Spironolactone, Furosemide, Valdimex, ambroxol. In this case found the existence of Drug
Related Problems (DRP) that areinteraction between cardace with canderin, both of them have
pharmacodynamic synergism. That allows the interaction seriously and untreated complaint.
Keyword: Drug Related Problem (DRP), HHD, Mintohardjo Hospital
1896
INTRODUCTION3,4,5,6,7
Paraparese inferior is paralysis caused by loss of motor functions of the nervous lumbar, sacral,
or thoracic. The general term used to describe paraparesis is incomplete paraplegia(3).Paraparese
can be caused by injury to the spinal cord.
Injuries to the spine can cause the occurrence of autonomic disorder. Autonomic Disfunction
(AD) has the potential to cause blood pressure becomes irregular and potentially cause
hypertension. Antihypertensive therapy should be given due to risk of causing death (4).
Paraparese the inferior opposite can also be caused by hypertension. Hypertension in the long
term can lead to rupture of the aorta (aortic dissection). The aortic rupture eventually lead to
inferior paraparesis(5).
Hypertension Heart Disease (HHD) is an abnormality of the spectrum which is an accumulation of
blood pressure increase. HHD recovery can be achieved by administering antihypertensive
therapy at every stage and condition. Hypertension is a factor that causes the greatest cause of
CVD risk as HHD other CVD risk factors. The final phase of HHD is heart failure / heart failure (6).
Pathogenesis of HHD starting from prolonged hypertension, causing Ventrcular Left Hypertrophy
(LVH) or myocardial infarction due to systolic blood pressure is too high increase muscle mass
left ventricle of the heart (LV). The occurrence of LVH in addition to the systolic blood pressure is
too high also due to other factors such as genes, race, anemia, and / or chronic kidney disease
(CKD). Meanwhile, in addition to myocardial infarction due to systolic blood pressure was also
supported by a factor of hypercholesterolemia, and / or diabetes. Both LVH and myocardial
infarction were not addressed would risk causing systolic and diastolic dysfunction, which in turn
leads to heart failure as HHD (7).
CASE PRESENTATION
Patient Mr. ZN, aged 56 years old, entered MintoharjoHosital on 25 November 2014. Patient
presented with leg paralyzed, shortness of breath, anxiety, and sleeplessness.
CLINICAL EVALUATION
In this case the patient was treated with Infusion RL for the balance of electrolytes, oxygen gas (O
2)
to assist breathing, Neurodek for the prevention and cure of neurotrophic, Mecobalamin for
deficiency of vitamin B12 as the formation of red blood cells, amlodipine to control high blood
1897
pressure, Cardace (Ramipril 5 mg) for the treatment of hypertension and heart failure, Canderin
(Candesartanecilexetil 8 mg and 16 mg Candesartanecilexetil) to inhibit blood pressure,
Spironolactone to lower blood pressure that is not controlled, Lasix (furosemide) for mild
hypertension that is effective for the treatment of edema , Valdimex to overcome sleeplessness,
ambroxol to cough up phlegm.
DOSAGE REGIMEN
On the first day and second day patient wastreated with: Infusion RL 28tpm / 500cc (IV),
Neurodex 2x1 tab (PO). On the third day patient was given: Infusion RL 28tpm / 500cc (IV),
Neurodex 2x1 tab (PO), Mecobalamin 3x500mg (PO), amlodipine 1x5mg (PO). On the fourth day
patient was give : Lasix 1x1amp (IV), Neurodex 2x1 tab (PO), Mecobalamin 3x500mg (PO),
amlodipine 1x5mg (PO), Canderin 1x8mg (PO). On the five and sixth day patient was give: Lasix
1x1amp (IV), Neurodex 2x1 tab (PO), Mecobalamin 3x500mg (PO), amlodipine 1x5mg (PO),
Canderin 1x8mg (PO), Cardace 1x2,5mg (PO). On the seventh day patient was give: O 2,Neurodex
2x1 tab (PO), Mecobalamin 3x500mg (PO), amlodipine 1x5mg (PO), Canderin 1x8mg (PO),
Cardace 1x2,5mg (PO), Furosemide 1x40mg (PO), Valdimex 1x5mg (PO). On the eight day patient
was give: Neurodex 2x1 tab (PO), Mecobalamin 3x500mg (PO), Canderin 1x8mg (PO), Cardace
1x2,5mg (PO), Spironolaktone 1x25mg (PO). On the ninth day to day twelve patient give:
Neurodex 2x1 tab (PO), Mecobalamin 3x500mg (PO), Canderin 1x8mg (PO), Cardace 1x2,5mg
(PO), Spironolaktone 1x25mg (PO), ambroxol 3x30mg (PO) .
BLOOD PRESURE RECORD
DATE
THE RESULTS
NORMAL VALUE
11/25/2014
160/70 mmHg
<120/80 mmHg
11/26/2014
160/70 mmHg
<120/80 mmHg
11/27/2014
130/80 mmHg
<120/80 mmHg
11/28/2014
190/80 mmHg
<120/80 mmHg
11/29/2014
170/80 mmHg
<120/80 mmHg
11/30/2014
110/80 mmHg
<120/80 mmHg
01/12/2014
170/80 mmHg
<120/80 mmHg
1898
02/12/2014
130/80 mmHg
<120/80 mmHg
12/03/2014
120/80 mmHg
<120/80 mmHg
04/12/2014
110/70 mmHg
<120/80 mmHg
05/12/2014
100/70 mmHg
<120/80 mmHg
DISCUSSION8
Patient visited hospital with any complaint, that is paralyze of led. Patient was diagnosed with
neuropathy caused paraparese inferior. Before entering hospital patient often experience
shortness of breath after walking. The complaint suspected because patient experiencing
hypertension Heart Diseasebefore. Based on medical records and medical history patient also
Suffered asthma, chronic obstructive pulmonary disease (COPD),Heart Disease and Hypertension
(HHD). Paraparese inferior or incomplete paraplegia experienced by patient on admission is
made possible because of antihypertensive therapy in the treatment of previously HHD is not
optimal. Based on research in some cases, inferior paraparese can occur because of the
possibility of aortic dissection due to hypertension (8).
At the time of entered hospital, patient was given infusion of RL and neurodex. RL infusion is
used to provide minerals for the body of the patient, Neurodexserves as a supplement intended
to diagnose treat neuropathy in paraparese inferior. Drug-related problems that occur when the
patient entered the hospital is the indication hypertension untreated until 25 to 26 November
2014. The patient's blood pressure at the time of admission is high ie 160/90 mmHg, patient
needed antihypertension therapy but doctor didn’t give him..On 27 November 2014 patient
received amlodipine for antihypertension in the therapy.
On 28 November 2014 the patient's blood pressure is 190/80 mm Hg is very high and at the time
the doctor giving injection therapy containing furosemide lasix as Loop diuretics. In addition to
furosemide, patient also received canderin containing candesartan (class ARB) and amlodipine
(CCB group ).
On 29 November 2014 the patient's blood pressure is still down significantly. Doctor gave
combination therapy amlodipine(CCB), canderin (ARB group), cardace (ACE group), and
spironolactone for aggressively lowering blood pressure. Amlodipine, canderin, and
spironolactone were given in the morning while cardace given at night. Patient feel uneasy after
1899
receiving the therapy. This was due to the possibility of side effects of spironolactone medication
or a combination of these cardacecanderin and symptomatic hypotension such as anxiety.
Although giving cardace at night and not in conjunction with other antihypertensive drugs, but
the half-life cardace (ACE group) is 13-17 hours (MD 36 p.1385). The half-life long enough that
allows the interaction with antihypertensive drugs were given on the following morning. By
because it is giving cardace cause potassium retention, if provided with spironolactone, which is
a potassium-sparing diuretics can cause hyperkalemia.
On 30 November - December 5, 2014 doctor wrote Diagnosed Hypertension Heart Disease (HHD)
due to the patient's blood pressure is not normal for 5 days of treatment. The same Diagnosed
with previous medical history of the patient, so it can be concluded that the inferior paraparese
experienced by the patient as a result of prolonged HHD.
A patient complaint sleeplessnessoccur on 27- December 30, 2014. This may be due to the
pattern of antihypertensive therapy remain and cause side effects similar difficulty sleeping
restlessly. In addressing the complaints of patients, nurses provide valdimex drugs containing
diazepam.
Shortness of breath experienced by each patient relapsed patient unpleasant smell. During
treatment, patient experience symptoms of shortness of breath on 27 November to 1 December
2014. This suggests that the symptoms due to asthma uncontrolled. Asthma has been
experienced by patient before entering the hospital patient never received asthma medication.
At the time of admission to hospital for up to one week of treatment in the ward doctors only
recommend the use of oxygen at the time of the patient experiencing shortness of breath. Drugs
for asthma do not give because the treatment is focused to overcome complaints paraparese
inferior and hyertension desease. Doctors hypertension more andgerous than asthma
concidered. However, we recommended that patient. Drug asthma should be adjusted with
patient condition and medications the patient ever received before condition of the patients who
have asthma because betablocker can induce broncho constricting.
1900
1.
a.
Untreated Disease
On the first day and the second day treatment, patientexperiance hypertension but he
received anti-hypertension therapy given at third day until seventh day.
b.
On third day until seventh day treatment, patient suffered asthma disease but doctor
didn’t give treatment for overcome the ashma disease.
2.
Drug interaction spironolactone with canderin and cadace can cause hyperkalemia
CONCLUSION
Based on the monitoring of drug therapy in Mintoharjo Hospital it can be concluded that the
presence of DRP (Drug Related Problems) is the interaction between cardace with canderin, both
of them have pharmacodynamic synergism. that allows the interaction seriously untreated
complaint.
REFERENCES
1. Barcelos, air conditioning, Scardino, FB, Patriota, GC, Rotta, JM, &Botelho, RV (2009).
Paraparesis or Incomplete Paraplegia?How Should We Call it?Springer-Verlag.
2. Izzo, JL, &Gradman, AH (2004). Mechanism and Management of Hypertensive Heart Disease:
Left Ventricular Hypertrophy to from Heart Failure. Medical Clinics of North America, 1257-1271.
3. Gerald, Mark F, et al. (2012). Global Strategy for Asthma Management and Prevention.
4. Hsu, Y.-C., & Lin, C.-CK (2004). Paraparesisasthe major Initial Presentation of Aortic Dissection:
Report of Four Cases. ActaNeurol Taiwan, 192-197.
5. Sweetman, Sean C., 2009, Martindale The Complete Drug Reference 36 thed, Pharmaceutical
Press, London
6. Myers, J., Lee, M., &Kirati, J. (2007). Cardiovascular Disease in Spinal Chord Injury;An Overview
of Prevalence of Risk, Evaluation, and Management. American Journal of Physiology, 86, 1-11
1901
CASE REPORT : DRUG RELATED PROBLEM IN VERTIGO
DISEASE AT MINTOHARDJO HOSPITAL JAKARTA
Sherly1 , Aprilita Rinayanti Efi2 and Diana Laila Rahmatillah2
1
Student of Pharmacist Professional Program Student, Faculty of Pharmacy UTA'45 Jakarta
2
Email: Sherly768@yahoo.co.id
ABSTRACT
Fever or febrile is an increase in body temperature of normal temperature variations everyday
associated with an increasing in temperature reference point in the hypothalamus
(1).
Normal
body temperature ranges from 36.6 to 37.2 ° C Degree of temperatures can say fever of a rectal
temperature ≥ 38.0 °
or oral temperature ≥ 37.5 ° C (2). Vertigo is a symptom that refers to the
existence of the sensation of moving both rational movement or linear movement that was not
there. Feeling as if the patient moves or rotates, or as if the objects around the patient moves or
rotates, which is usually accompanied by nausea and loss of balance (3).
Patient Mrs. H, aged 48 years old entered Mintohardjo Hospital on December 1 2014. Patient
was vertigo experience febrile. Patient was treated for hospitalized with IVFD RL, Ranitidine
injection, Paracetamol, Betahistine, Sucralfate, Mefenamic Acid, diphenhydramine, and injection
of Ondacentron. In this case found Drug Related Problems (DRP) that are interaction between
Sucralfate and Ranitidine, Sucralfate reduce the absorption or bioavailability of Ranitidine.
Ranitidine should be given 2 hours before giving Sucralfate and improper drug selective.
Keywords: Drug Related Problem (DRP), Vertigo, Mintohardjo Hospital
1902
INTRODUCTION4,5,6
Vertigo is a symptom that refers to the existence of the sensation of moving both rational
movement or linear movement that was not there. Feeling as if the patient moves or rotates, or
as if the objects around the patient moves or rotates, which is usually accompanied by nausea
and these abnormalities associated with impaired balance the body's system. Vertigo may last
only a few moments or may continue for several hours or even days. Patients often feel better
when lying still, but vertigo may continue even if the patient does not move at all (4).
Febrile is the increase (set-point) hypotalamus temperature, by increasing the benchmark point.
Then hypothalamus sends signals to increase body temperature. The body responds by shivering
and increase metabolism bases. Fever is an increase in body temperature of normal temperature
variations everyday associated with an increase in temperature reference point in the
hypothalamus
(5).
Normal body temperature ranges from 36.6 to 37.2 ° C Degree temperatures
can say fever of a rectal temperature ≥ 38.0 ° or oral temperature ≥ 37.5 ° C (6).
CASE PRESENTATION
Patient Mrs. H, aged 48 years old entered Mintohardjo Hospital on December 1, 2014. Patient
present with vertigo, fever ± 2 days before admission, fever, nausea and vertigo.
CLINICAL EVALUATION
In this case the patient got treatment therapy with IVFD RL instead of body fluids, Ranitidine
injection for gastric ulcer, Paracetamol as an antipyretic (fever), Betahistine as an anti-vertigo,
Sucralfate is indicated for gastric ulcer, Mefenamic Acid as an analgesic (pain reliever),
diphenhydramine as antivomiting, injection Ondacentron as an anti-nausea and antivomiting.
DOSAGE AND METHOD OF TREATMENT
First day: IVFD RL 28 gtt/mm, Ranitidine injection 50 mg bid , and Ondacentron injection 1 gram
bid, Paracetamol tablets 500 mg tid, Betahistine tablets 6 mg tid, Sucralfate syrup tid. Second day
: Paracetamol tablets 500 mg bid, Betahistine tabklets 6 mg tid, Sucralfate syrup tid, Mefenamic
Acid 500 mg tid. Third day: Paracetamol tablets 500 mg tid, Betahistine tablets 6 mg tid,
Sucralfate syrup tid, and Dextrometorphan syrup tid.
MEDICAL RECORD
1903
Date
02/12/2014
Blood Pressure
100/70 mmHg
Normal Value
120/80 mmHg
Laboratory results
4,800 leukocytes / ml
Erythrocytes 4:36 million / ml
Hemoglobin 13.2 g / dL
Hematocrit 37%
Platelets 139,000 thousand / ml
03/12/2014
100/60 mmHg
120/80 mmHg
04/12/2014
120/90 mmHg
120/80 mmHg
DISCUSSION
Patient entered into Mintohardjo Hospital with complaints experiencing vertigo, fever ± 2 days
before admission and febrile hospital, doctors diagnosed that patient suffered vertigo.On the
second day the patient complained of dizziness, weakness, nausea, and fever, and the receive
IVFD RL, Ranitidine injection, and Ondacentron injection. The results of laboratory showed WBCs
and platelets value were abnormal, RL IVFD is given for substitute body fluids, Ranitidine
injection for peptic ulcers, and Ondacentron injection for treat nausea and vomiting. We
recommend the use of injection Ondacentron replaced with Metoclopramide or Domperidone to
overcome the problem of nausea and vomiting. Ondacentron injection is appropriate for patient
who experienced nausea and vomiting post operative. On the third day, complaint of patient
about fatigue, headache, and cough has reduced, because patient experienced vertigo,
Betahistine therapy should be given on the first day of admission to the hospital.
On the fourth day the patient complained of weakness, dizziness small reduced, decreased
appetite, and blood pressure of 120/90 mmHg. Patient was treated with Paracetamol as an
antipyretic (fever), betahistine as an anti-vertigo, Sucralfate syrup is indicated for gastric ulcer,
and is used for cough Dekstrometorphan syrup.
DRUG RELATED PROBLEM7
a.
Drug Interaction
1904
Sucralfate with Ranitidine: Can reduce the absorption or bioavailibility of Ranitidine must be
given within 2 hours before giving Sucralfate(7).
b.
Improper drug selective
Ondacentron Injection is used to treat nausea and vomiting due to chemotherapy and
radiotherapy, for the prevention of nausea and vomiting post-surgery.
Suggestion: We recommend injection Ondacentron replaced with Metoclopramide or
Domperidone effective or prevent nausea and vomiting.
CONCLUSION
Based on the results of monitoring drug therapy conducted Mintohardjo, it can be cocluded that
the presence of DRP (Drug Related Problems) and drug interactions. Where there was interaction
between Sucralfate with Ranitidine: Sucralfate may reduce the absorption or bioavailibility of
Ranitidine that the drug must be given within 2 hours before giving Sucralfate. Ondacentron
injection for the prevention of nausea and vomiting caused by chemotherapy and radiotherapy
and the prevention of nausea and vomiting post-surgery. Ondacentron injection should be
replaced with Metoclopramide or Domperidone.
REFERENCES
1. Gelfrand, JA. 2005. Fever in hyperthermia 16
th
ed. The McGraw-Hill Company: Singapore,
Page: 9-16.
2. Zieve,D.
2010.
Fever.
Available
From:
http://www.nlm.nih.gov/medlineplus/ency/article/000980.htm (Update 29 January 2010).
3. Sen, Ahmet. 2007. Benign Paroxysmal Vertigo in an Airline Pilot. Aviation, Space, and
Environmental Medicine.
4. Anonymous. 2005. Stocley's Drug Interactions. The Pharmaceutical Press, Page: 80.
1905
CASE REPORT: DRUG RELATED PROBLEMS IN TREATMENT CAD,
HHD, BULLA LUNG AT PGI CIKINI HOSPITAL
Eni1, Aprilita Rinayati Efi2, Diana Laila Rahmatillah2, and Stefanus Lukas2
1
Student of pharmacist program, faculty of pharmacy UTA’45 Jakarta.
2 Lecturer of faculty of pharmacy UTA’45 Jakarta
Email: eni.pharm89@Gmail.com
ABSTRACT
Coronary artery disease (CAD) normally occurs due to atherosclerotic occlusion of the
coronary arteries that caused increasing vessel on blood vessel. So, that cause contriction which
molest blood flow. Mr. SP aged 62 years old was diagnosed with CAD, HHD, Bulla lung. Originally
patient come with shortness of breath problem, coughing mixed with blood, chest pain. Present
History of patient illnest were feeling chest pain which spread to the back, palpitations, shortness
of breath. Past medical history is of type II diabetes, hepatitis B. From the results of
echocardiography (ECG) showed LVH, suspected CAD, mild diastolic dysfunction (Grade1) and
decreased LV systolic function. And from the results of radiographic examination showed
pulmonary infiltrates appear smooth left apex, blood glucose tests as 199 mg/dl.
Drug therapy given by the doctor to Mr. SP includes standard therapies to treat diseases HHD,
Hepatitis B, diabetes mellitus type II, and a dry cough that are Captopril 12,5mg tab, Heplav 50mg
tab, Novorapid flexpen 10u, 25u Lantus Flexpen, and Fluimucil 600mg tabs. Result of monitoring
clinical practice in PGI Cikini Hospital. It can be concluded that there is found Drug Related
Problem that are adverse drugs reaction need aditional medication, patient uncompliance, dose
is too high, drug interactions.
Keywords : Drug related problem CAD, HHD, Lung Bulla, PGI Cikini Hospital.
1906
1. Introduction
Coronary artery disease occurs when the blood supply to the coronary artery myocardial (heart
muscle) is not adequate so that the heart can not pump blood effectively, resulting in blood
perfusion to organs impaired.
Organs and tissues need oxygen through the blood from the arteries to maintain its function1.
CAD can be caused by heredity, gender, age, increase blood cholesterol levels, smoking, physical
inactivity2.
Hypertension Heart Disease (HHD) is a term applied to mention heart disease as a whole, starting
from the left ventricle hyperthrophy (LVH), cardiac arrhythmias, coronary heart disease, and
chronic heart disease, which is caused due to an increase in blood pressure, either directly or
indirectly directly3. Increased systemic blood pressure increases the resistance to pumping blood
from the left ventricle, thus increasing heart load.
As a result of left ventricular hypertrophy to increase the contraction. Hypertrophy is
characterized by an increased wall thickness, which deteriorates the function space, and a
cardiac chamber dilatation.
However, the ability of the ventricle to maintain cardiac output with compensated hypertrophy
and dilation eventually exceeded and heart trouble. Heart increasingly threatened as the severity
of coronary atherosclerosis3. High blood pressure increases the heart, and over time, it can cause
the heart muscle becomes weak.
The function of the heart as a pump to increase blood pressure in the left atrium is enlarged to
the chambers of the heart and blood pumped by the heart each minute (cardiac output) to be
down, which without treatment, symptoms of heart failure may develop ingestive 4. High blood
pressure is the most common risk factor for heart disease and stroke. Ischemic heart disease can
cause (decreased blood supply to the heart muscle in the incidence of angina pectoris and heart
attacks) from the increased supply of oxygen needed by the heart muscle is weak.
High blood pressure also contributes to blood vessel walls that can aggravate atheroscherotis. It
will also increase the risk of heart attack and stroke4.
Bulla is a fluid-filled chamber (diameter ranging from 1 cm to very large) in the lung parenchyma
that occurs due to the deterioration of network alveola5. One of which play a role in the
1907
respiratory process is the presence of a negative pressure in the pleural cavity during the
respiratory cycle. In the event of a leak due to rupture of alveoli, bulla or bleb so will lead to a
relationship between a ruptured alveoli with pleural cavity, or leak chest wall trauma, then the
air will move into the pleural cavity negative pressure to the same pressure is reached or until
the leak closed. Negative pressure in the pleural cavity is not equal throughout the pleura, the
negative pressure at the apex compared with basal area. The mechanism of spontaneous
pneumothorax is the result of a more negative pressure in the lungs compared with the peak of
the basal part and the pressure difference will cause distension greater at the apex of the alveoli.
Excessive distension in normal lung will cause rupture subpleural alveoli. Another thing that
often causes spontaneous pneumothorax is rupture of bullae or subpleural bleb 5.
2.
Case Presentation
Mr. SP aged 62 years old admitted to PGI Cikini Hospital. Patient diagnosed with CAD, HHD, Lung
Bulla. The patient was hospitalized PGI Cikini dated October 3, 2014. Initially patient present with
shortness of breath, coughing mixed with blood, chest pain, blood pressure of 140/90 mmHg, 3636,30C temperature, pulse 72-82x/ min, respiratory 20x/min, 1-2 pain scale.
History of present illness patient feel chest pain radiating to the back, palpitations, shortness of
breath. Past medical history is of type II diabetes, hepatitis B. The results of echocardiographic
examination showed LVH, with suspected CAD, diastolic dysfunction milk (Grade 1) and
decreased LV systolic function. And from the results of chest X-ray showed pulmonary infiltrates
appear smooth left apex, blood glucose tests as 199 mg/dL.
3.
Discussion
Based on clinical data and the results of echocardiographic examination, radiographic
examinations, laboratory tests patient has diagnosed CAD, HHD, Lung Bulla.
1908
Hematological examination on October 4, 2014 showed the presence of some abnormal results,
including high blood sedimentation rate of 17 mm/h (reference value of 0-10 mm/h), low
hemoglobin 12.5 g/dL (reference value of 13.0 - 16.0 g/dl), erythrocytes 4.32 mm3 (reference
value of 4.5 - 5.5 million mm3), a low hematocrit 38% (40 - 48% reference value), high Eosinophils
5% (reference value 1-3%), neutrophils Trunk low 0% (2-6% reference value), high Monocytes
10% (2-8% reference value), high patient APTT 43.4 second (reference value 26,4 - 37.5 seconds).
Examination of Clinical Chemistry on October 4, 2014 indicated that there were some abnormal
results, including lower total protein 5.4 g/L (reference value of 6.0-8.0 g/L), low albumin 2.1 g/L
(reference value of 3.4 - 4.8 g/L), Calcium (Ca) low 8.1 mg/dL (reference value of 8.8-10.3 mg/dL)
and high blood glucose When 199 mg/dL (reference value 70-150 mg/dL).
Immunology examination on October 4, 2014 showed no abnormal results, including high HBsAg
232.60 S/N (Reference value > 2.0 : Positive).
Blood Pressure examination conducted regularly starting on October 3 to October 9, 2014. From
the data, high blood pressure on October 3, 2014 at 20:00 pm by 160/100 mm/Hg.
The treatment given during hospitalization. PGI Cikini include Captopril 12.5 mg tab, allopurinol
100 mg tab, Ponstan 500 mg tab, Bicnat 500 mg tab, Vitamin K tab, Transamin 500mg tab, Heplav
50mg tab, Novorapid Flexpen 10u, 25u Lantus Flexpen, folic acid tab, Fluimucil 600mg tab.
Captopril 12.5 mg tab is indicated for lowering blood pressure, allopurinol 100 mg tab drug
indicated for gout and hyperuricemia, Ponstan 500 mg tabs is indicated for pain, Bicnat 500 mg
tab indicated for acidosis seen from the value of urea (60 mg/dL) and triglyceridese (1.7 mg/dL),
Vitamin C tabs and 500mg tab Transamin as blood clotting factors due to the length of
erythrocyte sedimentation rate (17 mm/h) and APTT (43.4 seconds), Heplav 50mg tab indicated
for Hepatitis B, Novorapid Flexpen 10u as diabetes type II drug that works short-acting, Lantus
Flexpen 25u as drug DM type II who worked Long acting, folic acid tab are indicated for anemia
1909
patients experience coughing up blood and hemoglobin levels (12.5 g/dL), erythrocytes (4.32
mm3), Fluimucil 600mg tab indicated for dry cough.
4.
Drug Related Problem (DRP)
4.1 Adverse drugs reactions.
A. Patient experience renal failure that seen from laboratory results of urea value 60 mg/dL
(reference value of 10-50 mg/dL) and triglyceridese value 1.7 mg/dL (reference value of 0.6-1.1
mg/dL). But doctors give ponstans as NSAID that can aggaravete renal function. NSAIDs inhibit
COX catalyzes the formation of prostaglandins and impair renal function by decreasing the
synthesis of renal vasodilator synthesized in the kidney cortex and medulla by vascular
endothelial and glomerular mesangial cells. the use of NSAIDs in renal ischemia causes an
increase in the activity of prostaglandins that can cause a decrease in the balance between
vasoconstrictor and vasodilator activity in the kidney and increases blood pressure (DiPiro ,
2002).
B. In laboratory test did not reveal any hyperuricemia so use Allopurinol is not required.
4.2 Need additional medication.
A. On CAD disease should be added vasodilator drug such as CCB (Organic Nitrate).
B. On HHD and DM type 2, Captopril is drug of choice, but Captopril can cause dry cough side
effect. At this time the patient still experience cough with blood. So it is suggested that change
Captopril with ARB, Losartan, Valsartan.
C. From the result of Clinical Chemistry Examination it can be seen that the patient has
hypoalbuminemia, so that he need treatment for overcome the complaint
D. The Patients experienced cough with blood, use feared he has infection so giving antibiotic is
recommended.
4.3 Patient Uncompliance
1910
Non-compliance in drug delivery, among others Transamin 500mg tabs, Heplav 50mg tab,
Novorapid Flexpen 10u, 25u Lantus Flexpen not granted on October 3, 2014. Folic acid tabs and
600mg tab Fluimucil not granted on October 3, 2014 - October 4, 2014.
4.4 Dose is too high
The doses of Natrium bicarbonate is too high, doctors gave BicNat at the dose of 3x500mg but
the patient consume the drug at the doses 3x1000mg.
4.5 Drug interactions
A. Mefenamic acid (Ponstan) and captopril
mefenamic acid can decrease effects of captopril. NSAID decrease biosintesi of prostaglandin so
that the effect of Captopril can reduce.
B. Captopril increased the effect novorapid and Lantus increase hypoglycemic effect.
C. Allopurinol increased risk of toxicity Captopril, if Captopril use together with allopurinol
especially on renal function.
5.
Conclusion
Based on the result of monitoring treatment there is founded Drug Related Problems that is
adverse drug reaction, need additional medication, patient unclompliance, dose is too high, drug
interactions.
REFERENCES
1.Kang Y., Yang, I- S., & Kim, N. (2010). Corelates of health behavior in patiens with coronary
artery disease. Asian Nursing Research. 4 (1), 45-55.
2.Marulam M. Panggabean; Heart Disease Hypertension; Textbook of Internal Medicine Volume
III Fourth Edition; Hall Publisher Faculty of Medicine, University of Indonesia; 2006; 1639-1640
1911
3.Adnil Basha; Hypertensive Heart Disease; Textbook of Cardiology; Hall Publisher Faculty of
Medicine, University of Indonesian; 2003; 209-211.
4.Munther, K., & Homoud (2008) Coronary artery disease. Tufts New England Medical Center
Spring.
5.Sahn SA, Heffner JE. Spontaneuos pneumothorax. N Eng J Med 2000; 342 : 868-74.
6.Baxter, K. 2008. " Stockley's Drug Interaction ". Eight Editions. Pharmaceutical Press, London
and Chicago.
7.Lacy, CF, Armstrong, LL, Goldman, MP, lance, LL, 2009. Drug Information Handbook., APHA,
American.
8.MOH. 2008. "National Indonesian Medicine Information". Director General of Food and Drug
Administration. Jakarta.
9. Sutedjo, AY. 2009, Handbook Know Disease Through Laboratory Examination Results., Amara
books. Yogyakarta.
1912
STUDY OF DISEASE OF STRUMA THYROID WITH
ANNOYANCE COMPLICATED BALANCE ELECTROLYTE IN
GATOT SOEBROTO ARMY HOSPITAL
RosnaHarun1, Diana LailaRahmatillah2
1
Student of Pharmacist Profesional Program, Faculty of Pharmacy
2
UTA’45, Jakarta, Indonesia
Email :harunrosna@yahoo.co.id
ABSTRACT
Struma thyroid gland enlargement is caused by the addition of a tissue of glands which produces
thyroid hormone in a large quantities (hipertyroidism). Clinical symptoms of weight, tremors,
rapid fatigue, couldn't stand the heat, heart pounding, sometimes it accompanied with an
irregular heart rate and heart attack4.Excess thyroid hormones cause a thickening of the left
ventricle carries an increased risk of heart failure4. Two main thyroid hormone produced are
thyroxine (T4) and triodotironin (T3)4. There is patientMrs.Rsmaged 41 years attended to the
GatotSoebrotoHospital on December 11, 2014 with complaint body shaking during ± 2days and
at night fever, patient has a history of ulcer disease and struma of thyroid.Accompanying
diagnosis after treatment ofhiponatremia, hypokalemia and anemia, on December 11,2014,
chemical examination conducted clinics and Hematology showed the existence of a decrease in
sodium: 122 (mg/dL), a decrease of potassium that is 3.4 (mg/dL), hemoglobin decrease i.e. 11.9
(g/dL), decreased hematocrit 32 (4.2%), and the erythrocytes (million/: l), and platelets 131000
(/:l).Therapy treatment that obtained in 5 days are IV FD Nacl 0.9% + 3% Nacl, KCL, Paracetamol,
ranitidine and propanolol.
Keywords :Struma thyroid,Balanceelectrolyte, RSPAD GatotSoebroto,
1913
INTRODUCTION
The pituitary gland iodine controls processing that is used by the thyroid gland. Iodium is the
main ingredient that needs for body to form of thyroid hormone, thyrodstimulatinghormone
(TSH), arrange by thyroid datur releasing hormone (TRH) anneurohormon hipotalamaus5.
Thyroxine shows negative reciprocal of TSH secretion by working directly on the pituitary gland
produces thyroid tirotironin three types of different hormones.TheyareThyroxine (T4), T3 and
calcitonin4.5. T3 and T4 is a molecule containing amino acids niodium which is then synthesized
and stored in a state bound by proteins in the cells of the thyroid and in a state bound by the
protein binding of thyroxin-binding globulin (TBG)1.
The thyroid gland is working efficiently in taking iodine and blood and then agglutinated in the
gland cells where there is ions iodide will be converted into a molecular iodine reacts with
thyroxine (an amino acid) to form thyroid hormone secretion, thyrotropin/TSH by the pituitary
gland control celerity released of thyroid hormone, the next released of TSH on thyroid hormone
levels by specified in the blood decreases, the release of TSH was increased so that an increase in
output triiodothyronine (T3) and tetraiodothyronine (T4) this situation is an example of feedback
control (feeds back control)1. Thyrotropinreleases the hormone (TRH) which secrete by
hypothalamus exert influence that governs the release of TSH from hipofisis1. When TSH in the
blood decreases can express and can increase the output of T3 and T41.
Some drugs and plight can influence thyroid metabolism and release of synthesis and inhibits the
synthesis of T4 through feedback adversely increase the release of TSH1. Clinical symptoms in
patients hipertyroid in the synthesis of thyroid hormone deficiency will lead to increased
production of the hormone TSH which could lead to increase in the number and increase
hyperplasia cells thyroid hormone normalize to tiroid1,4. If the process is continued,it will cause
an enlargement of the thyroid gland if this process happens continuously inborn error will occur
the synthesis of thyroid hormone in the thyroid gland in the hiperthyroid forced out of bounds to
secreting so as to meet the needs of the cells of the thyroid gland enlarges and pressing of the
trachea and the esophagus area so impaired respiration, swallowing and shortness of breath may
also be caused by weakness of the respiratory muscles which can lead to dipsnea and edema1.3.
1914
Cardiovascular system like palpitations with a combination of thyroid hormones and
catecholamines thyroid hormone which influence in SA node and the presence of a vulnerability
to excessive hipertyroidism patients against sympathetic dystrophy system stimulation
sympathetic dystrophy chest pain/angina3. It is thought to be due to the increase of consumption
of oxygen by muscles heart1. Effects of T3 on the heart muscle as well as increased peripheral
oxygen needs, increasing ofpulse frequency and will rapidly if the activity as well as any change
of emotion, shortness of breath because there is a rise in oxygen consumption and heart of
precipitation at the time of activity4,6. In addition to the vital capacity will decrease the
circulatory disorders accompanied by new ventilation and if not found any signs of heart
failure1.3.
Often sweating as a result of the nature of thyroid hormones iscalorigenic due to an increase in
metabolic rate continuously hipertyroidismsufferers sometimes have trouble sleeping, effect on
the sensitivity of the nerve Synapse muscle tonus due to contain the occurrence of tremor is
smooth with a frequency of 10-50 x/s, the pulse flutter or above normal thyroid hormone effects
is also accelerating the work of the heart, eksoftalmus inflammatory reaction that occurs is
outoimun that adopting muscle extraocular, so that the muscles of the eyeball pressed out4,5,6.
Complications in heart rhythm disorders that impact (arrhythmia) due to irregular heart
contractions and ends in heart attacks and a crisis of thyrotoxic1,3,4.
CASE PRESENTATION
Patient Mrs.Rsm aged41 years old enteredGatotSoebroto Hospital on December 11, 2014 with
complaint shuddered of body since 2 days ago before entering the hospital and fever during the
night.a History of previous illness is struma of thyroid and ulcer treatment therapy. It was given
during 5 days treatments i.e. propanolol 10 mg 2x1 tablets for the treatment of hyperthyroid,
ranitidine 150 mg injection 2x1 ampules for stress ulcer and onandsentron 4mg 3x1 injection
ampules to prevent nausea and vomiting. Diagnosis of diseases that accompany the after care in
hospital are hiponatremia, hypokalemia and anemia.
CLINICAL EVALUATION
1915
The therapeutic principles for treatmenthipertyroidismdisease that breaks and a diet high in
calories, protein, multivitamins and minerals6.This is necessary in order to hypermetabolism in
patient not increasing4, nitrogen and calcium balance negative, then given antityroid drugs4,5.
Patient
gotpropanolol 10 mg 2x1 tablets for the treatment of thyrotoxicosis and to the
supraventricular of arrhythmia which is caused by hipertyroidism1,3. The patienthad a fever every
night got paracetamol 500 mg tablet 3x1 as antipyretic2.3, patient had a history of ulcer that was
got Ranitidine 150 mg 2x1 ampule2.3. Additional diagnosis in the patient of hiponatremia,
hypokalemia, and anemia therapy, patient got IV FD Nacl 3%, Nacl 9% which was parallel on the
drip with KCL and hyponatremia for the treatment of hypokalemia2.3.
LABORATORY RESULT DATA
Laboratory value
Hematology
Normal
11/12/14
13/12/14
15-12-2014
Hemoglobin
12-16 g/dl
11.9*
11*
11.4*
Hematocrit
37- 47 %
32*
31*
3.1*
Erythrocyte
4.3-6.0 billion/µl
4.2*
3.8*
4.0*
Sodium
135-147mmol/L
122*
121*
124*
Potassium
3.5-5.0mmol/L
3.4*
2.7*
3.1*
DRP 1
Patient was not getting the anemia therapy (indication was not handled)
DRP 2
For dispensing propanolol singly to note again because according to the literature that usually
combined propanolol as additional therapy with other antityroid drugs because it has a small
contribution for the treatment of hipertyroidism3. Propanololis usually used for granting post
thyroid surgery to prevent the occurrence of increasing heart pulse1.
CONCLUSION
1916
Based on the result of the practice of the Registrar of clinics on child care spaces at the
GatotSoebrotoHospital then it can be concluded that the existence of drug related problems
which happened in the patient, experience anemia who required therapy but did not receive
therapy treatment for this condition (indication which was not handled). For dispensing
propanolol singly to note again because according to the literature that usually combined
propanolol as additional therapy with other antityroid drugs because it has a small contribution
for the treatment of hipertyroidism3. Propanololis usually used for granting post thyroid surgery
to prevent the occurrence of increased heart pulse1.
REFERENCES
1.
Sumanggar Ps. Thyrotoxicosis di bagian Ilmu Penyakit Dalam Jilid I. Bagian Ilmu Penyakit
Dalam FK UNDIP Semarang 1981 hal. 53.
2.
BNF 61, 2011 British National Formulary 61 March 2011
3.
BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung Seto
4.
Djokomoeljanto, 2001., Kelenjar Tiroid Embriologi, Anatomi and Faalnya., Dalam:
Suyono, Slamet (Editor)., 2001., Buku Ajar Ilmu Penyakit Dalam.,FKUI., Jakarta
5.
De Jong. W, Sjamsuhidajat. R., 1998., Buku Ajar Ilmu Bedah. Edisi Revisi., EGC., Jakarta
6.
http://www.emedicine.com/med/topic917.htm
1917
EVALUATION OF PATIENT TREATMENT OF DIABETES
MELLITUS AND RBBB (RIGHT BUNDLE BRANCH BLOCK) AT
ISLAMIC CEMPAKA PUTIH JAKARTA HOSPITAL
Maryanti Tuharea1, Diana Laila Ramatillah2, Aprilita Rimayanti Eff2, Ihsanil Husna3
1
2
3
Doctor at Cempaka Putih Islamic Hospital Jakarta
Email: maryantituharea@gmail.com
ABSTRACT
DM (diabetes mellitus) is a metabolic disorder which is characterized by hyperglycemia
associated with abnormalities in the metabolism of carbohydrates, fats, and proteins caused by a
decrease in insulin secretion or a decrease in insulin sensitivity, or both and cause chronic
complications microvascular, macrovascular, and neuropathy3.
RBBB (Right bundle branch block) right bundle branch block is one of the cardiac conduction
system defects. at the time it happened, right bundle branch block right ventricle is not activated
directly by impulses that travel through the right bundle branch.
The patient, Mrs.Y , aged 48 years, entered the Islamic Hospital Jakarta on 3rd May 2014 with a
diagnosis: DM and RBBB. Therapy treatment during hospitalized ie Aspar K, Rantin, Metformin
500 mg, Aspilet, amlodipine, Simarc 2 mg, simvastatin, meticobal, Novorapid, Rantin Extra. In this
case found a Drug Related Problems (DRP) which was the indication without drugs and
interactions between Rantin and metformin in which the effect of metformin may increase,
causing a slow heart rate, muscle pain, shortness of breath, abdominal pain, fainting, and
drowsiness.
Keywords: Diabetes Mellitus, RBBB (Right bundle branch block).
1918
INTRODUCTION
Diabetes mellitus (DM) is defined as an illness or a chronic metabolic disorder with multiple
etiology that is characterized by high blood sugar levels accompanied with impaired metabolism
of carbohydrates, lipids, and proteins as a function insufficiency of insulin by the beta cells of
Langerhans of the pancreas gland, or due to lack of responsiveness of cells to insulin3.
Diabetes mellitus or diabetes is a chronic metabolic disease characterized by hyperglycemia
resulting from absolute deficiency of insulin or the occurrence of resistance in insulin receptors.
The symptoms of diabetes are Glukosaria, 3P (Polyuria, polydipsia, and polyphagia), weight loss,
wounds that are difficult to heal, tingling / numb, lethargy, weakness, and ketoacidosis.
The classic symptoms of diabetes is characterized by plasma glucose as 200 mg / dL (11.1 mmol /
L). Plasma glucose at any moment of time is the result of the examination on a day without
regard to time of last meal, fasting plasma glucose level of 126 mg / dL (7.0 mmol / L), fasting
means patients do not get the extra calories at least 8 hours, 2-hour plasma glucose levels in
OGTT (Oral glucose Tolerance Test) 200 mg / dL (11.1 mmol / L), the OGTT (Oral glucose
Tolerance Test) conducted by WHO standards, using a glucose load equivalent to 75 g of glucose
anhidrus dissolved into the water.
The main goal of therapy is to achieve DM good metabolic control in order to prevent long-term
complications. Unfortunately, the data in Indonesia regarding the quality of the management of
patients with type 2 diabetes is still not sufficient.
RBBB (Right bundle branch block) right bundle branch block is one of the cardiac conduction
system defects. In the event of a right bundle branch block right ventricle is not activated directly
by impulses that travel through the right bundle branch.
In the event of a right bundle branch block, right ventricle is not activated directly by impulses
that travel through the right bundle branch. Right bundle branch block usually has a pathological
cause although it can also be seen in healthy people the prevalence increases with age.
CLINICAL EVALUATION
Patient Mrs.Y, aged 48 years old entered the Islamic Hospital in Jakarta on December 3rd, 2014.
Patients came with symptoms of dizziness, nausea, vomiting, lethargy, lack of appetite. These
complaints felt throughout the day before admittedin hospital. In this case the patient got
1919
treatment therapies tablet Rantin given on 4 December 2014 to address the oral route stomach
irritation. The aim of this drug is delivery inhibits gastric acid secretion, amlodipine given on
December 5th, 2014 to control blood pressure due to the high calcium ions in the blood, giving
this amlodipine to inhibit calcium ions when blood entering the channel slow or selective voltage
sensitive areas in vascular smooth muscle and myocardium during depolarization. On December
5th also given simvastatin at night because it's essentially the formation of cholesterol at night.
Simarc given on December 5th 2014 as therapy treatment at night, the drug is given in order to
prevent of venous thrombus and as adjunct therapy to cope with coronary blockages. This
medicine is given to the prevention of venous thrombosis and as adjunct therapy to cope with
coronary blockages. Aspilet for the treatment and prevention of angina pectoris and myocardial
imfarc, given on December 6th, 2014. On December 4, high glucose levels of patient treated
with the administration of intravenous route Novorapid therapy that the patient's blood sugar
rapidly decreased until the 5th of December, giving of novorapid dismissed and replaced by
administration of metformin oral route on December 6, 2014. For diabetes mellitus Type II failed
controlled with diet, especially in patients who are obese, metformin also increase the sensitivity
of cells to insulin with a way to improve transport and increasing the use of glucose by muscle
cells and extra-hepatic other. On December 4, 2014 patients treated with Aspar K in which the
drug is used as an additional potassium in heart disease, in addition to the Aspar K is also used
for adjunctive therapy in the use of insulin. Meticobal given from 6 to 8 December 2014. It is
used for peripheral neuropathy and megaloblastic anemia due to vitamin B12 deficiency.
DOSAGE AND METHOD OF TREATMENT
Patient treated with 0.9% NaCl was given 30 drops / min on day one to day two with intravenous
administration to restore electrolyte balance, Aspar K is given for three times a day by the oral
route on day two where the patient injected insulin Novorapid 3x10U day up to three to lower
the blood glucose levels of patient and after the administration of insulin stopped on the fourth
day subsequent to therapy prevents high glucose levels, patient given metformin 500 mg , given
three times a day with the oral route of administration on day five. Aspilet given at a dose of 80
mg daily oral route, amlodipine 5 mg given once daily oral route, Simarc 2 mg was given in the
evening once a day by oral administration route. Rantin given twice daily administration of oral
1920
route, Simvastatin 20 mg given in the evening once a day oral route, Meticobal 250 mg once a
day oral route.
LABORATORY RESULTS
The results of laboratory tests performed by the patient Mrs. Y. laboratory showed that indicates
abnormal hemoglobin was 13.4 g / dL (normal values: 11.7 to 15.7), leukocytes 10.40 thousand /
ml (normal value: 3 , 60 to 11.00), hematocrit 39 (35-47) Platelets 485 thousand / ml (normal
value: 150-440), erythrocytes 4.56 106 / ml (3.80 to 5.20), MCV / VER 85 Fl (normal values: 80100), MCH / HER 29 pg (26-36), MCHC / Kher 35 g / dl, MCHC / Kher 35 g / dL (normal values: 3236), Sodium 130 mEq / dl (value norm 135-142), potassium (normal value: 3.5-5.0) chloride 90
mEq / dl (normal values: 94-111).
DRUGS RELATED PROBLEM (DRP)
1.
Drugs Interactions
a.
Warfarin + Aspilet
Using warfarin together with aspirin can cause bleeding.
Pharmacist intervention: required dose adjustments based on the prothrombin time or
International Normalized Ratio (INR). Contact your doctor immediately if unusual bleeding
b.
Amlodipin + Simvastatin
Simvastatin increased levels it may increase the risk of side effects such as liver damage and a
rare but serious condition called rhabdomyolysis involving damage to muscle tissue. In this case
the patient did not do check triglyceridese clearance and serum triglyceridese.
c.
Ranitidin + Amlodipin
Can cause bleeding, in this case the patient did not do a APTT test.
Pharmacist Intervention: Required dose adjustment in addition to the testing of prothrombin
time or International Normalized Ratio (INR). Immediately contact your doctor if you have
unusual bleeding or bruising.
d.
Aspilet + Amlodipin
Cause an increase in blood pressure.
Pharmacist intervention: Need to adjust the dose or blood pressure examination.
e.
Rantin + Metformin
1921
Increasing effects of metformin which can cause lactic acidosis conditions that can enandger life,
increasing sleepiness, slow heart rate, muscle pain, shortness of breath, stomach pain, feeling
light-headed, and fainting.
f.
Metformin + Nevorapid
Increasing effects of metformin, hypoglycemia..
Pharmacist intervention: shoud to check the blood sugar test.
2.
There were indications without giving the drugs
In this case the patient's levels of sodium and chloride decreased so it could intrude the
equilibrium of liquid electrolytes in the blood of patients.
Pharmacist Intervention: Provide adequate hydration to overcome the decreased levels of
sodium and chloride in liquid form Ringer lactate to help patient improving the balance of
electrolytes in the blood fluid.
CONCLUSION
Based on the observation that have been made in the case of a patient, it can be concluded that
the results of the doctor's diagnosis and examination results laboratotium patients suffering from
diabetes (Diabetes Mellitus), and RBBB (Right bundle branch block). Patient received treatment
and it found any problems in the DRP such as drug interactions and no drug given.
REFERENCES
1. Gunawan S. 2012. Farmakologi and Terapi, Universitas Indonesia Fakultas Kedokteran Jakarta.
2. Goldman, Lee.,2011. Goldman’s ecil Medicine Edisi 24. Philadelphia: Elsevier Saunders.
3. Nugroho, Dr. Agung.2009.Farmakologi Obat-obat Penting dalam Pembelajaran Ilmu
Kefarmasian and Dunia Kesehatan,Universitas Gadjah Mada Yogyakarta
4. Tan, Pinem, dkk, 2012. Appropriateness Of Prescribing Oral Hypoglycemic Drugs In Diabetes
Mellitus Type 2 According To Perkeni Consensus 2011 In Outpatient Clinic Of Abdul Moeloek
Hospital Bandar Lampung 2012. Diakses 11 November 2014
5. PERKENI. 2011. Konsensus Pengendalian and Pencegahan Diabetes Mellitus Tipe2 di Indonesia
2011. PB PERKENI. Jakarta.
1922
EVALUATION TREATMENT OF ACUTE LYMPHOBLASTIC
LEUKEMIA PATIENTS AT GATOT SUBROTO ARMY
HOSPITAL
Fatmawati Hardiyanti Putri1, Diana Laila Ramatillah2, Aprilita Rimayanti Eff2
1
2
Email :ayzaishi@gmail.com
ABSTRACT
Leukemia is a malignant hematopoietic diseases characterized by unlimited proliferation of
lymphocytes. There is a very quickly changes where these cells replace normal blood marrow
elements6. Patients WK came to the Pediatric to continue chemotherapy he has been
undertaken. Therapy treatments he had received during the course of chemotherapy at Gatot
Subroto Army Hospital were Methotrexat, vincristine, Dounorubisin, Dexamethasone, Alinamin,
Onandcetron, Cotrimoxazol, Curcuma, Allupurinol, Colistin, nystatin, BRM (Bilogical Response
Monofire). From the results of the monitoring on drug therapy, the patient, WK obtained DRP
(Drug Related Problems), including the dosage regimen is not in accorandce with the literatures
and also presence of adverse drug effects.
Keyword : Acute Leukimia Limphoblastik (ALL), RSPAD Gatot Soebroto.
1923
INTRODUCTION
Leukemia is the most common diseases suffered by children, for 33% of the total cancer cases
are found in children1,6. LLA is more often occurs in boys than girls9,6. Leukemia is a malignant
hematopoietic diseases characterized by unlimited proliferation of lymphocytes. There is a very
quickly changes where these cells replace normal blood marrow elements4,6.
LLA treatment includes several stages: remission induction, consolidation, intensification, the
treatment of central nervous system, and maintenances. With the exception of mature B-cell
leukemia that only require short term but intensive therapy, all children with LLA received
treatment within 2 to 3 years5..
CLINICAL EVALUATIONS
In the treatment, patient was given 1.5 mg Vincristine injection intravenously. Vincristine is a
vinca alkaloid class of cytotoxic drugs, used to treat acute leukemia and lymphoma at a dose of
1.5 mg based ALL treatment protocols in 2006. Alinamin 5 cc injection intravenously given to
cover the side effects of vincristine. Onandsetron Injection 3 mg intravenously to prevent nausea
and vomiting due to chemotherapy, daunorubicin 30 mg injection IFVD for the treatment of
acute leukemia in the induction phase, dounorubicin an anthracycline antibiotic class of cytotoxic
drugs. And for methotrexat it’s postponed, in order to await the patient's platelets within safe
limits to be given intrathecally to prevent bleeding. In addition to cytotoxic drugs for
chemotherapy, patient were also given drugs for prophylactic treatment support such as
Dexamethasone, it should be administered during the induction period. It may be useful as an
immunosuppressant or supportive palliative therapy in children with leukemia to reduce
intracranial pressure and also to control vomiting when combined with the appropriate
antiemetikum. Cotrimoxazole 120 mg 2 x 2 tablets are given to prevent pneumonia infection in
one week used within 3 days of use. They are on Monday, Wednesday, and Friday. Curcuma
given 3 times a day to help increase patient’s appetite. Allopurinol 100 mg given every 3 times a
day to overcome hiperleukositosis. Colistin 500,000 ui given every 3 times a day to prevent
infections due to gram-negative bacteria, and Nystatin 500,000 iu given every 3 times a day,
indicated for the prevention of candidiasis for mucisitis treatment due to side effects of
1924
chemotherapy. Biological Response Modifiers or better known by the acronym BRM used to
improve the immune system and the biological system of the patient. On 21 October, the patient
was given 12 mg Methotrexat route intrathecal. Intrathecal administration aims to prevent the
occurrence of central nervous system depression. Methotrexat is an antimetabolite that
prevents cell division, and combined with intrathecal dexamethasone to prevent organ rejection
in sensitive areas such as the mediastinum2,8.
DOSE AND HOW TO USE
Methotrexate was given for one day at a dose of 12 mg with intrathecal route. Dexamethasone 1
mg route intrathecal, Vincristine 1.5 mg by intravenous route, Alinamin 5 cc route intravenous,
30 mg Dounorubisin route IV Drip, onandcetron 3 mg by intravenous route. Supportive
treatment are; 4-4-4 Dexamethasone tablets every 12 hours, cotrimoxazol 1 tablet by the oral
route, cucuma 1 tablet by the oral route, Allupurinol 100mg oral route, tablets colistin 500,000 iu
the oral route, tablets nystatin 500,000 iu the oral route, BRM 1 capsules by the oral route.
LABORATORY RESULTS
The results of laboratory tests performed by patient WK:
Laboratory use values that indicate abnormal hemoglobin was 11.2 g / dL (normal values: 13-18
Mg / dL), hematocrit 33% (normal value: 40-52%), erythrocytes 3.8 million / mL (normal value 4,
3 to 6.0 million / mL), 700 leukocytes / mL (normal value 4800-10800 / mL), platelets 690 000 /
mL (normal value: 150,000 to 400,000 / mL), Eosinophils 0% (normal value: 1-3% ), Trunk 0%
(normal value: 2-6%), segment 6% (normal value: 50-70%), lymphocytes 63% (normal value: 2040%), monocytes 0% (normal value: 2- 8%).
1.
Doses Regimen
In this case, the patient got nystatin which dose and frequency of administrations are not in
accorandce with the dose and frequency found in the literature2. Where Nystatin should be given
every 6 hours in a day or 4 times a day, but it was given every 8 hours a day or three times a day.
2.
Adverse Drugs Effects
1925
In this case, patient experienced adverse drug effects, the patient experienced Leukopenia due
to the side effects of chemotherapy drugs that was given, in dealing with side effects, doctors
advise patient continously to keep the environment clean, wear a mask daily as long as the
condition of leukopenia, and maintain oral hygiene to prevent the risk of high infection.
Pharmacyst interfention : Meanwhile, the most effective way in the management of Leukopenia
is to address the cause (symptomatic). Because there is no diet, or drugs can increase the
number of white blood cells. If granulocytes very low, then the patient must be protected by a
source of infection. Culture from all orifices (eg, nose, mouth), blood also very important, and if
the fever come, it should be treated with broad-spectrum antibiotics, oral hygiene should be
maintained. The purpose of this treatment in addition to treatment of infection is to eliminate
the causes of bone marrow depression. Bone marrow function would return to normal
spontaneously (except in neoplastic disease) within 2 or 3 weeks if deaths from infections
preventable10.
CONCLUSION
Based on the observations that have made in the case of a patient, it can be concluded:
-
The patient diagnosed with Type 1 and election ALL therapy cancer treatment was in
accorandce with the standard procedures followed SPM Gatot Subroto Army Hospital and
chemotherapy protocol ALL Indonesia in 2006.
-
Patient experiencing some problems associated with the treatment, including the dosage
regimen was unappropriate, and adverse drug effects, that was leukopenia.
REFERENCES
1. American Cancer Society. 2009. Children and Cancer: Information and resources.
2. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung Seto.
3. Komaruddin, Boenjamin. 2012. Standar Pengobatan Medik Leukimi Limfoblastik Akut (LLA).
RSPAD Gatot Soebroto Ditkesad. Jakarta.
4. Luxuner, K.L. 2005. Delmar’s pediatric nursing care plants. Ed Clifton Park: Thomson learning.
P 619-632.
1926
5. Mia, R., IDG Ugrasena. at all. 2006. “Pengelolaan Medik Anak dengan Leukimia and
Kemungkinan Perawatan di RS Kabupaten”. Divisi Hemato-Onkologi Bagian Ilmu Kesehatan
Anak FK Unair RSU Dr. Soetomo Surabaya.
6. Mariasima, Tiurlan. 2011.”Respond and Koping Anak Penderita Leukimia Limfoblastik Akut
dalam Menjalani Terapi di Jakarta and Sekitarnya”. Universitas Indonesi. Jakarta
7. Medscape.Drug Interaction. 2014
8. Protokol Kemoterapi Acute Leukimia Limfoblastik Indonesia.2006
9. Tomlinson, D., & Kline, N.E. 2010. Pediatric oncology nursing anvanced clinical handbook (2th
edition). New York: Springer Heidenberg.
10. Suzanne C. Smeltzer, Bare G. Brenda. 2002. Buku Ajar Keperawatan Medikal Bedah.
EGC.Jakarta.
1927
CASE REPORT : EVALUATION OF DRUG RELATED
PROBLEMS PATIENT WITH URINARY TRACT INFECTION
DISEASE AND THYPOID AT MINTOHARDJO HOSPITAL
Hartini Bugis1, Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
thinybugis@yahoo.com
ABSTRACT
Urinary tract infection (UTI) is a conditum when microba grow and proliferate in the urinary tract
in excessive amounts. While the Thypoid is systemic infectious disease caused by the bacteria
Salmonella typhi into the human body (digestive tract) and is characterized by a long insidius
fever, headaches, body weakness, anorexia, relative bradikardi, and splenomegaly, and also a
group of diseases that are easily transmitted and attacked many people so it can cause
outbreaks. Patient 69 years old, went to patient was hospital with complaints of thypoid since 3
days ago, fever continuously, the temperature reached 39oC, patients experience decreasing on
appetite, with urinary and defecation. Patient was areated with Ceftriaxone injection, Ranitidine
injection Cefotaxime injection, RL injection, paracetamol, Betahistin, Levofloxacin, Neurodex and
Dulcolax. The of monitoring drug use that was found DRP (Drug Related Problem). Using of
ceftriaxone and cefotaxime injection was therapy the duplication drug interaction between
Levofloxacin injection and Vitamin B1 (Thiamin) can reduce the effect of vitamin B1 (Thyamin).
Keywords: Drug Related Problem, Urinary Tract Infection, Mintohardjo Hospital
1928
INTRODUCTION
Urinary tract infection is an infection caused by microorganisms in the growing in the urinary
tract. In normal conditum urine do not contain bacteria, viruses or other microorganisms1.
Urinary tract infection has 3 following criteria. It is found germs that grow from the new breed of
liquid instead of urine or tissue taken from a location suspected of being infected, the presence
of other infections or abscesses can be seen either by direct examination during surgery through
the examination of histopatologis and there is two of the signs – signs: fever (38o C) pain
cuprapubic pain, press on the area of suspected infection. The causes of this disease are
Salmonella Typhosa and microorganisms. Salmonella Typhi, A, B, and C. This Microorganism in
feces, human feces and food or drink that is exposed to the microorganisms that brought on by
flies. In fact the main source of this disease are can environments that dirty and unhealthy.
Unlike viruses the microorganisms live in the poor sanitation such as dirty surroundings, foods
and beverages that are not higenis2.
The purpose of the treatment of urinary tract infections is to prevent the occurrence of renal
parencim damage using that can clinically improved3.
CASE PRESENTATION
Patient Mr. M. Dirin, 69 years old, was Hospital Mintohardjo with complaint of fever since 3 days
ago, continuous fever to 39oC. Patient experienced a decrease in appetitc.
The Date Of
Leukocytes
Pulse
Breathing (14-
Temperature
Examination
(5.000-10.000
(60-100x/minute)
18x/minute)
(36-37⁰C)
01/11/2014
17.700
-
-
38,5 ⁰
02/11/2014
17.000
-
-
38,5 ⁰
03/11/2014
-
-
-
37,5⁰
1929
04/11/2014
17.800
92 x / minute
24x / minute
37,8 ⁰
05/11/2014
-
80 x / minute
28 x / minute
37,4⁰C
06/11/2014
-
88 x / minute
29 x / minute
38,9⁰
07/11/2014
17.500
86 x / minute
27 x / minute
39,2⁰
08/11/2014
-
80 x / minute
09/11/2014
-
10/11/2014
-
-
37⁰
-
-
-
-
-
-
CLINIC EVALUATION
In this case patient was areated with intravenous RL. Ceftriaxon injection as an antibiotic.
Paracetamol as analgetic for reduce pain and fever. Patient also got dulcolax for handling
constipation.
TREATMENT FOR URINARY TRACT INFECTIONS AND THYPOID
Date
The Name Of
The Way A
The Drug
warding
RL
IV
√
Inj.Ceftriaxone
IV
Inj.Ranitidin
1/11 2/1
3/11
4/11
5/11
6/11 7/11 8/11 9/11 10/11
-
-
-
-
-
√
√
-
√
√
√
√
-
-
-
-
-
-
-
IV
√
√
√
√
√
√
√
√
-
√
Paracetamol
PO
√
√
√
√
√
√
√
√
-
-
Betahistin
PO
-
-
√
√
√
stop
-
√
-
√
Inj Cefotaxime
IV
-
-
-
√
√
-
-
-
-
-
Levofloxacin
PO
-
-
-
-
-
√
√
√
-
√
Neurodex
PO
-
-
-
-
-
√
√
√
-
√
Dulcolax
Supp
-
-
-
-
-
√
√
√
√
-
THE RESULTS OF LABORATORY EXAMINATION
1930
Examination of data laboratory show that increasing of leukocyt indicates patients exposed to
urinary tract infections, decrease in the number of leukocyte can occur in certain infection
sufferer. While the increase in the number of leukocyte indicates an acute inflammatory process
or infection. And result of hematologic examination increasing of leukocyte indicate the patient
experience infection.
In this physical gave enfusim of RL. In Ceftriaxon injection two daily dose for 7 day as an
antibiotic and paracetamol as analgetic. Cefotaxime as urinary tract infections, meningitis and
septicemia. Levofloxacine as acute bacterial, pneumonia, infections of the skin structures without
complications, urinary tract infection and complication and acute as pyelonephritis.
DISCUSSION
Patient came to the hospital with complaints of fever since 3 days ago, fever a constant
temperature until 390C, patient experienced a decrease in appetite, and a normal. Vital sign and
laboratory examination show increase of leukocyte that.
Imunoserology
Wal Test
S. Typhi-H
Positive 1/80
Negative
S. Paratyphi A-H
Positive 1/320
Negative
S. Typhi-O
Negative
Negative
S. Paratyphi A-O
Negative
Negative
1. There is No indication of Drug
The patient does not need to be given because in the view of Dulcolax the patient (bowel
movements and urinary is normaly.
2. Drug interaction
1931
a. Levofloxacin with Vitamin B1 (Thyamin) contained on Neurodex
Levofloxacine will lower levels or the effect of thiamin (B1) by changing the amount of flora.
b. Levofloxacin with Vitamin B6 (Pyridoxine) contained on Neurodex, will lower the levels of
Levofloxacine or effects of thiamine by changing the amount of flora.
Ranitidine with Vitamin B12 (Cyanocobalamin) contained on Neurodex, Ranitidine lowers the
levels by inhibiting gastrointestinal absorption cyanocobalamine.
CONCLUSION
Based on the results of the practice of clinical work in Mintohardjo Hospital it can be concluded
that happens DRP (Drug Related Problem) There is no indication of drug and drug interaction.
REFERENCES
1. Coyle, e. a., r. a., 2005, Urinary Tract Infection in J.T., Dipiro et al, Pharmacotherapy: A
Pathophysiologic Approach 6th, Appleton And Lange, Stamford
2. Djoko Widodo. 2006. typhoid fever. In: Aru w. Sudoyo, Bambang Setiyohadi Idrus Alwi,
Marcellus k. Simadibrata, Siti Setiati, eds. Textbook Of internal medicine. Vol III. Issue IV, Jakarta:
Publishing Department Of Pathology In The Faculty Of Medicine Of The UI.
3. RI Department of health, 2001. Center For Health Data.
4. Ngastiyah, 2005. Care Of Sick Children. Issue 2, EGC, Jakarta
5. Sukandar, e., 2004, urinary tract infection of Adult Patients. Textbook In Pathology, Vol I.
Jakarta: Balai Publisher FK UI
1932
CASE REPORT : DRUG RELATED PROBLEM (DRP)
ASSOCIATED WITH THE TREATMENT OFCONGESTIVE
HEART FAILURE (CHF)IN PGI CIKINI HOSPITAL
Iksan Santoso1,Aprilita Rinayanti Efi2,Diana Laila Rahmatillah2
1
Student OfPharmacist Program, Faculty of Pharmacy UTA'45 Jakarta
2
Email:Ikhsan_tex2@yahoo.co.id
ABSTRACT
Congestive heart failure (CHF) is a condition in which the heart failurethe to pump blood in order
to meet the needs of oxygen nutrien and oxygen adequately. This results in stretching of the
heart chambers (dilated) in order to accommodate more blood to be pumped around the body
or result in stiff and thickened heart muscle. The heart is able to pump blood only for a short
time and the walls weakened heart muscle can not pump strongly. As a result, the kidneys often
respond to resist water and salt. This will lead to dam the liquid in some organs of the body such
as arms, legs, lungs, or other organs so that the body becomes swollen. (Udjianti, 2010)
Patient Mr. AS aged 55 year old . Patients came to the hospital in with complaints of shortness of
breath, palpitations, cold sweat sleeplessness, quickly tired, nausea, constipation and swollen
feet, but did not experience chest pain, vomiting and fever. In this case the patient was treated
with Heparin Na 25000 IU / ml, KSR (Potassium chloride 600 mg), Digoxin 0:25 mg, Ranitidine 50
mg / 2 ml, Durefo (Furosemide 40 mg).
Based on the practice of clinical work in cikini hospital it can be concluded that there is found
drug related problem that are drug interaction and dose ranitidin is to low.
Keywords: PGI Cikini Hospital,Drug related problem Congestive Heart Failure (CHF)
1933
1.
INTRODUCTION
Congestive heart failure (CHF) is a condition in which the heart pumps blood repetition of failure
in order to meet the needs of the cell - the cell body nutrients and oxygen adequately. Etiology of
Congestive Heart Failure (CHF) According to(Udjianti, 2010), The etiology of congestive heart
failure (CHF) are grouped based on the etiology of the external and internal factors, namely
external factors (outside the heart) Renal hypertension, hyperthyroidism, anemia and chronic /
severe internal factors (of the heart) valve dysfunction: ventricular septal defect (VSD), Atria
Septal Defect (ASD), mitral stenosis and mitral insufficiency, dysrhythmias: atrial fibrillation,
ventricular fibrillation, and heart block, myocardial damage: cardiomyopathy, myocarditis, and
myocardial infarction, infection: bacterial endocarditis sub – acute Pathophysiology of Congestive
Heart Failure (CHF). The mechanisms underlying heart failure include an impaired ability of the
heart kontraaktifitas causes cardiac output is lower than normal, heart rate is a function of the
autonomic nervous system. When cardiac output is reduced, the sympathetic nervous system
will speed up the heart rate to maintain cardiac output.
2.
CASEPRESENTATION
Mr. The US came with complaints that patients have become heavy tightness, palpitations, cold
sweat patients have difficulty sleeping, quickly tired , nausea, bowel movementsand leg swelling
patients, but did not experience chest pain, vomiting and fever
3.
CLINICAL EVALUATION
In this case patient is treated with heparin therapy Na 25000 IU / ml to prevent trombus or
clotting, KSR (Potassium chloride 600 mg) is used to increase potassium levels that are needed to
maintain heart function in order to avoid hypokalemia and causes of weakness / quickly
exhausted, Digoxin 0:25 mg as positive inotropic drugs in order to increase the force of
contraction of the heart muscle, congestive heart failure, Ranitidine 50 mg / 2 ml is used to
prevent nausea and vomiting, ulcers duedonum acute, acute gastric ulcer, pathological
hypersecretory conditions such as Zollinger syndrome - Ellison , and other conditions associated
with gastric hiposekresi. Durefo (Furosemide 40 mg) is used for edema in the legs and associated
1934
with congestive heart failure, liver cirrhosis, kidney disease as well as additional therapy for
hypertension
4.
PATIENT EXAMINATION RESULTS
Examination of blood pressure
Examination
Systole
04 oct
130
130
5 oct
140
130
6 oct
14
13
12
0
0
0
1
140
90
80
80
90
90
90
90
90
Breathing
20
20
20
20
20
20
20
20
50kg/160
5
9
0
2
0
8 oct
9 oct
13
12
0
0
90
80
90
90
90
90
20
20
20
20
20
20
150
140
90
20
0
Diastole
BB(Kg)/TB(cm)
7 oct
120
11
0
110
50kg/160cm
1935
Examination of laboratory hematology and clinical chemistry
examination
normal
unit
The Results
hemoglobin
12,4 – 14,9
g%
15,8*
Hematokrit
40 – 48
%
48
Trombosit
150.000 – 400.000
Ribu mm3
246.000
SGOT
< 35
u/i
16
SGPT
<35
u/i
22
Uremia
10 – 50
Mg/dl
29
Kreatinin
0,6 – 1,1
Mg/dl
1,6*
Na
135 – 147
Mmol/l
141
K
3,5 – 5
Meq/l
4,1
Ca
8,8 – 10,3
Mg/dl
8,3*
Blood Sugar when
74 – 106
Mg/dl
100
CPK
10 – 80 %
u/i
68
CKMB
<1,0 u/i
u/i
13*
Troponin
<1,0
Mg/ml
0,6
5.
Profile of treatment
1936
Drug
4/10/14
5/10/14
6/10/14
7/10/14
8/10/14
9/10/14
10/10/14
11/10/14
12/10/14
Heparin
25000
25000
-
-
-
-
-
-
-
I.U./
I.U./
5 ml
5 ml
KSR
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
Digoxin
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
Ranitidin
2x1 amp
2x1 amp
2x1 amp
2x1 amp
2x1 amp
2x1 amp
2x1 amp
2x1 amp
2x1 amp
Durefo
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
1x1 tab
6. Discussion
TN. The US entered the age of 55 years old. enteredPG Cikini Hospital on the date of October
2014 At this time the patient received heparin therapy Na 25000 IU / ml Uses drugs to prevent
thrombus or clotting, KSR (Potassium chloride 600 mg) is used to increase potassium levels that
are needed to maintain heart function in order to avoid hypokalemia and causes of weakness /
fast tired, Digoxin 0:25 mg as positive inotropic drugs in order to increase the force of
contraction of the heart muscle, congestive heart failure, Ranitidine 50 mg / 2 ml is used to
prevent nausea and vomiting, ulcers duedonum acute, acute gastric ulcer, pathological
hypersecretory conditions like syndrome Zollinger - Ellison, and other conditions associated with
hiposekresi gastric.with therapy TN treatments in the US, it can reduce levels of hemoglobin,
triglyceridese patient.
7.
Drug Related Problem (DRP) :
Drug interactions (Drug Interactions), between durep and digoxin. Durep as diuretic can increse
plasma level of digoxin that can toxicity of digoxin. So it can be replaced with other diuretics are
potassium-sparing diuretics such as spironolactone. Recomendation Therapy treatment for
patients already rational, but still monitor the administration of drugs that cause interaction
1937
drug interactions as a diuretic can increase plasma level of digoxin, that can cause toxicity of
digoxin and monitoring plasma level
8. Conclusion:
Drug interactions as a diuretic can increase plasma level of digoxin that can cause toxicity of
digoxin. Recommendation monitoring plasma level based on the practical of clinical work in PGI
cikini Hospital it can be concluded that there is any drug related problem that are drug
interaction and drug dose is to low of ranitidine
REFERENCES
1. Aru, W, Sudoyo. 2009. Buku Ajar Ilmu Penyakit Dalam Jilid ketida Edisi kelima. Jakarta : Interna
Publishing
2.Jayanti,
N.
2010.
Gagal
jantung
kongestif
dalamhttp://rentalihikari.wordpress.com/2010/03/22/Ip-gagal-jantung-kongestif/
dimuat
(diakses
6
maret 2014)
3. Soeharto, Iman. 2011. Serangan Jantung And Stroke.Jakarta : Gramedia
4. Udjianti, J, Wajan. 2010. Keperawatan Kardiovaskuler. Jakarta : Salemba Medika
1938
ASSOCIATED WITH THE TREATMENT OF
INFLAMMATIONOFTHEGALLBLADDER (CHOLECYSTITIS) IN
PGI CIKINI HOSPITAL
Muhammad Saleh1,Aprilita Rinayanti Efi2,Diana Laila Rahmatillah2
1
Student OfPharmacist Program, Faculty of Pharmacy UTA'45 Jakarta
2
Email: helmi_bola70@yahoo.co.id
ABSTRACT
Cholecystitis is a gallbladder disease is divided into two, acute and chronic. Acute cholecystitis
refers to inflammation of the bile content, it is usually irritate the lining of the gallbladder and
can be solid in the cystic duct obstruction and inflammation that causes the gallbladder wall and
trigger infection(Engram, 2012). Cholecystitis is an acute inflammation of the gall bladder, the
most frequent precipitation factorstriggeringthis situation is obtruksi gallstones. Ten percent
cases of cholecystitis without gallstones usually found in patients with severe pain such as
postoperative state, severe trauma, severe burns, multisystem organ failure, sepsis, prolonged or
circumstances hyperalimentation postpartum (Mitchell, 2009). Patient aged 49 years old came to
cikini hospital with complaintsof pain in the abdomen, nausea, abdominal bloating and pain.in
this case the patient was treated with Inpepsa Sucralfate Suspension 500 mg / mL, Strocain
Tablets (400mg Polymigel), Ranitidine 150 mg Tablets, Ultracet (Tramadol HCl 37.5 mg,
acetaminophen 325 mg.), Sharox (Cefuroxime, Cefuroxime 500 mg). Based on the practice of
clinical work in PGI cikini hospital it can be concluded that there is drug related problem. that is
drug interaction between ranitidin,paracetamol and cefuroxime
Keywords:Drug Related Problem ,Cholecysititis, PGI cikini Hospital
1939
1.
INTRODUCTION
The gall bladder is a pouch-shaped avocado which is located just below the right lobe of the liver.
The main function of the gallbladder is to store and concentrate bile (Widiastuty, 2010). The
cause of cholecystitis is static bile, bacterial infection and ischemia gallbladder wall. There are
many factors that influence such as the concentration of bile, cholesterol, lysolecithin and
prostaglandins that damage the mucosal lining of the gallbladder wall was followed by an
inflammatory reaction and suppuration(Noer, 2011).sign nd Symptoms Clinical In cholecystitis
patients usually showed any and symptoms include abdominal pain, right upper quadrant or
epigastric pain, mild fever, anorexia, tachycardia, diaphoresis, and nausea / vomiting, and nausea
/ vomiting (Mitchell, 2009).long enough and got parenteral nutrition in gall bladder obstruction
due to malignancy, or emepedu duct stone is one of the complications of other diseases such as
fever typhoidal (Noer, 2011).
2.
CASE PRESENTATION
Patients Mrs RS came to PGI CikiniHospital of pain in the abdomen, nausea, abdominal bloating
and pain.
3.
CLINICEVALUATION
In this case the patient was treated with Inpepsa Sucralfate Suspension 500 mg / mL for Gastric
and ulcer doudenum, Strocain Polymigel 400mg Tablets for nausea, bloating due to gastric or
duodenal ulcer and gastritis, abdominal pain, hyperacidity, Ranitidine 150 mg tablets for stomach
ulcers and ulcer duodenum, reflux esophagitis, chronic episodic dyspepsia. Ultracet (Tramadol
HCl 37.5 mg, acetaminophen 325 mg.)
for mild and, moderate to severe pain.. Sharox
(Cefuroxime, Cefuroxime 500 mg) Prophylactic surgery, is more active against Hemophilus
influenzae and N. gonorrhoeae, infection with Gram-positive and Gram-negative infections.
4.
PATIENT EXAMINATION RESULTS
Laboratory Hematology and Clinical Chemistry
1940
Examination
unit
Reference
Values
Complete peripheral blood
Erythrocyte sedimentation
27*
mm/jam
0 – 10
rateHemoglobin
12.8
g/dL
13.0 – 16.0
Leukosit
8.2
10^3μL
5.0 – 10.0
Eritrosit
4.43
10^3μL
4.50 – 5.50
Hematokrit
38 *
%
40 – 48
Retikulosit
10
Permil
5 – 15
Basofil
1
%
0 – 1
Eosinofil
2
%
1 – 3
Neutrofilbatang
0*
%
2 – 6
Neutrofilsegmen
69
%
50 – 70
Limfosit
22
%
20 – 40
Monosit
6
%
2 – 8
Trombosit
342
10^3μL
150 – 450
MCV
86
fL
81 – 92
MCH
28.9
pg
27.0 – 32.0
MCHC
33.7
g/dL
32.0 – 37.0
Period Bleeding (IVY)
3
menit
1 – 6
Freezing Period (Lee-White)
10-11
menit
10 – 16
PT control
12.2
detik
11.0 – 14.2
Clinical Chemistry
12.5
detik
Leukocyte count
Period prothrombin(PT)
PT patient
Bilirubin Total
1941
Bilirubin Direk
Bilirubin Indirek
1.1
mg/dL
0.1 – 1.0
0.2
mg/dL
0.1 – 0.2
0.8
mg/dL
0.1 – 0.8
92
U/L
30 – 120
H 36
U/L
0 – 30
Fosfatase Alkali (ALP)
Gamma GT (GGT)
Examination of blood pressure
Tanggal
13 okc 2014
14 okc 2014
15 okc 2014
16 okc 2014
17 okc 2014
18 okc 2014
19 okc 2014
20 okc 2014
21 okc 2014
Blood Pressure
Time
time
time
SistolandDiastol
04.00
12.00
20.00
S
-
-
120
D
-
-
80
S
110
100
100
D
80
80
80
S
110
100
120
D
90
80
90
S
110
100
110
D
80
90
70
S
120
100
120
D
80
90
80
S
110
110
110
D
90
80
90
S
120
110
110
D
80
80
70
S
110
110
110
D
80
90
80
S
110
-
-
D
80
-
-
1942
5.
Profile of treatment
Date
name of
medication
Inpepsa (sukrafat
13/10 14/10 15/10 16/10 17/10 18/10 19/10 20/10 21/10
3x1
3x1
3x1
3x1
3x1
3x1
3x1
3x1
3x1
3x1
3x1
3x1
3x1
3x1
tab
tab
tab
Tab
Tab
Tab
tab
Ranitidine (150
2x1
2x1
2x1
2x1
2x1
2x1
2x1
mg)
tab
tab
tab
Tab
Tab
Tab
tab
-
-
3x1
3x1
3x1
3x1
Tab
Tab
Tab
-
-
2x1
2x1
Tab
Rantin (
2x1
2x1
ranitidin150mg)
Tab
Tab
500 mg)
Strocain
(polymigel 400
mg)
Ultacet (tramadol
hcl 37,5)
Sharox (
cefuroxime, Sefu
roksim500)
-
-
-
-
-
-
3x1
3x1
3x1
Tab
Tab
Tab
Tab
2x1
2x1
2x1
2x1
2x1
Tab
Tab
Tab
Tab
Tab
Tab
2x1
2x1
2x1
2x1
2x1
2x1
2x1
Tab
Tab
Tab
Tab
Tab
Tab
Tab
6. Discussion
The results of laboratory tests and abdominal ultrasonographyon to Mrs. RS, found some
abnormalitiesThe results of abnormal hematologic ie erythrocyte sedimentation rate,
hematocryte, and neutrophil stem indicates that the presence of gamma glutamyl transferase
and infection (GGT) show that up normal and hematology ie erythrocyte in infection thesis
incricen of gamma glutamyl transferase indicate the patient in the case. The patient was treated
with Inpepsa Sucralfate Suspension 500 mg / mL for Gastric and ulcer doudenum, Strocain
Polymigel 400mg Tablets for nausea, bloating due to gastric or duodenal ulcer and gastritis,
abdominal pain, hyperacidity, Ranitidine 150 mg tablet for gastric ulcer and duodenal ulcers,
reflux esophagitis, chronic episodic dyspepsia. Ultracet (Tramadol HCl 37.5 mg, acetaminophen
1943
325 mg.) Of short-term therapy for mild pain, moderate to severe. Sharox (Cefuroxime,
Cefuroxime 500 mg) Prophylactic surgery, is more active against Hemophilus influenzae and N.
gonorrhoeae, infection with
positive gram and negative gram infections. the existence of
multiple drug interactions, namely the use of Ultracet (Paracetamol) will increase the effect
when used in conjunction with ranitidine and Rantin (Ranitidine) will reduce the bioavailability
Sharox (cefuroxime) if used simultaneously.
7. DRUG RELATED PROBLEM
Drug interaraction : Ultracet / Paracetamol can increase the effect ranitidine and Ranitidine can
reduce bioavailability of cefuroxime
8. Conclusion:
Based on the practice of clinical work in PGI Cikini Hospital i can be concluded that there found
drug related problem that is drug interaction between ranitidine with paracetamol, and
ranitidine with cefuroxime
REFERENCES
Dorland, W.A. Newman. 2011. Kamus Saku Kedokteran Edisi 28. Terjemahan Oleh Albertus
Agung Mahode, dkk. Jakarta : EGC.
Engram, Barbara. 2012. Rencana Asuhan Keperawatan Medikal Bedah Volume 3. Jakarta : EGC
Mitchell, Richard N., dkk. 2006. Buku Saku Dasar Patologis Penyakit. Terjemahan Oleh Andry
Hartono. 2009. Jakarta : EGC
Noer, Sjaifoellah. 2011 Ilmu Penyakit Dalam. Jakarta : HKUI.
Rubenstein, David, dkk. 2012. Lucture Notes Kedokteran Klinis, Edsisi 6. Terjemahan Oleh dr.
Annisa Rahmalia. 2007. Jakarta : Erlangga.
Saragi, Sahat. 2012. Panduan Penggunaan Obat. Jakarta : PT. Rosemata Sampurna.
Widiastuty, Astri Sri. 2010. Patogenesis Batu Empedu. Palembang : Fakultas Kedokteran
Universitas Muhammadiyah.
1944
LIVER CIRRHOSIS AND CONGESTIVE HEART FAILURE AT
PGI CIKINI HOSPITAL
Ayu Andira1, Diana Laila Ramatillah2,Stefanus Lukas2
1
Student of Pharmacist Professional Program Student, Faculty of Pharmacy
UTA’45 Jakarta
2
Lecturer of Faculty of University ofPharmacyUTA’45 Jakarta
Email: Aiiu.jef@gmail.com
ABSTRACT
Liver cirrhosis is a disease in which the micro-circulation, a large blood vessel anatomy and the
entire system architecture of the liver becomes irregular changes and the addition of connective
tissue (fibrosis) around the regenerated liver parenchyma8. Factor precursor liver cirrhosis:
Hepatitis (B, C, and D), Alcohol, metabolic abnormalities8. Some other causes of liver cirrhosis
associated with increased pressure gradient of which CHF (Congestive Heart Failure) or
congestive heart failure8. Congestive Heart Failure (CHF) is a condition in which the heart has
failed to pump blood9. The cardiac dysfunction due to coronary atherosclerosis disrupt cardiac
contraction by myocardial infarction and ischemia9. Patients Mr. MC age of 44 years, entered PGI
Cikini Hospital on August 13, 2014 with a diagnosis of liver cirrhosis, congestive heart failure,
shortness of breath, cold sweat, nausea and vomiting stomach. Therapy treatment for
hospitalized ie cefotaxime, spironolaktone, digoxin, Dorner, cormega, hepabalance, hepamers,
lesichol, Lasix, ciproflotaxim, sistenol, and heparin. Based on the results, it can be deduced that
the presence of DRPs (Drug Related Problems) form Failed / did not receive the drug (Failure to
receive medication) patients do not get (Potassium Chloride) to prevent hypokalemia4,
Furosemide drug interactions and digoxin4, spironolactone and digoxin4, Omega 3 and heparin4.
Keywords: Liver Cirrhosis, Congestive Heart Failure (CHF).
1945
INTRODUCTION
In developed countries, cirrhosis of the liver is the third largest cause of death in patients aged
45-46 years (after cardiovascular disease and cancer)8. Throughout the world cirrhosis ranks
seventh leading cause of death8. Approximately 25,000 people die each year from the disease8.
Cirrhosis of the liver is a liver disease that is often found in the Department of Internal Medicine
ward8. Hospitalization most cases primarily intended to address a variety of diseases caused such
as upper gastrointestinal bleeding, peptic coma, hepatorenal syndrome, and ascites,
spontaneous bacterial peritonitis and Hepatosellular carcinoma8. Clinical symptoms of liver
cirrhosis varies widely, ranging from asymptomatic to obvious symptoms8. Where noted, reports
in developed countries, the cases of liver cirrhosis who come to see the doctor only
approximately 30% of the entire population of this disease, and approximately 30% were
discovered by chance when seeking treatment for other diseases, the rest was found when the
autopsy8.
The term liver cirrhosis given by Laence 1819, which is derived from the word meaning Khirros
yellow orange (orange yellow), because the color changes in nodules formed8. Definition of
cirrhosis of the liver can be said as follows, namely a state of the diffuse disorganisassi of normal
liver structure due to regenerative nodules surrounded by tissue fibrosis8. A complete liver
cirrhosis is a disease in which the micro-circulation, a large blood vessel anatomy and the entire
system architecture of the liver becomes irregular changes and the addition of connective tissue
(fibrosis) around the regenerated liver parenchyma8.
Patient with liver cirrhosis is more common in men compared with women About a 1.6: 1 with an
average age of majority in the age group 30-59 years with a peak of about 40-449 years8. Factor
precursor liver cirrhosis: Hepatitis (B, C, and D), alcohol, metabolic disorders including
Hemakhomatosis (iron overload), Wilson's disease (copper overload), Alphal-antitrypsin
deficiency, Glikonosis type-IV, galactosemia, Tirosinemi8.
Some other causes of liver cirrhosis associated with increased pressure gradient of which CHF
(Congestive Heart Failure) or congestive heart failure9.Congestive Heart Failure (CHF) is a
condition in which the heart pumps blood to fail in order to meet the needs of the cell - the cell
body and oxygen nutriaen adequately9. This results in stretching of the heart chambers (dilated)
1946
in order to accommodate more blood to be pumped throughout the body or cause the heart
muscle stiff and thickened9. The heart is able to pump blood only for a short time and the walls
weakened heart muscle can not pump strongly9.
At the time of a normal heart at rest, then the dominant influence of the parasympathetic
system in maintaining a heart rate of about 60 to 80 beats /minute 3. Heart rate in a healthy state
is affected by the work, blood pressure, emotions, way of life and the age of3. At the time a lot of
movement, the need for oxygen (O2) and expenditure increased carbon dioxide (CO2) is also
increased so that the heart rate can achieve 150x/minutes3. In normal circumstances the amount
of blood pumped by the right ventricle and left ventricle same so there is no accumulation of 3. If
the return of venous unbalanced and failed to keep up with the power ventricular heart pump
the veins near the heart so swollen with blood so that the pressure in the veins go up in the long
term, could be edema3.
Factors that can trigger the development of heart failure through the circulation of a sudden
emphasis can be: arrhythmias, systemic infections and infections of the lungs and pulmonary
embolism1. Effective treatment for heart failure requires the introduction and handling not only
the mechanisms underlying physiological and disease, but also the factors that lead to heart
failure1. Heart failure is associated with increased levels of arginine vasopressin in circulation,
which also is vasokontriktor and inhibiting fluid excretion7. In heart failure, atrial natriuretic
peptide increased due to an increase in the atrium, which shows that here there is resistance to
the effects of natriuretic and vasodilator7.
CASE PRESENTATION
Mr. MC male aged 44 years treated, patient are admitted in PGI Cikini Hospital on August 13,
2014. The patient was admitted with complaints of feeling shortness of breath before entering
the hospital, cold sweat, nausea and vomiting stomach. The patient went to the hospital. PGI
Cikini. Patient already have a history of CHF. After the patient is doing the re-examination was
turns out the patient has liver cirrhosis as well.
From the results of laboratory, clinical chemistry examination showed a high SGOT at 53 U / L (050 U / L), an increase in globulin values are 5.8 g / dL (1.3 to 3.7 g / dL), Gamma GT (GGT) 92 U / L
(0-30 U / L)6. On examination the patient's hematologic APTT 47.2 seconds (26.4 to 37.5
1947
seconds)6. Liver function examination showed an increase in the value of total bilirubin 4.9 mg /
dL (0.1-1.0 mg / dL), direk bilirubin of 3.3 mg / dL (0.1-0.2 mg / dL) , indirect bilirubin 1.6 mg / dL
(0.1 to 0.8 mg / dL), total protein of 9.3 g / dL (6.0 to 8.0 g / dL) 6. While the electrolyte
examination, a decline in the value of Sodium (Na) Blood 133 mEq / L (135-147 mEq / L)6. From
the results of laboratory examination of patients diagnosed with liver cirrhosis and congestive
heart failure (CHF)6.
In this case, the patient was treated with ciprofloxacin orally 1x1 gram used to infectious
pathogens, the use Spironolaktone 2x100 mg orally as diuretics, Digoxin penggunaa 2x½ mg
orally to strengthen the pulse and heart pump power, the use of Dorner (Beraprost Na) 3x1
tablet orally to treat pain, the use of Cormega 3x1 capsules orally help maintain health, the use
of capsules and Hepamers Hepabalance3x1 (L-ornithine-L-aspartate) 3x1 packs of orally taken on
an empty stomach (1 or 2 hours before / after meals) to maintain healthy liver function, use
Lesichol 3x300 mg orally multivitamin help cure heart disease and lower the risk of heart disease,
the use of Lasik (Furosemide) 1x40 mg orally used as a diuretic drug used to treat edema in
patients, the use of Sistenol to reduce fever, use of heparin (Heparin Na) 15000 IE subcutaneous
injection given to prevent blood clots, use Cefotaxim2x500 mg / day orally for respiratory tract
infections2,5.
CLINIC EVALUATION
Drug Related Problems(DRPs) including:
1.
Failed / no to receive drugs (Failure to receive medication): Found, patient did not to get
(Potassium Chloride) for prevent occurrence4 hypokalemia.
Pharmacist Intervention: Should Potanssium Chloride given to prevent hypokalemia4.
2.
a.
Interaction drug (Drug Interactions):
Drug Related Problems 1:
Furosemide - digoxin: Found an interaction between; digoxin and Lasix (furosemide) where
digoxin may increase the effects of furosemide, so that digoxin was not able to strengthen the
heart rate and pump power4.
Pharmacist Intervention: Should Potanssium Chloride given to prevent hypokalemia4.
b.
1948
Spironolactone - Digoxin: Spironolactone may weaken the effect of digoxin and impede tubular
secretion of digoxin4.
Pharmacist Intervention: Given the distance between the use of spironolactone and digoxin4.
c.
Omega 3 - heparin: Using omega 3 polyunsaturated together with heparin can cause bleeding
risk4.
Pharmacist Intervention: Given the distance between the consumption of omega 3 and heparin,
to prevent bleeding4.
CONCLUSION
Based on the results of, it can be concluded that the presence of DRPs (Drug Related Problems)
form Furosemide drug interactions namely – digoxin: Found an interaction between; digoxin and
Lasix (furosemide) where digoxin may increase the effects of furosemide, so that digoxin was not
able to strengthen the heart rate and pump power, spironolactone and digoxin: Spironolactone
may weaken the effect of digoxin and impede tubular secretion of digoxin, Omega 3 – heparin:
Using fatty acid Omega-3 polyunsaturated together with heparin can cause bleeding risk. Failed /
not receiving the drug (Failure to receive medication): Found, patient did not get (Potassium
Chloride) to prevent hypokalemia.
REFERENCES
1. Barbara C. Long. Medical Surgical Nursing (Translation), Padjadjaran Bandung IAPK
Foundation, September 1996, p. 443-450
2. BPOM. 2008. National Indonesian Medicine Information (ioni). Jakarta: Sagung Seto
3. Maarif F Vishnu. 2013. Radiology Congestive Heart Failure(CHF). New York: Journal of
Medicine UII.
4.
Medscape.2014. Drug Interaction Checker. http://reference.medscape.com/drug .
Accessed on October 10, 2014.
5. Priyanto, Drs. M. Biomed, Apt. 2009. Pharmacotherapy and Medical Terminology. Jakarta:
Leskonfi
1949
6.
Santosa, Budi. 2007. NANDA Nursing Diagnosis Guide. London: Prima Medical
7.
Suharto, Faith. 2004. Heart Attack And Stroke. New York: Scholastic
8.
Sutadi S Maryani. 2003. Hepatitis Cirrhosis. Journal of Medicine USU.
9.
Udjianti, J, Wok. 2010. Cardiovascular Nursing. Jakarta: Salemba Medical
1950
DRUG RELATED PROBLEM TUBERCULOSIS RELAPSE AND
DISEASE HYPERTENSION AT PERSAHABATAN HOSPITAL
Dewi Anggereni1, Aprilita Rinayanti Eff.2 and Diana Laila Rahmatillah2
1
2
Lecturer of Faculty of Pharmacy UTA’
dewi_libieimmer@yahoo.co.id
ABSTRACT
Tuberculosis (TB) is a disease caused by complex infection of Mycobacterium tuberculosis.
Mycobacterium tuberculosishave straight bacillli form or slightly curved, no spored or not
encapsulated. Nowdays lung tuberculosis disease still be public health problem (PDPI, 2013).
Hypertension is an increasing in blood pressure at a certain level and gradually at three times of
intermittent measurement during three weeks which can cause damage of the body. The
increasing of blood pressure, which diastolic blood pressure above 90 mmHg or systolic blood
pressure above 140 mmHg (Nugroho,2009).
Patient Mr. KN, 49 years old, entered to the hospital ( Persahabaan hospital) on 07 october 2014,
23.00 pm with diagnoses : Community Acqured Pneumonia (CAP), TB relapse with complaints of
shortness of breat, hypertension grade II buthave been not detected. Treatment therapy for
hospitalized were Ambroxol, Amlodipine, Ceftazidim, Ventolin Inhalation, Candesartan. In this
case was found the Drug Related Problems (DRPs) there are using of drugwithout indication and
dose of amlodipine is can increase.
Keywords:Drug Related Problem, TB relapse, Hypertension Grade II, andPersahabatan Hospital.
1951
I
INTRODUCTION
It is estimated that approximately 80% increasing in cases of hypertension especially in
developing countries in 2025 of there are 639 million cases in 2000, is estimated to be 1,15
billion cases in 2015. This prediction based on the number of current hypertension patients and
current population growth(Armilawati,2007).
Hypertension is an increasing in blood pressure at a certain level and gradually at three times of
intermittent measurement during three weeks which can cause damage of the body. The
increasing of blood pressure, which diastolic blood pressure above 90 mmHg or systolic blood
pressure above 140 mmHg (Nugroho, 2009).
Mycobacterium tuberculosis have straight bacillli form or slightly curved, no spored or not
encapsulated. These bacteria with widthof 0.3 - 0.6mmand
mycrobacteriumis
verycomplex,
consistingoflipid
length of1-4mm. Wall
layeris
veryhigh(60%).
mainconstituentcellwallof
mycrobacteriumtuberculosisismikolat,
thehalosadimikolatcalledas
cordfactorandmycrobacteriumsulfolipidsthat
The
complex-wexes,
play
a
roleinvirulence(Djojodibroto, 2009).
World TBC report by WHO in 2006, that Indonesia as the largest contributor number three in the
world after India and China with the number of new cases of approximately539,000people
peryear. AccordingNotoatmodjo(2003) in addition tothe homeenvironmentsanitationfactors, the
incidence ofpulmonaryTBdiseaseis alsoveryconcerned with the behaviorandthe amount
offamilyincomebecausethe majority ofTB patientsarepoor peoplewhoseeducationlevelis low.For
theexamination ofpulmonary TB,3sputum specimensexaminedwithin2days,spot-morning-spot
(SMS).
Based on the guidelines of the national TB program, the diagnosis of pulmonary TB in adults is
enforced with the discovery of TB germs (BTA). Whereas such checks photo thoracic, culture and
sensitivity test can be used as a support in diagnosis in accorandce with the indications and not
justified in diagnosing TB (Djojodibroto, 2009).
II
PRESENTATION OF CASES
Patient Mr. KN, 49 years old, entered to Persahabaan Hospital on October 07, 2014, 23.00 pm
with diagnoses: Community Acqured Pneumonia (CAP), TB relapse with complaint of left lung
1952
field, Suspect MDR TB, and Hypertension Grade II but has been not detected. The patient also
complaints with severe shortness of breath ± 2 weeks before entering the hospital. The shortness
of breaset increased when the patient was doingactivity and patient also experience cough with
blood cough ± 1 last month, and decreasing in appetite and weight loss ± 8 kg for 1 months.
The patientis received anti tuberculosisdrugs in 1995 for 1 year cured and physician has declared
that patient was cured.
III
Date of
Blood Pressure
Pulse
Breathing
Temperature
eximination
(120/80 mmHg)
(94-
(20-25x/minute)
(37⁰C)
105x/minute)
08/10/2014
189/110 mmHg
105 x / minute
23 x / minute
37⁰
09/10/2014
185/105 mmHg
103 x / minute
23 x / minute
37⁰
10//10/2014
175/80 mmHg
105 x / minute
25 x / minute
37⁰
11/10/2014
140/90mmHg
90 x / minute
20 x / minute
37⁰
12/10/2014
139/85mmHg
102 x / minute
24 x / minute
37⁰
13/10/2014
140/78mmHg
94 x / minute
23 x/ minute
37⁰
IV
CLINICAL EVALUATION
Administration of ambroxol as mucolitic for overcome. Cough and amlodipine for decreasing
blood pressure in combination with candesartan. Ceftazidim for overcome Community Acqured
Pneumonia (CAP). Ventolin Inhalation for overcome tightness.
V
Drugs
DRUG REGIMEN
Doses
08/09/14
09/10/14
10/10/14
11/10/14
06.12. 18. 24. 06. 12.18. 24. 06.12. 18. 24. 06. 12. 18.24.
00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00
Ambroxol
3x 1 gr
T
√
T
√
Amlodipine
1 x 5 mg
T
√
T
√
Candesartan
1 x 80 mg
M
T
1953
Ceftazidim (inj)
Ventolin
3 x 1 gr
3 x day
Inhalation
Drugs
Doses
√
√
√
√
12/09/14
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
13/10/14
06. 12. 18. 24. 06. 12. 18. 24.
00 00 00 00 00 00 00 00
Ambroxol
3x 1 g
√
Amlodipine
1 x 5 mg
√
√
Candesartan
1 x 80 mg
√
√
Ceftazidim
3x1g
√
√
√
√
Ventolin Inhalation
3 x day
√
√
√
√
VI
√
√
√
DISCUSSION
Thelaboratory resultsin the first day treatmentshow that leukocytevaluesabovethe normal limits
(23.1 thousand/mm3) this is indicatethat the patient suffered infection disease,so physician
giveceftazidima semisyntheticcephalosporinantibiotic. Mechanism of action ofceftazidimby
inhibiting the enzymes responsible for the synthesis of cell walls. Invitro Ceftazidim can affect the
micro-organisms in the range/wide spectrum including strains resistant to gentamicin and other
aminoglycosides. Additionally ceftazidim very stable against most β-lactamases, plasmi and
chromosomal clinically produced by gram-negative andgram-positive and thus ceftazidim active
against
several
strains
resistant
to
ampicillin
and
other
cephalosporins.
3
Insubsequenttreatmentleukocytes value to be low(15.33 and11.83thousand/mm )(BPOM, 2008).
Patient Mr.KNcametothe hospitalwitha bloodpressure ofabove normal 189/110 mmHg, doctors
prescribeamlodipinewhich is calciumantagonist, aclass ofdihydropyridinethatinhibitsthe influxof
calcium
ionsthroughthe
membraneintothe
muscleandcardiacmusclethataffectsvascular
vascular
smoothmusclecontractionand
smooth
theheartmuscleis
1954
usedtotreathypertension. Amlodipine inhibits calcium ion selective in fuks, where most have
effects on vascular smooth muscle cells than cardiac muscle cells(Yulianah, 2008).
Patient experince hypertention uncotrolled, so the doctors provides a combination therapy
using candesartan (Angisotensin Receptor Blockers Angisotensin Receptor Blockers/ (ARB) class)
with amlodipine. Candesartan works by inhibiting angiotensinIIon AT1 receptor thereby reducing
sympathetic activity causes vasodilatation with decreased peripheral resistance thereby
increasing cardiac output (Gunawan S, 2012).
Ventolin inhalers containing salbutamol which is a sympathomimetic amines including betaadrenergic agonist class that has a special effect on receptor beta (2) -adrenergic contained in
adenyl cyclase. Adenyl cyclase catalyse the process of change of adenosine triphosphate (ATP) to
cyclic-3 ', 5'-adenosine monophosphate (cyclic AMP). This mechanism increases the amount of
cyclic AMP which affects the relaxation of bronchial smooth muscle and inhibits the release of
mediators cause hypersensitivity reactions. The using of ventolin inhalers for overcome shortness
of breath (Gunawan S, 2012).
The patient suffered cough with sputum approximately 1 month before entering the hospital, the
administration of ambroxol as mucoliticand secretolytic.mucolitic and scretolytic canbring out
sputum and reduce the mucus. Thus the liquid secretions as membrane on the surface of the
mucous respiratory tract can carry out the function of the protection normally again. (Yulianah,
2008).
VII
1.
Untreated complaint
Patient experince decreasing in appetile but physician do not give vitamin for increasing it. We
suggestedtoprovide additionaltherapysuch asvitaminBcomplexandcarried outmonitoring ofthe
state ofthe patient'sappetite.
2.
The dosage regimen is too low
Theprescriptionof amlodipine5mg once dailyes is too low,according to Dr.AineBurns, it should be
given 10 mg daily(Renal DrugHandbook, 2009). Recommendto thedoctorto re-evaluatethe use
oftherapeuticdoses ofamlodipine. Docheck listnursesnotes periodically
1955
VIII
CONCLUSION
Based on theresults ofclinical workpracticeinpulmonarydiseaseswardPersahabatanHospital, it
can be concluded thatthe presence ofDRP(Drug Related Problems) in the form ofuntreated
complaint and the dosage regimen is too low.
REFERENCES
Armilawati, 2007. Hipertensi and Faktor Resikonya dalam Kajian Epidemiolog. FKM UNHAS.
Available from: http://www.cerminDuniaKedokteran.com. [Accessed 15 March 2010].
BPOM, 2008. Informatorium Obat Nasional Indonesia. Koperpom : Jakarta.
Djojodibroto, Dr. R. Darmanto, Sp. P, FCCP. 2009. Respirologi (Respiratory Medicine). EGC :
Jakarta.
Gunawan S., 2012. Farmakologi and Terapi. Universitas Indonesia Fakultas Kedokteran : Jakarta.
Nugroho, Dr. Agung.2009.Farmakologi Obat-obat Penting dalam Pembelajaran Ilmu Kefarmasian
and Dunia Kesehatan,Universitas Gadjah Mada Yogyakarta.
PDPI, 2013. Pedoman diagnosis and penatalaksanaan Tuberkulosis . Jakarta.
Yulianah,Sukandar .,dkk. 2008. Iso farmakoterapi. PT.ISFI Penerbitan : Jakarta.
1956
DRUG RELATED PROBLEMS IN TREATMENT OF BRONCHIECTASIS
INFECTED WITH SEPSIS
A.Ririn Perawanti Asgap1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
Student of Pharmacist Professional Program Student, Faculty Of Pharmachy UTA’ 45 Jakarta
2
Email : Andiririnpa@gmail.com
ABSTRACT
Bronchiectasis is a morphological abnormalities consisting an abnormal dilation of the bronchi
and settle caused damage of elastic components and muscular bronkus7. Sepsis is a clinical
syndrome that occurs due to the excessive body's response concering to mikroorganisme
stimulan4. Patient Mrs.KH, 29th years old entered the Persahabat Hospital on 13 December 2014.
Patient presented with cough ± 8 months before entered, white and many sputum in the
morning, fever 2 days before entered, continuous nausea ± 2 days before entered. Shortness of
breath ± 6 months before entered, sometimes chest pain since ± 6, ± 2 months limp, appetite
decreased 2 days before entered. History of previous disease is tuberculosis on OAT. Therapeutic
treatment is 3 x 500 mg paracetamol for fever overcome, N-acetyl cysteine syrup therapy 3x c1
used to overcome viscous and thick mucus hypersecretion in the respiratory tract, 3 x 50 mg
ranitidine useful in the reduction of gastric acid conditions, levofloxasin 1 x 750 mg used for the
treatment of chronic bronchitis with the usual dose of 500 mg / day, meropenem inj. 3x 1 g were
used for infection of gram-negative and gram-positive with usual doses of 2 g every 8 hours3.
Based on the results of their clinical practice in Pulmonary care room, Persahabatan Hospital in
bronchiectasis treatment given to the patient has right, but need to be considered in granting
regimens of levofloxasin doses.
Keywords: Bronchiectasis, sepsis and pulmonary care department of Persahabatan Hospital
1957
INTRODUCTION
Bronchiectasis is a chronic dilatation of the bronchi and bronchioles that may be caused by
various conditions, including lung infections and bronchial obstruction, foreign body aspiration,
vomit, objects from the upper respiratory tract, and the pressure due to a tumor, blood vessels
are dilated and limfa node enlargement2.
Pathophysiology of bronchiectasis starting from infection bronchial wall damage, causing loss of
supporting structure and produce thick sputum that can eventually clog bronki2. Bronchial walls
become stretched permanently as a result of severe coughing, infection extends to peribronkial,
so that in the case of bronchciectasis cellular, each tube actually dilated is pulmonary abscess,
which eksudat flow freely through bronkus2. Bronchiectasis usually attacked Local lobe lung
segment.
Based on bronchography (shape) and pathology, bronchiectasis can be divided into three,
namely:
1.
Bronchiectasis tube (Tubular, Cylindrikal, fusiform Bronchiectasis)
Bronchiectasis is a form brokiektasis most ringan1. This form often found in the bronchiectasis
with bronchiectasis chronic1.
2.
Shape of bag (saccular Bronchiectasis)
This form is a form of classical brokiektasis characterized by dilation and constriction of bronchi
that are irregular, this form is sometimes shaped a cyst1.
3.
Varicose Bronchiectasis
It is a combination of both forms previous1. This term used for varicose veins resembling
bronchial vena1.
There is still no exact data on the prevalence of bronchiectasis. In western countries the
prevalence of bronchiectasis estimated 1.3% of the population ada8. The high prevalence was
experiencing a significant decline with controlling cases of pulmonary infection with medication
use antibiotik8.
Sepsis can occur as a result of infectious microorganisms in wherever body5. The cause of sepsis
is a gram-negative bacterial infection with a percentage 60-70% of cases produce a variety of
products which can stimulate cell imun5. These products will lead to release inflammatory
1958
mediators such as LPS (lipopolysaccharide)5. Example of gram-negative bacteria that can cause
sepsis is Pseudomonas aureuginosa, Klebsiella, enterobakter, echoli, Proteus, and others5.
CASE PRESENTATION
Patient Mrs. Kh, aged 29 years entered Persahabatan Hospital on 13 December 2014. Patient
present with cough ± 8 months before entered, the trouble removing phlegm cough, sputum
white and a lot in the morning, fever 2 days before entered, nausea continuously ± 2 days before
entered. Shortness of breath ± 6 months before entered, sometimes chest pain since ± 6, ± 2
months limp, appetite decreased 2 days before entered. Weight loss, bowel and bladder
normally.
History of previous disease was tuberculosis on OAT (checks at PHC 2009) before check sputum
(+) and radiographic declared cured. History of TB on OAT (examination in the clinic god 2014),
already 6 months of TB and said there was fluid (not injected, given OAT non-DOTS). Directly
Observed Treatment Shortcourse (DOTS) was pulmonary TB treatment strategy that prioritizes
supervision OAT taking medication during the treatment period, preventing patient dropped out
(breaking treatment) as well as the search and discovery of new cases in the community.
CLINICAL EVALUATION
Treatment of patient with bronchiectasis consists of two groups, namely the conservative
treatment and surgery treatment6. Conservative treatment consists of general management,
special management, and treatment symptomatic 6.
General management, include: (1) create a good environment and appropriate for the patient;
(2) improve the drainage of bronchial secretions to perform postural drainage, melt the thick
sputum, adjust position of patient's bed, and control respiratory tract infections6.
Special management include: (1) chemotherapy in bronchiectasis; (2) drainage of secretions with
a bronchoscope; (3) symptomatic treatment (such as the treatment of bronchial obstruction, for
example with bronchodilator drugs; treatment of hypoxia by giving oxygen; treatment of
hemoptysis for example with hemostatic drugs; treatment of fever with antipyretics)6.
Indications surgery to remove (resection) segment / lung lobes were exposed, namely
bronchiectasis patients are limited and resektabel, do not respond to conservative measures are
1959
adequate; but it also limited the patient, but often have recurrent infections or hemoptysis from
the area, patients with massive hemoptysis absolutely need operating action6.
Treatment of fever in patient with acute exacerbation of infection should be given appropriate
antibiotics and antipyretics should be added as needed, medication therapy is 3 x 500 mg
paracetamol to cope with fever, N-acetyl cysteine syr therapy 3x c1 is used to overcome the
viscous and thick mucus hypersecretion in channel respiratory, 3 x 50 mg ranitidine useful in the
reduction of gastric acid conditions, levofloxasin 1 x 750 mg used for treatment of chronic
bronchitis with usual dose of 500 mg / day, meropenem inj3. 3x 1 g were used for infection of
gram-negative and gram-positive with usual doses of 2 g every 8 jam3.
The results of laboratory tests performed by patient Mrs.Kh who showed abnormal laboratory
value was 29.81 thousand leukocytes / mm3 (normal value 5-10 thousand / mm3), Neutrophils
84.2% (50-70% of normal value), lymphocytes 6.7% (normal values 25-40), erythrocytes 5.99
million / uL (normal value of 3.6 to 5.8 million / uL) Monocytes 8.8% (2-8%), Eosinophils 0.1 % (24%), hemoglobin 9.2 g / dl (normal values of 12-16 g / dl), MCV 58.4 fL (normal value 80-100 fL),
MCH 17.9 pg (normal value 26- 34 pg), MCHC 30.6% (32-36% of normal value), RDW-CV of 20.2%
(from 11.5 to 14.5%), Fibrinogen 568 mg / dl (normal values of 200-400 mg / dl ), control of 13.2
seconds (normal value of 9.2 to 12.4 seconds), D-dimer was 1518 mg / dl (normal values of 0-500
mg / dl), globulin 3.6 g / dl (normal values 1, 3 to 2.7 g / dl).
Dose Regimen
In this case the patient got levofloxasin which drug administration does not comply with the
literature where levofloxasin given with higher doses 1 x 750 mg.
Pharmaceutical interventions of this case that levofloxasin dose should be reduced from
according to the dose stated on the literature where levofloxasin given intravenous dose is 500
mg / day3.
Indications Without Drugs
Laboratory results of patient who showed abnormal values that MCV, MCH, MCHC, and RDW and
also decreased hemoglobin value indicated anemia, but not given the anemia drug.
1960
Pharmaceutical intervention of this case that the patient should be given multvitamin
supplements containing vitamin B12 and folic acid as well as improve the prophylactic treatment
of vitamin B12 or folat acid deficiency9. And suggest to patient consume foods that contain iron
such as vegetables, meat and fish9.
CONCLUSION
Based on the result of clinical practice in pulmonary care room at Persahabatan Hospital then
bronchiectasis treatment given to the patient has right, but need to be considered in granting
levofloxasin2 regimen doses. And also any indication without medication9.
REFERENCES
1. Aru W. Sudoyo. 2006. Buku ajar Ilmu Penyakit Dalam.Jilid II, Edisi IV. Jakarta : FKUI.
2. Brunner & Suddarth. 2000. Medical Surgical Nursing, Edition 9. Philadelphia : Lippincott.
3. Galileopharma. 2008. BNF Edition 56. Alexandria Universiti.
4. Guntur HA. Terapi sepsis SIRS & sepsis. In: Imunologi, Diagnosis,
Penatalaksanaan. Sebelas Maret University Press, 2006.p.10
5. Iskandar,Japardi.2002.”Manifestasi Neurologik Shock Sepsis”
http://library.usu.ac.id/download/fk/bedah.
6. Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia. Bronkiektasis. In: Sudoyo AW,
Setiyohadi B, Alwi I, et al; editors. Buku Ajar Ilmu Penyakit Dalam. Jakarta: Interna Publishing;
2009.
7. Soeparman & Sarwono W, (1998), Ilmu Penyakit Dalam Jilid II Balai Penerbit FKUI, Jakarta.
8. Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiasi S. Buku Ajar Ilmu Penyakit Dalam.
Edisi 4 – Jilid II. Jakarta: Pusat Penerbitan Ilmu Penyakit dalam FKUI. 2007. Hal; 1035-1039.
9. Wells, Barbara G., DiPiro, Joseph T., Schwinghammer, Terry L., Hamilton, Cindy W.
2006.Pharmacotherapy Handbook, 6th Edition. USA: The McGraw-Hill Companies, Inc.
1961
Evaluation of Drug Related Problems In Patient With
Dyspepsia Disease At PGI Cikini Hospital
Ety Nursulasih1, Aprilita Rinayati Efi2, Diana Laila Ramatillah2, and Stefanus Lukas2
1
2
ety1212@gmail.com
ABSTRACT
Dyspepsia is a syndrome or a collection of symptoms consisting of pain or discomfort in the
epigastrium, nausea, vomiting, bloating, early satiety, the stomach feel full, and belching2.
Dyspepsia is generally divided into organic dyspepsia and functional dyspepsia. Organic
dyspepsia caused by various diseases which showed a pathological disorder either structural or
biochemical. If the diagnostic check up did not reveal any abnormalities that are included in
functional dyspepsia3. Peptic ulcer in the elderly is often more serious than the same case at a
young age due to the risk factors more ulcers in the elderly, as well as the complications and
mortality associated with peptic ulcer3.
Patient Mrs E. N aged of 64 years old, entered PGI Cikini Hospital on 6-11 October 2014.
Physician was diagnosed that patient suffered dyspepsia, patient has history of hypertension and
diabetes mellitus. Patient was treated with ranitidine injection, onandsetron injection, miniaspi
tablet 80 mg. Based on the assessment of the treatment, that is the condition of hipoalbumin,
but physician did not give treatment. DRPs (Drug Related Problems) experience hipoalbumin.
Keywords : Drug Related Problems (DRPs), Dyspepsia, PGI Cikini Hospital
1962
INTRODUCTION
Dyspepsia is divided into two subclassification, namely organic dyspepsia and functional
dyspepsia. Organic dyspepsia, when it has been known organic disease as the cause. Organic
dyspepsia syndrome is disorders that significantly affect organs such ulcers (sores) of the
stomach, intestine 12 fingers, inflammation of the pancreas, inflammation of the bile, and
others. Non-organic dyspepsia or functional dyspepsia or non-ulcer dyspepsia, when no obvious
cause. Functional dyspepsia without abnormalities or disorders organ structures based on clinical
examination, laboratory, radiology, and endoscopy after 3 months with symptom dispepsia4. To
maintain the data needed diagnosis investigation to see organic disorders / structural or
exclusion to enforce the diagnosis of functional dyspepsia. Additional complaints that threaten
such as weight loss, anemia, difficulty swallowing, bleeding, and others, indicate that the
diagnostic exploration immediately. In addition to radiology, the usual checks include laboratory,
endoscopy, manometry, esofago-gastro-duodenal and gastric time emptied2. Although the
management of dyspepsia (uninvestigated) individual, the initial approach that is cost-effective is
the examination of H.pylori infection and treat the infection with bacteria eradication if positive
test results (test and treat approach). When testing for H. pylori negative, empiric therapy with
gastric acid suppressants or prokinetic recommended. If complaints persist or recur after six or
eight weeks of empiric therapy, it is necessary to endoscopy5.
CASE PRESENTATION
Patient Mrs E. N 64 years old, weight 52 kg. Patient entered PGI Cikini Hospital on October 6 to
11, 2014. He complaint of nausea, vomiting, can not eat, body weakness, fever, cough, shortness
of breath, chest pain, frequent urination, diarrhea. Patient has past medical history of
hypertension and diabetes mellitus.
LABORATORY DATA
Table results of blood pressure measurement
Review
06-
07 oct
8 oct
09 oct
10 oct
11
oct
Systolic
110
oct
120
140
150
130
150
140
130
140
160
160
110
140
110
1963
Diastolic
80
80
80
80
80
80
90
80
90
80
90
90
90
90
Breathing
20
20
20
20
20
20
20
20
20
20
20
20
20
20
Weight
52 Kg
(Kg)/
Height
(cm)
Table. Laboratory examination
Review
Result August 2014
Denomination
Reference Value
50*
mm/hour
0-20
11,5*
g/dl
12,0-14,0
Leukosit
5
103/mL
5,0-10
Eritrosit
4,15
106/mL
4,0-4,5
Hematokrit
33*
%
37-43
Retiklosit
16*
‰
5,0-15
Basofil
1
%
0-1
Esinophil
4*
%
1,0-3
Neutrophils Trunk
0*
%
2,0-6
Neutrophils Segment
45*
%
50-70
Lymphocytes
38
%
20-40
10
11
12
Hematological
Peripheral Blood
LED
Hemoglobin
Calculate Type Leukocytes
1964
Monocytes
12*
%
2-8,0
3
Platelet
118*
10 /mL
150-450
MCV
79*
fL
81-92
MCH
27,5
Pg
27-32
MCHC
35,4
g/dL
32-37
Table. Clinical examination
Review
Result
Denomination
Reference Value
Albumin
2,8*
g/dL
3,4-4,8
SGOT
35
u/L
0-35
SGPT
21
u/L
0-35
Sodium (Na) Blood
137
mEq/L
135-137
Potasium (K) Blood
3,6
mEq/L
3,5-5.0
Calcium (Ca)
8,8
mEq/L
8,8-10,0
Clinical Chemistry
Sodium Potasium
Table Patient Treatment Profile
Name
Dose
Medicine
Ranitidine
2x1 amp
(25mg)
Onandsentr
2x1 amp
on
(4mg)
Miniaspi
3x1 tab
Date Monitoring
6
7
8
9
10
11
12
13
14
15























(80mg)
EVALUATION CLINIC
1965
Patient over 64 years old Mrs. E. N came to the hospital, she complaints : nausea, vomiting, loss
of appetite, weakness, fever. At this time patient receive medications such as ranitidine injection
as histamine H2-receptor antagonist that competitively inhibits the action of histamine on H2
receptors and reduces gastric acid secretion, onandsetron as serotonin antagonist drug group 5 HT3, which works by inhibiting the selective serotonin 5- hydroxytriptamine (5HT3) binding to its
receptor in the CTZ (chemoreseceptor trigger zone) and in the gastrointestinal tract, miniaspi
(Acetylsalicylic acid) mechanism of action of these drug is associated with inhibition of COX-1
activity, which contribute to the main enzyme metabolism of arachidonic acid is a precursor of
prostaglandins which play a major role in the pathogenesis of inflammation, pain and fever.
Patient suffering dyspepsia and also hipoalbumin, but the patient did not receive 25% albumin.
DISCUSSION
Physician-diagnosed dyspepsia and patient was has a history of hypertension and diabetes
mellitus. Ranitidine injection 25 mg was given per 12 hours to reduce the secretion of gastric
acid, 4 mg of onandsetron injection was given per 12 hours to overcome nausea and vomiting,
miniaspi 80 mg tablet per 8 hours to prevent platelet aggregation in myocardial infarction and
unstable angina, prevent attacks ischemic brain cursory 6,7,8.
Drug Related Problem is all the problems associated with the treatment which may cause the
treatment to be not optimal, it can even lead to adverse events for pasien8, the patient
experienced hipoalbumin, but the patient did not receive 25% albumin.
CONCLUSION
Based on the results of clinical work practice in hospital wards K PGI Cikini it can be concluded
that the presence of Drug Related Problems that is patient experienced hipoalbumin, but the
patient do not receive 25% albumin.
REFERENCES
1. Bonner GF. Upper gastrointestinal evaluation related to the pelvic floor in; Davilla; 2006
2. Djojodiningrat D. Functional Dyspepsia. In: Sudoyo AW (ed). Textbook of Medicine. Volume 1
edition IV. BP FK UI. Jakarta. 2006 354-6
1966
3. Linder JD, Wilcox CM. Gastrointestinal disorders in the Elderly: acid peptic disease in the
Elderly. Gastroenterol Clin North AM 2001; 30; 363-76
4. Baxter, K. 2008. Stockley's Drug Interactions eighth edition. Pharmaceutical Press. London
5. Montalto M, Santoro L, Vastola M, Curigliano V, Cammarota G, Manna R, et al. fuctional
dyspepsia: definition, classification, clinical and therapeutic management. [article in Italian]. Ann
Ital Med Int. 2004 Apr-Jun: 19 (2): 84-9
6. Yulinah, Sukandar, Dkk 2008, ISO Pharmacotherapy, ISFI enforcement, Jakarta
7. Tjay, TH, 2007, Essential Drugs, Elex Media Komputindo, Jakarta
8. Priyanto, 2009, Pharmacotherapy and Medical Terminology, LESKONFI, Jakarta
9. BNF, 2009. The British National Formulary. BMJ Group. UK
10. Harkness, Ricchard, translated by Goeswin Agoes and Mathilda B, 1989, Drug Interactions,
ITB, Bandung
1967
TREATMENT FOR DIABETES MELLITUS WITH
HYPERLIPIDEMIA DISEASE AT MINTOHARDJO HOSPITAL
Widya Selawa1, Aprilita Rinayanti Eff2, Diana Laila Rahmatillah2
1
Student Of Pharmacist Professional Program, Faculty of Pharmacy UTA'45 Jakarta
2
chibisuke.flawlesss@gmail.com
ABSTRACT
Diabetesmellitusis
a
metabolic
disordercharacterized
byhyperglycemiaassociatedwith
abnormalities inthe metabolism of carbohydrates, fats, andproteins, causedbya decrease
ininsulin
secretionora
decrease
ininsulinsensitivity,
or
both,
and
it
canlead
tochroniccomplicationsof microvascular, macrovascular, andneuropathy(Sukandar et al, 2009).
Hyperlipidemiaisone ofthe causesof diabetes. Hyperlipidemiais a condition whichfat levelsin the
bloodriseabove thenormal value(DepKes, 2007). Inthiscase, 59-year-old female patient came to
the hospitalwith complaints offrequent thirstandhunger, oftenfeelstiffinthe fingers and toes.
Patientwastreated withRinger's lactate, Ranitidine, Onandsentron, Ulsicralsyrup(Sucralfate),
Novorapid, Lantus, and Pletaal(Cilostazol). There areseveralDRPin this case, patient complain ofa
stiffinthe fingers and toes, butphysician did not giveneurotrophicvitamine, the use
ofantiemeticsOnandcentronarenotas indicated, and untreated Hyperlipidemia.
Keywords: Drug Related Problem,Diabetes Mellitus,Hyperlipidemia,Mintohardjo Hospital
1968
1.
Introdution
Diabetesmellitusis
a
metabolic
disordercharacterized
byhyperglycemiaassociatedwith
abnormalities inthe metabolism of carbohydrates, fats, andproteins, whichare causedbya
decrease ininsulin secretionora decrease ininsulinsensitivity, or both, and it canlead
tochroniccomplicationsof microvascular, macrovascular, andneuropathy. There are 2 type of
diabetesmellitus,type 1 diabetesmellitusandtype 2 diabetes mellitus (Sukandar, et.al, 2009).
Hyperlipidemiais
a
conditionwhichfat
Fatincreaseincludescholesterol,
levelsin
triglycerides,
or
the
both.
bloodrises
abovenormal
Hyperlipidemiaisone
value.
of
the
complicationsof diabetesmellitus(DepKes, 2007).
Insulininhibitslipolysisin the normal statebylowering thelipolytic activityinadipose. Patient
withinsulindeficiencywillincreasethe lipolysissothe concentration offree fatty acidsinthe blood
increases.
Liveruse
mostof
these
fatty
acidsto
formtriacylglycerolwerethenusedto
formtriglycerides, LDL, andVLDL. Triglycerides, LDL, andVLDLis notstoredin the liverbutis
excretedinto the bloodso its concentrationin the serumwill increased(DepKes, 2007).
2.
Case Presentation
Female patient, 59-year-old, came to the hospitalwith symptomps ofweaknesssince3daysbefore
admission, feel tiredwhen walkingaway, and oftenfeelthirstyandhungry. Patientfeelstiffinthe
fingers and toes.
3.
Clinical Evaluation
In this case, the patient was treated with infusion of Ringer's lactate (RL) which is indicated for
the treatment of electrolytes and minerals. Ranitidin Inj. and Ranitidine tablets were indicated
for reducing gastric acid secretion. Onandsentron Inj. and tablets were indicated as prevention of
nausea and vomiting due to chemotherapy, radiotherapy, and surgery. Ulsictal syrup (Sucralfate)
was indicated to protect the gastric mucosa. Novorapid and Lantus was indicated for the
treatment of diabetes mellitus to decrease the blood sugar levels by stimulating peripheral
1969
glucose uptake and inhibits hepatic glucose production. Cilostazol was indicated as an
antiplatelet.
4.
Dosage and Route of Administration
Ringer's lactate infusion 14 drops per minute, Ranitidine injection 25mg twice daily IV, Ranitidine
tablet 150mg twice daily oraly, Onandsentron 1g twice daily IV, Onandsentron tablet 4mg third
times daily, Ulsicral syrup 1 tablespoons third times daily orally, Novorapid 6UI third times daily
SC, Lantus 10UI third times daily SC, and Pletaal 50mg twice daily oraly.
5.
Laboratory Value
Results oflaboratory testsshowed increasing in HbA1C 12,8% (normal value ≥ 6,5% , cholesterol
255mg/dL (normal value < 200 mg/dL), and LDL 166mg/dL (normal value < 100 mg/dL).
6.
Discussion
Diabetesmellitus(DM) isagroupof metabolic diseaseswithcharacteristichyperglycemia(increased
blood sugar levels) thatoccurdue to abnormalinsulinsecretion, insulin actionor both.
Hyperlipidemiaisone ofthe causesof diabetes. In patient withdiabetesmellitus, impairedinsulin
productionandits small amountscauseonlylittleglucosecanenterin the tissuetobecomeenergyso
theenergy requirementsare not fulfilled. Energy needs to be done with lipolysis which
breakdown fat into triglyceride and fattyacids. The breakdown of fatscancausehigh content
offatin the bloodthat causing hyperlipidemia (Kimble and Youngs, 2013).
Inthiscasethe patientcame to the hospitalwithsymptompsof weakness,tiredwhen walkedaway,
alwaysfeelthirstyandhungry, andoftenfeelstiffinthe fingers and toes. Laboratory testsshowedthe
value ofHbA1c12.8% this indicated that the patient under uncontrolled diabetes mellitus. Patient
also suffered hyperlipidemia. For overcome this problem, physician gavenovorapid(long-acting
insulin), Lantus(short-acting insulin), pletaal(cilostazol), ranitidine, ulsicralsyr(sucralfate), Ringer's
lactate, andonandsentron. NovorapianddLantusis indicatedtoreduceandcontrol thepatient's
bloodsugar. Because value of HbA1c is too high, patient received 2 kinds of insulin, Novorapid
and Lantus. Pletaalis indicatedtoreduceplaqueinthe walls ofblood vessels that canlead to stroke.
Ranitidineandulsicralsyrupindicatedtoovercome theside effectsofpletaal,becauseitcanirritate the
stomach. Onandsentronis indicatedto reduce thenauseaexperienced bypatient.
Drug Related Problem 1: Untreated Disease
1970
a.
Patient hassuffered hyperlipidemiasinceadmission. Duringtreatment in hospital, the
physicianonlygivepletaalas antiplateletbutthe physician do notgiveantihypercholesterol.
Pharmacist Intervention: advice the physician to give HmgCoAreductase like simvastatin for
decreasing cholesterol level.
b.
Patientdon’tgetneurotropic
vitaminwhilethe
patientcomplain
ofa
stifffingerand
toesduringtreatment.
Pharmacist Intervention: adviced the physician to give neurobion to cure the stiff finger and toes.
Drug Related Problem 2 (Improper Drug Selection)
Patient receivedonandsetrontocure the complaint ofnausea.Onandcentron is improperuse
inthiscasebecauseonandcentron
isindicationforthe
prevention
ofnauseaandvomitingaftersurgeryandchemotherapy.
Pharmacist Intervention: advice the physician to change onandsentron with other antiemetic
drugs like domperidone or metoclopramide.
7.
Conclusion
In this case, we found 2 DRP, that are untreated disease and improper drug selection.
Refferences
1. Chien PC, Frishman WH. 2003. Lipid Disorder in Current Diagnosis and Treatment in Cardiology
2nd Edition. New York.
2. Departemen Kesehatan RI. 2007. Diabetes Melitus. Jakarta.
3. Medscape. 2014. Drug Interaction.
4. Kasim,Fauzi, et al. 2008. Informasi Spesialite Obat Indonesia volume 43. Jakarta: PT ISFI
Penerbitan.
5. Kimble K, Youngs. 2013. Applied Therapeutics The Clinical Use of Drugs 10th Edition.
Philadelphia: Market Street.
6. Sukandar EY, Andrajati R,et al. 2009. ISO Farmakoterapi. Jakarta: PT ISFI Penerbitan.
1971
CASE REPORT: DRUG RELATED PROBLEM IN THERAPY
HYPERTENSIVE HEART DISEASE AT MINTOHARDJO HOSPITAL
Iga Abigael1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
Email : abigaeliga@gmail.com
ABSTRACT
Hypertensive Heart Disease (HHD), is illness of heart complications term applied overall of heart
disease, including the left ventricle hyperthrophy (LVH) or left ventricular hypertrophy (HVK),
cardiac arrhythmia, coronary heart disease, and chronic heart disease, which is caused due to
increasing blood pressure, either directly or indirectly (Braverman, e. R, 2009). Patient Mr. Tw,
age 37 years old, entry Mintohardjo hospital on September 11, 2014 with a diagnosis of
Hypertensive Heart Disease (HHD). Shortness of breath, cold sweats, and sleeplessness. Patient
was treated with ranitidine injection, ringer lactate, amlodipin, catopril, lasix (furosemide), KSR,
letonal (spironolactone) and concor (bisoprolol). Based on the results of clinical practice at
Mintohardjo hospital is can be concluded that there is DRP (Drug Related Problem) in the form of
drug use without indication (granting of cefotaxime) and drug interactions between Concor
(bisoprolol) and letonal (spironolactone), letonal (spironolactone) and KSR, and captopril with
letonal (spironolactone).
Keywords: Drug Related Problem, Hypertensive Heart Disease and Mintohardjo Hospital
1972
INTRODUCTION
The cardiovascular system includes the heart, the circulatory/blood circulation and a State of
blood, which is a very important part of the body because it is the regulator and the funneling of
O2 and nutrients throughout the body. When one of these organs is experiencing interference,
especially the heart, it will interfere with all body systems (Faqih R, 2006).
Increased blood pressure systemically improving resistance to pumping blood from the left
ventricle, so that the burden of the heart increases. As a result, the left ventricle hypertrophy
occurs for increased contraction. This marked hypertrophy with increased wall thickness,
function space, and worsening of heart hypertrophy with space dilation compensation eventually
earned dilation occurs and exceeded the heart.
High blood pressure increases the heart's workload, and over time it can cause a thickening of
the heart muscle, because the heart pumps blood increased pressure against the blood vessels,
the left ventricle is enlarged and the amount of blood the heart pumps in every minute of it
decreases. High blood pressure is a major risk factor for heart disease and stroke. At the early
stage of hypertension, seem signs due to chronic stimulation of sympathetic dystrophy. The
heart beat fast and strong. Hyper circulation that may occur as the neurohormonal activity
increased with hypervolemia. Picture clinic such as shortness of breath, one of the symptoms of
impaired diastolic function, ventricular filling pressure increased, although still normal systolic
function. When developing continuously, there is the eccentric hypertrophy and eventually
became the dilatation of the ventricles, symptoms arise and jaded heart (Peter L, 2004).
Hypertensive heart disease diagnosis is based on history, blood pressure measurement, physical
examination, and laboratory examination. Treatment of patients with hypertensive heart disease
can use various drug antihypertensive groups: thiazides, beta-blockers, calcium channel blockers,
ACE inhibitors, angiotensin receptor blocker and vasodilator like hydralazine (Djohan T, 2004).
CASE PRESENTATION
Patient Mr. Tw 36 years old entered Mintohardjo hospital on September 11, 2014, with
complaints of claustrophobic shortness of breath, cold sweat, and sleeplessness. Patient have a
history of kidney stones right and hypertension.
1973
On the first day, the patient treated injection of cefotaxime, injection of ranitidine, ringer lactate,
captopril, amlodipin, furosemide. Then on the second day physician stooped using of furosemide
and captopril. And added additional lasix (furosemide), KSR, letonal (sporonolakton), and concor
(bisoprolol).
DOSAGE AND USING THE DRUGS
In this case the patient was treated with Lasix (furosemide) with a dose of 20 mg bid day with the
use of orally. With a dose of Captopril 25 mg tid a day with oral consumption. Amlodipine 5 mg
od. KSR 25 mg of did. Letonal (spironolactone) with a dose of 25 mg bid. Concor (bisoprolol) 2.5
mg od with Ranitidine injection 50 mg bid. Cefotaxime injection 2 gram bid.
DISCUSSION
Hypertensive heart disease is a disease that is associated with a secondary impact on the heart
due to long systemic hypertension and prolonged. Patient Mr. Tw 36 years old entered
Mintohardjo hospital with complaints shortness of breath, cold sweat, and sleeplessness. The
patient have a history of kidney stones right and hypertension.
Patient was treated with lasix (furosemide) for the treatment of pulmonary edema as a result of
overcome heart failure, catopril and diuretic for overcome hypertension and hypertension
renovaskuler, the symptoms of shortness of breath. Amlodipine as vasodilator for treatment of
hypertension and angina prophylaxis (Tjay,2002). Using of potassium supplements is indicated
for KSR or prevention of hypokalemia, and Letonal (spironolactone) is indicated for the treatment
of severe heart failure and edema. However, it should be suggested that the using of KSR and
spironolactone do not give at the same time because both of them have a synergistic effect and
can lead to hyperkalemia, and can make heart beat weaken. Concor (bisoprolol) is indicated for
the treatment of heart disease with blockade of beta-1 reseptor result negative inotropic effect,
chronotropic negative effect and decrease blood without causing peripheral constriction of
vessels and bronchia (Tjay,2002). Ranitidine Injection is indicated for the treatment of peptic
ulcers, and other conditions where a reduction of gastric acid would be beneficial. Cefotaxime
injection is indicated for overcome infection due to gram positive and gram negative (FDA, 2008).
1974
LABORATORY RESULTS
The results of laboratory examination showed that abnormality on Triglycerides value ie 1.5
mg/dL (normal value: 0.9-1.3 mg/dL) and Uremia value is 48 mg/dl (normal value 17-43 mg/dl),
this is indicated that patient experienced kidney disease.
1.
Drug Use Without Indication
a.
Using of cefotaxime as antibiotic is not appropriate because the patient did not
experienced infection disease that seen from leucocyte value is normally ie 9400 (normal value :
5000-10000/ µL) the wrong antibiotic use can improve resistance.
b.
Using of drug that contain of potassium such as KSR and suplemen K can cause
hyperkalemia
2.
DRP 2. Drug Interaction
a. Concor (bisoprolol) and Letonal (spironolactone)
UsingBisoprolol and spironolactone at the same time potentially to increase serum potassium.
Strictly monitoring is required
b. Letonal with Captopril (spironolactone)
Synergistic interaction can occurs if both of them using at the same time and can cause
hyperkalemia.
c. Letonal (spironolactone) and KSR
Both of KSR and Spironolactone potentially increase potassium serum. That can cause serious
interaction (Medscape, 2014).
CONCLUSION
Based on the results of clinical practice disease clinic at Mintohardjo hospital it can be concluded
that there is found DRP (Drug related problem) in the form of drug use without indication and
drug interaction.
1975
REFERENCES
BPOM, 2008. Informatorium Obat Nasional Indonesia 2008 (IONI). Jakarta : Agung Seto.
Braverman, E.R, Braverman, D.2009. Dua Penyebab Penyakit Jantung Tekanan Darah Tinggi and
Kenaikan
Kadar
Kolesterol,
available
from
:http://www.jantunghipertensi.com/index2.php?option=com_content&do_pdfi&id=340.pdf(Accessed Desember 2014).
Burns, Dr. Aine.2009. Renal Drug Handbook third edition. New York : Oxford.
Carol T, Brown (2006). Patofisiologi Konsep Klinis Proses Penyakit, edisi 6. Volume 1 : Jakarta :
Buku Penerbit Kedokteran EGC.
Djohan T.B.A, 2004. Penyakit Jantung Kororner and Hipertensi, Ahli Penyakit Jantung. Fakultas
Kedoketeran Universitas Sumatera Utara: 1-7 From http://liibrary.usus.ac.id/download/fk/gizibahri10.pdf (Accsesed 18 March 2012)
Faqih, R. 2006. Asuhan Keperawatan Pada Klien Dengan Gangguan Sistem Kardiovaskuler.
Malang : Universitas Muhammadiyah Malang.
Medscape.2014. Drug Interaction checker.
Peter L. 2004. Vascular Disease In : Harrison's Princilpes Of Intenal Medicine. 16 th Edition : 14681660.
Tjay, T. H. and Rahardja K. (2002). Obat – Obat Penting. 5th Edision. Publisher : Elex Media
Komputindo. Jakarta.
1976
CASE REPORT: DRUG RELATED PROBLEM IN THERAPY
DYSPEPSIA SYNDROME AT MINTOHARDJO HOSPITAL
Haslinda1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
Email : Lhyndha.indha@yahoo.com
ABSTRACT
Dyspepsia is a recurrent or chronic pain of bad taste/abdominal pain in the upper part are
accompanied by another complaint, the hot feeling in the chest, the heart (heart burn),
regurgitation, bloating, stomach feels full, quick satiety, saltpeter, anorexia, nausea, vomiting,
and a couple of other complaints. There are at least based on the dyspepsia causes of dyspepsia
is divided into organic and functional dyspepsia (Matsuda, et. 2009).
Patient Mr. E, 37 yeard old, admitted to the Mintohardjo hospital on 04 september 2014. Patient
was diagnosed dyspepsia. Therapy for the treatment during hospitalization is ceftriaxone
injection, onandsetron injection, omeprazole injection, tramadol injection , antacid, ambroxol,
alprazolam, and mefenamic acid. Based on the clinical practice result in selayar floor care III of
the Mintohardjo Hospital, it can be concluded that was found DRP (Drug Related Problem) in
the form of a less appropriate drug selection such as onandsetron and mefenamic acid,
interactions between onandsetron and tramadol which can reduce the effect of tramadol,
alprazolam and omeprazole may increase the levels of alprazolam.
Key words: Drug Related Problem’s, Dyspepsia Syndrome, Mintohardjo Hospital
INTRODUCTION
1977
Dyspepsia of Greece, namely the dys-(bad) and – peptein (digestion). Based on the consensus of
the International Panel of Clinical Investigators, dyspepsia is defined as pain or discomfort that is
primarily felt in the upper abdomen area. According to the criteria of Rome III, functional
dyspepsia is defined as a syndrome that includes one or more of the following symptoms:
stomach feeling full after a meal, quick satiety, or the sense of burning in the solar plexus, which
takes place at least in the last 3 months, with the early symptoms
for at least 6 months prior to diagnosis occurred. This complaint or syndrome may be caused or
are based on a variety of disease, including the disease of the stomach, or better known as
disease Ulcer (Douglas a. Drossman and M, 2009).
Causes of dyspepsia are irregular diet, alcohol consumption, medications such as steroids, bitter
taste of drugs drug (NSAID), antibiotics such as erythromycin and tetracycline, smoking and
lifestyle stress. Stress is one of the factors that affect dyspepsia due to movement and activity
can change the secretion of gastrointestinal traktus (Koda, Kimble & young's, 2009).
Dyspepsia is a common problem throughout the world. In the United States, the prevalence is
around 25%, not including those who have symptoms of GERD. In the United States, about 9% of
the people who do not have symptoms of dyspepsia annually in the previous year reported new
onset of symptoms. In Scandinavia, the incidence rate of 1% for < 3 months have been reported.
Symptoms of dyspepsia affects up to 40% of the adult population in Western countries (Talley,
NJ, Vakil N, and 2005).
CASE PRESENTATION
Patient Mr. E, 37 yeard old, admitted to the Mintohardjo Hospital on 04 September 2014.
Patient come to hospital with complaints of nausea, vomiting four times, limp, stomach pain, felt
tightness in his chest and pain in right chest. Patient has a history of ulcer disease beginning in
2012.
CLINICAL EVALUATION
The Results of laboratory tests Mr. E, admitted the hospital of the obtained abnormal leukocyte
levels i.e. 10.600/ul (3200 – 10,000/uL) indicating the presence of an infection. On day four to
1978
seven treatments indicate abnormal platelet levels in (170-380 x 103/mm3) and on the seventh
day shows abnormal on erythrocytes 5,81 million/µl (4.4 – 5.6 million/µl) and Hb 16.6 g/dl (13 –
16 g/dl). Dengue IgG positive on examination and negative IgM dengue.
DOSAGE AND USING THE DRUGS
Dosage and using of the drug in patients Mr. E i.e. ringer lactate is given IV 20 drop per minutes
to prevent dehydration and a dose of common laktac accorandce with ringer condition of
patient, ceftriaxone injection 1 time 2 grams given as antibiotics to combat infection,
onandsetron injection 4 mg/ampules 3 times given in intravenous to overcome nausea and
vomiting with usual dose of onandsetron 8 mg, omeprazole injection 2 times 1 is given
intravenously to cope with dyspepsia with a dose of omeprazole 20 mg antacid tablets, 3 times 1
is given orally is indicated for the treatment of dyspepsia, tramadol injection 2 times 1 is given
intravenously to cope with the pain in the abdomen and pain in the right arm with the customary
dose is 100 mg 3 times a day, alprazolam tablets 1 time 1 at night before sleep to overcome
difficulties sleeping at night ambroxol tablets 3 times 1 is given orally for overcome cough due to
patients complaining of cough a dose of 30 mg and mefenamic acid tablets 3 times 1 is given
orally to for reduce pain (BPOM RI, 2008).
DISCUSSION
Patient Mr. E has diagnosed dyspepsia syndrome is based on frequent nausea, vomiting, feeling
the heat in the chest and also pain in the chest. Results of laboratory examination show
abnormality in leukocytes i.e. 10.600/ul indicates the presence of infection, where as levels of
trombolity decreased. Results of examination by IgG and IgM is IgG dengue positive and IgM
dengue negative. Treatment of acquired during treatment at the hospital on the first day until
the sixth day was given an infusion of ringer lactate 20 drop per minutes, ceftriaxon injection is
indicated for infections, omeprazole injection and antasida is indicated for overcoming the
dyspepsia and peptic ulcers due to side effects of mefenamic acid, onandsetron injection
indicated for nausea and vomiting, tramadol injection and mefenamic acid is indicated for pain in
the abdomen. On day five of the patients complained of frequent cough at night so it was given
an additional drug ambroxol and alprazolam is indicated to overcome trouble sleeping at night.
1979
On day eight of the patients already can go home and get the drug omeprazole, antasida,
tramadol, mefenamic acid and alprazolam.
1)
Improper Drug Selection
a.
He gave the drug Onandzetron to cope with nausea and vomiting, Onandsetron more
specifically used for symptoms of nausea or vomiting in cancer therapy treatment or post
operative. Scientific publications about efficacy onandsetron for nausea or vomiting in the case
of gastrointestinal disorders is still lacking.
b.
given mefenamic acid for abdominal pain should not need because it had been given the
drug tramadol as an analgesic is strong.
2)
Drug Interactions
a.
Onandsetron with Tramadol
Onandsetron reduces the analgesic efficacy of tramadol and at least double the dose was
required in one clinical study. This resulted in more vomiting despite the onandsetron. It would
seem prudent to use alternative analgesics if onandsetron is required (Baxter, K. 2009).
b.
Omeprozole with Alprazolam
Omeprazole increases levels of alprazolam by decreasing metabolism. Minor interaction
(Medscape, 2014).
CONCLUSION
DRP (Drug Related Problem) in the form of a less appropriate drug selection such as onandsetron
and mefenamic acid, interactions between onandsetron and tramadol, alprazolam and
omeprazole.
REFERENCES
Baxter, K. 2009. “Stockley’s Drug Interaction”. Eight Edition. Pharmaceutical Press, London and
Chicago, hal : 287
BNF 61, 2011. Britsh National Formulary 61 March 201I, hal : 37
BPOM, 2008. Informatorium Obat Indonesia (IONI) ;Sagung Seto. Jakarta.
Brunton L.L. 2011. Goodman n Gilman’s The Pharmacological Basis of Therapeutics. 12th Edition.
Mc Graw Hill Medical, hal : 968
1980
Douglas A and Drossman M. appendix B Rome III Diagnostic Criteria for Functional
Gastrointestinal Disorders. Am J Gastroenterol. 2009;105:798–801.
Matsuda et all. Fonctional dyspepsia review of phatophysiology and treatment the open
gastroenterology journal. 2009.3.11-12
Medscape. 2014. Drug Interactions checker.
Koda, kimble & young’s. 2009. Applied therapeutics tenth edition. Lippinco williams & wilkins.
Philadelpia, hal : 667
Kemenkes RI. 2011. Pedoman Interpretasi Data Klinis. Jakarta.
Tack J, Bisschops R, Sarnelli G. Pathophysiology and Treatment of Functional Dyspepsia.
Gastroenterology. 2004;127:1239-55
Talley, NJ., Vakil, N., and the Practice Parameters Committee of The American College of
Gastroenterology. Guidelines for The Management of Dyspepsia. American Journal of
Gastroenterology. 2005. By Am. Coll. of Gastroenterology, Published by Blackwell Publishing,
ISSN 0002-9270, doi: 10.1111/j.1572-0241.2005.00225.x.
1981
EVALUATION OF DRUG RELATED PROBLEMS ( DRP ) IN
THE TREATMENT OF MYOCARDIAL INFARCTION AT
HOSPITALS OF ISLAM JAKARTA CEMPAKA PUTIH (RSIJCP)
Ismeiyeni¹, Diana Laila ²Aprilita Rinayanti Eff²
¹Student of Pharmacy Program, Faculty of Pharmacy UTA’45 Jakarta
²Lecture Pharmacy of Pharmacy UTA’45 Jakarta
(University of 17 August 1945 Jakarta)
Email
: Ismeiyeni05@gmail.com
ABSTRACT
Clinically myocardial infarction is the rapid development of necrosis of heart muscle which is
caused by the imbalance between supply and demand oxygen.¹ clinical condition is very worrying
which attack this is often surprise attack without any prior symtoms, which usually occurs in men
aged 35-55 years . Predisposing diseases, among others, old age, gender where men are more
prone to this disease, hiperkolestrolemia, diabetes, hypertension, and obesity.²
Mrs. WR patient, aged 54 years, entered RSIJCP on 28 September 2014 with a diagnosis of
myocardial infarction. Therapy treatment for hospitalized was amlodipine, Letonal, Candesartan,
Lasix, CPG ( clopidogrel ), Aptor, Simvastatin , Cedocard, Ceftriaxon, insulin. Based on clinical
evaluation results in RSIJCP, it can be deduced that the presence of DRP ( Drug Related Problems
) was the frequency of improper administration of drugs and drug interactions arising between
one drug and other drugs but still can be tolerated by monitoring the patient's condition.
Keywords : myocardial infarction and Hospital of Islam Cempaka Putih,
Necrosis.
1982
INTRODUCTION
Myocardial infarction is the rapid development of necrosis of the heart muscle which is
caused by the imbalance between supply and demand oxygen.¹ clinical condition of patient very
worrying which attack this is because it is often a surprise attack without any prior symptoms,
which usually occurs in men aged 35-55 years. Predisposing diseases, among others, old age,
gender where men are more prone to this disease, hiperkolestrolemia, diabetes, hypertension,
and obesitas.² Myocardial infarction occurred by heterogeneous causes, among others:
Myocardial infarction spontaneously occur because plaque rupture, fissure, or dissection of
atherosclerotic plaque. In addition, an increase in the need and availability of oxygen and
nutrients are inadequate trigger myocardial infarction. These things are the result of anemia,
arrhythmias and hyper or hypotension. Myocardial infarction is caused by spasm of the arteries
lowers vaskonstriksi and myocardial blood flow. In this situation, an increase in biochemical sign
is not found . This is due to the patient's blood sample is not obtained or the patient died before
the levels of biochemical sign of myocardial infarction was increased.³ Genesis begins with the
formation of atherosclerosis which then rupture and clog blood vessels. Atherosclerotic disease
characterized by the gradual formation fattyplaque in arterial walls. Over time this plaque
continues to grow into the lumen, so that the diameter of the lumen narrows. Narrowing of the
lumen interfere with blood flow distal to the blockage occurs.⁴ Factors such as age, genetics, diet,
smoking, diabetes mellitus type II, hypertension, reactive oxygen species and activation of
inflammation and endothelial dysfunction. Exposure to the above factors causing injury to the
endothelial cells. Due to endothelial dysfunction, the cells can no longer produce vasoactive
molecules such as nitric oxide, which works as a vasodilator, anti - thrombotic and anti proliferation. In contrast, endothelial dysfunction actually increase the production of the
vasoconstrictor, endothelin - 1, and angiotensin II plays a role in the migration and growth sel.⁴
PERCENTAGE CASE
Patient aged 59 years Mrs. WR entered RSIJCP on 21 September 2014. The patient
before admission got shortness of breath , and no appetite. The patient had a history of previous
disease which is hypertension and diabetes .
1983
CLINICAL EVALUATION
The treatment given during treatment that tailored to the myocardial infarction
diagnosis, therapy treatment given was based on laboratory results showed CK - MB high
important indicator of muscle tissue damage, and brain miocardium because blood flow was
blocked due to plaque thrombus arterosklorosis.⁵ So to overcome given PG ( lopidogrel and
Aptor orally. To trigger the heart to function optimally, given Digoxin was oral.⁶ Based vital sign
checks, showed that the patient's blood pressure was above normal, the antihypertensive drug
therapy: amlodipine, candesartan, clonidine administered orally.⁶ To overcome edema also
functions to lower blood pressure then given orally and Lasix letonal IV ( Intra Venous .⁶
Provision for the prevention of angina pectoris and overcome pain after cedocart no longer given
IV, then replaced with Nitrokaf retard given orally.⁶ Judging high patient laboratory results
leukocytes indicates infection or inflammation in patient with myocardial infark.¹¹ So Ceftriaxon
drug therapy as an anti- cholesterol antibiotik.⁶ As an anti- cholesterol given orally Simvastatin at
night.⁷ For the treatment of diabetes given insulin injection ( Novorapid .
Drug name
Ro
and
ute
Dose
Date and Time Giving
compositio
2
2
2
2
2
2
2
2
2
3
n
1
2
3
4
5
6
7
8
9
0
1 1
0
0
0
0
0
0
0
0
8
6
6
6
6
6
6
6
1 1
0
0
0
0
0
0
8
6
6
6
6
6
6
CPG
Ora
1x
(Clopidogrel
l
tablet
I
2
3
4
5
0
0
0
0
0
0
6
6
6
6
6
6
6
0
0
0
0
0
0
0
0
6
6
6
6
6
6
6
6
per hari
Letonal
Ora
1x
50mg
l
tablet
(spironolakt
1
per hari
1984
on)
Candesarta
Ora
1x
n 16mg
l
tablet
1 1
0
0
0
0
0
0
*
0
1
0
0
0
0
0
8
6
6
6
6
6
6
N
6
8
6
6
6
6
6
1
1
1
S
1
*
1
1
1
1
1
8
8
8
8
*
8
8
8
8
8
per hari
Digoksin
Ora
1x
1 1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
l
tablet
8
6
6
6
6
6
6
6
6
6
6
6
6
6
6
Ora
2x1table -
0
0
0
0
0
0
0
0
1
0
0
0
0
0
l
t
6
6
6/
6
6
6
6
6
8
6
6
6
6
6
1
1
1
1
1
1
*
1
1
1
1
1
8
8
8
8
8
8
*
8
8
8
8
8
per hari
Amlodipin
per
hari
Aptor
Ora
1x
(Acetosal)
l
tablet
1 -
0
0
0
0
0
0
0
0
0
0
0
0
0
0
6
6
6
6
6
6
6
6
6
6
6
6
6
6
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
-
--
-
-
-
-
-
-
-
0
0
1
0
0
per hari
Simvastatin
Ora
1x
20mg
l
tablet
1 -
per hari
Clonidin
Ora
2x1
-
l
tablet
6
6
8
6
6
perhari
1
1
*
1
1
8
8
*
8
8
-
1
0
0
0
2
6
6
6
(Glycery
1
1
1
rinitrate)
8
8
8
Nitrokaf 2,5 Ora
2x1table -
mg
t perhari
Ceftriaxon
2mg
l
IV
1x2mg
-
-
-
-
-
-
-
-
-
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
8
8
8
8
8
8
8
8
8
8
8
8
8
8
8
1985
Lasix 10mg/
IV
ampoule
2x2amp
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
ul
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
2
0
0
9
0
4
6
9
(Furosemid)
Cedocard
IV
(Isosorbit
***Prn
dinitrat)
6
1
1
6
2
Note : * NS = No Supplies, **Drug No Given,***Prn : if Needed
EXAMINATION
NORMAL VALUE
21/9/14
Hemoglobin
12-16 g/dL
L 11.2
Hematokrit
37-47 %
L 32
Eritrosit
4.3-6 juta/μL
L 3.72
Leukosit
4800-10.800 / Μl
H 13.75
Trombosit
150.000-400.000/μL
361
MCV
80-96 fL
85
MCH
27-32 pg
30
MCHC
32-36 g/dl
35
SGOT
10-32 U/L
18
SGPT
9-36 U/L
10
Blood Urea
10-50mg/dl
42
Blood Triglyceridese
<1.4 mg/dl
0.8
CK-MB
<24U/L
H 26.10
Na
135-147 meq/L
139
23/9/14
142
1986
K
3.5-5.0meq/L
L 3.1
4.0
Cl
94-111meq/L
101
101
Blood glucose during
70-200mg/dl
H244
PH
7.370-7.450
L 7.345
CO2
33-44 mmHg
41.5
O2
71-104 mmHg
H235.5
O2 seturation
94.00-99.00%
H 99.70
HCO3
21-28 mmol/L
L-3.00
Base excess (ecf)
-2.00-3.00 mmol/L
L -3.00
Bae excess (B)
-24- +2.3 mmol/L
-2.0
EXAMINATION OF GLUCOSE AND GRANT OF INSULIN IN SEPTEMBER AND OCTOBER 2014
Examination
22
23
24
25
26
27
28
29
30
01
02
Glukosa 05Hours
131
183
126
179
222
161
130
149
160
128
158
(mg/dl)
(N
(N
(N
(N
(No)
(N
(N
(N
(N
(N
(N
O)
O)
O)
O)
O)
O)-
O)
O)
O)
O)
Glukosa 11 Hours
200
201
276
151
119
261
160
185
221
205
217
(mg/dl)
(4
(4ui (8ui
(N
(NO )
(N
(N
(
(No
(N
(No
O)
O)
NO
)
O)
)
(Unit)
ui)
)
)
O)
)
Glukosa 17 Hours
(mg/dl)
241
280
266
295
207
341
177
246
310
243
267
(4ui (8ui
(N
(8ui
(No)
(N
(N
(4ui
(N
(N
(No
O)
O)
)
O)
O)
)
)
)
O)
)
Glukosa 23 Hours
250
188
146
306
199
190
201
167
165
199
318
(mg/dl)
(4
(8ui
(N
(12
(NO)
(N
(No
(N
(N
(N
(No
Ui)
)
O)
ui)
O)
)
O)
O)
O)
)
NOTE:
1987
Blue:
glucose in a state of normal values, so insulin is not given.
Red:
glucose above normal values, but insulin is not given.
Black:
Insulin is given according to the standard administration of insulin.
DRUG RELATED PROBLEMs (DRPs)
3.
Indications Were Not Addressed
Patient complain of loss of appetite should be given in the form of B Multivitamin
Complex, where there were various vitamins such compositions B1 , B2 , B3 , B5 , B6 , B7 , B9 ,
B12 , in addition to helping improvement of appetite, these vitamins can also cope with low
hemoglobin indication, low hematocrit and erythrocyte low. In accorandce with the examination
of patient laboratory data. Intervention doctor: Can prescribe appetite enhancer vitamins and
vitamins as indicated.
4.
Not Receiving Drug Therapy
In this case the drug did not receive drug treatment Candesartan 28 -9-2014 and dated
30-9-2014, Amplodipin on 30-9-2014, clonidine on 3-10-2014 due to factors depleted drug supply
room of nursing. Nursing interventions: before the drug out immediately ask the doctor to
prescribe medications the patient back. Pharmaceutical Intervention: pharmacists and pharmacy
technicians can be an important part of the health care team and can help patients take their
medication regularly.
5.
Non observance
26 , 28 , 30 in september and dated 01 , 02 in October 2014 patient would not receive
insulin injections. Pharmacistl interventions: therapeutic failure patient with chronic diseases are
often the result of non-compliance to drug therapy and non- drug therapies.¹²
1988
CONCLUSION
On the result of clinical Pharmacy practice in the RSIJCP, it can be deduced that a given drug is
enough for optimal myocardial infarction disease but still their Drug Related Problems form :
Indications not overcome that patients complain no appetite and laboratory data of patients
include hematokrit, hemoglobin, erythrocyte low which should be overcome by administering a
multivitamin as indicated. Patients did not receive the drug candesartan drug therapy, clonidine,
amlodipine. And non-compliance of patients on insulin drug therapy because patients do not
want to receive insulin injections.
REFERENCES
1.
Fenton,
D.E.,
2009.
Myocardial
Infarction
Available
from:
http://emedicine.medscape.com/article/759321-overview
2.
Santoso, M., Setiawan, T., 2005. Penyakit Jantung Koroner. Cermin Dunia Kedokteran.
Availablefrom:http://ojs.lib.unair.ac.id.
3.
Alpert, J.S., Kristian, T., MD, Allan S. J., Harvey D.W., 2010. A Universal Definition of
Myocardial Infarction for the Twenty First Century AccessMedicine from McGraw Hill .
4.
Ramrakha, P., Hill, J., 2006. Oxford Handbook of Cardiology: Coronary Artery Disease. 1St
ed. USA: Oxford University Press.
5.
Nigam. P.K., 2007. Biochemical Markers of Myocardial Injury Indian Journal of Clinical
Biochemistry
6.
ISO Indonesia.2009. Ikatan Sarjana Farmasi Indonesia.Jakarta.
7.
BPOM RI. 2008. IONI. Baand Pengawasan Obat and Makanan Republik Indonesia. Jakarta.
8.
Medscape.com, Drug Interaction Checker. 2014
9.
Syamsudin. 2013. Interaksi Obat Konsep Dasar and Klinis. UI-Press. Jakarta.
10.
Price, A. S., Wilson M. L., 2006. Patofisiologi Konsep Klinis Proses-Proses Penyakit Alih
Bahasa: dr. Brahm U. Penerbit. Jakarta: EGC
11.
ISO Indonesia.2014.Ikatan Apoteker Indonesia.Jakarta.
1989
12.
Kementrian Kesehatan Republik Indonesia. 2011. Pedoman Interpretasi Data Klinik.
Jakarta: Bina Kefarmasian and ALKES.
13.
Cannon,C.P., Braunwald, E 2005.Unstable Angina and Non-ST-Elevation Myocardial
Infarction In: Kasper, D.L., Fauci, A.S., Longo, D.L.,Braunwald, E., Hauser, S.L., Jameson, J. L., eds.
Harrison’s Principles of Internal Medicine.16Th ed. USA: McGraw Hill 1444-1445.
14.
Patel, N.R., Jackson. G., 1999. Serum markers in myocardial infarction. J Clin Pathol.
15.
Samsu, N., Sargowo, D., 2007. Sensitivitas and Spesifisitas Troponin T and I pada
Diagnosis Infark Miokard Akut. Tinjauan Pustaka. Malang: Faku ltas Kedokteran Brawijaya.
1990
HEMORRHAGIC STROKE WITH DIABETES MELITUS TYPE II IN UNIT
STROKE RSPAD GATOT SOEBROTO
Nelstyani Elisabeth1, Diana Laila Rahmatillah2, Aprilita Rinayanti Eff2
1
2
Email : nels.tyanie@gmail.com
ABSTRACT
Hemorrhagic strokeisafunctionaldisorderof brainthatoccurs suddenlywithsignsandsymptoms
ofbothfocaland
globalclinicallasting
morethan24hoursorcanlead
todeathdue
tocirculatory
disordersof brainrupture, rupture ofblood vesselsof the brain(hemorrhage). 1
StrokeclassifiedinCerebroVascularDisease (CVD), which is an emergency diseaseandneed helpas
soon as possible.2
A patientnamed Mr.S.K50years old, Attended to hospital RSPAD GATOT SOEBROTOon
4thDecember2014
withanamesaHaemorrhagicCVD.
historywasheartandhypertension,
Previously
Mr.
bothdetectedapproximatelyayearago.
forhospitalizedwasinjectionciticolin1000mg,
Nimotoptablet
60mg,
S.Kmedical
Therapytreatment
Bisoprolol
tablets5mg,
Noperten tablets5mg, Amlodipinetablets 10mg, Metformin tablets500mg. Based on theresults
of a clinical workpractice, was foundthe existence of DRPs(Drug Related Problems) ofdrug
interactions. The types ofdrugs that interactareAmlodipineandBisoprolol.
Keywords : Stroke, Hemorrhagic Stroke, Diabetes Mellitus, RSPAD
1991
Introduction
Asrapidly the development of science in the world, currently
pharmacy not onlyoriented
todrugsorproducts derived(drug-oriented) butalsothrivein the presence ofpharmaceutical
service-oriented
paradigmin
patients(patient-oriented).
servicespreviouslyonlyfocusedondrugmanagement
ascommodities
now
Pharmacy
has
grown
with
orientationpatient service care (pharmaceutical care).
Strokeis
non-communicable
diseaseswhichrecently
becamea
concernof
many
people.StrokeclassifiedinCereboVascularDisease (CVD), which is an emergency diseaseandneed
helpas soon as possible.2
Strokeisabrainattackas
a
result
ofdisturbancein
theblood
vesselsthatsupply
bloodcarryoxygenandglucosemetabolism ofbrain cellsin order tocontinue its function. The
attacksaresuddenlyandsymptoms, it is according to thepart of brainthat can not besupplied
theblood.3
Hemorrhagicstrokesare
classifiedintointracerebral
hemorrhageandsubarachnoidhemorrhage.
Intracerebral hemorrhageis primer bleedingfroma blood vesselinthe brainparenchyma.
Subarachnoidhemorrhageisan
availability
condition
orentry
ofblood
intothe
subarachnoidspacedue torupture of aneurysm, AVMorsecondary tobleedinginserebral.4
Quickdiagnosisis very important to minimizethe damage. CTScan(Computerized tomography
scanner) isthe method of choicefor assessmentof acutesigns ofcerebralvascularinjury. CTscan is
verysensitive tohemorrhagic, an important considerationbecausethere arevitaldifferencesin
thetreatmentof
ischemic
strokeandhemorrhagic
stroke.
Acutestroketreatmentistoreduceneurologicalinjurysustained,
termdisability,
The
reduced
preventsecondarycomplicationsmorbidityand
aims
of
mortalityandlong-
neurologicaldysfunction,
preventstrokeRecurrent, primary strokepreventioninplaceothers.5
Case Presentation
A patient named Mr.SKage of50years, was broughtto the RSPAD GATOT SOEBROTO byhis
familyon December 4th2014at22:07, due tothe weakness ofthe limbsperceivedright side
5hoursbeforeenteringthe hospitalwhenthe patient isin the bathroom. Patientseemsleepy, do
1992
notfeel theheadache. Nauseabut novomiting.Patient hadfever andnoseizures. He difficulted to
communicate.PreviousHe was never sick like this.
Previously
medical
history
of
Mr.SKwasheart
disease
bothcontrolledapproximatelyoneyearago.
andhypertension,
Previouslypatienttreatment
historyisLisinopril5mg/24h, Bisoprolol5mg/24h, Aspilet80mg/24h, Simvastatin10mg/24h. The
patienthad no historyof allergies.
Physical examination: generalcondition(KU): composmentis(CM), the GlasgowComa Scale(GCS):
14, BloodPressure: 200/170mmHg, RespirationRate: 20x/ minute, Heartrate:64x/ minute,
BodyTemperature: 36,5° C, weight: 85kg, Height: 170cm
Laboratory findings: hematological on December 4th2014, namely hemoglobin 14.3 g / dL (13-18
g / dL), hematocrit 42% (40-52%), erythrocyte 5.2 million / mL (4.3-6.0 million / ml), leukocytes
12500 / uL * (4800-10800 / mL), platelets 210 000 / mL (150,000 to 400,000 / ml), mean
corpuscular volume (MCV) 80 Fl * (80-96 fL), mean corpuscular hemoglobin (MCH) 27 pg (27 -32
pg), mean corpuscular hemoglobin concentration (MCHC) 34 g / Dl (32-36 g / Dl).
Clinical
chemistryshowedSGOT(AST)
urea48mg/dL(20-50
mg/dL),
150*mmol/L(135-147
mmol/L),
20U/L(<35
U/L),
SGPT(ALT)
triglyceridese.1.7*mg/Dl(0.5-1.5
potassium(K)
3.4*mmol/L(3.5-5.0
31U/L(<40
U/L),
mg/Dl),
sodium(Na)
mmol/L)
,chloride(Cl)
104mmol/L(95-105 mmol/L), totalprotein7.5g/dL(6-8.5 g/dl), albumin4.5g/dL(3.5-5.0 g/dl),
globulin3.0g/dl(2.5-3.5
triglycerides144mg/dl(<160
g/dL),
totalcholesterol208*mg/dl(<200
mg/dl),
mg/dL),
HDLcholesterol28*mg/dl(>35mg/dL),
LDLcholesterol151*mg/dl(<100 mg/dL), uricacid5.7mg/dl(3.4 -7.0mg/dL).
The result of physiology examination including examination of coagulation hemostasis time
prothrombin time (PT) is obtained control of 10.5 seconds, on patient PT was obtained the same
value with the reference value of 10.5 seconds (9.3-11.8 seconds). Activated partial
thromboplastin time control (aPTT) 32.8 seconds on patients 29.7 seconds * normal values of
31-47 seconds, fibrinogen 301 mg / dl (136-384 mg / dl).
Clinical Evaluation
1993
The beginning therapy was given when the patient in the ER room which was citicoline injection
500 mg per 12 hours and giving oxygen 3L per minute. Then the patient was transferred to the
stroke unit care.
Whenenteringthe treatment roomstroke unit, thepatientgiven intravenousAsering20MDGs,
insertedfolley
catheter,
giving
injectionciticolin500mgper12
intravenousandnimotop60mgtabletsorallyper6
hours.
hours
as
th
OnDecember
8 2014patient
givenadditionaltherapy Lisinopril5mgper24 hoursandamlodipine10mgto lowerbloodpressure,
Bisoprolol5
mgper24
hoursformildhypertension-
moderatewithcoronaryheartdisease/arrhythmias.
Citicolintherapyincreasedthe
dose
to1000mgper12hours. On December 13th 2014the patientcomplained ofslightdizziness so
doctorsgive500mgparacetamol as an extraifthe patient's getfeverorheadache.
Duringtreatment,
the
Patientslooksfreshandable
patient'scomplaintsandclinicalsymptoms
to
communicateverballywithclear,
getimproved.
nolispagain.
The
Blood
pressureandblood glucosealsocontrolled.
Laboratory Data
Results
oflaboratory
testsof
4th2014that12,500leukocytes/mL*,
kreatinin1.7*mg/Dl(0.5-1.5
150*mmol/L(135-147
mg/Dl)
mmol/L),
hematology,
clinical
chemistryon
meancorpuscularvolume(MCV)
,blood
glucose202*mg/dL(<140
potassium(K)
3.4*mmol/L(3.5-5.0
December
80Fl*(80-96
mg/dL),
fL),
sodium(Na)
mmol/L.
Results
ofhemostaticcoagulationphysiologyexaminationincludingexaminationtimeprotrombinetime(PT)
is obtainedcontrol of10.5seconds, thepatientPTthat was obtainedthe same valuewith
thereferencevalue
of10.5seconds(9.3-11.8
partialthromboplastintime(aPTT)
seconds).
Controlactivated
32.8secondsto29.7secondspatients*normal
values31-
47seconds, fibrinogen301mg/dl(136-384 mg/ dl).
On December 5th 2014carrieda chest radiographandMSCTscan which showedtheimpression
ofcardiomegalywithaorticelongation, invisibleradiographic abnormalitiesin the lungonchest
radiographandimpressionintraparenkimbleedinginthe leftthalamusand the estimatedvolume
1994
of5.6cc,
bleedingintraventrikelleftlateralposteriorkormuandinfarctionin
theleftexternaldikapsulalakurnaMSCTscanexamination.
Results ofclinical chemistrylaboratory tests, urinecompleteonDecember 8th2014sodium(Na)
148*mmol/L(135-147
mmol/L),
potassium(K)
3.4*mmol/L(3.5-5.0
mmol/L),
Gammaglutamyltransferase64*U/L(8-61 U/L), CK-MB (creatinkinase-MB) 57*U/L(7-25 U/L),
totalcholesterol208*mg/Dl(<200
LDLcholesterol151*mg/dl(<100
mg/dL),
mg/dL),
HDLcholesterol28*mg/dl(>35mg/dL),
fastingbloodglucose131*mg/dL(7-100
mg/dL)
,bloodglucose2hoursPP172*mg/dL(<140 mg/dL), proteins+1*(negative), nitritepositive(negative),
otherspositivebacteria(negative).
Drug Related Problems (DRPs)
1.
Drug Interactions
Amlodipineandbisoprolol
a.
InteractionbetweenBisoprololandamlodipinecanincreaseanti-hypertensive
workofamlodipinewithpotentialharmfulinteractions.
Usecautionandcloselymonitorbloodpressure. The occurrence ofdrugs interactionsintherecipe,
including the factorsthatshould beconsidered more carefully, polypharmacyisan assessment of
theconditioncan
be
observedthrough
anumber
oftypes
ofmedicationreceived
bypatientsespeciallyto theamountof drug administeredat the same time.
b.
Pharmacistintervention: Polypharmacyis possible to occurin patientswithstrokewith
infection.
The
role
ofthe
pharmacistis
verylargein
theidentification
ofDrugRelatedProblems(MTO), Recommendationcompletion/preventionMTO(intervention), the
provision
ofdruginformation,
andmonitoringthe
results
ofthe
intervention,
especially
inintensivecarepatientswhoreceivesome sort.
CONCLUSION
Basedonthe results ofclinical workpracticeRSPAD GatotSoebrotostrokeunit, it can be
concludedthat thepresence ofDrugRelatedProblems(MTO) in the form ofan interaction ofthe
drugwithsignificanteffectsbetweenAmlodipineandbisoprolol.
Interactionswere
serious.
1995
Bisoprololandamlodipinecanincreaseanti-hypertensive
potentiallyandgerousinteractions.
It
is
ofamlodipinewith
needed
a
carefully
usecautionandcloselymonitorbloodpressure.
After discussionswith theResponsibleCarePhysician of patient(DPJP), drugsuseddare in
accorandcewith
theStandardsof
Medical
Services(MSS)
and
theRSPAD
GatotSoebrotoAssociationStandardsof Medical CareSpecialist DoctorNerveIndonesia(PERDOSSI
2014) forhemorrhagicstrokeanddiabetes mellitustype II. Fromthe analysis ofdrug-related
problems(Drug Related Problems) canbe deduceddrug interactionswithdrugsa bad effect onthe
patient's conditionifnot treated properly.
References
1.
Drafting Teamof MedicalPersonnel. 2014.Standardsof Medical CareinRSPAD GATOT
SOEBROTO DITKESAD. Jakarta : RSPAD GatotSoebroto
2.
Nerve
SpecialistDoctorsAssociationof
Indonesia.2014.Standardsof
Medical
CareNeurology. Jakarta: PERDOSSI
3.
Department
of
Health
RI.
2007.Guidelines
forCardio
VascularDisease
Controlandbloodvessels. Jakarta: DirectorateGeneral ofDisease Controland Environmental
Health,Ministry of Health.
4.
Dewanto, dr, george, SPS, et al. 2009.PracticalDiagnosis and Management ofNeurological
Diseases. Jakarta: ECG
5.
Corwin,ElizabethJ.2008.HANDBOOKOFPATOFISIOLOGY3rd,
translatedby:
NikeBudhiSubekti, EgiKomarYudha, et al., Jakarta:ECG
1996
DRUG RELATED PROBLEM IN PATIENT WITH STROKE
DISEASE, TYPE II DIABETES, HYPERTENSION AT
PERSAHABATAN HOSPITAL
Andiel Rianto Ratu1, Aprilita Rinayanti Eff2 and Diana Laila Rahmatillah2
1
Student of Pharmacist Programe Faculty of Pharmacy UTA’45 Jakarta
2
andiel_rianto_ratu@yahoo.co.id
ABSTRACT
Stroke is an acute neurological dysfunction caused by circulatory disorders of the brain, which
occurs suddenly (within seconds) or rapidly (within hours) symptoms and signs in accorandce
with the focal area of the brain is interrupted (AK Saenger, Christenson RH, 2010). Ischemic
stroke is caused by focal cerebral vascular occlusion causes a decline in the supply of oxygen and
glucose to the brain that undergo occlusion (Hacke, 2003). DM (diabetes mellitus) is a metabolic
disorder characterized by hyperglycemia associated with abnormalities in the metabolism of
carbohydrates, fats, and proteins caused by a decrease in insulin secretion or a decrease in
insulin sensitivity, or both and cause chronic complications microvascular, macrovascular, and
neuropathy (David, 2012). Hypertension is an increase in blood pressure at a certain level and
gradually at three times during the three weeks of intermittent measurements which can cause
damage to the body. Increased blood pressure, diastolic blood pressure which settled above 90
mmHg or systolic pressure above 140 mmHg settle (Nugroho A, 2009). Patient Mrs. SDH, aged 47
years entered Hospital on October 12, 2014 patient has diagnosis of ischemic stroke, type II
diabetes, hypertension, dyspepsia syndrome. Patient has treated with IVFD Aminofluid 500 ml,
Metformin, Gliquidone, Catopril, Ranitidine IV, Domperidone, Simvastatin, KSR, Ascardia,
clopidogrel, Mecobalamin, Novorapid, Citicholin. In this case has found a Drug Related Problem
(DRP) that are drug dose of Ranitidin is too low and the interaction between Ascardia,
Clopidogrel, and Heparin that can result risk of bleeding.
Keywords: Drug Related Problem ( DRP ), ischemic stroke, hypertension, Type II diabetes,
Persahabatan Hospital
1997
1.
INTRODUCTION
According to WHO, stroke is the clinical manifestations of brain dysfunction, both focal and
overall (global) that progresses rapidly, with symptoms lasting for more than 24 hours or cause
death without any other cause other than vascular disorders (Junaidi, 2003 ; Aliah et al, 2007).
Stroke cases worldwide is estimated at 50 million, and 9 million are suffering from severe
disability. Even more worrying 10 percent among those who had a stroke suffered death.
In industrialized countries, stroke is the leading cause of death in general third most in the
elderly after heart disease and cancer (Lumbantobing, 2003). The incidence of stroke in the
United States ± 700,000 per year and is the third leading cause of death after coronary heart
disease and cancer. Comparison of patients with stroke in the United States between men and
women is 1.2: 1 and the ratio of stroke among blacks and whites that is 1.8: 1 (Caplan, 2000).
Indonesian data showed an increase both in the case of stroke mortality, incidence and disability.
Mortality rates by age of: 15.9% (age 45-55 years), 26.8% aged 55-65 years, and 23.5% aged> 65
years. While the incidence of stroke by 51.6 / 100,000 population and disability: 1.6% unchanged,
4.3% more advancing. Patients with more male than female stroke with profiles aged <45 years
of 11.8%, age 45-64 years by 54.2%, and age> 65 years by 33.5% (Misbach J, 2000).
Diabetes mellitus (DM) is defined as an illness or a chronic metabolic disorder with multiple
etiology that is characterized by high blood sugar levels accompanied with impaired metabolism
of carbohydrates, lipids, and proteins as a function insufficiency of insulin by the beta cells of
Langerhans of the pancreas gland, or due to lack of responsiveness of the cells to insulin
(Nugroho A, 2009)
Diabetes mellitus or diabetes is a chronic metabolic disease characterized by hyperglycemia
resulting from absolute deficiency of insulin or the resistance to the insulin receptor. The
symptoms of diabetes are Glukosaria, 3P (Polyuria, polydipsia, and polyphagia), weight loss,
wounds that are difficult to heal, tingling / immune, lethargy, weakness, and ketoacidosis
(Nugroho A, 2009).
High blood pressure or hypertension is a chronic condition in which the systemic arterial blood
pressure increases beyond the threshold of normal blood. Range normal blood presure is 60-80
mmHg for diastolic, and 90-120 mmHg for systolic. Patient with hypertension said if his blood
1998
pressure over 90 mmHg for diastolic, and 140 for systole. While the range of 80-90 mmHg in
diastole, and 120-140 in systole of said condition prehypertension. In this condition although not
yet hypertension prehypertension, but patient should start doing therapy especially therapeutic
pharmacological therapy, and prevent activities that can increase blood pressure (Nugroho A,
2009).
2.
PERCENTAGE OF CASE
Patient Mrs. SDH, aged 47 years entered the Persahabatan hospital on 12 October 2014. Patient
present with limb weakness since one night right before going to the hospital. Patient also
complained of nausea and vomiting. The patient has DM since last 6 months, and had consumed
glibenclamide and metformin, and patient has hypertension too.
3.
CLINICAL EVALUATION
In this case patient received metformin and glibenclamide to overcome DM. Ranitidine to
overcome gastric irritation, nausea, vomiting. Domperidone to overcome, Captopril to cope with
mild to moderate hypertension and severe hypertension that is resistant to other treatments,
KSR (potassium chloride) for
hypokalemia. Simvastatin for hypercholesterol, Clopiogrel as
antithrombotic events, Ascardia was as secondary prophylaxis or prevented or stroke /
thromboembolism, Novorapid (insulin aspart) is the main hormone preparations quick work
involved in energy metabolism and the effect is a decrease in blood glucose concentration, used
to overcome DM, Citicholin used as a neuroprotective, so that the cells in the brain alive.
4.
DISCUSSION
In this case the patient has the right limb weakness, patient given clopidogrel aims to improve
blood flow in the brain, and citicholin for the protection and repair of neurovascular. This
medicine is an exogenous form of cytidine 5-diphosphate choline, which is essential for the
biosynthesis of membrane phospholipids.
This patient also had a history of diabetes mellitus and hypertension which has been examined
GDS (Blood Sugar As) and the patient's blood pressure results obtained 213 mg / dl for the GDS
and 140/90 mmHg for blood pressure. Infusion of Ringer's lactate for repair / liquid electrolyte
meet patient.
1999
Ranitidine injection, an antihistamine H2 receptor blockers. In H2 receptor inhibitor ranitidine
work fast, specific and reversible through reduction and hydrogen ion concentration of gastric
fluid. The purpose of giving ranitidine for the treatment of peptic ulcers.
Metformin is an oral antidiabetic which lower blood sugar in diabetics whose pancreas is still
able to produce insulin. In addition, Novorapid was given for treated Type I and II diabetes
mellitus (Nugroho A, 2009). Result of laboratory tests showed that increasing of blood glucose (
231 mg / dl) (normal 70-150 mg / dl). Novorapid (insulin aspart) is the main hormone
preparations quick work involved in energy metabolism and the effect is a decrease in blood
glucose concentration, was administered subcutaneously. In the liver, insulin inhibitor
glycogenolysis and glukogneogenesis, as well as increasing glycogen synthesis and use of glucose
(glycolysis).
KSR (potassium chloride) is the main cation of intracellular fluid and induces nerve impulses in
the heart, brain, skeletal muscle, smooth muscle contraction and, maintaining the normal
function of the kidneys, acid-base balance, carbohydrate metabolism and secretion of
gastrointestinal (GI) (Isniati, 2003 ).
Domperidone is a dopamine antagonist that works as an antiemetic (Mycek, 2003). Captopril is
used to decrease blood pressure (140/90 mmHg), which already includes the category of
hypertension grade I according to the seventh report of the Joint National Committee on
prevention, detection, evaluation, and treatment of high blood pressure (JNC 7). Captopril is a
class of angiotensin-converting enzyme inhibitors (ACE-I) are important in the renin-angiotensin
system. ACE is also called peptidyl dipeptide hydrolase or peptidyl dipeptidyl dipeptidase. These
enzymes convert angiotensin I to angiotensin II on the surface of endothelial cells. ACE-I used in
the handling of hypertension, heart failure, myocardial infarction, patient with diabetic
nephropathy and progressive disorder. This drug is not affect blood glucose levels so that
appropriate when used in diabetic patients with hypertension (Nugroho A, 2009).
5.
Types of
Dose
Drugs
Regim
DOSE AND TREATMENT
Date of giving the drug
12/10/14
13/10/14
14/10/14
15/10/2014
16/10/2014
2000
en
M
2x12,5

D
A
N M


D
A
NPP M


D
A
N
M D
A
N
M
D
A
N
Oral
Captopril





mg
Simvastatin
1x20
STOP
mg
Ascardia
1x80


-
-
-
mg
Clopidogrel
1x1


-
KSR
1x600


Stop
mg
Domperido
3x10
ne
mg
Metformin
3x50






Stop



  





mg
Injection
Ranitidine
2x50
c


mg

Cithicolin
Heparin
Stop

1x5000


  

u
 
Others
Novorapid
3x4 u
Types of
Dose
Drugs
Regim









Date of Giving the Drugs
17/10/14
18/10/14
19/10/14
20/10/2014
21/10/2014
2001
en
M
2x12,5

D
A
N M


D
A
NPP M


D
A
N
M D
A
N
M
D
A
N
Oral
Captopril





mg
Simvastatin
1x20
STOP
mg
Ascardia
1x80
-


-
-
-


-
-

  



  




mg
Clopidogrel
1x1
KSR
1x600
Stop
mg
Domperido
3x10
ne
mg
Metformin
3x50
Stop
 






mg
Injection
Ranitidine
2x50





mg
Cithicolin
Heparin
Stop
1x5000



Stop
u
Others
Novorapid
3x4 u
 








Information : M = Morning ( 06.00 a.m ) ; D = Day ( 12.00 p.m ) ; A = Afternoon ( 18.00 p.m ) ;
N = Night ( 24.00 p.m ) ; C = Cancel
2002
LABORATORY DATA
No.
Type Of Examination
Value Lab
Normal Value
Hematology
1
Leukocyte
10.94 ribu/mm3*
5-10
2
Neutrophil
69,8%
50-70
3
Lymphocyte
24,8%*
25-40
4
Monocyte
4,8%
2-8
5
Eosinophil
0,2%*
2-4
6
Basophil
0,4%
0-1
7
Erythrocyte
4,84juta/
4,5-6,5
8
Hemoglobin
14,1 g/dl
13,0-18,0
9
Hematokrit
42%
40-52
10
MCV
86,8fL
80-100
11
MCH
29,1pg
26-34
12
MCHC
33,6 %
32-36
13
RDW-CV
13,0 %
11,5-14,5
14
Trombosit
259 mm3
150-440 ribu
15
GDS
213 mg / dl
70-199
6.
1.
Dose Regimen
Drug dose Ranitidin is too low, the recipe is given 2x50 mg, according to the BNF ed 67 doses of
ranitidine injection 50 mg every 6-8 hours, the administration of a dose of ranitidine less
prevalent then discuss with your doctor ranitidine administration increased to 3x50 mg and look
at the list of therapeutic administration of ranitidine periodically usual dose is appropriate or not.
2.
Drug Interaction
Giving clopidogrel with heparin, can increase the risk of intracranial hemorrhage, need to be
monitored INR values, and protombin time.
2003
7.
CONCLUSION
Based on the results of clinical work practice at Cempaka wards under (medicine) in
Persahabatan Hospital, it can be concluded that the presence of DRP (Drug Related Problems)
improper dosage regimen in the use of ranitidine (drug dose is too low) and drug interaction
between clopidogrel and heparin can that are cause intracranial hemorrhage.
REFERENCES
1. Hacke W, Kaste M, Bogousslavsky J, Brainin M, Chamorro A, Lees K et al.. Ischemic Stroke
Prophylaxis and Treatment - European Stroke Initiative Recommendations 2003.
2. Isniati,2003,Hubungan Tingkat Pengetahuan Penderita Diabetes Militus Dengan Keterkendalian
Gula Darah Di Poliklinik RsPerjan Dr. M. Djamil Paandg Tahun Jurnal Kesehatan Masyarakat,
September 2007, I (2).
3. Misbach, J. 2000. Stroke in Indonesia: a first Large Prospective Hospital-Based Study of Acute
Stroke in 28 Hospitals in Indonesia. Journal of Clinical Neurosciences 8: 245-249.
4. Mycek, mary J. dkk. 2003. Farmakologi Ulasan Bergambar edisi 2, Jakarta: Widya Medika
5. Nugroho, Dr. Agung.2009.Farmakologi Obat-obat Penting dalam Pembelajaran Ilmu
Kefarmasian and Dunia Kesehatan,Universitas Gadjah Mada Yogyakarta
6. Saenger AK, Christenson RH, 2010. Stroke biomarkers: Progress and challenges for diagnosis,
prognosis, differentiation, and treatment. Clinical Chemistry 56(1): 21-33.
7. Stockley, I.H. (2008). Stockley’s DrugInteraction. Edisi kedelapan. Great Britain: Pharmaceutical
Press. Halaman 1-9.
2004
DRUG RELATED PROBLEM IN PATIENT WITH COPD
EXACERBATION AND HEART FAILURE
AT PERSAHABATAN HOSPITAL
Fatimah Maulida1, Aprilita Rinayanti Eff.2 and Diana Laila Rahmatillah2
1
2
Lecturer of Faculty of Pharmacy UTA ’45 Jakarta
fatimahmaulida20@gmail.com
ABSTRACT
Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation in the lungs
and progressive. Acute exacerbation of COPD is defined as chronic symptoms (shortness of
breath, cough, sputum production) that can cause worsening. Causes of acute exacerbation is
usually by a viral or respiratory track infections, air pollution, or other exposure.1 Heart failure is a
functional cardiac disorder that impairs the ability of the ventricle to pump sufficient blood to
meet the body’s metabolic needs.1 Patient Mr. S, aged 59 years, entered Persahabatan Hospital
on 26 September 2014 with a diagnosis: Community Acquired Pneumonia (CAP) in geriatrics,
COPD exacerbations, heart failure, dyspepsia syndrome. Patient was treated with ISDN,
valsartan, ascardia® (acetylsalicylic acid), sucralfat, fluimucyl® (N-acetylcysteine), paracetamol,
vitamin B complex, dorner® (Beraprost sodium), spironolactone, methyl prednosolon injection IV,
ranitidine injection IV, furosemide injection IV, levofloxacin injection IV, combivent® inhalation (a
combination of salbutamol and ipatropium bromide), aminophylline infusion. Based on the result
of clinical it can be concluded that Drug Related Problems (DRP) that are dose is too low
ranitidine administration while according to the BNF ed 67 doses of ranitidine injection IV is 50
mg every 6-8 hours so administration a dose of ranitidine less common, drug interactions
aminophylline with furosemide and aminophylline with methyl prednisolone increases to effects
of hypokalemia, aminophylline with ranitidine increases to effects of aminophylline, valsartan
with furosemide increases to effects hypotensive, spironolactone with valsartan increases to
effects of hyperkalemia so these drugs must be monitored levels of potassium and blood
pressure.
Keywords: Drug Related Problem ( DRP ), COPD Exacerbation, Heart Failure, Persahabatan
Hospital
2005
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation in the lungs
and progressive. Acute exacerbation of COPD is defined as chronic symptoms of patients
(shortness of breath, cough, sputum production) are worsening. Causes of acute exacerbation is
usually by a viral or respiratory track infections, air pollution, or other exposure. COPD generally
refers to emphysema or chronic bronchitis. Emphysema is characterized by alveolar wall
destruction and air space enlargement. Chronic bronchitis is clinically defined as a chronic cough
for at least 3 months for 2 consecutive years which is a sign of inflammation in the respiratory
tract. Both of these conditions is mainly caused by smoking. 1
Cigarette smoking is the major risk factor for COPD and most cases of COPD are attributed to a
current or past history of cigarette smoking. Evidence exists that among patients with severe
emphysema approximately 99% have a history of regular cigarette smoking. Other factors
include dust, chemicals, air pollution, viral and bacterial respiratory infections and human
immunodeficiency virus infection (HIV). 1
Heart failure is a functional cardiac disorder that impairs the ability of the ventricle to pump
sufficient blood to meet the body’s metabolic needs. The signs and symptoms of primary (eg,
peripheral edema, shortness of breath, fatigue) heart failure must be evaluated from the
patient's medical history and physical examination. 1
I.
CASE PRESENTATION
Patient Mr. S. aged 69 years old smoker of 12 cigarettes / day for 50 years, entered in
Persahabatan Hospital of on 26 September 2014. Patients present with shortness of breath since
1 month before admission, shortness of increasingly severe with activity, not affected by weather
and do not wheeze. Cough with yellow sputum since 3 weeks before entering the hospital,
sometimes fever. Since 1 year ago suffered heart disease and hypertension and was treated with
valsartan and ISDN.
Examination results revealed patient need oxygen characterized by decreasing PCO2 (34.6
mmHg) and increased PO2 (131 mmHg). Laboratory investigation showed abnormal values of
2006
neutrophil (85.3%), lymphocytes (2.8%), monocytes (10.8%), eosinophils (0.3%), and platelets
(147.000/ mm3).
Patient treated with 0.9% NaCl IVFD 500 cc / 24 hours and O2 2-3 L / minute, infusion
aminophylline of 300 mg / 12 hours. ISDN 3x5 mg, valsartan 1x80 mg, Ascardia® (acetylsalicylic
acid) 1x80 mg, Sucralfat 3xC1, Fluimucyl® (N-acetylcysteine) 3xC1, paracetamol 3x500 mg,
Vitamin B complex 3x1 tablet, Dorner® (Beraprost sodium) 3x20 mcg, Spironolactone 1x25 mg,
methyl prednisolone injection IV 3x62,5 on day five lowered to 2x62,5 mg, Ranitidine injection IV
2x50 mg, Furosemide injection IV 1x1 ampoule, levofloxacin injection IV 1x750 mg. The patient
was given an inhaler combivent® (combination ipatropium bromide and salbutamol).
II.
CLINICAL EVALUATION
In this case the patient get aminophylline for acute exacerbations, levofloxacin as antimicrobal,
methyl prednisolone as antiinflammatory, combivent® inhalation (a combination of salbutamol
and ipatropium bromide) is a combination of anticholinergics and beta-2 agonist strengthens
bronchodilation effect, fluimucyl® (N-acetylcysteine) for reduce exacerbations with antioxiandt
effect and mucolytics, sucralfate to coating the cell wall of the stomach so avoid stomach
irritation, ranitidine for dyspepsia, paracetamol is used patients to relieve pain, vitamin B
complex to prevent a deficiency of vitamin B1, B2, B6, nicotinic acid, pantothenic acid and
choline, furosemide to lower blood pressure, spironolactone to maintain the balance of
potassium, ISDN to heart, ascardia® (acetylsalicylic acid) to prevent thrombus, Dorner for
hypertension, sodium chloride 0.9% to maintain osmolaritaas and acid base balance in the body.
III.
ADMINISTRATION OF DRUGS FOR HOSPITALIZED
Types of
Dose
Drugs
Regim
Administration of drugs date
28/9/14
30/9/14
en
01/10/2014
02/10/2014
29/9/14
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
Oral
2007
4
ISDN
3x5 mg
Valsartan
1x80




  

STOP
mg
Ascardia


1x80



mg
Sucralfat
3XcI



  

Fluimucyl
3XcI



  

Paracetam
3x1
-
-
Vit. B komp
3x1


Dorner
3x20
-
ol



  


  



mg
Spironolakt
1x25
on
mg

Injection
Metil pred.
3x62,5
 







  
STOP and start
2/102x6,25
Metil pred.
2x62,5
Ranitidin
2x50










mg
Furosemide

1x1


amp
Levofloxaci
1x750
n
mg





Other
Combivent
NaCl 0,9%
500 cc +
4x/hari
 










 Aminophylline STOP because
the pulse exceeds the
2008
aminofilin
maximum (120x/minute)
300 mg/12
jam
Information : 1= 06.00 a.m.
IV.
2= 12.00 a.m 3= 18.00 p.m. 4= 24.00 p.m
DISCUSSION
In COPD disease, that can alter the decline in lung function but drugs can reduce symptoms,
exacerbation rate, hospitalization rates and with exercise to improve health status. As initial
therapy that oxygen was used characterized by decreasing PCO2 (34.6 mmHg) and increasing
PO2 (131 mmHg). The combination of inhaled beta-adrenergic agonists (salbutamol) and
anticholinergics (ipratropium bromide) can improve the airflow during acute exacerbations of
COPD. Bacterial infections can contribute to acute exacerbations of COPD, it can be seen from
abnormal laboratory values neutrophil (85.3%), lymphocytes (2.8%), monocytes (10.8%), and
eosinophils (0.3%). During the hospitalized, patient is given ciprofloxacin injection IV to increase
expiratory flow rate and reduce the risk of treatment failure and mortality.3
Systemic corticosteroids accelerate improvement in airflow, gas exchange, reduce symptoms and
reduce the rate of treatment failure, initial therapy methyl prednisolone 3x62,5 then on day fifth
lowered to 2x62,5 mg this is done to avoid acute adrenal insufficiency thus improving the
function of the adrenal glands has long not produce endogenous corticosteroids because of low
feedback by exogenous corticosteroids. Sucralfate syrup is given to protect the mucosa from
attack pepsin acid in gastric and duodenal ulcers caused Ascardia® (acetylsalicylic acid) that
affects the gastrointestinal tract irritation. injection Ranitidine IV is an antihistamine H2 receptor
blockers (AH2) works by inhibiting gastric acid secretion. In H2 receptor inhibits, ranitidine work
specifically and reversibly. 4
Patient also feel pain and doctor is given paracetamol. Aminophylline causes smooth muscle
relaxation, especially in case of bronchial smooth muscle contraction due to histamine, infusion
of aminophylline given on fourth day of treatment but was stopped by the doctor the next day
because it exceeds the maximum pulse (120x / min). Bronchodilation effect of Aminophylline
caused by antagonism of adenosine receptors. 4
2009
Because patient has a productive cough, giving Fluimucyl® (N-acetylcysteine) is appropriate as a
mucolytic to mukoprotein by releasing disulfide bonds thus decreasing the viscosity of sputum.
ISDN is the preparation of organic nitrates may cause vasodilation resulting blood collection in
peripheral venous. 4
In heart failure patients an increase plasma levels of aldosterone, causing water and sodium
retention and excretion of potassium and magnesium trigger cardiac remodeling, giving as an
aldosterone antagonist spironolactone can reduce the progression of cardiac remodeling so
reduce mortality and morbidity due to heart failure. Valsartan works by inhibiting the
angiotensinogen II on AT1 receptor to reducing sympathetic activity cause vasodilation by a
decrease in peripheral resistance so increasing cardiac output. Ascardia® (acetylsalicylic acid) is
used secondary prophylaxis or prevented of stroke / thromboembolism. Furosemide is a strong
diuretic to overcome the excess fluid, use of diuretics to quickly eliminate shortness of breath.
Vitamin B complex to prevent a deficiency of vitamin B1, B2, B6, nicotinic acid, pantothenic acid
and kolin.4
Sodium Beraprost (Dorner®) works by binding of prostacyclin receptors (PGI2) and inhibit the
release Ca2+ from intracellular storage. This effect causes relaxation of smooth muscle cells and
vasodilation, dorner® also can reduce vascular thrombosis by inhibiting platelet aggregation.5
V.
1.
Inappropiate dose regimen
Drug dose is too low, the prescription Ranitidine injection IV 2x50 mg a day, according to BNF ed
67 doses of ranitidine injection IV 50 mg every 6-8 hours, the administration of a dose of
ranitidine less common so discuss with the doctor to ranitidine injection administration increased
to 3x50 mg and view administration of ranitidine on list of therapeutic periodically is appropriate
common dose or not.
2. Drugs Interaction 6
a.
Aminophylline and Methylprednisoline cause additive effect of hypokalemia so monitor
potassium levels
2010
b.
Aminophylline and furosemide cause additive effects of hypokalemia so monitor
potassium levels
c.
Aminophylline and ranitidine increase the effect of aminophylline so monitor potassium
levels and monitoring of side effects of aminophylline (arrhythmias, nausea, no appetite)
d.
Valsartan and furosemide cause additive hypotensive effect so monitor blood pressure
e.
Valsartan and spironolactone cause additive effects of hyperkalemia so monitor
potassium levels
VI.
CONCLUSION
Based on the monitoring of drug therapy internal medicine wards in Persahabatan Hospital, it
can be concluded that the presence of Drug Related Problems (DRP), that is inappropriate dosage
regimen in the use of ranitidine (drug dose is too low) and drug interactions.
REFERENCES
1.
Alldredge, B.K., Corelli, R.L., and Ernst, M.E., 2012. Koda-Kimble and Young’s Applied
Therapeutics: The Clinical Use of Drugs. Lippincott Williams & Wilkins.
2.
BMJ Group, 2014. British National Formulatory (BNF) 67. London: BMJ Group and the
Royal Pharmaceutical Society of Great Britain, pp. 53-54
3.
Basnet, S., Adhikary, P., Aryal, B, 2013. Acute Exacerbation Of Chronic Obstructive
Pulmonary Disease. Journal of Chitwan Medical College, 3(3): 67-68
4.
Gunawan, S., 2012. Farmakologi and Terapi. Universitas Indonesia Fakultas Kedokteran
Jakarta
5.
Na. et al., 2013. Effect of beraprost sodium on arterial stiffness in patients with type 2
diabetic nephropathy. Trials,14:275
6.
Stockley, I.H., 2008. Stockley’s Drug Interaction. Edisi kedelapan. Great Britain:
Pharmaceutical Press. Halaman 36, 1178, 1180, 1181.
2011
DRUG RELATED PROBLEM IN PATIENT WITH
TUBERCULOSIS HEMOPTYSIS DISEASE AT PERSAHABATAN
HOSPITAL
Melisha Adelina Hotmaida1, Aprilita Rinayanti Eff2 and Diana Laila Rahmatillah2
1
2
Lecture of Faculty of Pharmacy UTA ’45 Jakarta
melisha_ida@yahoo.com
ABSTRACT
Tuberculosis (TB) is a pulmonary disease chronic bacterial infection caused by
Mycobacterium tuberculosis. Microbials are usually entered into the human body through
breathing air into the lungs. Then the bacteria are spread from the lungs to other parts of the
body, through the circulatory system, lymphatic duct system, via the airways (bronchi) or direct
spread to other body parts. TB can occured in all age groups, both in pulmonary and extra
pulmonary.
Coughing up blood is a symptom or sign of an infectious disease. Blood volume
varied and sputum coughed blood mixed in a certain volume, depending on the rate of bleeding
and bleeding sites. Hemoptysis is the coughing of blood or blood expectorated due to bleeding in
the airway below the larynx or bleeding out through the lower respiratory tract of the larynx.
Mr.MCN, aged 61 years old, entered in Persahabatan Hospital on September 30, 2014
with a diagnosis of Tuberculosis Hemoptysis. Patient was treated with NaCl 0.9% IVFD,
Tranexamic Acid, Vitamin K, Vitamin C, Ceftazidim and Gentamicin. In this case has found a Drug
Related Problems (DRP) that are drug interaction between gentamicin with Ceftazidim which can
increase Nephrotoxycity and the indication but was not handled, ie the results of laboratory
hemoglobin decreased patient should be given a blood supplements and patient has TB
Hemoptysis but not given TB drugs.
Keyword : Drug Related Problem ( DRP ), Hemoptisys, Persahabatan Hospital
2012
1.
INTRODUCTION
Tuberculosis (TB) is a pulmonary disease chronic bacterial infection caused by Mycobacterium
tuberculosis. Microbials are usually entered into the human body through breathing air into the
lungs. Then the bacteria are spread from the lungs to other parts of the body, through the
circulatory system, lymphatic duct system, via the airways (bronchi) or direct spread to other
body parts. TB can occur in all age groups, both in pulmonary and extra pulmonary.1
Coughing up blood is a symptom or sign of an infectious disease. Blood volume varied and
sputum coughed blood mixed in a certain volume, depending on the rate of bleeding and
bleeding sites. Coughing up blood or hemoptysis is expectorated blood due to bleeding in the
airway below the larynx or bleeding out through the lower respiratory tract of the larynx.
Coughing up blood is often a sign or symptom of underlying disease so etiology should be sought
through a more thorough examination. Coughing up blood can be classified based on the volume
of blood ejected at a certain period. Coughing up blood still require immediate action as it may
interfere with gas exchange in the lungs and can destabilize the patient hemodynamics so if not
handled properly can be life-threatening. 2
In Hemoptysis, the source of bleeding generally arises from one of two source: pulmonary
circulation or bronchial circulation. The pulmonary circulation flooding of the alveoli and alveolar
ducts with blood, low-pressure circulation system with blood vessel walls are thin. Bronchial
circulation making to bleeding trachea, main bronchi to bronchioles and lung tissue support, the
esophagus, the posterior mediastinum and pulmonary artery vasa vasorum. The bronchial
circulation consists of bronchial arteries and bronchial venous.2
2.
PRESENTATION CASE
Patient Mr. MCN aged 61 years old entered Persahabatan Hospital on September 30 2014.
Patient present with cough blood from 1 day before entering the hospital, blood cough since 1
day before entering the hospital approximately 5cc, fresh red blood, not mixed the food.
3.
CLINIC EVALUATION
In this case the patient was treated with Tranexamic Acid to reduce and stop coughing up blood,
vitamin K to help coagulation, vitamin C increase endurance, Ceftazidim for respiratory tract
2013
infections and Gentamicin as a broad spectrum antibiotic with activity against gram negative
bacteria.
4.
DOSE AND DRUG DELIVERY
4.1.
Dose
Drug Name
Dose
Indication
How to Use
Usual Dose
Prescription
Tranexamic
50ml/12 hour
Stop the Bleeding
Injection
0,5-1 gr every 8 hours (25-
Acid
50mg/kg/day)
Renal Drugs Handbook
NaCl
0,9% 500ml
Electrolyte
Injection
1000ml/day
Vit K
3x10mg
Coagulation
Injection
5-40 mg/day
Vit C
3x200mg
Body endurance
Injection
0,5-1 gr/day
Gentamisin
1x160mg
Antibiotics
Injection
5-6 mg/kg/day
Ceftazidim
3x1gr
Antibiotics
Injection
1-6 gr/day
4.2.
Types of Drugs
Dispensing Drug During Patient was Hospitalized
Dose
Drug Delivery Date
Regiment
30/9/14
1
01/10/14
2
3
4
0,9% 500ml
 


50ml/12
 

1
02/10/14
2
3
4







1
2
3
4
Drug Injectoin
NaCl
Tranexsamic
Acid
hours







Vitamin K
3x10mg
 







Vitamin C
3x200mg
 







Ceftriaxone
1x2gr

STOP
2014

Azithromycin
1x500mg
STOP
Gentamisin
1x160mg



Ceftazidim
3x1gr



Information : 1=06.00 a.m
4.3.
2=12.00 a.m
3=18.00 p.m
4=24.00 p.m
Laboratory Data
Check Up Result
Type of
examination
29/9/14
30/9/14
Unit
Normal Value
02/10/14
HEMATOLOGY
Routine Blood
Leukocyte
27,46*
-
6,57
Ribu/mm3
5-10
Neutrophil
84,5*
-
77,9*
%
50-70
Lymphocyte
6,8*
-
14,8*
%
25-40
Monocyte
8,4*
-
5,9
%
2-8
Eosinophil
0,0*
-
1,1*
%
2-4
Basophil
0,3
-
0,3
%
0-1
Erythrocyte
4,24*
-
3,74*
Juta/uL
4,5-6,5
Hemoglobin
10,7*
-
10,5*
g/dL
13,0-18,0
Hematokrit
32*
-
31*
%
40-52
MCV
76,1*
-
82,4*
L
80-100
MCH
25,2*
-
28,1
Pg
26-36
MCHC
33,1
-
34,1
%
32-36
RDW-CV
12,29
-
16,6*
%
11,5-14,5
Trombosit
312
-
321
Ribu/mm3
150-440
Type Calculate
CLINICAL CHEMISTRY
Blood Gas Analysis
pH
-
7,489*
7,424
7,34-7,44
2015
PCO2
-
24,3*
26,2*
mm Hg
35-45
PO2
-
60,6*
61,8*
mm Hg
85-95
HCO3
-
18,3*
16,9*
mmol/L
22-26
TCO2
-
19,0*
17,7*
mmol/L
23-27
Base Excess
-
-4,6*
-6,7*
Std HCO3
-
21,9*
19,8*
mmol/L
22-26
Saturasi O2
-
92,9*
92,1*
%
96-97
GDS
123
-
mg/dL
<180
Sodium (Na)
132*
-
135,0
mmol/L
135-145
Pottasium (K)
4,20
-
3,60
mmol/L
3,5-5,5
Clorida (Cl)
98,0
-
105,0
mmol/L
98-109
Uremia
58*
-
-
mg/dL
20-40
Triglycerides
1,1
-
mg/dL
0,8-1,5
Protein total
-
-
8,8*
g/dL
6-8
Albumin
-
-
2,6*
g/dL
3,4-5
Globulin
-
-
6,3*
g/dL
1,3-2,7
AST (SGOT)
-
-
108*
U/L
0-37
ALT (SGPT)
-
-
26
U/L
0-40
Bilirubin Total
-
-
0,5
mg/dL
0,1-1,1
Bilirubin Direk
-
-
0,35
mg/dL
0,1-0,4
Bilirubin Indirek
-
-
0,15
mg/dL
0,0-0,7
-2,5-2,5
Elektrolyte
Liver Function
DISCUSSION
In this case the patient has tuberculosis hemoptysis. Patient treated with infusion of
0.9% NaCl as the electrolyte fluid. Fibrinolytic inhibitor tranexamic acid is a synthetic form of the
trans-cyclohexane carboxylic acid aminometil. In vitro, tranexamic acid 10 times more potent
than aminocaproic acid. Tranexamic acid is a competitive inhibitor of plasminogen activator and
2016
plasmin inhibitors. Plasmin it self plays destroy fibrinogen, fibrin and other blood clotting factors,
therefore tranexamic acid can be used to help overcome excessive bleeding due to fibrinolysis.
Known natural vitamin K 2 types of vitamin K 1 (filokuinon + Phytonadione) and vitamin K 2
(compound menakuinon) and 1 vitamin K synthesis. Pharmacodynamics in the normal vitamin K
does not have pharmacodynamic activity but in patient with vitamin K deficiency is useful to
improve the biosynthesis of several blood clotting factors. Vitamin K deficiency causes
hipotrombinemia and decreasing levels of several blood clotting factors so that the elongated
blood clotting time of blood and bleeding can occur spontaneously as ecchymosis, epistaxis,
hematuria, gastrointestinal bleeding, intracranial bleeding, postoperative bleeding occasionally
hemoptysis. Vitamin K in absorption through the gut, is highly dependent on the solubility. On
the 1st day of treatment the patient has added coughing up blood so that therapy with
tranexamic acid (iv) and vitamin C (iv). Two drug combination therapy aims to stop the bleeding
that may be caused by hemoptysis or rupture of the pulmonary veins as a result of the formation
of tubercles-tubercles are attached to the pulmonary vasculature. Coughing up blood stops on
the 3rd day of treatment but still bloody cough with bloody cough frequency was reduced.3
Vitamin C in these patient is used to enhance the patient immune system. Vitamin C is
known as ascorbic acid, is included in the class of water-soluble vitamins, namely chemical
formula (C6H8O6). Pharmacodynamic administration of vitamin C in normal circumstances do not
give a clear pharmacodynamic effect, but in a state of deficiency, vitamin C will eliminate the
symptoms of the disease quickly. Physiology of vitamin C plays a role in the formation of
substances between cells and collagen tissue that is part of connective tissue. Also needed in the
maturation of red blood cells and bone formation of dentin. Therefore, vitamin C has many
physiological functions in the body, then the deficiency of vitamin C resulted in extensive, which
can cause a disruption in the blood vessel wall which increases capillary fragility that minor
trauma can easily cause bleeding. The existence of vitamin C in leukocytes and platelets greater
than in plasma and red blood cells. Excretion through urine in the form of sulfate salts and in the
form of ascorbic acid, this situation occurs when the levels in the blood passes through the
kidneys excitatory threshold. Side effects are rare, but sometimes cause diarrhea.3
2017
Indications of Ceftazidim is septicemia, meningitis, pneumonia, lower respiratory tract
infections. While Gentamicin as a broad-spectrum antibiotic with activity against gram-negative
bacteria. On the first day of treatment there was an increase of leukocytes (27.46 thousand /
mm3) indicate the presence of infection, so that the patient was given Gentamicin and
Ceftazidim. After administration for 2 days worth of leukocytes of patients showed a decrease in
leukocytes (6.57 thousand / mm3). Gentamicin and Ceftazidim drug interaction that may
increase the risk of nephrotoxicity (level 2). Necessary to monitor the concentration of
gentamicin and renal function of patient. Action needs to be done to monitor the results of the
triglyceridese, urea whether high or low.4
5.
a.
Untreated Complaint
-
The value of the patient laboratory low hemoglobin blood booster should be given
supplements and monitoring of the patient hemoglobin value.
-
The patient has TB Hemoptysis but not given TB drugs.
b.
Drug Interactions
Gentamicin with Ceftazidim (Drug Interaction Facts 2005): Both of these drugs may increase the
risk of Nephrotoxicity so necessary to monitor the concentration of gentamicin and the patient
renal function.
CONCLUSION
Based on the clinical outcome of pulmonary disease ward at Persahabatan Hospital, it can be
concluded that the presence of DRP (Drugs Related Problems) untreated complaint ie namely in
terms of the patient laboratory values decreased hemoglobin blood booster should be given
supplements and TB patients experienced hemoptysis but not given TB drugs and drug
interactions where there is interaction between Gentamicin and Ceftazidim which can increase
the risk of Nephrotoxicity so it is necessary to monitor the concentration of Gentamicin.
REFERENCES
1.
Departeman Kesehatan, Republik Indonesia. Pedoman Nasional Penanggulangan
Tuberkulosis, 2007: Jakarta.
2.
Arif N., 1992. Batuk darah dalam pulmonologi klinik. Bagian pulmonologi FKUI;
2018
Jakarta : 179-183
3.
Gunawan, S., 2012. Farmakologi and Terapi. Universitas Indonesia Fakultas Kedokteran
Jakarta
4.
George, et al., 2005. Med Facts Pocket Guide Of Drug Interactions. Nephrology Pharmacy
Associates, Inc.
2019
PERINATOLOGY SEPSIS ec Psuedomonas pufida IN HIGH
RISK PERINATAL ROOM RSPAD GATOT SOEBROTO
Sri Wahyuni 1, Diana Laila Ramatillah2 , Aprilita Rinayanti Efi2
1
2
Email: dot_maridot@yahoo.co.id
ABSTRACT
Sepsis is a state of the discovery of the clinical symptoms of an illness severe infection,
accompanied by the discovery of a systemic response that can be hypothermia, hyperthermia,
tachycardia, hyperventilation and lethargy1. Baby of. Mrs. DB, born spontaneously on 29th of
September 2014 at 23:55 pm, a baby boy, with pregnancy 39 weeks. At birth there was nuchal
cord 1x, the weight is 3700 grams, body length is 52 cm, amniotic clear, indirect born crying,
bluish skin, less active motion, a Score Apgar is 5/10, meconium is not out. At the moment, the
baby is treated in high risk Perinatal Room.
During the treatment, the patient received drug therapy and fluid requirement. Drugs given to
the patient were ceftazidime, omeprazole, fosfomycin, diflucan, flagyl, heparin, amikacin,
ampicillin sulbactam, vitamine E, becombion, mycostatin. Fluid given to the patient were glucose
protein II 40 mg/kg/day, intralipid, breast milk and formula milk. Based on the results of
Professional Practice Pharmacists, it can be concluded that there was any dosage regimen and
schedule of giving the drugs.
Keywords : Sepsis, Pseudomonas And RSPAD Gatot Soebroto.
2020
INTRODUCTION
Neonatorium Sepsis is a disease in neonates which are clinically ill and showed positive in
blood culture 2. The incidence in South east Asia ranged from 2.4 to 16 per 1,000 live births, in
USA 1-8 per 1,000 live births, while the Division of Perinatology Department of Pediatrics Faculty
of medicine/RSCM (2003) of 56.1 per live births. The mortality rate can reach 50% in infants of
untreated3.The etiology of sepsis in neonates is from bacteria, viruses, fungi and protozoa
(rarely)3. Gram-positive bacteria such as streptococcus group B is the most common cause3.
Coagulase-negative staphylococci is the main cause of nosocomial bacteremia streptococcus
group B who not gram-negative bacteria Escherichia coli causes the number two most,
H.influenzae, monositogenes Listeria, Pseudomonas, Klebsiella, Enterobakter, Salmonella,
anaerobic bacteria, Gardenerella vaginalis3.
Kaukasive treatment with antibiotics, ceftazidime and gentamicine is early awarded if
ampicillin resistance. In nosocomial sepsis is adapted to local patterns of germs. Continued
therapy is performed based on the results of culture and sensitivity, clinical symptoms, and a
series of laboratory tests (CRP). Supportive therapy with monitoring of fluid, electrolyte and
glucose, gives correction in case of hypovolemia, hyponatremia, hypocalcemia, and
hypoglycemia. Giving diflucan and flagyl drugs to treat anaerobic bacteria and fungi 3.
CLINICAL EVALUATION
Hepatitis B patient received 0.5 ml of vaccine immunity as post-birth. At the beginning of the
incoming fluid therapy was 10% dextrose and ceftazidime. Dextrose 10% utilizing to fulfill
requirement of dillution of nutrition and avoid hypoglicaemia. Ceftazidime hypodermic 170 mg
twice one day as empirical medication at the same time awaited the results in blood culture.
Giving of Hypodermic omeprazole 5 mg once one day to overcome disturb gastric marked with
result of osofaring gastric tube (OGT) residue was turning white. After result of culture exited on
6th October 2014 with result of Enterobacter aerogenes breeding represents negative gram,
Giving of ceftazidime hypodermic was discontinued and changed by fosfomisin hypodermic 185
mg twice one day and consorted with giving of diflucan hypodermic (flukonazol) 11 mg every 48
hour at neonates 2-4 week to overcome fungi, and also flagyl hypodermic 30 mg twice one day
to overcome anaerob germ. Giving of Fosfomisin was changed with ampisillin sulbactam 125 mg
2021
thrice one day and amicasin 26 mg twice one day after result of both of exit with result of
Pseudomonas pufida breeding.
Residue has still colour, so patient has fasting to accomplishment of requirement of dillitution is
totally parenteral nutritions by Protein glucose II 40 ml/mg/day with compositions amino acid 17
Ca gluconase 1,6 ml, KCL 1 ml, Nacl 3 % 2,7 ml, Dextrose 40% 7,4 ml, Dextrose 10% 10,3 ml and
giving of intralipid 1g/kg/day and increase until 3 g/kg/day. The intralipid (fat 20%) was
compositions of trigliserida 20 g and trigliserida 2 kcal /ml. Heparin to prevent emboli because of
lipid has condensed character. If baby’s residue does not have color, the baby will be given by
breast milk or formula milk to quicken requirement of nutritions. In inotropik therapy, baby is
given by vitamins E, becombion, gamaras and mycostatin for the impenetrability of body4.
DOSE AND ADMINISTRATION5,6
Name of drug
Administrati
on
Dose Regimen
Indicate
Dose maintenance
Vaccine Hep B
IM
0,5 ml
Immunity
0,5ml im
Ceftazidime
IV
2 x 170mg/day
Antibiotic
Peds. 30–50 mg/kg/dose IV q8h
Omeprazole
IV
1 x5 mg/day
Gastric disturb
Peds 2–16 y <20 kg:10 mg PO q
day.
Fosfomisin
IV
2 x 185mg//day
Antibiotic
3 g PO in
90–120 mL of H2O single dose
IV
11 mg x 48 hour
Anti fungi
Peds. 3–6 mg/kg/d PO or IV;
IV
2 x30mg/day
Anti anaerob
Peds. 30 mg/kg PO/IV/d dividen
germ
6h
Diflucan
Flagyl
Ampisilin
IV
3x125mg/day
Antibiotic
100-150 mg/kg q6h
IV
2 x26 mg/day
Antibiotic
Age <7 d, >2000 g: 10
Sulbactam
Amicasin
mg/kg/dose q12h. Age >7 d,
>2000 g: 7.5–10 mg/kg/dose
q8h
2022
Heparin
IV
2,4 cc/day
Anticoagulan
Load 50 units/kg IV
bolus, then 20 units/kg/h IV by
cont Inf.
Gamaras
IV
Imunoglobulin
Vit E
PO
0,5 ml
Vitamine
Becombion
PO
3 drop
Vitamine
Mycostatin
PO
3 drop
impenetrability
3-15 mg
200,000 units PO q6h
of Body
Dextrosa 10%
IV
10cc/kg.bw/day
Sugar dillution
Protein Glucose
IV
According to
Total parenteral
2
Age 5 d 140-160 ml/d
requirement.
Intralipid
IV
According to
Total parenteral
requirement.
LABORATORY RESULT
Type Of
Normal
Examination
Velue
th
30 sept
1st
oct
4th oct
6th oct
13rd oct
20th oct
21st oct
Routine Haematology
Haemoglobin
13-18 g/dL
19,6
18,8
16,4
13,1
11,1 *
Haematocrit
40-52 %
55
52
47
38*
34*
Erythrocyte
4.3-6
5,5
5,3
4,8
4,0
3,5*
23.700*
11.180*
16.420*
16.970*
2.1260
278.000
196.000
244.000
152.000
215.000
million/
Leukocytes
4800-10.800
/
Platelets
150.000400.000/
MCV
80-96 Fl
101*
98*
98*
95
97*
MCH
27-32 pg
36
35
34
33
32
2023
MCHC
RDW
32-36 g/dl
36
36
35
*
19,90*
18.60
0,5-1,5%
1,0
0,9
0,1
0,2
<0,1
0,04
0,05
0,10
0,06
Basofil
0-1%
0
0
0
0
Eosinofil
1-3%
0
2
0
0
Rod
2-6%
3
3
3
3
Segmen
50-70%
73*
55
39*
47*
Lymphocytes
20-40%
15*
32
51*
44
2-8%
9*
8
7
6
IT Ratio
19,50
33
*
11,5-14,5%
Reticulosit
18,30
35
*
Diff count
Monocytes
Clinical
Chemistry
CRP
< 6 mg/L
<6
<6
15,70*
10,61*
Total Bilirubin
<1.5 mg/dL
Bilirubin Direk
<0.3
1,08
Bilirubin Indirek
<1.1
9,53*
Blood Gas
Analysis
pH
pCO2
7,37-7,45
7,251
33-44
33,4
mmHg
pO2
71-104
211,3*
mmHg
Bicarbonat
(HCO3)
Base excess (BE)
22-29
14,8*
mmol/L
(-2)-3
-10,7
mmol/L
2024
O2 Saturasi
94-98%
99,6*
1. Drug interaction
There was drug interaction between ampisillin sulbactam and amicasin that can degrade effect
or rate from amikacin6.
Intervention of giving drug in pharmacy was a distance in giving between two drugs2.
2. Drug interaction resulted of laboratory
At this case clinically patient showed pale, which was marked with degradation assess
haemoglobin6. According to literature one of the adverse drug's reaction (ADR) from amicasin is
anaemia.
Intervention of pharmacy was to overcome problems, It was needed PRC (Packet Red Cell)
transfuse6.
3. Dosage Regimen
At this case, patient got ampisillin sulbactam dose 125 mg every 8 hours.
Intervention of Pharmacy according to literature the dosage of ampisillin sulbactam was 100-150
mg every 6 hour and the pertained time pattern was dependent on kill's6. Schedule giving of
Amicasin and ampisillin sulbactam was better spaced out 1 hour, where amicasin was given
ahead then ampisillin sulbactam for the avoiding of degradation of amicasin effect6.
CONCLUSION
Based on the result of Practice Pharmacist in Hygiene Child Treatment of High Risk
Perinatal Room of RSPAD Gatot Soebroto Ditkesad, It can be concluded that the existence of
ampisillin sulbactam dosage of regimen which was according to literature is given by 100-150 mg
every 6 hour. The schedule giving of amicasin was better be given ahead 1 hour, then ampisillin
sulbactam because giving in one time will degrade amicasin effect. Adverse Drug Reaction (ADR)
Amicasin generated anaemia
2025
References
1. Komaruddin, Boenjamin. 2012. Standar Pengobatan Medik Sepsis Neonatus. RSPAD Gatot
Soebroto Ditkesad. Jakarta.
2. Ikatan Dokter Anak Indonesia. Buku Ajar Infeksi & Pediatric Tropis Edisi Kedua. 2008: Jakarta.
3. Bone RC. The Sepsis Syndrome: Definition and General Approach to Management. Clin Chest
Med. 1996.
4. BPOM.2008.Informasi Obat Nasional Indonesia (IONI). Jakarta: Sagung Seto.
5. Gomella, Leonard A dkk.2009. linician’s Pocket Drug Refence.McGraw Hill Medical. New York.
6. Taketomo,Carol K.2011.Pediatric & Neonatal Dosage Handbook. 18th Edition. Lexicom:
Ohio.
7. Direktorat Bina Farmasi Komunitas and Klinik Ditjen Bina Kefarmasian and Alat Kesehatan
Depkes RI. 2009. Pedoman Pencampuran Obat Suntik and Penanganan Sediaan Sitostatika. Bakti
Husada: Jakarta.
2026
CASE STUDY DIABETES MELLITUS IN WARD MEDICINE RS.PGI
CIKINI
Dewi Veronika W1, Diana Laila Rahmatillah2, Aprilita Rinayanti Eff2, Stefanus Lukas2
1
2
Lecturer of Faculty of Pharmacy UTA’45 JakartaEmail : deverwelcatchy26@yahoo.co.id
ABSTRACT
Diabetes mellitus ( DM ) is a chronic metabolic disease that took place where people with
diabetes can not produce insulin in sufficient quantities or the body is unable to use insulin
effectively so that there was an excess of sugar in the blood and is felt after further complications
in organs1. Insulin is a substance or a hormone produced by the beta cells in the pancreas , where
insulin is not there then the glucose can not enter cells with glucose result will remain in the
blood vessels which means that the levels of glucose in the blood increases2. Patient Mr. HH, the
age of 70 years, admitted PGI CIKINI August 29th 2014 with a diagnosis of Type II diabetes
mellitus. Therapy treatment for hospitalized is lantus, novorapid, omeprazole, onandsetron,
neurobion, metronidazole , trombo aspilet, ketorolac, hp pro, nymico, folic acid, vitamin B
complex and albumin 25 % . Based on the results of clinical work practice in hospital wards K PGI
CIKINI we can conclude the existence of DRPs ( Drug Related Problems ) in the form of drugs are
less precise ( improper Drug Selection ) and drug interactions.
Keywords : Diabetes Mellitus , Dyspepsia , Internal Medicine Ward , RS PGI CIKINI
2027
INTRODUCTION
According to the American Diabetes Association ( ADA ) in 2010 , diabetes mellitus is a group of
metabolic diseases with charasteristics hyperglycemia that occurs due to abnormal insulin
secretion, insulin action, or both3. Early symptoms associated with the direct effects of high
blood sugar levels. If blood sugar levels more than 160-180 mg / dL glucose will get into the
urine. In type II diabetes mellitus normal amount of insulin, but the number of insulin receptors
located on the cell surface that are less so glucose enter the cells slightly and glucose in the blood
is increased. The term dyspepsia related to food and illustrates the complaint or collection of
symptoms consisting of pain or discomfort in the epigastrium, nausea, vomiting, bloating, early
satiety, taste full stomach, belching, regurgitation and heartburn are spread in the chest4. The
cause of dyspepsia can be classified into organic dyspepsia and functional dyspepsia. The cause
of dyspepsia can be classified into organic dyspepsia and functional dyspepsia.
CASE PRESENTATION
Patients Mr. HH the age of 70 years , admission PGI CIKINI August 29th 2014 had complaints of
nausea and vomiting since 2 days before admission, vomit ± 15 times in 2 days, the patient
complained of pain in her neck and canker sores on lips, no fever. Patients had a previous history
of diabetes and the patient's father had a history of diabetes. In hematological examination
showed erythrocyte sedimentation rate (ESR ) which is as high as 39 mm / hour, low hemoglobin
values 10, 1 g / dL, high leukocyte value 20.6 10 ^ 3μL, low erythrocyte value 3.39 10 ^ 3μL, a low
hematocrit value of 29 %, a high reticulocyte value of 18 per mil, eosinophils 0 % ( 1-3 ),
neutrophil rod 0 % ( 2-6 ), neutrophil segment of 90 % ( 50-70 ), 6 % lymphocytes ( 20- 40 ),
prothrombin patients 14.5 seconds ( 11 to 14.2 ). Clinical examination showed a decrease in the
amount of albumin 2.1 g / dL ( 3.4 to 4.8 ) and an increase in the amount of AST 664 ( 0-50 ),
SGPT 312 ( 0-50 ), Uremia 54 ( 10-50 ) , Triglyceridese 1,2 ( 0.6 to 1.1 ) and high blood glucose as
226 mg / dL ( 70-150 ). Clinical examination of the patient's blood sugar is inspection, where the
results of normal blood sugar 291 mg / dL ( < 110 ), pp blood sugar 313 mg / dL ( < 140 ), blood
glucose 230 mg / dL ( 74-106 ). In urine and parasitological examination showed urine specific
gravity 1.010 g / ml ( 0.015 to 0.025 ) clarity cloudy urine ( clear ), there is a value in the urine
2028
leukocytes caterace Trace / 15 cells / ml ( negative ), leukocytes 7 / LPB ( 0-2 ), epithelial 3 / LPB (
0-1 ).
DISCUSSION
On the first day of the hematological examination showed erythrocyte sedimentation rate (ESR)
which was as high as 39 mm / hour, low hemoglobin values 10, 1 g / dL, high leukocyte value 20.6
10 ^ 3μL, a low value of 3.39 erythrocytes 10 ^ 3μL, a low hematocrit value of 29 %, a high
reticulocyte value of 18 per mil, eosinophils 0 % (1-3), neutrophil rod 0 % (2-6), neutrophil
segment of 90 % (50-70), 6 % lymphocytes (20-40), prothrombin patients 14.5 seconds (11 to
14.2). Clinical examination showed a decrease in the amount of albumin 2.1 g/dL ( 3.4 to 4.8 )
and an increase in the amount of AST 664 (0-50), SGPT 312 (0-50) , Uremia 54 (10-50),
Triglyceridese 1,2 (0.6 to 1.1) and high blood glucose as 226 mg/dL (70-150). On the second day
of the clinic examination that the patient's blood sugar tests, where the results of normal blood
sugar 291 mg / dL ( < 110 ) , pp blood sugar 313 mg / dL ( < 140 ), blood glucose 230 mg / dL ( 74106 ) . On the third day of examination APTT ( Activated Partial Thromboplastin Time ) and blood
sugar patients per hour, where at 12:00 hours the patient's blood sugar decreased 64 mg / dL (
70-150 ), where as normal APTT patients at the time of high 50.0 seconds ( 26.4 to 37.5 ) and the
value of albumin 1.9 g / dL (3.4 to 4.8). On the fourth day the examination of blood sugar, urine
and parasitological show urine specific gravity 1.010 g / mL ( 1.015 to 1.025 ), clarity rather
cloudy urine, the urine contained in the value of leukocytes Caterace Trace / 15 cells / ml (
negative ), leukocytes 7 / LPB ( 0-2 ). During hospitalization PGI CIKINI patients received 14 types
of drugs. On the first day the patient was given ceftriaxone 1 g vial with 1 x 2 g dose for
abdominal infections, omeprazole 20 mg injection of 2 x 1 ampoule for dyspepsia, onandsentron
3x1 4 mg injection ampoules for the prevention and treatment of patients suffered nausea,
lantus 20 mg tablets with dose of 1 x 20 mg and 5 mg tabs novorapid with a dose of 1 x 5 mg for
the treatment of diabetes mellitus type II, ketorolac 10 mg injection of 2 x 1 ampoule to reduce
the pain felt by the patient after surgery, 1 x 10.000ui Heparin to prevent blood clots after
surgery. metronidazole 1 g vial with a dose of 2 x 1 to antibiotics in patient injury, trombo aspilet
80 mg 1 x 80 mg tab, nymico mouthwash 3 x 1 cc to treat thrush patients, folic acid 100 mg tab 3
2029
x 1 tab for overcome anemia, vitamin B Complex 500 mg 3 x 1 tab, neurobion 1000 mg 1 x 1 tab,
Hp Pro 7.5 mg 3 x 2 tabs and albumin 25 % 1 x 100cc .
CLINICAL EVALUATION
DRP 1: Improper Drug Selection
Use of Torasic (ketorolac) in this case is not quite right, because the use of postoperative
ketorolac maximum of two days. While in this case ketorolac used for five days8.
Pharmacist intervention: recommend the use of ketorolac after the second postoperative day
was replaced with another drug.
DRP 2: Drug Interactions
4.
Interactions Ceftriaxone and Heparin
Ceftriaxone and heparin use, which will increase the level of ceftriaxone or anticoagulant effect
of heparin with8.
Pharmacist intervention: recommend to use other alternatives. Because cephalosporins can
decrease the activity prothombin8.
5.
Interaction Ketorolac and Heparin
Use of Torasic (Ketorolac) and heparin, both of which can increase the anticoagulant8.
Pharmacist intervention: Used with caution and should be monitored closely.
6.
Interaction Omeprazole and Onandsentron
Use of OMZ (omeprazole) and ondasentron where Omeprazole will reduce the level or effect of
onandsentron by affecting metabolism in the liver enzyme CYP1A28.
Pharmaceutical interventions: should the use onandsentron and omeprazole given distance less
than two hours.
Conclusion
Based on the results, it can be concluded that patient was suffering from Diabetes Mellitus and
Dyspepsia . In addition there was the presence of DRPs ( Drug Related Problems ) in the form of
2030
drugs were less precise ( improper Drug Selection ) that Ketorolac and drug interactions between
the use of Ceftriaxone - Heparin , Ketorolac - Heparin and Omeprazole – Onandsentron
REFERENCES
1. Smeltzer S. & Bare, B.G, 2008, Brunner & sudarth’s textbook of medical surgical Nursing, EG
2. Suyono, S. 2009. Diabetes Melitus di Indonesia. . Dalam Aru W.S., Bambang S., Idrus A.,
Marcellus S.K., Siti S. Buku Ajar Ilmu Penyakit Dalam Edisi Kelima. Jakarta: Interna Publishing. Hal:
1877-84.
3. American Diabetes Association. Therapy for Diabetes Melitus and Related Disorder. 4th ed.
ADA Inc,USA.2004
4. Purnamasari, D. 2009. Diagnosis and Klasifikasi Diabetes Melitus. Dalam Aru W.S., Bambang
S., Idrus A., Marcellus S.K., Siti S. Buku Ajar Ilmu Penyakit Dalam Edisi Kelima. Jakarta: Interna
Publishing.
5. Riaz, S. 2009. Diabetes Mellitus.Department of Microbiology and Molecular Genetics. Pakistan:
Punjab University.
6. Corwin Elizabeth J, 2009, Buku Saku Patofisiologi, Edisi III, diterjemahkan oleh Nike Budi
Subekti, Buku Kedokteran EGC, Jakarta.
7. Djojoningrat D. Dispepsia Fungsional.Buku Ajar : Ilmu Penyakit Dalam, Edisi 5. Jakarta
9. Ashley Caroline and Currie Ailen.2009. The Renal Drug Handbook third Edition. UK Renal
Pharmacy Group
2031
TREATMENT OF GASTROENTERITIS ACUTE WITH CORONARY
ARTERY DISEASE FOR PATIENT AT PGI CIKINI HOSPITAL JAKARTA
Diah Fatmawati1, Diana Laila Rahmatillah2, Aprilita Rinayanti Eff2, Stefanus Lukas2
1
2
ABSTRACT
Gastroenteritis is a condition of abnormal stools expenditure or unusual, characterized by an
increase in volume, dilution, as well as the frequency is more than 3 times1. Coronary artery
disease usually occurs due to the presence of atherosclerotic occlusion of the coronary arteries
that lead to an increase in the vessel so that the blood vessels narrowing that interfere with
blood flow, this makes the heart muscle is deprived of blood and oxygen2.
Case Presentation: Patient Mrs. IC 88 years old was treated in the room K3 disease, at PGI Cikini
Hospital Jakarta. Patient diagnosed with acute gastroenteritis disease and coronary artery
disease.
Keywords: gastroenteritis acute, coronary artery disease, PGI Cikini Hospital
2032
Introduction
Gastroenteritis is an increase in dilution and frequency feces3. Gastroenteritis can occur as
a result of solute that can’t be absorbed in the feces, called osmolitik diarrhea, or gastrointestinal
tract irritation. The most common cause of irritation is a viral or bacterial infection in the distal
small intestine or large intestine.
Acute gastroenteritis is characterized by vomiting and diarrhea associated with loss of fluid and
electrolyte disturbances that cause dehydration and fluid and electrolyte balance. The main
cause of diarrhea is a virus (adenovirus enteric and robavirus) and parasites (biardia
lambiachristopodium). These pathogens cause disease by infecting the cells produce enterotoxin
or kristotoksin attached to the intestinal wall. Impaired digestion tool in patients with acute
gastroenteritis are small intestine3.
Coronary artery disease usually occurs due to atherosclerotic occlusion of the coronary arteries
that lead to an increase in the vessel, causing narrowing of the blood vessels that disrupt blood
flow. This makes the heart muscle is deprived of blood and oxygen2.
Coronary artery disease is caused by the interruption of blood supply to the coronary arteries so
that the heart muscle is starved of nutrients and oxygen4. It is also supported by a statement
saying that coronary artery disease occurs when the blood supply to the coronary artery
myocardial (heart muscle) is not adequate so that the heart can not pump blood effectively,
resulting in blood perfusion to organs impaired5. Organs and tissues need oxygen through the
blood
from
the
arteries
to
maintai
n
its
function
.
2033
Presentation Case
IC is a 88 years old woman who was treated at the room medicine. The patient entered the PGI
Cikini Hospital Jakarta on August 28, 2014 with diarrhea since 2 days before admitted hospital
and she got heartburn, nausea, weakness, and chest pain too.
The physical examination of patient showed a blood pressure of 140/80 mmHg, pulse 80x/min,
respiratory 20x/sec, and body temperature 36,4oC.
The results of laboratory tests on August 28, 2014 which was not normal as shown in the table
below:
Examination of Hematology
Normal Values
Unit
Result
0-20
mm/hour
61*
Hemoglobin
12,0 – 14,0
g%
11,4*
Erythrocyte
4-6 million
mm3
3,79*
Hematocrit
37–43
%
33*
Neutrophils
2-6
%
0*
Lymphocytes
20-40
%
16*
2-8
%
14*
Normal Values
Unit
Result
Urea
10-50
mg/dL
54*
Triglyceridese
0,6-1,1
mg/dL
1,4*
Complete Peripheral Blood
Erythrocyte sedimentation rate
Calculate Type Leukocytes
Monocytes
Therapy given to patient:
Drug
28/08/14 29/08/14 30/08/14
31/08/14 01/09/14 02/09/14 03/09/14
2034
Rindopump
2x1 FLC
1x1 FLC
1x1 FLC
1x1 FLC
-
-
-
Farsorbid
3x5mg
3x5mg
3x5mg
3x5mg
2x5mg
3x5mg
3x5mg
Placta
1x75mg
1x75mg
1x75mg
1x75mg
1x75mg
1x75mg
1x75mg
Lansoprazole
-
-
-
-
1x1cps
1x1cps
1x1cps
Digoxin
-
-
-
-
1x1/2tab
1x1/2tab
1x1/2tab
Folic Acid
-
-
-
-
1x2tab
1x2tab
1x2tab
New Diatabs
-
-
-
-
-
2 tab
2 tab
Drug
04/09/14 05/09/14 06/09/14
Indication
Farsorbid
3x5mg
3x5mg
3x5mg
Prophylaxis and treatment of angina
Placta
1x75mg
1x75mg
1x75mg
Reduce atherosclerosis in myocardial infarction
Lansoprazole
1x1cps
1x1cps
1x1cps
Duodenal ulcers and gastric ulcers, reflux esophagitis
1x1/2tab
1x1/2tab
1x1/2tab
Folic Acid
1x2tab
1x2tab
1x2tab
Vitazym
-
1 tab
3x1tab
2x2 tab
2x2 tab
-
Digoxin
New Diatabs
Congestive heart, atrial fibrillation, atrial tachycardia
proximal
Deficiency Fe
Improve and enhance the digestibility of the
gastrointestinal tract (stomach and small intestine)
Diarrhea nonspecific
Clinical Evaluation
Drug Related Problems 1
Drug interaction Placta (Clopidogrel) with PPI (Proton Pump Inhibitors) such as:
1.
Placta (clopidogrel) with rindopump (omeprazole) where omeprazole inactivate
cytochrome CYP2C9 and CYP2C19. CYP2C19 is important for the cytochrome system prodrug
activation of clopidogrel, a platelet antiagregasi, to its active form. So coadministration of
omeprazole with clopidogrel should be avoided; except with certain considerations7.
2035
Replace it with pantoprazole pantoprazole which has different cytochrome pathway, which is
dominated by CYP3A4 and CYP2C19 just a little on. Therefore pantoprazole still be accepted as a
proton pump inhibitor that was supplied with clopidogrel7.
2.
Placta (clopidogrel) with lansoprazole. Lansoprazole has a working mechanism through
inactivation of pathway cytochrome CYP3A4 that interaction to clopidogrel lower than
omeprazole7.
Time of drug administration are spaced 2 hours and monitoring of drugs interaction7.
Drug Related Problems 2
Coadministration of digoxin with proton pump inhibitors such as rindopump (omeprazole) and
lansoprazole, which omeprazole and lansoprazole probably will increase serum digoxin levels by
increasing gastric pH. This change was still considered a normal variation levels of digoxin and
not considered significant. But there was one patient experienced digoxin toxicity after using
omeprazole for 3 months7.
The use of omeprazole and lansoprazole only for short-term7.
References
1. Hidayat, Alimul, Aziz, A. 2006. Introduction to Child Nursing. Jakarta : Salemba Medica
2. Munther, K., & Homoud (2008) Coronary artery disease. Tufts New England Medical Center
Spring
3.
Corwin, E, S. 2000. Handbook Pathophysiology. Jakarta : EGC
4. Kang, Y., Yang, I-S., & Kim, N. (2010). Corelates of health behavior in patients with coronary
artery disease. Asian Nursing Research. 4 (1), 45-55
5. Ignatavicius, D.D., & Workman, M.L. (2010). Medical surgical nursing critical thinking for
collaborative care. Six edition. USA Elseiver
6. Smeltzer, S.C., & Bare, B.G (2002). Textbook of medical surgical nursing. EGC 8th ed : 776-784
2036
DRUG PROBLEM RELATED DISEASE IN CHRONIC RENAL
FAILURE COMPLICATIONS CONGESTIVE HEART FAILURE
Hardianti jufri1, Diana Laila Rahmatillah2, Aprilita Rinayanti Eff2, Stefanus Lukas2
1
2
Tel : +62852-5584-7333
Email : jufrihardianti@yahoo.co.id
ABSTRACT
Chronic renal failure or end-stage renal disease is a chronic disorder of kidney function that's
progressive and irreversible6. In which the body's ability to maintain metabolism and fluid, and
also the failed electrolyte, caused by retention of urea and other nitrogen garbage in the blood6.
Based on the study, approximately 70 % of patient with kidney failure cause of death was due to
heart disease5. One of the effort to improve blood biochemical abnormalities caused by
disruption of kidney function, it can be performed by using a hemodialysis machine3.
Hemodialysis is one kind of therapy to replace the kidney (renal replacement therapy/ RRT) and
it can replace a portion of the kidney erectile function only3. Kidney failure will cause premature
narrowing in the coronary arteries, the heart muscle will be impaired as a result of increased
body fluid volume and increased blood pressure, the presence of anemia in patients with kidney
failure will disrupt the heart muscle with all its consequences5. Presentation case : Mr. PS 52
years old, man who was treated in the ward of PGI CIKINI Hospital. The patient complained his
whole body felt weak, even walking was not able to. The patient has a history of chronic renal
failure and hemodialysis has been doing since 2 years ago. The patient only consumed
clopidogrel and folic acid. Clinical evaluation: Drug related problem that occurred in this patient
was failed or did not receive drug to lower uric acid8. Drug interaction between clopidogrel and
omeprazole used9.
Keywords : Chronic Renal Failure , Drug Related Problem¸ PGI Cikini Hospital
2037
1.
Introduction
Chronic renal failure or end-stage renal disease is a disorder of renal function which is
progressive and irreversible6. In which the body's ability to maintain metabolism and fluid and
also electrolyte balance that failed causing retention of urea and other nitrogen garbage in the
blood6. Kidney is one of the organs of the urinary system or urine in charge of filtering and
dispose of fluids, blood metabolic waste in the body, such as we know that body cells convert
food into energy, it will be produced as well as the garbage metabolic byproduct of the process
that must be disposed as soon as possible, in order not to poison the body1.
In developed countries, chronic diseases can't be communicable (chronic non-communicable
diseases), especially for the cardiovascular disease, hypertension, diabetes mellitus and chronic
kidney diseases have replaced infectious diseases as a major of public health problems2. Chronic
renal disease that occurs in a decrease of renal function requiring replacement therapy is costly3.
One of the effort to improve blood biochemical abnormalities that occur as a result of impaired
renal function, it can be done by using hemodialysis machine. Hemodialysis is one form of renal
replacement therapy (RRT) and it only replaces a portion of the erectile function of the kidney3.
Hemodialysis performed in patients with chronic kidney disease at the fifth stage and in patients
with AKI requiring renal replacement therapy. According to the procedure performed, the HD can
be divided into three, namely emergency HD, preparation HD/ perspective an chronic HD/
regular.Based on the study, approximately 70 % of patients with kidney failure cause of death
was due to heart disease3.
Kidney failure will cause premature narrowing in coronary arteries, the heart muscle will be
impaired as a result of increased body fluid volume (volume overload) and increase blood
pressure (pressure overload). The presence of anemia with kidney failure will disrupt the heart
muscle with all its consequences5.
A few studies show that the risk of heart failure is about 2 times higher than men and 5 times
higher in women with kidney failure. This relationship is even more elevated in young patients
(<65 years old) to 4Times and 8 times higher in men and women with diabetes disease compared
with patients without renal failure4.
2038
2.
Presentation Case
Mr. PS 52 years old, man who was treated in the ward room of PGI CIKINI Hospital. The patient
complained his whole body felt weak, even walking was not able to. The patient had a history of
chronic renal failure and hemodialysis has been doing since 2 years ago. The patient only took
clopidogrel drug and folic acid. After conducting several clinical interventions, especially
laboratory for blood tests on CKD patient on dialysis with serum triglyceridese 7,6 mg/dl,
hemodialysis done 2 times a week, and CHF based on the patient's complaints of shortness of
breath, the body feels very weak and anemia. Anemia occurs as a side effect of hemodialysis.
As for drug therapy given to the patient (Mr. PS) is clopidogrel administration aimed to thinner
the blood that occurs in patient on 25 November to 4 December 2014, a total of 1 x 75 mg.
Where as for renal therapy given bionat on 25 November to 1December 2014, a total of 3 x 500
mg. For the treatment of anemia given folic acid on 25 November to 4 December 2014, o total of
1 x 2 tab. For a given drug therapy of peptic ulcers omeprasol 27 November to 4 December 2014,
a total of 2 x 1 stamp. For the therapy of nausea is given by 4 mg on onandsetron injection on 4
December 2014.
The results of laboratory tests :
Examination
The results
Normal
Retikilosit
16
5 – 15
Globulin
3,8
1,3 - 3,0
Urea
180
10 – 50
Triglyceridese
7,6
0,6 – 1,1
2039
Uric Acid
11,5
< 6,8
Phosphorus
7,7
2,5 – 4,8
Hematocrit
32 %
40-48 %
The data from laboratory result above explains that patients with impaired renal function is
characterized by increased levels of urea and triglyceridese, and hematocrit will be decreased.
On liver function check, namely globulin increased. Examination of renal physiology will see an
increase of triglyceridese, phosphorus and uric acid. This increase is due to impaired renal
function.
3.
Clinical Evaluation
3.1 . DRP 1 : Failed or did not recive the drug
In this case found DRP the patient did not recieve a drug patient had high for uric acid levels ,
while the results of the examination of patients have high uric acid 8.
Pharmacist Intervention : suggest to the Doctor to prescribe a drug that lowers uric acid levels is
to provide Allupurinol drug to patients with impaired renal failure given a dose of 100-200 mg
daily8.
3.2
. DRP 2 : Interaction Drugs
Found an interaction items, namely the provision of clopidogrel with OMZ where Omeprazole
lowering effect of clopidogrel WHO worked on CYP2C19 enzyme metabolism . The interaction is
long - term . Clopidogrel may cause a Decrease in the drug - a drug that inhibits CYP2C197
enzyme works7.
Pharmacist intervention : the use of proton pump inhibitors should be avoided in Patients
treated with clopidogrel . If PPI needed some options like dexlanzoprazole , lanzoprazole ,
pantoprazole or perhaps safer alternatives . If not , H2 - receptor antagonists or antacids should
be prescribed when enable9 .
2040
4.
Conclusion
Based on the results of clinical work practice in Ward K in RS PGI Cikini, it can be
concluded that the patient had chronic kidney disease accompanied with congestive heart failure
. Additionally DRP ( Drug Related Problems ) in which patients did not receive the drug is a drug
that lowers uric acid levels , while the results of the examination of patients have high uric acid .
Drug interaction between clopidogrel administration denagn use OMZ where Omeprazole
lowering effect of clopidogrel who worked on CYP2C19 enzyme metabolism . The interaction is
long-term . Clopidogrel may cause a decrease in the drug - a drug that inhibits the enzyme
CYP2C19 works .
Refrences
1. Mansjoer A, et al.Gagal kidney Kronik. Kapita Selekta Kedokteran Jilid II Edisi 3.Jakarta: Media
Aesculapius FKUI, 2002.
2. Sukandar, Enday. 2006. Gagal Kidney and Panduan Terapi Dialisis. Pusat Informasi
3. Rahardjo, P., E. Susalit and Suhardjono. Hemodialisis. Dalam : Aru W Sudoyo, Bambang S., Idrus
Alwi, M. Simadibrata K. and Siti Setiati (Eds). Buku Ajar Ilmu Penyakit Dalam. Pusat Penerbitan
Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia, Jakarta, 2006. 590591.
4. Lintong, Poppy M. 2005. Kidney And Saluran Kencing Bagian Bawah. Bagian Patologi
5. Charles F. Lacy et al. Lexicomp. 2003. Drug Information Handbook 20th Edition.
6. Suwitra, K. Penyakit Kidney Kronik. Hal. 581. Dalam : Aru W Sudoyo, Bambang S., Idrus Alwi, M.
Simadibrata K. and Siti Setiati(Eds). Buku Ajar Ilmu Penyakit Dalam. Pusat Penerbitan
Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia, Jakarta, 2006.
7. Medsape.Drugs interaction.2014
8. Priyanto, Farmakologi Dasar Untuk mahasiswa Farmasiand Keperawatan. Edisi III, Jakarta,
2008.
9. Chahid Y, Kragten JA, Leers MPG, van Rossum LK, Krings AWH, Reinders MK. Change in
response to clopidogrel after switching from omeprazole to pantoprazole. Eur J Hosp Pharm
2012;19:189
2041
CASE REPORT: DRUG RELATED PROBLEM ASSOCIATED WITH
KIDNEY STONE DEASE AT PGI CIKINI HOSPITAL
Heru Susanto1, Aprilita Rinayanti Eff2, Diana Laila Rahmatillah2
1
2
Email: heru.farm@gmail.com
ABSTRACT
Kidney stone is the stone of urinary tract(urolithiasis), the stone of urinary tract can be
found in the urinary tract from the kidney calix system, pielum, bladder and urethra. Kidney
stone is stone that form in the kidney tubules then be in calix, infundibulum, renal pelvis and it
can even fill the pelvis and the entire calix kidney and the stone of urinary tract is most common
happen1. Patient Mrs. RN, aged 57 years old entered PGI Cikini Hospital on 06 October 2014,
with a diagnosis of right ureter stones. Patient has treated with Urispas (flavoxate hydrochloride
200 mg), vitamin K, Bicnat, paracetamol, metronidazole, omeprazole, Lanzoprazol and
Rindopump (omeprazole), Cefixime and cefoperazol, Vomceram (Onandsetron), ketorolac. Based
on the results of clinical work practice in hospital wards K PGI Cikini it can be concluded that the
presence of DRP (Drug Related Problems) that is drug interactions between: Ketorolac with
Vitamin K, Paracetamol (Acetaminophen) with Proton pump inhibitors and Metronidazole with
Acetaminophen.
.
Keywords: Drug Related Problem, Kidney Stones and PGI Cikini Hospital
2042
1.
INTRODUCTION
Urinary tract stone disease spread throughout the world wide with difference
in many
developing countries are found stone jar, while in developed countries are more common upper
urinary tract stone (kidney and ureter). The difference was affected the nutritional status and
mobility activities of daily living. The average prevalence rate in worldwide is 1-12% of the
population suffer urrinary tract stone. The cause of formation of urinary tract stone allegedly
associated with impaired urine flow, metabolic disorder, urinary tract infection, dehydration and
other circumtances that remain unclear(idiophatic). Epidemiologically, the are several factors
that facilitate the occurance of urinary tract stone. There are instrinsic factors and extrinsic
factors 1.
Intrinsic factors, including:
1.
Hereditary; thought to be passed down from generation to generation.
2.
Age; The most frequent in the age of 30-50 years
3.
Gender; the number of male patients 3 times more than female patients.
Extrinsic factors, including:
1.
Geography; in some areas showed a higher incidence than other areas, so that the area
known as the stone belt.
2.
Climate and temperature
3.
The water intake; lack of water intake and high levels of calcium minerals can increase
the incidence of urinary tract stones.
4.
Diet; a diet high in purine, oxalate and calcium facilitate the occurrence of urinary tract
stones.
5.
Work; This disease is often found in people who work a lot of sitting or lack of physical
activity (sedentary life).
Clinical & Investigations
Urinary tract stones can cause complications such as obstruction and urinary tract infections.
Manifestations obstruction in the lower urinary tract is urinary retention or other micturition
complaints while the upper urinary tract stones can cause hydroureter or hydronephrosis. stones
2043
that eft in the urinary tract can cause infection, kidney abscess, pionefrosis, urosepsis and
permanent kidney damage (renal failure) 7.
2.
CASE PRESENTATION
Patient Mrs. RN, aged 57 years entered RS.PGI Cikini on 06 October 2014. Patients has diagnosed
primary right ureter stones with past medical history of URS (Ureterorenoscopy) 8, Lithotripsy 8,
Installed double J stent since 6 months ago not controlled.
3.
CLINIC EVALUATION 5
Result of complete blood hematology test evaluation earlier show that the value of the LED 42
(0-20mm / h), erythrocytes 4,53 (4:00 to 4,50 x106 / mL) and Eosinophils 5 (1-3%) above normal,
decreasing of neutrophils 0 (2-6%), then hematological examination when the patient came back
to the hospital, show that decreasing of erythrocyte sedimentation value is rate 25 (0-20mm /
h), Neutrophils rod 0 (2-6%), lymphocytes 14 (20-40%) and increasing in reticulocyte 17 (5-15
mile) and Neutrophil segment 78 (50-70%).
Table 1. Profile of Treatment
No.
Drug Name
Dosage
Date Dispensing
06/1
07/10
0
08/1
09/10
0
10/1
13/10
0
14/1
15/1
0
0
Oral Agents
1.
2.
3.
Urispas 200 mg
Vit-K 10mg
Transamin
3x1 tabs
3x1 tab
3x1 tabs
1x1
3x1
3x1
3x1
3x1
2x1
3x1
1x1
tab
tab
tab
tab
tab
tab
tab
tab
-
1x1
3x1
3x1
3x1
2x1
2x1
1x1
tab
tab
tab
tab
tab
tab
tab
1x1
3x1
3x1
3x1
2x1
3x1
1x1
tab
tab
tab
tab
tab
tab
tab
1x1
3x1
3x1
3x1
2x1
3x1
1x1
cps
cps
cps
cps
cps
cps
cps
1x2
1x2
3x2
3x2
2x2
3x2
1x2
tab
tab
tab
tab
tab
tab
tab
-
-
3x1
2x1
3x1
1x1
-
500mg
4.
5.
Bicnat 500mg
Paracetamol
3x1 cps
3x2tab
-
-
500 mg
6.
Mitronidazol
3x500m
-
1x1
2044
7.
500 mg
g
Omeprazole 20
2x20 mg
-
-
-
tab
tab
tab
tab
tab
-
1x1
-
-
-
1x2
1x2
1x2
cps
cps
cps
1x1
-
-
mg*
8.
Cefixime 100
tabs
1x2 cps
-
-
-
-
-
mg**
9.
lansoprazole 60
2x1 cps
-
-
-
-
-
mg*
cps
Drug Injection
1.
2.
Ketorolac 30 mg
Cefoperazone
3x1
-
2x1gr
-
1000 mg**
3.
Vomceram 1
2x1
2x1
-
-
-
-
-
amp
amp
1x1
2x1
2x1
1x1
-
-
-
amp
amp
amp
amp
1x1
-
1x1
-
-
-
-
-
-
2x1
-
-
-
1x1
1x1
1x1
2x1
1x1
amp (4mg)
4.
Rindopump
20mg*
4.
No
Name of Drug
Dose
Usage
Indication
1.
Urispas 200 mg
PO
3x1 tab
To reduce the symptoms of urinary tract
disorders.
2.
Vit-K 10mg
PO
3x1 tab
For the treatment and prevention of
bleeding
3.
Transamin 500 mg
PO
3x1 tabs
For abnornal bleeding and kidney
bleeding after ESWL
4.
Bicnat 500 mg
PO
3x1 cps
Metabolic acidosis
5.
PCT 500 mg
PO
3x2tab
For pain in patients.
6.
Mitronidazol 500 mg
PO
3x500mg
Antibacterial
2045
7.
Vomceram
INJECTION 1x1
For nausea and vomiting
(Onandsetron) 1
amp (4mg)
8.
Ketorolac 30 mg
INJECTION 3x1
For acute pain
9.
lansoprazole 60 mg*
PO
As a proton pump inhibitor that is
2x1 cps
controlling gastric acid secretion
10.
Omeprazole 20 mg*
PO
2x20 mg
as a proton pump inhibitor that is
11.
Rindopump 20mg*
INJECTION 2x1
As a proton pump inhibitor that is
12.
cefoperazone 1000
INJECTION 2x1gr
urinary tract infections
PO
urinary tract infections
mg**
13.
Cefixime 100 mg**
1x2 cps
Note :
(*)Omeprazole, lanzoprazol and rindopump not in use for dual therapy but instead of one only,
(**) as well as cefixime and cefoperazone.
5.
DISCUSSION
Results of a complete blood hematological examination and X-rays, patient diagnosed right
ureter stones, and has done ESWL. Patient was given that containing flavoxate hydrochloride 200
mg, Urispas can reduce the symptoms of urinary tract disorders such as dysuria, urgency,
nocturia, pain supra pubic, frequency and inontinence happened on urethritis, uretrosistitis and
uretrogonitis2,4,10. Vitamin K for the treatment and prevention of bleeding and Transamin
containing tranexamic acid was used for abnornal bleeding and kidney bleeding after ESWL, work
by inhibiting fibrinolysis. Tranexamic acid is aminocaproic acid analogue, can be given orally,
work by blocking the binding site of lysine that normally interact with plasmin, inhibit
competitively against plasminogen activator4. Bicnat was used on condition of metabolic acidosis.
Bicnat was given to improve salicylate excretion in the urine with the mechanism of action of
2046
separation to produce bicarbonate ions to neutralize the hydrogen ion concentration and
increase the pH of the urine and blood pH 4. Paracetamol for reducing pain2,4.
Metronidazole is a synthetic antibacterial and antiprotozoal nitroimidazol derivatives which have
bactericidal activity, amebisid and trikomonosid. Omeprazole, Lanzoprazole and Rindopump
were not be used for dual therapy but to substitute one course, third as a proton pump inhibitor
that is controlling gastric acid secretion by inhibiting the proton pump that transports H+ ions out
of the gastric parietal cells2,4.
Cefixime and cefoperazone also not a double but as a replacement therapy are indicated for
treatment of infections caused by microorganisms of uncomplicated urinary tract infections
caused by Escherichia coli and Proteus mirabilis2,4. Patient given Vomceram contains onandsetron
used for nausea and vomiting because the patient complained of nausea vomiting and was given
ketorolac for pain severe acute short-term (<5 days) because the patient feels pain2,4.
6.
DRUG RELATED PROBLEM 5,12
6.1
Adverse drug reactions:
6.1.1
Ketorolac with Vitamin K
The effect of Ketorolac is increased by vitamin k (anticoalugant). Interaction effect is not clear, it
sholud be used cautiously because of the potential for interactions should be monitored 4,11.
6.1.2
Paracetamol (Acetaminophen) with Proton pump inhibitors 3
Lansoprazole may increase absorption of paracetamol by indirectly increasing the rate of gastric
emptying. Omeprazole may induce CYP1A2 isoenzyme of cytochrome p450, and may increase
the formation of hepatotoxic metabolite of paracetamol. However, the findings here indicate
that omeprazole does not have an important effect on CYP1A2 3.
6.1.3
Metronidazole with Acetaminophen
Metronidazole will increase the effects of acetaminophen by affecting liver enzymes CYP2E1
metabolism. Interaction is small or insignificant 11.
7.
CONCLUSION
Based on the results of clinical work practice of PGI Cikini hospital in this case found Drug
Related Problems (DRP) that is the existence of drug interacions.
2047
8.
REFERENCES
1.
Purnomo, BB ( 2000), Dasar-dasar Urologi, Sagung Seto, Jakarta
2.
Anderson, Philip, et.al. 2002. Handbook of Clinical Drug Data 10rdEdition. United States of
America : The McGraw-Hill Companies
3.
Baxter, K, et al. 2008. Stockley’s Drug Information Eight Edition. London: Pharmaceutical
Press
4.
BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta: Sagung Seto.
5.
Departemen Kesehatan Republik Indonesia. (2011). Pedoman Visite Apoteker. Jakarta:
Departemen Kesehatan Republik Indonesia.
6.
Suhardjono.2001.Ilmu penyakit dalam jilid II,Jakarta:Widya Utama
7.
Price & Wilson (1995), Patofisologi-Konsep Klinis Proses-Proses Penyakit, Ed.4, EGC,
Jakarta
8.
Pahira, J.J., Pevzner, M., 2007. Penn Clinical Manual of Urology: Nephrolithiasis.
Amerika Serikat: Saunders Elsevier
9.
Turk, C. et.,al 201l, Guidelines on Urolithiasis, European Association of Urology: Update
March 2011
10.
Sukandar Y.E dkk. 2011. ISO Farmakoterapi 2. Penerbit Ikatan Apoteker Indonesia.
Jakarta
11.
Medscape.com.drug-interactionchecker.2014
12.
Cipolle, Robert J, et al. 2004. Pharmaceutical Care Practice Second Edition. USA: The
Mc.Graw-Hill Companies Inc.
2048
CASE REPORT: DRUG RELATED PROBLEMS IN PATIENT
WITH TYPE II DIABETES MELLITUS, DYSPEPSIA AND
FATIQUE AT MINTOHARDJO HOSPITAL
Agus usman1, Aprilita Rinayanti Eff2 and Diana Laila R2
1
2
taugagah@rocketmail.com
ABSTRACT
Diabetes mellitus (DM) is a group of metabolic diseases with characteristic hyperglycemia
(increased blood sugar levels) that occur due to abnormal insulin secretion, insulin action or
both.1 Dispepsia is chronic or recurrent pain or discomfort centered in the upper abdomen. Set of
complaints / clinical symptoms consist of discomfort / pain in the upper abdomen persistent or
relapsing. Fatigue or tiredness is a protective mechanism of the body so that the body protected
from further damage resulting in the recovery after the break.2 In the arrangement of nerves
there activation system (sympathetic) and inhibition (as parasympathetic). Patients Mr. IR, age
62 years old, entered Mintohardjo Hospital on 17 November 2014, with complaints of he has
dine weakness, and decreased consciousness, vomiting, and sweating if activity patien was
treated for 3 days with Infusion RL, Novorapid insulin, Lantus insulin, metformin, neurodex,
omeprazole, sucralfate, folic acid, biscor (bisoprolol), CaCO3, Codeine, Eclid (acarbose). In this
case was found DRP (Drug Related Problems) that is drug interactions between CaCO3 and Biscor
(Bisoprolol), Metformin and folic acid, omeprazole and neurodex, Metformin lowers the effect of
neurodex.
Keywords: Drug related problems (DRP), Diabetes Mellitus (DM), Dyspepsia, Fatigue and
Mintohardjo Hospital
2049
INTRODUCTION
both.
Dispesia is chronic or recurrent pain or discomfort centered in the upper abdomen. Set of
complaints/clinical symptoms consist of discomfort / pain in the upper abdomen persistent or
relapsing.3
Fatigue or tiredness is a protective mechanism of the body so that the body protected from
further damage resulting in the recovery after the break. In the arrangement of nerves there
aktivasin system (sympathetic character) and inhibition (are parasympathetic).
CASE PRESENTATION
Patient Mr. IR 62 years old entered Mintohardjo hopital on 17 November 2014. Pasien came
with complaints of weakness, and decreased consciousness, was vomiting, and sweating if the
activity.
Blood pressure
Pulse
Respiratory (14- Temperature
(120/80 mmHg)
(60-100x / min)
18x / min)
(36-37 ⁰ C)
11/17/2014
110/80 mmHg
72 x / minute
18 x / minute
36.2 ⁰ C
11/18/2014
110/70 mmHg
72 x / minute
18 x / minute
36.2 ⁰ C
11/19/2014
120/80 mmHg
72 x / minute
18 x / minute
36.2 ⁰ C
Date of Inspection
Laboratory tests on the first day showed that low erythrocyte levels of 3.9 million / mL (4.6 to
6.2), hematochryl level at 25% (42-48), hemoglobin level at 9.2 q / dL (14- 16), increasing
triglycerides 1.5 mq / dL (0.9 to 1.3), fasting glucose 152 mq / dL (70-100).4
DOSAGE AND HOW USING DRUGS
The first time patient was hospitalized he received Ringer lactate (RL) 20 drop per minute,
novorapid 3x10 units, Lantus 1x10 units, 3x500 mg metformin. On the second day he received RL
infusion but Novoravid dose and lantus dose were lowered to 3x4 unit and 1x4 unit respectively
and patient also was given neurodex as blood booster, omeprazole 2x20 mg and sucralfate 3x10
2050
mg. On November 19, 2014, doctors has discharged and the patient prescribed folic acid tid, 3x1
Biscor (Bisoprolol) tid, CaCO3 tid, Codeine bid and eclid (acarbose) od.
DISCUSSION
both.
In this case patient Mr. IR, age 62 years old entered Mintohardjo Hospital on 17 November 2014.
Patient present with fatigue, and decreased consciousness, was vomiting, and sweating he has
done if the activity. laboratory examination showed that decreafe levels of erythrocyte at 3.9
million/mL (4.6 to 6.2), hematochrit (42-48), low hemoglobin ie 9, 2 q / dL (14-16),and mcreasing
triglyceridese 1.5 mq/dL (0.9 to 1.3), fasting glucose 152 mq/dL (70-100).
During patient was hospitalized he received treatment Ringer lactate (RL) 20 MDGs for fluid
requirements, novorapid 3x10 units, and units Lantus 1x10 3x500 mg metformin to treat
diabetes mellitus. On the second day of treatment, patient received. RL Infusion, Novorapid and
lantus dose were lowered to 3x4 unit and 1x4 unit respectively and patient also was given
neurodex as blood booster, omeprazole 2x20 mg and sucralfate 3x10 mg. On November 19,
2014. doctor have discharged and the patient prescribed folic acid 3x1, 3x1 Biscor (Bisporolol)
3x1, CaCO3 3x1, Eclid (Acarbose) 1x1 and Codeine 2x100 mg.5
Drug Interaction
a.
CaCO3 with biscor (bisoprolol). Caco3 can decrease the effect of biscor by interfere GI
absorption
b.
Metformin with folic acid, metformin decrease the effect of quality folic acid by
pharmacokinetic interactions
c.
Omeprazole with neurodeks, Omeprazole decrease plasma level of neurodeks by
interfere GI absorption
d.
Metformin with neurodeks, where metformin decrease the effect of neurodeks after
some year old use in this case6
CONCLUSION
2051
Based on the results of clinical work practice in pulau sangeang wards in Mintohardjo hospital it
can be concluded that the presence of DRP (Drug Related Problems) ie drug interaction.
REFERENCES
1. Ganiswara SG, "Pharmacology and Therapy, Edition Four, section
Pharmacology " Faculty of
Medicine University Press, 1995.
2. ISFI, 2009. "ISO Indonesia Vol. 44 ". Noble Berlico Farma. Yogyakarta
3. Wikarsono, amirsa nur. 201 4. Syndrome Dyspepsia (Dyspepsia syndrome).
Line 10 December
4. Sutedjo, AY, 2008. Book pocket recognize disease through examination laboratory,. Jakarta.
5. BPOM. 2008. Information is Drug National Indonesia (ioni) .Jakarta: Sagung Seto.
2052
CASE REPORT:DRUG RELATED PROBLEM IN PATIENT WITH
ASCITES DISEASE AT PGI CIKINI HOSPITAL JAKARTA
Panji kumoro1, Aprilita Rinayanti Eff2, Diana Laila Ramatillah2
1
2
Email: anji_fui@yahoo.com
ABSTRACT
Ascites Is an accumulation of serous fluid in the form of a fluid ( usually pale yellow liquid and
clear ) in the abdominal cavity ( peritoneal ).The abdominal cavity is located under the chest
cavity.A liquid ascites is found in many patients such as liver, cancer, congestive heart failure,
and kidney. ( grace, 2006 ).Patient Mr .U.S. aged 65 years, came to PGI cikini hospital with
diagnosis of ascites.Patient was treated with ferotam injection, (furosemid) lasix, aldacton
(spironolakton), hepabalance ( fructus schusandra chinensi, lecithin, silybum marianum cement,
curcuminoid 2, vitamin ).Based on the results in clinical practice at PGI cikini, there is found drug
related problem, that are drug interaction
between lasix ( furosemid ) and aldacton(
spironolakton ) and untreated complaint.
Keywords: Drug related problem, ascites PGI Cikini Hospital
2053
INTRODUCTION
Ascites is derived from the Greek language meaning Askos bag or purse. Ascites is the
accumulation of patologis fluid in the abdominal cavity. Male healthy adults do not have or are
slightly intraperitoneal fluid, but the women there are as many as 20 ml depending on the
menstrual cycle. Approximately 80% of the estimated cases of ascites due to cirrhosis. Some of
the other causes of ascites is congestive heart failure and kidney failure, inflammation,
infections, nephrosisetc (Fredman, 2010).
Classification of ascites is divided into 2 following as :
1.
Exudative ascites have a high protein content and occurs in inflammation (usually TB
infection) or malignant process.
2.
Transudative ascites due to cirrhosis occurs in pulmonary hypertension and changes in
clearance renal sodium. Constricting pericardium and ascites nephrotic syndrome can cause
Transudative.
Clinical Presentation and Examination Support (Fredman, 2010).
Massive ascites can be apparent on inspection in the presence of abdominal distension,
often accompanied by umbilicus protruding outward.
Examination Support
1.
Examination ascites fluid: check the color, proteins, bacterial cell count and malignancy.
Ascites in cirrhosis usually yellowish, reddish and murky malignancy in infection.
2.
Ultrasound abdomen to measure heart size (small to cirrhosis), signs of pulmonary
hypertension and pulmonary veins and vein with hepatica. Also useful to find a focal abnormality
(directing alleged disseminated malignancy) and for the diagnosis of intra-abdominal tumors eg
ovarian tumors.
3.
Tests other blood: biochemical tests and liver function tests to look for markers of liver
cirrhosis (albumin decreased, hyperbilirubinemia, increase in liver enzymes, thrombocytopenia
and others. Examination of tumor markers if there is suspicion of malignancy (especially αfetoprotein for hepatoma, CA 125 for ovarian cancer).
Management
2054
1.
Ascites exudative: treat the underlying disease. Bacterial peritonitis: antibiotics, ascites in
patients with low protein content could be given prophylactic antibiotics.
2.
Ascites with malignancy: treat the cause of malignancy (most often because the ovaries).
Generally, therapeutic paracentesis should be done to alleviate the symptoms.
3.
Ascites Transudative: treat the underlying disease and doing consider :
a.
Fluid and salt restriction, fluid restriction is usually sufficient to get ≤ 1-1.5 / day and a
diet without added salt.
b.
Diuretics, spironolactone and furosemide, a diuretic commonly used.
c.
Therapeutic paracentesis for ascites refractory ascites that is unresponsive to diuretic
therapy or experience side effects that can not be avoided such as hyponatremia,
encephalopathy and etc (Grace, 2006).
CASE PRESENTATION
Patient Mr.As 65 yearsold entered PGI Hospital cikini on june 28 september 2014.The
patient has complaint enlargement of his stomatch.
CLINICAL EVALUATION
From the results of the laboratory, examination on hematology indicated that
increasingvalue the ofblood sedimentation rate (BSR) is , 70 mm/h (0 to 20 mm/h), the increasing
of value of globulins 3.9 g4 / ln ( 1,5-13,2 g4 / etc. ), eosinophils 18 % ( 1-3 % ) and monocytes 11
% ( 2-8 % ), decreasing of hemoglobin a hb 12.3 g4 / ln ( 13,0-16,0 g4 / etc. ), Mcv ( 95 ), 81-92 .
Neutrophils 0 % ( 2-6 % ) and hematokrit 35 % ( 40-48 % ).
DOSES AND HOW TO USE OFDRUGS
In this case patients was treated with ferotam injection with a dose of 2 x 1 ampul,
furosemide lasix injection with a dose of 1 x 1 ampul a day use aldacton ( spironolakton ) with a
dose of 1 x 100 mg a day , hepabalance with a dose of 2 x 500 mg a day . `
DISCUSSIONS
On the outcome of the examination of hematology on the first day , showed the the
value blood sedimentation rate (BSR) was high, 70 mm/h (0 to 20 mm/h), a globulin that is an
increase in 3.9 g / dl ( 1,3-3,7 g / dl ) where an increase in the rate of endap blood ( led ) usually
2055
occurs due to the elevated levels of a globulin and fibrinogen of infections acute sistemis local
and, eosinophils 18 % ( 1-3 % ) and of monocytes 10 % ( 2-8 % ) show happened a viral infection,
the decline in neutrophils 0 % ( 2-6 % ) is found in a viral infection, and hematokrit 31 % ( 37-43 %
) where the decline in hematokrit occurs in patients who have anemia, malnutrition, and cirrhosis
hepatis .
On examination faal liver show an improvement in the value of the bilirubin direk namely
0.44 mg / dl ( & it; 0.44 mg / dl ) where increasing bilirubin direk usually is caused by jaundice
obstructive intrahepatik or ekstrahepatik because damage cells or stone and a decline in value of
albumin 3,0 g / dl ( 3,4-4,8 g / dl ) where the decline of albumin resulting in a discharge vascular
heading into the network so happened udema.A disease which causes hipoalbumineria among
others of malnutrition and a cirrhotic liver.While the decline in the value of cholinesterase ( CHE )
4.2 KU / L ( 5.4 - 13.2 KU / L ) where the decline of cholinesterase ( CHE ) there are on
malabsorption, a cirrhotic liverand infections ( sutedja, 2007 ).Infection that occurs maybe
because tuberculosis infection based on the acts of disease patients previous.
During which the patient treated in the hospital cikini pgi , to four patients the type of
medicines .In 10 days given therapy care 4 the type of medicines of them ferotam injection with
a dose of 2 x ampul 1 , where ferotam injection used for abdominal infection , the use of lasix (
furosemide ) dosage of 2 x 1 ampul a day used as a diuretic drug used to address udem in
patients .The use of aldacton ( spironolakton ) that dosage 1 x 100 mg a day used as a diuretic
drug where combination furosemide spironolakton and most effective to reduce the build up of a
fluid in the abdomen is and prevent the occurrence hipokalemia due to
( fredman
furosemide, 2010; mathew, 2008 & moore center , 2006 ), the use of hepabalance with a
dose of 2 x 500 mg a day used societys health the function of the heart . `
Drug related problem
The patient experienced hipoalbuminemia but he do not received for overcome his
complaint.It is the responsibility of albumin in the blood, terikatnya compound a medicine if the
weak are the responsibility of albumin in the blood is lower - and so is free to the effects of the
drug are so it can cause the decrease or toksisitas.
Conclusion
2056
Based on the results of the clinical at cikini hospital it can be concluded there is found drug
related problem that are drug interaction between lasix and spironolacton and untreated
complaint.
REFERENCES
1. Anonim. 2014. CA125. http://en.wikipedia.org/wiki/CA-125
2. Anonim. 2009. British National Formulary 57. London : BMJ Group and RPS Publishing.
3. Anonim. 2005. Stocley’s Drug Interactions. The Pharmaceutical Press
4. Cipolle, Robert J, et al. 2004. Pharmaceutical Care Practice Second Edition. USA: The
Mc.Graw-Hill Companies Inc.
5. Fredman, L. Scott. 2010. Clinical Hepatology : Principles and Practice of Hepatobiliary Disease
Volume 1.London : Springer.
6.P, grace n. borley2006.At a glance surgical, science third edition.Jakarta: erlangga.Hlm 40-41
7.Isselbacher, kurt. j1999Harrison principles of science disease / editor in an edition of the
british kurt j.Et al isselbacher; editor edition indonesian language ahmad h.Asdie ed.13.Jakarta:
egc.
8.Mathew, k.George, aggarwal praveen.2008.Medicine: prep manual for undergraduates 3rd
edition.New delhi: elsevier
9.Sutedjo, ay, 2007.Pocketbooks disease through recognize the results of laboratory
examination.Jakarta: birata work
2057
TREATMENT OF OSTEOMYELITIS DISEASE at
Harun Arrasyid1, Aprilita Rimayanti Effi 2, Diana Laila Ramatillah 3
1
Student of Pharmacist Professional Program Student
Faculty Of Pharmacy UTA’ 45 Jakarta
2
Email: harunarrasyid90@gmail.com
ABSTRACT
Osteomyelitis is an infection of the bone disease that is caused by a bacterial infection1. Mr. Nn,
49 years old, entered Mintohardjo hospital on 4 September 2014 with a diagnosis of
osteomyelitis, pain sensation in pelvic, hobble, and fever. The therapy treatment during
hospitalized were ceftriaxone, ketorolac, and gentamycin. Based on the results of clinical practice
in Pulau Salawati room at Mintohardjo hospital it can be concluded that the presence of DRP
(Drug Related Problems) such as untreated disease (anemia) and drug interactions (ketorolac
with gentamicin).
Keyword
: Drug Related Problem (DRP), Osteomielitis, Mintohardjo hospital
2058
INTRODUCTION
Osteomyelitis is an infection of the bone disease that is caused by a bacterial infection in the
bone tissue1.
Osteomyelitis can be divided into acute osteomyelitis and chronic osteomyelitis. According to
research conducted in America, found about 25% of acute osteomyelitis progress to be chronic
osteomyelitis1,2. The treatment of chronic osteomyelitis is still a problem in the field of
orthopedics because it is so common in society, but it is also costly, take a long time,
considerable experience from the surgeon, and difficult to handle, especially to deal with the
complications and bacterial resistance3.
Recovery of Chronic osteomyelitis is quite difficult, because it is often accompanied by
recurrence and exacerbations. Even found the statement "once osteomyelitis, constantly
osteomyelitis", it indicates a pessimist from the surgeon and the patient’s own in dealing with
the osteomyelitis4.
An Acute osteomyelitis is characterized by the presence of a suppurative or production of pus, an
infection be accompanied with edema, vascular occlusion and thrombosis. At the beginning, the
blood supply to the bone is reduced, followed by soft tissue around it. When the blood supply to
the marrow and periostal blocked, there will be widespread death of bone, called sequester.
However, if treated quickly and adequately, with antibiotics and surgery, acute osteomyelitis can
be stopped before the mortality of the bone. Immediately after an infection, fibrous tissue and
chronic inflammatory cells will form around the bones that are dead. Due to a decrease in blood
supply in the area, the inflammatory response cannot be produced effectively. This will add the
severity of disease. An acute osteomyelitis without a effective treatments can lead to chronic
osteomyelitis in terms of both clinical and histological5.
Pathological sign of chronic osteomyelitis is a bone necrosis, the formation of new bone, and
exudate from the white blood cells. The formation of new bone fragments derived from the
periosteum and endosteum life at the location of the infection. The new bone will form a sheath,
known as involucrum, around the dead bone beneath the periosteum. Involucrum irregularly
shaped and perforated that form a sinus as the passage of pus. Involucrum will grow in density
2059
and thickness to form a part or whole of the new diaphysis. Until now a debridement and the use
of intravenous and oral antibiotics therapy is adopted to manage osteomieliti in general5.
Based on the research founded the Drug Related Problems (DRP), therefore the author would
like to know the management of osteomyelitis in Mintohardjo hospital.
CASE PRESENTATION
Mr. Nn, 49 years old, entered Mintohardjo hospital on 4 September 2014 with a diagnosis of
osteomyelitis. Patient also feel a sensation of pain in pelvic, hobble, and fever.
One year ago the patient had been diagnosed osteomyelitis but not performed surgery. Patient
did not have allergies with the medications used previously or disease due to heredity.
CLINIC EVALUATION 7
In this case the patient was treated with ketorolac injection, gentamycin injection and cefriaxone
injection. Ketorolac injection is for the short-term management of the acute pain, gentamycin as
an antibiotic against Streptococcus viriands and Streptococcus faecali because osteomylitis is a
disease caused by the bacteria Streptococcus and Cefriaxone as an antibiotic for Gram positive
bacteria and Gram negative bacteria.
DOSAGE REGIMENT
In this case the patient was treated with gentamycin injection 2 ampoule bid, ketorolac injection
1 gr bid, and ceftriaxone injection 1 gr bid.
LABORATORY RESULT
The laboratory results obtained abnormal WB ’s value ie 10,600 (normal value: 5000-10000)
shows that the patient occur an infection, abnormally in hematocrit value of 36% (normal value:
43-51%), decrease of lymphocytes 18% (normal values: 20 - 40%), hemoglobin value of 11.5 g/dl
(normal values of 14-18 g/dl), it indicates the occurrence of anemia and an increasing of segment
Neutrophils 72% (normal value: 50-70%) showed an infection/inflammation liver function tests
show increasing ALT 48 U/I (normal value: <41 U/I) and renal function showed increase
2060
triglyceridese values, which on 4 september 2014 laboratory results 2.3 mg/dl, and on 12
september 2014 1,4 mg /dl (normal values: 0.9-1.3).
DISCUSSION
In this case Mr.Nn hospitalized on 04 September 2014 with a complaint abscess on the left leg,
fever and hobble. Based on the history of the disease can be determined goal of drug is treated
the infections, relieve the symptoms and surgery. The parameters measured were blood
pressure, laboratory values associated hematologic values and vital signs such as temperature,
respiration rate and heart rate. On the first day Mr. Nn has blood pressure 120/70, pulse 92x
/min and temperature 380C. The patient received ketorolac injection for management of acute
pain and ceftriaxone injection as antibiotic. On the fourth day, the patient is given additional
medication that is gentamycin as an antibiotic against Streptococcus viriands and Streptococcus
faecali because osteomylitis is a disease caused by the bacterium Streptococcus.
Examination of the laboratory results obtained leukocyte values above the normal range
indicates the patient experienced an infection and increase the value of Neutrophils segments
indicate the presence of infection/inflammation result of liver function and kidney function show
the fungsion of liver and kidney have reduced, it must suggested monitor using of ceftriaxone
and gentamycin that the drugs can cause side effect on kidney. But laboratory examination on
the eight day sowed that triglyceridese value only 1,4 that is show tent using of ceftriaxone and
gentamycin do not affect renal fungsion.
6.
DRP 1 : Untreated Complain
Laboratory findings stated that the patient had anemia, but he did not received supplement for
overcome the anemia.
7.
DRP 2 : Drug Interactions6
Interaction between ketorolac and gentamycin, where ketorolac can increases levels of
gentamicin and reduced renal clearance. Potential for interaction, so it needs interval uses for
the both drugs
2061
CONCLUSION
Based on the results of clinical work practice in Pulau Salawati room at Dr.Mintohardjo hospital it
can be concluded that the presence of DRPs (Drug Related Problems) such as untreated
complaint (anemia) and drug interactions (ketorolac with gentamycin).
REFERENCES
1.
Siregar PU. Chronic Hematogenous Osteomyelitis in children. Majalah Kedokteran
Indonesia Juni 2005,Vol:55,Nomor: 6: 435 - 438.
2.
Walenkamp G H.chronic osteomyelitis.Acta Orthop Scand 1997 ; 68 (5): 497-506.
3.
Khan AN, MBBS, FRCP, FRCR. Osteomyelitis Chronic.
http://www.emedicine.com/ Osteomyelitis, Chronic Article by Ali Nawaz Khan, MBBS, FRCP,
FRCR.htm (9 Desember 2014)
4.
Gentry LO, MD. Osteomyelitis: Treatment Overview.
http://www.medscape.com/Osteomyelits Treatment Overview.htm (9 December 2014)
5.
Luca Lazzarini, Jon Mader, and Jason Calhoun. 2004. Journal Osteomyelitis in Long
Bones. http://www.ejbjs.org/cgi/reprint/86/10/2305.pdf. (10 November 2014).
6.
Anonim. 2005. Stocley’s Drug Interactions. The Pharmaceutical Press
7.
BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung Seto
2062
ASSOCIATED WITH THE TREATMENT OF PATIENTS WITH
HYPOGLYCEMIA IT WARDS PGI CIKINI HOSPITAL
Sukria1, Aprilita Rinayanti Efi2, Diana Laila Rahmatillah2
1
2
Email: Sukria0311@gmail.com
ABSTRACT
Hypoglycemia is a state of that of blood glucose levels less than 45 mg / dL (2.6 mmol / L).
Hypoglycemia is the most common metabolic problem in neonates. The most common clinical
manifestations may include the level of consciousness, seizures, vomiting, and lethargy.
Hypoglycemia often occurs due to low glucose reserves. Hypoglycemia is not managed propely
will cause damaged the central nervous system and death. Hypoxemia and ischemia potentiate
Hypoglycemia and can cause permanent brain damage and disrupt neurological development.
Patient Mr. S aged 73 years old entered the ward space K PGI Cikini Hospital on 26 September
2014. Patient complain of loss of consciousness, difficulty, and dizziness. Patent was treated for
11 days with Captopril, Dextrose, ambroxol, Vit B complex, KCL, cefotaxime, Lasix (Furosemide),
Folic acid, trombo aspilet, Valsartan, Laxadin. Based on the results of clinical work practice in PGI
Cikini hospital it can be concluded that the presence of Drug Related Problems (DRP), that is drug
interactions.
Keywords: Drug Releated Problem, Hypoglycemia, PGI Cikini Hospital
2063
1.
INTRODUCTION
Hypoglycemia is a state of the blood glucose level measurement results is less than 45 mg /
dL (2.6 mmol / L). Hypoglycemia is the most common metabolic problem in neonates.
Hypoglycemia often occurs due to low glucose reserves. Glucose is an important source of
calories for survival during childbirth and the first few days after birth. Occurs Reduces stress that
any existing glucose reserves for improving the use of glucose reserves, for example in asphyxia,
hypothermia, hyperthermia, respiratory disorders. Patients with hypoglycemia may be
asymptomatic or may present with severe central nervous system (CNS) and cardiopulmonary
disorders. The most common clinical manifestations may include the level of consciousness,
seizures, vomiting, unresponsiveness, and lethargy. Each child is sick should be evaluated for
hypoglycemia, especially when history reveals decreased oral intake .
Sustained or recurrent hypoglycemia in infants and children have a great impact on
normal brain development and function. Evidence suggests that hypoxemia and ischemia
potentiate hypoglycemia, causing permanent brain damage can impair neurological development
.
2.
CASE PERCENTAGE
Patient Mr. S 73-year-old entered Cikini hospital with complaint loss of consciousness. Patient
had history illness 1 day before admission, the patient experienced a loss of consciousness,
breathlessness and dizziness and constipation.
3.
CLINICAL EVALUATION
The patient is given dextrose infusion and captopril. Dextro is given because the patient
experience loss of consciousness due to lack of fluids while captopril and lasix given to lower
blood pressur. Patient also received vitamin B and folic acid as supplement , ambroksol as
mocolytic
kalium, cefatoxim as antibiotic, thrombo aspilet antiplatelete and laxadin for over
come costripation.
4. PATIENT EXAMINATION RESULTS
1.
Examination
Results
Unit
Reference Values
2064
26 – 9 – 2014
Complete peripheral blood
*26
mm/jam
0-10
rate
15,6
g/dL
13-16
Hemoglobin
*24,0
10^3μL
5-10
Leukosit
4,87
10^3μL
4,5-5,5
Eritrosit
45
%
40-48
Hematokrit
14
Permil
5-15
rate
0
%
0-1
Basofil
*0
%
1-3
Eosinofil
*1
%
2-6
neutrophils rod
88
%
50-70
neutrophils segment
7
%
20-40
Limfosit
4
%
2-8
Monosit
217
10^3μL
150-450
Trombosit
92
fL
81-92
MCV
32,0
pg
27-32
MCH
34,8
g/dL
32-37
Retikulosit
MCHC
2.
Examination of Clinical Chemistry
Results
Examination
26 – 9 – 2014
Unit
Reference Values
SGOT
24
U/L
0-50
SGPT
38
U/L
0-50
Uremia
15
mg/dL
10-50
2065
Kreatinin
1,3
mg/dL
0,6-1,1
Sodium (Na) blood
139
mEq/L
135-145
Potassium (K) blood
3,6
mEq/L
135-147
Calcium (Ca)
L 0,2
mg/L
8,8-10,3
specific gravity
1.020
g/ml
1.015-1.025
color
Kuning
Kuning
clarity
Jernih
Jernih
Esterase leukosit
Negatif
Negatif
blood
Trace/10
pH
H 7,5
4,8-7,4
Protein
Negatif
Negatif
glucose
1 + 250
mg/dL
Negatif
Bilirubin
Negatif
-
Negatif
Urobilinogen
0,2
-
< 0,2
Keton
Negatif
-
Negatif
Urine and Parasitology
sel/µl
Negatif
Sedimen
Leukosit
1
/LPB
0-2
Eritrosit
H 10
/LPB
0-3
Epitel
1
/LPB
0-1
Silinder
0
/LPK
0-1
Bakteri
2
/LPB
<5
2066
5.
TREATMENT AND DOSE
Name of medication
Dose
Total daily
Vit. B comp 50 mg
3 x 1 tab
3 tablet
Folid acid 5 mg
1 x 2 tab
2 tablet
Ambroxol 30 mg
3 x 1 tab
3 tablet
Valsartan 80 mg
1 x 1 tablet
1 tablet
Captopril 12,5 mg
3 x 1 tablet
3 tablet
KCL 500 mg
2 x 1 tablet
2 tablet
Dextro 40% 50cc
1 infus
1 infus
Cefotaxime 1 g
3 x 1 ampul
3 ampul
Lasix 2 ml inj
2 x 1 ampul
2 ampul
Laxadin 60 ml
2 x 1 sdm
2 sdm
Trombo aspilet 80mg
1 x 1 tablet
1 tablet
6. Discussion
On The first day of hospitalization the patient is given an infusion handed and captopril.
Dextro given because patients experience loss of consciousness due to lack of fluids while
captopril was given to lower blood pressure on the second day he was given vitamin B and folic
acid, ambroxol for tightness due to respiratory illness, KCL , cefotaxime for over come bacterial
infections because
laborator result so that in creasing of leucocyte, Lasix was given to lower
blood pressure in combination with other antihypertensive drugs.
On the third day, giving of dextro and captopril is stopped. On the fourth day patient received is
trombo aspilet and laxadin. Trombo aspilet as anti platelet for prevent thrombus while laxadin
for overcome. On the fifth and sixth day is still the same. On the seventh dose administration of
kcl and lasix was lowored, initially bid into one daily.
7.
Drug interaction :
a. Captopril with KCL
2067
Captopril increases levels of potassium chloride by lowering elimination. The risk of
hyperkalemia.
b. Lasix deerease level plasma of folic acid and interaction increase renal clearance.
c. Trombo aspilet with valsartan
Trombo aspilet reduce the effects of valsartan by antagonism
d. Trombo aspilet with lasix pharmacodinamic.
Trombo aspilet reduce the effects of Lasix by antagonism pharmacodynamics.
e. Trombo aspilet with Folic acid
Trombo aspilet decreasing plasma level of folic acid by inhibiting absorbtion in GI5.
Conclusion:
Based on the results of the practice at PGI Cikini Hospital it can be concluded that the
presence of DRP (Drug Related Problems) that is drug interactions between captopril with KCL,
Lasix with Folic acid, trombo aspilet with valsartan, trombo aspilet with lasix , and trombo aspilet
with Folic acid.
REFERENCES
2. Baand POM RI, 2008. Informasi Obat Nasional Indonesia. Baand POM; Jakarta
3. Lippincott Williams & Wilkins, 2004. Hypoglycemia.eds. Manual of neonatal care; edisi ke-5.
Boston 569-76 Cloherty JP, Stark AR
4. Mansjoer, Arif., et all. 1999. Kapita Selekta Kedokteran. Fakultas Kedokteran UI
5. Madescape http://reference.medscape.com/drug-interactionchecker
2068
DRUG RELATED PROBLEMS IN PATIENT WITH LUNG RIGHT
PNEUMONIAE DISEASE AT THE K ROOM OF PGI CIKINI HOSPITAL
JAKARTA
Yulianita Eka Sriastati1, Aprilita Rinayanti Eff, and Diana Laila R2
1
2
Lecturer of Faculty UTA’45 Jakarta
yes.eka88@gmail.com
ABSTRACT
Pneumoniae is an infection in the end of bronchial and alveoli caused by microorganisms, such as
bacteriae, fungus, virus, and parasite. Pneumoniae is also caused by non-microorganisms, such as
chemical substances, radiation, toxic substance aspiration, drugs, etc. A patient named Mr KI, 65
years old, weight of 40 kilograms, entered K room of PGI Cikini Hospital with diagnose of having
lung right pneumoniae disease, which is based on the thorax photo and anemia, he previously
had Tuberculosis (TB) lung. The therapies given during the treatment were NaCI 0.9%,
Ceftriaxone inj, Neurobion inj, Lesichol 600 kaps, and Ulvice inj. Based on the clinical
examination, it was found DRP (Drug Related Problem). Its the patient had complaints but
physical didn’t give treatment medicine and inaccurate prescriptions like giving the ceftriaxone
antibiotic. In this case, ceftriaxone isn’t drug of choice for pneumoniae disease.
Key words: Drug Related Problem, Pneumoniae, and PGI Cikini Hospital
2069
INTRODUCTION
Infection of respiratory tract is still the main problem in health, either in the developing
or advanced countries. The cause of pneumoniae is difficult to be figured out and it needs a few
days to get the result, whereas this disease can cause death if it is not immediately cured. Hence,
at the first step, antibiotic is given empirically1. Pneumoniae can be caused by various kinds of
microorganisms, such as bacteria, virus, fungus, and protozoa. Based on the literary, pneumoniae
community suffered by the people in overseas is because of positive gram, on the other hand
pneumoniae in the hospital is mostly caused by negative gram, and aspirated pneumoniae is
mostly caused by anaerob bacterias. Recently, the report from some cities in Indonesian shows
that bacterias found in the sputum examination, patient of pneumonia community is because of
gram negative bacteria2.
Pneumoniae is the result of microba poliferation pathogen in the degree of alveolar
response hosts to the pathogen. Microba enters the underpart of respiratory tract by orofaring
aspiration2.
A Mechanical defense factor is very important. The mechanism of cough is a protection
from the aspiration. When smaller microorganism is inhalled to the alveolar stage, macrofag
cleans and kills pathogen efficiently. Macrofag assisted by the local protein, for example
surfactan A and D which have nature of intrinsic opsonizing or antibateria/antivirus. After the
microfag is swallowed accidentally, and if it does not get killed by the macrofag, it will be
eliminated by mucosiliary that can keep the contagion. But when the capacity of alveolar
macrophage is not sufficient to kill the pathogen, it will cause pneumoniae. Then respiratory
tract will start to response inflammatory to increase the defense of respiratory tract.
Inflammatory mediator releases macrophage and produces neutrophil. This makes capilary
leakage that equals with the syndrome of acute respiratory infection although in pneumoniae
this leakage is localised (in the first stage). Some pathogen bacterias appear and they cause the
alveoli is full filled with the water. This makes the onerus hypoxemia3.
The increase of breath pressure in the systematic inflammatory response syndrome
causes the breath alkalosis. The decrease of respiratory system caused by capilary leakage,
hipoxemya, increase in breath rythm, increase in secretion, and sometimes bronchospasm are
2070
related with the occurrence of infection that causes dyspnea. If it is bad enough, conversion in
the secondary lungs mechanical can cause death3.
CASE PRESENTATION
A patient named Mr KI, 65 years old, weight of 40 kilograms entered PGI Cikini Hospital
with complaints of his body is weak, dizziness, heart palpitation, short of breathness and chest
pain, low appetite in the last two days. Condition of patient when he entered the hospital; blood
pressure 180/90 mmHg, pulse 80 times/minute, temperature 36oC, CM (Compos Mentis)
awareness or normal awareness that the patient can answer questions about the surroundings.
Patient has background of Tuberculosis (TB) lung which the treatment had been completed and
the patient was declared to be healthy.
CLINICAL EVALUATION
On the first day patient entered hospital, he was given ceftriaxone and NaCl 0.9%.
Ceftriaxone as antibiotic was given because from hemathology and thorax photo results indicate
that the patient experience infection disease. Ceftriaxone as the third generation of antibiotic
cephalosporins, it is specific to the negative gram bacteria infection. On the second day, the
patient was given Lesichol 600 as hepatoprotector and Neurobion 5000 as the vitamin to
prevent and cure disease. Then on the third day, Ulvice inj (vitamin C) was added to maintain
healthy and endurance.
DOSAGE AND DIRECTION4
Medicine names
Ceftriaxone
How to
Dosage
use
regimen
IV
1x2 g
Indication
Antibiotic
General dosage
Adults and children>12
years old and children
with
weight>
50
kilograms: 1-2 grams
once a day. In the
infection, the dosage
measurement can be
2071
increased until 4 grams
once a day.
NaCl 0.9%
IV
/12 hours
Electrolyte liquid
2.5 ml/kg W/hours or
60 drops/70 drops kg
W/minute or 180 ml/70
kg W/hour
Neurobion 5000
IV
1x1 ampul/3ml
Fulfill needs of vitamin 1x3 ml
B1, B6, B12
Lesichol 600
PO
3x1
Hepatoprotector
3x1 capsule
Ulvice
IV
3x1 ampul/5 ml
Vitamin C deficiency
1000-2000 mg
RESULT OF CLINICAL LABORATORY
Check up type
Result
Normal value
HEMATOLOGHY
Complete perifer blood
Erithrocyte Sedimentation Rate
*32mm/hour
0¨10
Leukocytes
*3.700/ul
5.000¨10.000
Erythrocyte
*2.98 million/ul
4.5¨5.5
Hemoglobin
*10.5 g/dl
13¨16
Hematocrite
*29%
40¨48
Reticulocyte
*25 permil
5¨15
0%
0¨1
Basophil
1%
1¨3
Eosinophil
*0%
2¨6
Neutrophil scape
*74%
50¨70
Neutrophil segmen
*19%
20¨40
4%
2¨8
Count leukocyte sorts
Lymphocyte
2072
Monocyte
*107.000/ul
150.000¨450.000
85 fL
81¨92
MCV
30.2 pg
27¨32
MCH
36.1 g/dL
32¨37
AST (SGOT)
29 U/I
<50
ALT (SGPT)
33 U/I
<50
Urea
25 mg/dL
<50
Triglyceridese
1.1 mg/dL
0¨1.1
Natrium (Na)
135 mmol/L
132¨147
Kalium (K)
3.7 mmol/L
3.6¨6.1
Clorida (Cl)
91 mmol/L
95¨116
Platelet
MCHC
Liver Function
Kidney Function
Electrolyte
6.0¨8.0
Total protein
7.0 g/dL
3.4¨4.8
Albumin
*3.1 g/dL
1.3¨3.7
Globulin
3.6 g/dL
DISCUSSION
Pneumoniae is caused by microorganisms (bacteriae, fungus, virus, and parasite) and
non-microorganisms (chemical substances, radiation, toxic substance aspiration, drugs, etc).
Patient entered hospital with complains of body feels weak, headache, heart palpitates, cough,
and low appetite. Based on the thorax photo and laboratory test, patient suffered pneumoniae.
This is shown by the increasing of Erythrocyte Sedimentation Rate (ESR) and the reduction of
leukocyte also shows that isn’t the existence of infection. The reduction of hematocryte can
cause anemia and and deficiency of vitamins B and C. The reduction of hemoglobin,
thrombocyte, and erithrocyte shows the symptom of anemia. On the first day of treatment, the
2073
patient was given Ceftriaxone inj and NaCl 0.9%. Ceftriaxone is the group of the third generation
of cephalosporin antibiotic which has wide spectrum, effective to the positive and negative
grams. Using of antibiotic must be the first line penicillin for pneumoniae, but the fact patient
was given cephalosporine group. NaCl 0.9% infusion is to recover the balance of electrolyte
liquid. On the second day, the patient did not feel short of breathness when he cough and
palpitaion because blood pressure of the patient was getting normal. Neurobion 5000 inj was
added to recover health condition and over come patient nutrition hindrance, Lesichol 600 as
hepatoprotector. On the third day, patient was give of Ulvice inj as vitamin C. But headache and
low appetite of patient is still not cured yet. Until the last day of treatment, the patient still had
low appetite but the headche got better.
1. Untreated Indication
Patient needs analgesic theraphy to overcome headache and needs additional vitamin to
increase the patient’s appetite. Patient also has hipoalbumine with the value of 3.1 g/dL. He did
not get albumin theraphy.
2. Improper Drug Selection
The dosage in giving the ceftriaxone 1x2 g was already correct, but it was not really
correct if ceftriaxone was used at the first stage which is actually the treatment for pneumoniae.
CONCLUTION
Based on the practical result in the K room of PGI Cikini Hospital, it can be concluded that DRP
(Drug Related Problem) is Untreated indication and improper drug selection.
REFERENCES
1. PDPI, 2003. Pneuomonia Komuniti Pedoman Diagnosa and Penatalaksanaan di Indonesia.
Jakarta
3. Mansyur Arif, dkk., 2000. Kapita Selekta Kedokteran Edition 3: 480). Jakarta : Media
Aesculapius
2074
4. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI): 352). Jakarta : Sagung Seto
5. AHFS drug information 2004. McEvoy GK, ed. Methotrexate. Bethesda, MD: American Society
of Health-System Pharmacists; 2003:1082-9)
7. Joseph Loscalzo et all, 2010 Harrison’s Pulmonary and Critical Care Medicine 17th Editions, The
McGraw-Hill Companies, Inc., New York
8. Kasper L, Dennis., et al, 2010, Harrison’s Infectious Diseases, The McGraw-Hill Companies, Inc.,
New York.
2075
EVALUATION OF DRUG RELATED PROBLEMS IN STROKE
HEMORRHAGIC IN GATOT SOEBROTO ARMY HOSPITAL
Ahmad Safi’i 1, Diana Laila Rahmatillah2 , Aprilita Rinayanti Efi2
1
2
Email : Sixseventy77@yahoo.com
ABSTRACT
Hemorrhagic stroke is the rupture of blood vessels of the brain causing brain parenchyma
bleeding network, cerebrospinal fluid space around the brain or a combination of both 4.
Bleeding causes disruption of nerve fibers of the brain through the suppression of brain structure
and also by a hematoma which causes ischemia in the surrounding tissue 4. Increased intracranial
pressure in turn will lead to herniation of brain tissue and suppress the brain stem Tn.Xx 4.
Patient, aged 51 years, entered Gatot Subroto Army Hospital on October 18, 2014 at 02:51 with a
diagnosis of hemorrhagic stroke. During the treatment of patients treated with Asering,
Mannitol, Perdipin, Brain acrt, Ceftazidin, Ondacentron, Ketorolac, Astrovastatin, Paracetamol,
on 21 perdipin and paracetamol replaced amlodipine and farmadol. Based on the results of
clinical work practices on the third floor of stroke unit care Gatot Subroto Army Hospital, it can
be
concluded
Keywords
that
the
presence
of
DRP
is
significant
drug
interactions.
: Haemorrhagic Stroke, and Gatot Subroto Army Hospital.
2076
INTRODUCTION
Stroke is a state of partial or complete loss of neurological function that occurs
suddenly, lasts more than 24 hours or the cause of death, which is solely caused by
spontaneous rupture of a blood vessel (hemorrhagic stroke) 9. Hemorrhagic stroke is the
rupture of blood vessels of the brain causing brain parenchyma bleeding network,
cerebrospinal fluid space around the brain or a combination of both. The cause of bleeding
of the brain nerve fibers through the suppression of brain structure and also by a hematoma
which causes ischemia in the surrounding tissue. Increased intracranial pressure in turn will
lead to herniation of brain tissue and brain stem pressing 5. The etiology of hemorrhagic
stroke there are two kinds of intracerebral hemorrhage was found in 10% of all stroke cases,
consisting of 80% in the hemispheres of the brain and the rest of the brainstem and
cerebellum. And subarachnoid hemorrhage is a condition in which there is bleeding in the
subarachnoid space resulting in primary. Broadly speaking, the risk factors of stroke divided
into modifiable risk factors (modifiable) and which can not be modified (nonmodifiable).
Modifiable stroke risk factors include hypertension, heart disease (atrial fibrillation),
diabetes mellitus, smoking, alcohol consumption, hyperlipidemia, less activity, and arterial
stenosis karotis. While the risk factors that can not be modified include age, gender, race /
tribes, and genetic factor 10. Data in Indonesia showed a tendency to increase both in terms
of cases of stroke mortality, incidence, and disability. The death rate by age is: 15.9% (age
45-55 years) and 26.8% (age 55-64 years) and 23.5% (age 65 years). Stroke events
(incidence) of 51.6 / 100,000 population and disability; 1.6% unchanged; woresen. sufferer
4.3% more men than women and more than 45 years of age profile of 11.8%, 54.2% aged
45-64 years, and age above 65 years of age 33.5% of stroke attack productive and elderly 9.
CASE PRESENTATION
Patient Mr. xx aged 65 years entered Gatot Subroto Army Hospital on October 18, 2014.
pasein referral of Merdeka Center Hospital, patients present with loss of consciousness
since 18 hours ago astringent patient fell and hit his head (top right) after the fall of patients
did not connect when spoken . Right hand and right leg weakness, decreased consciousness
2077
and no vomiting. The patient had a history of hypertension since six months ago. Patient
entered the CVD diagnosis of cerebrovascular desease SH or hemorrhagic stroke. Patients
treated with Perdipin, Brain acrt, Ceftazidin, Ondacentron, Ketorolac, Astrovastatin,
Paracetamol on October 21, 2014 Perdipin replaced amlodipine and Paracetamol replaced
Farmadol.
CLINICAL LABORATORY VALUES
Type of examination
Normal Value
20/10/2014
Hemoglobin
12 – 16 g/dL
13,8
Hematocrit
42 – 52%
38
Erytrocyt
4.3 – 6.0 juta/μ L
4,8
Leukocytes
4,800 – 10, 800/ μ L
11,860
Platelets
150,000 – 400,000/ μL
218000
MCV
80 – 96 fl
87
MCH
27 – 32 pg
29
MCHC
32 – 36 g/dL
36
Bilirubin Total
< 1,5 mg/dL
0,69
SGOT
< 35 U/L
23
SGPT
< 40 U/L
17
Protein Total
6-8,5 g/dL
7,2
Albumin
3,5-5,0 g/dL
3,9
Globulin
2,5 – 3,5 g/dL
3.3
Total cholesterol
< 200 mg/dL
225
Triglycerides
< 160 mg/dL
82
HDL cholesterol
>35 mg/dL
37
LDL cholesterol
<100 mg/dL
202
Hematology
2078
uric acid
3.5 – 7.4 mg/dL
3,7
Fasting blood glucose
70 - 100 mg/dL
107
Blood glucose (2 hours
<140 mg/dL
112
PP)
Urinalysis
Color
Yellow
Yellow
Clarity
Clear
Clear
pH
4,8-7,4
8
Thickness
1,015 – 1,025
1,010
Protein
Negative
Negative
Glucose
Negative
Negative
Birilubin
Negative
Negative
Nitrite
Negative
Negative
Ketones
Negative
Negative
DOSAGE AND USE
Drugs
Giving
Regimen
18/10
19/10
20/10
21/10
22/10
23/10
24/10
method
dose
RL
IV
20 tpm
√
√
√
√
√
√
√
Perdipine
IV
6cc/hour
√
√
√
Manitol
IV
20 tpm
√
√
√
√
√
Stop
√
√
2079
Ceftazidim
IV
2x1g
√
√
√
√
√
√
√
Citicoline
IV
2 x 500mg
√
√
√
√
√
√
√
Ondasentron
IV
1x 4mg
√
√
√
√
√
√
√
Ketorolak
IV
2x50mg
√
√
√
√
√
√
√
Atorvastatin
PO
1x1 tab
√
√
√
√
√
√
√
Paracetamol
PO
3x500mg
√
√
√
Amlodipine
PO
1x10mg
√
√
√
√
Farmadol
IV
10mg/ml
√
√
√
√
Stop
CLINICAL EVALUATION
From the examination results obtained some abnormal result is an increase in high blood
pressure and treated with perdipin, hypercholesterolemia which is a risk factor for stroke
should be treated with astrovastatin, citicoline recovery awareness and improve blood
circulation of the brain, giving ondasetron to prevent nausea, in patients there is
inflammation of the right arm that was treated with ketorolac. The patient has a fever and
treated with paracetamol but the patient still has a fever and treated farmadol, ceftazidim
semisynthetic cephalosporin class of antibiotics antibiotics that are bactericidal.
1. Selection of appropriate medication
Drug selection was improper use of ketorolac can cause bleeding and increase stomach acid,
it is recommended the selection of safe analgesics to reduce pain is tramadol and antibiotics
use of ceftazidim less precise because it can extend protobmin time, causing bleeding, it was
recommended to be replaced with cefadroxil 1,4.
2080
2. Drug interactions
significant interaction occurred between:
a. nifedipine and ketorolac blood pressure will menigkat as ketorolac going to nifedipine
inibisi 2.
Pharmacist Intervention: Recommended use should not be done simultaneously and must
be jailed gift, then closely monitored its use 2.
b.nifedipine and atorvastatin, nifedipine may increase blood pressure and the effects of
atorvastatin. This can increase the risk of side effects such as liver damage and a rare but
serious condition called rhabdomyolysis which involves the destruction of skeletal muscle
tissue. In some cases, rhabdomyolysis can lead to kidney damage and even death 2.
Pharmacist Intervention: Recommended use should not be done simultaneously and must
be jailed administration, atorvastatin drunk at night and perdipin given in the morning and
afternoon, and then closely monitored its use 2.
CONCLUSION
Based on the results of clinical work practice ward stroke unit at Gatot Subroto Army
Hospital, it can be deduced that the presence of DRPs (Drug Related Problems) in the form
of a correlation between drug therapy with clinical conditions such as the presence of an
antibiotic drug selection should be replaced ceftazidim cefadroxil, use of ketorolac which
should be replaced tramadol and drug and drug interactions between nifedipine and
atovastatin that the use of nifedipine may affect the levels of atovastatin, nifedipine and
ketorolac blood pressure will increase as ketorolac going to inibisi nifedipine, recommended
use and should not be done simultaneously dijarakkan gift, then closely monitored its use.
Blood pressure monitoring is necessary, total and LDL cholesterol levels of patients.
REFERENCES
1. AHFS drug information 2004. McEvoy GK, ed. Methotrexate. Bethesda, MD: American
Society of Health-System Pharmacists; 2003:1082-9)
2081
3. Goetz Christopher G. Cerebrovascular Diseases. In : Goetz: Textbook of Clinical
Neurology,3rd ed. Philadelphia : Saunders. 2007.
4. Junaedi, Iskandar. (2004). Paduan Praktis Pencegahan and Pengobatan Stroke. Jakarta : PT.
Bhuana Ilmu Populer.
5. Koda-Kimble et al., 2009, Applied Therapeutics: The Clinical Use of Drug 9th Edition,
Lippincott Williams & Wilkins, USA.
6. Lacy, F.C., Armstrong L.L., Goldman, M.P., Lance L.L.et al, 2010, Drug Information
Handbook,Lexi-Comp, American Pharmacist Association.
7. PERDOSSI, 2011. GuidelineStroke. Jakarta
8. Ropper AH, Brown RH.
erebrovascular Diseases. In : Adam and Victor’s Priciples of
Neurology. Eight edition. New York : Mc Graw-Hill. 2005.
2082
CASE REPORT : DRUG RELATED PROBLEM ON
TUBERCULOSIS DISEASE AND PLEURAL EFFUSION IN PGI
CIKINI HOSPITAL
Ardiansah1, Aprilita Rinayanti Efi2, Diana Laila Rahmatillah2
1
Student Of Pharmacist Program, Faculty Of Pharmacy UTA’45 Jakarta
2
Lecturer Of Faculty Of Pharmacy UTA’45 Jakarta
Email : Ardiansah_sfarmapt@yahoo.com
ABSTRACT
Tuberculosis is the disease that commonly at PGI Cikini Hospital. Transmission source can
cause from patient with positive TBA when they were cough or sneeze and the microba was
spreading. TB is classified is into 2 kinds, that are. Tuberculosis Lung and Tuberculosis Extra
Lung. Pleural effusion is buildup of fluid in the cavity (cavity) pleurathat exceeds normal
limits. RU is a 27-year-old man was hospitalized in internal medicine wards. The patient was
diagnosed with pulmonary tuberculosis and pleural effusion.patient was related with
rifampisin 300 mg, INH 100 mg , ethambutol 150 mg.Result of clinical monitoring on
tuberculosis disease. There is found drug related problem that are.Drug intereactions and
adverse drug reaction.
Keyword : Drug Related Problem Tuberculosis, Pleural Effusion, PGI Cikini Hospital
2083
1.
Introduction
Tuberculosis (TBC or TB) is a disease respiratory tract infections caused by bacteria
(Mycobacterium Tuberculosis)3. This bacterium is a bacterium bacillusis very strong so it
takes a long time to heal5. This bacterium typically infects the pulmonary (90%) compared
too ther parts ofthe human body, the source of infection is smear positive TB patients when
coughing orsneezing, peoplespead germsin to the airin the form of droplets/droplets3.
The classification is divided into two, namely tuberculosis Pulmonary Tuberculosis and Lung
Tuberkulosi Extras6. Pulmonary tuberculosis attacks the tissue (parenchymal) lung, excluding
the pleura (the lining of the lung) and hilar glands6. Extra pulmonary tuberculosisis that
attacks organ so ther than thelungs, such as the pleura, the lining of the brain, the lining of
the heart (pericardium), lymfe gland, bone joints, skin, intestine, kidney, urinary tract,
genitals, etc6.
Pleural effusion is a medical condition characterized by an increase in excess fluid between
the two layers of the pleura7. Thereare two types of pleural effusion: pleural effusion a
transudate formed due to increased hydrostatic pressure(CHF), decreased oncotic
(hipoalbumin) and increase of intra-pleural (acute atelectasis) sexudative pleural effusions
are formed as a result of pleural disease self that associated with increased capillary
permeability (pneumonia) or reduced lymphatic drainage (lymph flow obstructiondue
tocarcinoma)2.
2.
Case Presentation
RU is a 28 year old man was hospitalzed, in PGI Cikini hospital. Patient has tuberculosis and
pleural effusion. Patient had complaints feeling weak, tightness, chestpain 2 days before
entered the hospital. Cough, weight loss, decreasing appentite, nausea and vomiting. The
patient was diagnosed with tuberculosis based on the results of microbiologi examination,
sputumpositive for Acid Resistant Bacteria (BTA), increase if er throcyte sedimentation rate is
(109 mm/h) and decrease lymphocytes.
3.Discussion
Based on microbiological examination patient was diagnosed tuberculosis in the first day but
in the second day and third day the physician give rifampicin 300 mg daily, INH 100 mg 3
2084
time daily, ethambutol 1500 mg 2 time daily and pyrazinamid as antituberculosis drugs and
sangobion as. a vitamin, vitamin b complex in third day for cenduaring side effect of INH. On
the fourth day the patient was treated with a combination of FDC (Fixed Dose Combination)
as anti tuberculosis drug. In addition, patient was also given onandsetron 8 mg orally 3 times
daily on the fourth day until the tenth day as antivomiting and new diatab because the
patient had diare
4.Drug Related problem
4.1 Drug interaction
A.Isoniazid and rifampin are combination of TB drugs is used by 2 month as initial phase and
4 months as continuation phase. Concomitant use of both types of anti tuberculosis can
cause significant interactions, which increases rifampicin the can increase induction of
metabolisem1.
Pharmacist Intervention : advise the patient to use rifampisin and isoniazid with different
time, for rifampicin should be used in the morning and to isoniazid is used at night.
B.Onandsetron is a drug that is indicated to treat nausea and vomiting. The using of
onandsteron with isoniazid can cause serum
interaction by reducing the effect of
onandsetron.
Pharmacist intervention
: using of onandsetron and isoniazid with different time,
approximately 2 hours onandsetron is given, 2 hours after INH
4.2. Adverse Drug Reaction
Paracetamol as AINS drug using for fever. using of paracetamol with isoniazid can worsen the
patient's liver function.
Intervention pharmacist : monitoring liver function
5.Conclusion
After the assessment of the patient's treatment, it can be concluded that there are two drugs
related problem from this case, drug interaction between rifampicin and adverse drug
reaction
REFERENCES
1. Baxter, K 2008. “ Stockley Drug Interaction Eight Edition “. London.
2085
2. Bramardianto. 2014. “Penyebab, gejala and pengobatan efusipleura”.Jakarta
3. Departemen Kesehatan Republik Indonesia. 2006. Pedoman Nasional Penanggulangan
Tuberkulosis. Depkes RI : Jakarta
4. Joint formulary comite. 2009 ”Brithis National Foemulary” BMJ Grop.London
5. Konsensus TB Paru. 2013. “Kapitas elekta kedokteran. Edisi II. Jakarta : Media Aesculapius,
FKUI.
6. Perhimpunan Dokter Paru Indonesia, 2014. “Klasifikasi Tuberkulosis”.jakarta
7. Pudjo, Astowo, 2014.“Efusi Pleura”. Jakarta
2086
CASE REPORT : DRUG RELATED PROBLEMS IN PATIENT WITH
SPONDYLITIS ARTHROSIS LUMBOSACRALIS DISEASE AND TYPE
II DIABETES MELLITUS AT MINTOHARJO HOSPITAL JAKARTA
Siti Hadijah1, Aprilita Rinayanti Eff and Diana Laila R2,
1
Student of pharmacist Program Faculty of Pharmacy UTA’45 Jakarta
2
Email : zi3yah@yahoo.com
ABSTRACT
Spondylo Arthrosis Lumbosacralis is a disease that is often found in nerve ward
Hospital AL Dr. Mintoharjo particularly in the Numfor treatment room. Spondylo Arthrosis
Lumbosacralis is a condition in which the disease has occurred degeneration in the joints and
intervertebral discs are between vertebral body. Patient also suffer from Type II Diabetes
Mellitus, which is a metabolic disorder characterized by hyperglycemia associated with
abnormalities in the metabolism of carbohydrates, fats, and proteins caused by a decrease in
insulin secretion or a decrease in insulin sensitivity, or both and cause chronic complications
microvascular, macrovascular, and neuropathy.
Case Presentation: Ms. Siti Fatimah 42 years old entered Mintoharjo Hospital on
November 14, 2014 with a diagnosis: Spondylo Arthrosis Lumbosacralis, Type II Diabetes
Mellitus. Patient was given Ceftriaxone inj, Gentamicin inj, Actrapid inj, Lantus inj, Lasix inj,
Onandcentron 8 inj, tramadol inj, Sanmol drip, Hepabalance tablets, Diclofenac Na tablets,
Diazepam tablets, Omeprazole tablets, tablets ISDN, Bisoprolol tablets, paracetamol tablets .
The results of the monitoring of drug therapy is found Drug Related Problems, that are using
of drug without indication, improper drug selection and drug interactions.
Keywords: Spondylo Arthrosis Lumbosacralis, Type II Diabetes Mellitus, Mintohardjo
Hospital.
2087
INTRODUCTION
Type II Diabetic Mellitus, which is a metabolic disorder characterized by hyperglycemia
associated with abnormalities in the metabolism of carbohydrates, fats, and proteins caused
by a decrease in insulin secretion or a decrease in insulin sensitivity, or both and cause
chronic complications microvascular, macrovascular, and neuropathy. (MOH, 2005)
Clinical symptoms in Type II diabetes symptoms complained of generally almost
nothing. Type II diabetes often occur unnoticed, and new management began a few years
Slater when the disease has developed and complications have occurred. Type II diabetic
patients are generally more susceptible to infection, difficult to recover from injuries,
eyesight is getting worse, and generally suffer from hypertension, hyperlipidemia, obesity,
and also complications in blood vessels and nerves. Examination of blood glucose levels as >
200 mg / dl and fasting blood glucose levels > 126 mg / dl is used as a benchmark diagnosis
of DM. (MOH, 2005)
Spondylitis Lumbosacralis Arthrosis is a disease that is often found in the nerve ward
RSAL Mintoharjo Numfor particularly in the treatment room. Lumbosacralis arthrosis
spondylitis is a disease condition where there has been a degeneration of the intervertebral
joints are between the disc and the vertebral body. Lumbar area consists of L1 to L5 and L5 S1 receive the greatest load or weight so that the lumbar region receives the most stylish
and great mechanical stress along the spine. (Hamdyalfin, 2010)
CASE PRESENTATION
Patient Mrs Siti Fatimah 42 years old entered on 14 November 2014 with a complaint
of pain 3 days before admission, patient has history felt in the bathroom 3 months ago, and
after that she felt paint and swelling at her buttock.
EVALUATION
In this case the patient get RL infusion therapy as body fluid replacement therapy,
albumin for hypoalbuminemia, Ceftriaxone and Gentamicin inj as antibiotics, Actrapid inj
and Lantus for diabetes, inj lasix for edema, Onandcenton inj for nausea and vomiting,
tramadol inj for acute pain, sanmol drip for fever, Hepabalance tab as a supplement for liver,
diclofenac Na tab for acute pain, diazepam tab for muscle spasms, Omeprazole for ulcer
duedenum, ISDN for the prophylaxis and treatment of angina and heart failure, Bisoprolol as
2088
antihypertensives, Paracetamol for fever , Codeine tab for cough, Fujimin tab to
hypoalbuminemia, KSR for hypokalemia, Meloxicam as antiinflammatory, Gabapentin for
neuropathic pain, laxadine syr as a laxative, ranitidine tablets as inhibitors of gastric acid
secretion.
laboratory examination
Date
GDS
Kidney Function
Urea
14/11
*579
15/11
*595
16/11
*404
17/11
Hematology
Triglyceridese Leukocytes
52
0,8
Erythrocytes
HB
Hematocrit
Platelets
*19.300
3,32
9,3
29
308.000
*467
*19.200
2,95
8,4
24
288.000
18/11
*427
*11.900
2,56
7,1
21
206.000
19/11
*214
*14.600
3,28
9,2
29
188.000
20/11
*235
*17.700
3,83
10,9
31
163.000
21/11
*230
22/11
*220
*15.200
4
11,3
35
231.000
28/11
179
*11.900
3,93
11,3
33
407.000
Date
SGOT
*52
SGPT
0,9
Protei
Albumin
Globulin
Trigliserida
n
Cholesterol
HDL
LDL
16
50
Total
Total
14/11
19
*56
15/11
28/11
*36
32
2,5
2,5
*5,0
2,7
2,3
7,9
3,5
4,4
*the value above normal
2089
174
101
DISCUSSION
Patient, Mrs Siti Fatimah with early diagnosis Spondyloarthrosis Lumbosacralis. The
patient was admitted to hospital on November 14, 2014 with complaints of lower back pain,
3 months ago patient has felt in the bathroom, and swelling of her right buttock.
Based on the history of the disease it can be determined goal of drug therapy is
treating the infection, relieve symptoms or do surgery. The parameters measured were
blood pressure, laboratory values associated hematologic values and vital signs such as
temperature, Respiration Rate and Heart Rate. On the first day hospitalized Mrs Siti Fatimah
has 90/50 blood pressure, pulse rate is 108X / min and temperature is 37,50c.
Result of laboratory examination showed that leucocyte values above the normal
range, indicating the patient experience infection. Hematocrit, hemoglobin and erythrocytes
showed abnormal value occurrence of anemia, examination of blood glucose and HbA1c
showed above the normal range, this is indicated the patient suffering type II diabetes.
Trigliseride value above normal and HDL cholesterol below normal value. Examination of
renal function obtained urea values above the normal range, indicated the patient has
impaired renal function.
Drugs were given on the first day of treatment are diazepam, omeprazole and
diclofenac Na, diazepam is indicated for the management of short-term to muscle spasms,
diclofenac Na as inflammatory and degenerative rheumatic musculo skeletal disorders,
especially in acute as well as for pain control and non-rheumatic inflammation. Omeprazole
for the prevention of gastric irritation due to the use of NSAIDs. In the second day patient
received antibiotic ceftriaxone injection 2 g once daily, and the dose of ceftriaxone increase
to 2 gram b.d until seventh days treatment. Gentamicin injection is given on fifth day of the
dose 320 mg once daily. On the second day patient also treated with 2 kinds of insulin, there
are actrapid IV as a short acting insulin and lantus sc at night as long acting insulin for
maintenance blood sugar levels.
2090
Drug Related Problems
1. Using of the drug without indication
Patient did not experience nausea but physician gave onandcentron for overcome the
nausea. If the patient need nausea drug, it should be given domperidone or metoclorpamid.
2. Selection of the lack of proper medication
Using of ceftriaxone and gentamycin can increase renal toxicity. We can recommended to
identification of the type of bacteria so can be selected appropriate antibiotic and
monitoring of treatment efficacy.
3. Untreated Disease
Patient experienced hypelipidemia that seen from laboratory result but she did not received
treatment for overcome her disease we should recommended to give gembifrozil or
fenofibrat for decrease the LDL value and more HDL value.
4. Drug Interactions
• Gentamycin with furosemide and gentamycin can increase risk of ototoxicity and
nephrotoxicity (stokley ed8 287)
I.
CONCLUSION
From the result of monitoring drug therapy in patient with spondylitis arthrosis
lumbosacralis disease and type II diabetes mellitus at Mintoharjo Hospital, it can be
concluded there is found drug related that are using of the drug without indication, selection
of the lack of proper medication, untreated disease and drug interactions.
2091
REFERENCES
1. BNF staff. 2011, British National Formulary 61, Pharmaceutical Press, London,UK,P
2. Direktorat Bina Farmasi Komunitas And Klinik Direktorat jenderal Bina Kefarmasian And
Alat Kesehetan Departemen Kesehatan RI . 2005. Pharmaceutical care untuk penyakit
diabetes mellitus. Jakarta
3. Medscape.com. online 29 november – 2 desember 2014. http://www.medscape.com/
druginfo/ druginterchecker
4. Stockley, I.H. (2008).Stockley’s Drug Interaction. Edisi kedelapan. Great Britain:
Pharmaceutical Press.
5. Teori FISIOTERAPI PADA PENDERITA LBP AKIBAT SPONDYLOSIS diakses tgl 2 Desember
2014 http://fisioterapishamdialfin.blogspot.com/
2092

Clinical CAse Reports - International Online Medical Council

Transcription

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