International Journal of Pharmacy Teaching

Transcription

Vol 5, Issue 3
Supplement
2014
International Journal of Pharmacy
Teaching & Practices (IJPTP)
Clinical Case Reports - September, 2014
Published by: DRUNPP Association of Sarajevo, Bosnia & Herzegovinia
www.iomcworld.com/ijptp
email: [email protected]
ISSN: 1986-8111
International Journal of Pharmacy Teaching & Practices, Vol5, issue3, Supplement I, 1020-1552.
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
1020
Table of Contents
1.
ISCHIALGIA AND LUNG TUMOR IN MINTOHARDJO HOSPITAL ............................................................ 1026
2.
THE MONITORING OF DRUG THERAPY FOR CRF (Chronic Renal Failure) PATIENT IN Dr. MINTOHARDJO,
INDONESIAN NAVY MILITARY HOSPITAL.............................................................................................. 1031
3.
DIABETES MELLITUS TYPE II, and CHRONIC RENAL FAILURE ............................................................... 1036
4.
DRUG RELATED PROBLEMS ASSOCIATED OF TREATMENT UROLITHIASIS DISEASE PATIENT IN PGI CIKINI
HOSPITAL ............................................................................................................................................. 1043
5.
STUDY OF PULMONARY DISEASES WARD PULMONARY TB BTA (+) LLKB (The lesion Area new cases) on
OAT kat II.............................................................................................................................................. 1050
6.
BRONCHOPNEUMONIA IN PULMONARY DISEASE WARD.................................................................... 1058
7.
DRUG RELATED PROBLEMS IN THE TREATMENT OF GUILLAIN-BARRE SYNDROM DISEASE, ANTI
PHOSPOLIPID SYNDROME AND DIABETES MELLITUS TYPE 2 ............................................................... 1065
8.
STUDY IN DISEASE WARD CHRONIC RENAL FAILURE AND TYPE II DIABETES MELLITUS ...................... 1076
9.
COMBINED DRUG RELATED PROBLEMS IN THE TREATMENT OF TUBERCULOSIS (TB) AND PLEURAL
EFFUSION SINISTRA .............................................................................................................................. 1081
10. DRUG RELATED PROBLEMS IN TREATMENT HEMODIALYSIS ON CHRONIC RENAL FAILURE ............... 1086
11. RELATED DRUG PROBLEM IN THE TREATMENT OF VERTIGO DISEASE AND HYPERTENSION IN PGI CIKINI
HOSPITAL ............................................................................................................................................. 1091
12. DRUG RELATED PROBLEM TREATMENT OF FEMORAL NECK FRACTURES IN MINTOHARJO HOSPITAL 1095
13. PHYSIOTHERAPY STUDY ISCHIALGIA .................................................................................................... 1100
14. TREATMENT OF THE CHRONIC KIDNEY DISEASE (CKD) PATIENT IN THE PGI HOSPITAL CIKINI JAKARTA
............................................................................................................................................................. 1105
15. DRUG RELATED PROBLEMS ASSOCIATED AND TREATMENT FOR CERVICAL CANCER IN INTERNAL
MEDICINE WARD IN PGI CIKINI HOSPITAL ........................................................................................... 1120
16. DRUG RELATED PROBLEMS IN ACUTE GASTROENTERITIS (GEA) AND CORONARY ARTERY DESEASE
(CAD) .................................................................................................................................................... 1124
17. PERIODIC PARALYSIS OF HYPOKALEMIA FAMILIAL IN GENERAL CARE WARD OF GATOT SUBROTO
HOSPITAL JAKARTA INDONESIA ........................................................................................................... 1130
18. PANCREATIC TUMOR DISEASE ............................................................................................................. 1136
19. PNEUMONIA AND MELENA PATIENT IN PULMONARY DISEASE WARD AT GATOTSOEBROTO ARMY
HOSPITAL JAKARTA INDONESIA ........................................................................................................... 1142
20. COMBINED DRUG RELATED PROBLEMS IN DISEASE TREATMENT FOR DYSPEPSIA IN INTERNAL MEDICINE
WARD IN PGI CIKINI HOSPITAL............................................................................................................. 1149
21. CHRONIC OBSTRUCTION PULMONARY DISEASE (COPD) ..................................................................... 1153
1021
22. CASE STUDY OF CKD (CHRONIC RENAL DISEASE) IN PGI CIKINI HOSPITAL .......................................... 1156
23. STUDY OF DRUG RELATED PROBLEMS (DRPS) ASSOCIATED WITH THE PATIENT TREATMENT MILIARY
TUBERCULOSIS (TB) AT INTERNAL MEDICINE WARDS PGI CIKINI HOSPITAL ....................................... 1161
24. ABSTRACT............................................................................................................................................. 1161
25. DRUG RELATED PROBLEM ON DISESASE THERAPY MANAGEMENT COMPLICATIONS STROKE WITH FEW
COMPLICATIONS TYPE II DIABETES, HYPERLIPIDEMIA AND HYPERTENSION ....................................... 1168
26. ABSTRACT............................................................................................................................................. 1168
27. A CASE STUDY CHRONIC KIDNEY DISEASE STAGE V ON HEMODIALYSIS ............................................. 1174
28. CKD (CHRONIC KIDNEY DISEASE) AND ANEMIA ................................................................................... 1181
29. DRUG RELATED PROBLEMS ASSOCIATED WITH THE TREATMENT FOR TUBERCULOSIS (TB) IN
PERSAHABATAN HOSPITAL .................................................................................................................. 1186
30. DRUG RELATED PROBLEMS IN THE COMBINATION OF TREATMENT OF TYPE 2 DIABETES MELLITUS AND
CAD (CORONARY ARTERY DISEASE)/CORONARY ARTERY DISEASE ...................................................... 1189
31. DRUG RELATED PROBLEMS IN TYPE II DIABETES MELLITUS ............................................................... 1194
32. DRUG RELATED PROBLEMS IN REGIMEN OF DOSE FOR TUBERCULOSIS (TB) PATIENT AT INTERNAL
WARD RSUP HOSPITAL ......................................................................................................................... 1199
33. DRUG RELATED PROBLEMS IN HIV-AIDS PATIENT ............................................................................... 1204
34. DRUG RELATED PROBLEMS ASSOCIATED WITH THE TREATMENT FOR CHRONIC KIDNEY DISEASE (CAD)
STAGE III WITH DIABETES MELLITUS (DM) TYPE II ............................................................................... 1209
35. DRP ASSOCIATED WITH TREATMENT OF MELENA DISEASE WITH D.M TYPE II AND PARKINSON HISTORY
............................................................................................................................................................. 1215
36. TUBERCULOSIS DISEASE AT CIKINI HOSPITAL ...................................................................................... 1221
37. DRUG RELATED PROBLEMS IN STROKE NON HEMOROGIK DISEASE ................................................... 1225
38. DRUG RELATED PROBLEMS IN TREATMENT OF BRAIN TUMOR DISEASE ACCOMPANIED TB ............. 1229
39. COMBINED DRUG RELATED PROBLEMS IN TREATMENT MENINGITIS TUBERCULOSA, HEMIPARESIS THE
RIGHT, PULMONARY TUBERCULOSIS, PNEUMONIA, VASCULITIS, AND ENCEPHALITIS, IN PGI CIKINI
HOSPITAL, CENTRAL JAKARTA. ............................................................................................................. 1235
40. THE EVALUATION OF DRUG RELATED PROBLEMS (DRPs) ASSOCIATED WITH THE TREATMANT FOR
ACUTE EXACERBATION OF COPD IN GATOT SOEBROTO HOSPITAL ..................................................... 1250
41. DRUG RELATED PROBLEM ON THE TREATMENT A SIMPLE FEVER SEIZURE ........................................ 1258
42. DRUG RELATED PROBLEMS ON DISEASE MANAGEMENT OF DYSPEPSIA IN GERIATRIC PATIENT IN THE
INTERNAL MEDICINE WARD PGI CIKINI HOSPITAL ............................................................................... 1263
43. DRPs (DRUG RELATED PROBLEMS) ASSOCIATED WITH TREATMENT TO FEBRILE OBSTRUCTION PATIENT
IN PGI CIKINI HOSPITAL ........................................................................................................................ 1267
44. BRONKIEKTASIS (BE) AT LUNG INFECTION WARD RSUP HOSPITAL .................................................... 1271
1022
45. DRUG RELATED PROBLEMS PNEUMONIA DISEASE .............................................................................. 1276
46. DRUG RELATED PROBLEMS IN ASCITES PATIENT ................................................................................. 1281
47. DRUG RELATED PROBLEMS (DRPs) ASSOCIATED WITH THE TREATMENT FOR TUBERCULOSIS DISEASE IN
PERSAHABATAN JAKARTA HOSPITAL ................................................................................................... 1287
48. TREATMENT ASSOCIATED WITH OF PATIENT CHRONIC HEART FAILURE (CHF) DISEASE IN CIKINI
JAKARTA HOSPITAL .............................................................................................................................. 1293
49. INAPROPRIATE DRUGS FOR PNEUMONIA & BRONCHIOLITIC PATIENT AT PEDIATRIC WARD RSPAD
HOSPITAL ............................................................................................................................................. 1299
50. STUDY OF CHRONIC RENAL FAILURE DISEASE IN THE WARD OF DISEASE IN PGI CIKINI HOSPITAL .... 1304
51. STUDY IN DISEASES WARD TYPHOID FEVER......................................................................................... 1309
52. DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT TO HEMORRHAGIC STROKE PATIENT IN
PGI CIKINI HOSPITAL ............................................................................................................................ 1313
53. TREATMENT MEDICINE TO PATIENT ACUTE LOW BACK PAIN,DISPEPSIA AND POST INFECTION BUILDING
OF ORIF AT PGI CIKINI HOSPITAL ......................................................................................................... 1319
54. DRUG RELATED PROBLEM AMONG RIGHT EMPYEMA PULMUNARY, TUBERCULOSIS WITH THE TYPE 2
DIABETES MELLITUS IN GATOT SUBROTO HOSPITAL .......................................................................... 1324
55. DRUG RELATED PROBLEMS ASSOCIATED WITH THE TREATMENT FOR CONGESTIVE HEART FAILURE
(CHF) IN PGI CIKINI HOSPITAL JAKARTA ............................................................................................... 1329
56. EVALUATION OF TREATMENT ANGINA PECTORIS DISEASE AT GATOT SOEBROTO ARMY HOSPITAL . 1333
57. DRUG RELATED PROBLEMS ON TYPE II DIABETES MELLITUS DISEASE TREATMENT IN MINTOHARDJO
HOSPITAL ............................................................................................................................................. 1337
58. EVALUATION OF TREATMENT SEIZURES, CEREBRAL TOXOPLASMOSIS, ORAL CANDIDIASIS, HEMIPARESE
DEXTRA, SUSPECTED OF PULMONARY TUBERCULOSIS, PULMONARY PNEUMONIA, HYPOKALEMIA,
HYPONATREMIA AND PATIENTS ON HIV / AIDS IN FLOOR GENERAL MAINTENANCE IV ARMY HOSPITAL
EDUCATION GATOT SUBROTO JAKARTA .............................................................................................. 1347
59. CASE STUDY IN HOSPITAL K OF DISEASE NON HEMORRHAGIC STROKE (SNH) POST. HEAD TRAUMA 1356
60. DRUG RELATED PROBLEM ASSOCIATED IN TREATMENT OF HNP (HERNIATED NUCLEUS PULPOSUS)
DISEASE IN MINTOHARDJO NAVY HOSPITAL ...................................................................................... 1361
61. DRUG RELATED PROBLEM ASSOCIATED IN TREATMENT CHRONIC KIDNEY FAILURE DISEASE ............ 1365
62. DRUG RELATED PROBLEMS ON URINE RETENTION DISEASE IN PGI CIKINI HOSPITAL ........................ 1370
63. DRUG RELATED PROBLEMS WITH THE TREATMENT FOR DIABETES MELLITUS (TYPE II DM) IN
64. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR NASOPHARYNX CANCER PATIENT IN
PGI CIKINI HOSPITAL ............................................................................................................................ 1379
65. HAS NOT TREATED WITH ARV YET ON GATOT SUBROTO ARMY HOSPITAL ........................................ 1384
1023
66. DRUG RELATED PROBLEM IN THERAPY CHRONIC KIDNEY DISEASE (CKD) IN INTERNAL MEDICINE WARD
Dr. MINTOHARDJO NAVY HOSPITAL .................................................................................................... 1399
67. DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT ON ACUTE GASTROENTERITIS DISEASE IN
MINTOHARDJO HOSPITAL .................................................................................................................... 1406
68. CASE STUDY OF DISEASE IN PGI CIKINI HOSPITAL JAKARTA MASSIVE ASCITES ................................... 1409
69. DRUG RELATED PROBLEMS ON NON-HEMORRHAGIC STROKE AND DIABETES MELLITUS DISEASE
TREATMENT IN MINTOHARDJO HOSPITAL......................................................................................... 1417
70. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR STROKE HEMORRHAGIC PATIENT IN
MINTOHARDJO HOSPITAL .................................................................................................................... 1423
71. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR DIABETES MELLITUS KETOACIDOSIS
PATIENT IN GATOT SOEBROTO ARMY HOSPITAL ................................................................................ 1427
72. TREATMENT EVALUATION ON PATIENTS WITH IHD (ISCHEMIC HEART DISEASE) AT ARMY HOSPITAL
“GATOT SOEBROTO” ............................................................................................................................ 1433
73. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR TUBERCULOSIS (TB) PATIENT IN
PERSAHABATAN HOSPITAL JAKARTA ................................................................................................... 1437
74. EVALUATION OF DRUG RELATED PROBLEMS (DRPs) ASSOCIATED WITH THE TREATMENT FOR
PULMONARY TUBERCULOSIS WITH HYPOALBUMINEMIA AND CIRRHOSIS IN GATOT SUBROTO
HOSPITAL ............................................................................................................................................. 1442
75. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR DYSPEPSIA PATIENT IN MINTOHARDJO
HOSPITAL ............................................................................................................................................. 1448
76. DRUG RELATED PROBLEM IN CORONARY ARTERY DISEASE TREATMENT AMONG PATIENTS IN PGI CIKINI
HOSPITAL ............................................................................................................................................. 1453
77. ANEMIA GRAVIS, HYPOKALEMIA, HEMATOSKEZIA DISEASE ................................................................ 1457
78. DRUG RELATED PROBLEM TREATMENT OF PNEUMONIA IN PATIENTS TREATED IN THE LUNG GATOT
SOEBROTO ARMY HOSPITAL ................................................................................................................ 1461
79. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR UPPER RESPIRATORY INFECTIONS AND
DIABETES MELITUS TYPE II PATIENT IN MINTOHARDJO JAKARTA HOSPITAL ...................................... 1468
80. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT PLEURAL EFFUSION TUBERCULOSIS PATIENT
IN PGI CIKINI HOSPITAL ........................................................................................................................ 1472
81. DRUG RELATED PROBLEMS (DRPs) ASSOCIATED WITH TREATMENT FOR COLIC RENAL PATIENT IN PGI
CIKINI HOSPITAL ................................................................................................................................... 1477
82. DRUG RELATED PROBLEM ASSOCIATED WITH THE TREATMENT FOR HYPERCOAGULATE IN PGI CIKINI
HOSPITAL ............................................................................................................................................. 1482
83. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR TUBERCULOSIS (TBC) PATIENT IN
1024
84. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR CONGESTIVE HEART FAILURE PATIENT
IN MINTOHARDJO HOSPITAL ............................................................................................................... 1491
85. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR ATELECTATION AND PNEUMONIA
PATIENT IN PERSAHABATAN HOSPITAL ............................................................................................... 1497
86. DISEASE TYPE II DIABETES MELLITUS (DM) AND HYPERTENSION IN GENERAL HOSPITAL CENTER
PERSAHABATAN JAKARTA .................................................................................................................... 1501
87. DRUG RELATED PROBLEM (DRPs) ASSOSIATED WITH TREATMENT OF DIABETES MELLITUS TYPE 2
DISEASE AT PERSAHABATAN HOSPITAL ............................................................................................... 1507
88. DRUG RELATED PROBLEM ASSOCIATED WITH THE TREATMENT FOR HYPERTENSIVE DISEASE IN
MINTOHARJO HOSPITAL ...................................................................................................................... 1511
89. CASE REPORT: DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR URETHRAL STRICTURE
PATIENT IN MINTOHARDJO NAVY HOSPITAL ....................................................................................... 1515
90. DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT FOR ACUTE RESPIRATORY INFECTION
PATIENT IN PGI CIKINI HOSPITAL ......................................................................................................... 1519
91. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR LUNG TUBERCULOSIS PATIENT IN
92. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR HEMORRHAGIC STROKE PATIENT IN
GATOT SOEBROTO HOSPITAL .............................................................................................................. 1528
93. GENERAL STUDY CARE WARDS GERIATRIC .......................................................................................... 1533
94. DRUG RELATED PROBLEM ASSOCIATED WITH THE TREATMENT FOR CHRONIC KIDNEY DISEASE AT THE
INTERNAL DISEASE IN PGI CIKINI HOSPITAL ......................................................................................... 1538
95. DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT FOR PULMONARY TUBERCULOSIS PATIENT
IN PERSAHABATAN HOSPITAL .............................................................................................................. 1544
96. DRUG RELATED PROBLEM ASSOCIATED WITH THE TREATMENT FOR BENIGN PROSTATE HYPERPLASIA IN
MINTOHARJO HOSPITAL ...................................................................................................................... 1549
1025
ISCHIALGIA AND LUNG TUMOR IN MINTOHARDJO HOSPITAL
Agnes Anggraeny Para’pak1 , Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
Pharmacist Professional Program Student, Faculty of Pharmacy UTA'45 Jakarta
Lecturer Pharmacy in Pharmacy Faculty University of 17 August 1945 Jakarta
(UTA’45 Jakarta)
2
Email : [email protected]
ABSTRACT
Ischialgia is pain sensation from lower back, pain from butt area, stiffness on lower
back . Pain sensation radiating or as a sense of shock, which is perceived from the buttocks
radiating to the thigh, calf and even up to the foot depending which part of the nervous is
wedge6. Lung tumors are one type of tumor that grows in the lungs is difficult to recover8.
Lungs tumor is caused by cells that divide and grow uncontrollable in lungs8. Mr.MI
patients, aged 23 years, entered the Dr. Mintohardjo hospital on 10 June 2014 with a chief
complaint of low back pain radiating to the left leg up since a month ago. Therapy for the
treatment of hospitalized namely ceftriaxone, ringer lactate, ketorolac, CTM, paracetamol,
Taxotere (docetaxel), Platinol (cisplatin), and zonal (Epherison HCL). Based on the results
of their clinical practice in TNI AL Dr.Mintohardjo hospital on room Salawati it can be
concluded that the presence of Drug Related Problems (DRP) in the form of drug
interactions, but did not receive needed medications and side effects from used drug.
6
Keyword : Ischialgia And Lung Tumor Hospital Navy Dr.Mintohardjo
INTRODUCTION
Ischialgia is the symptom of sensation pain from nerve ischiadicus stimulation6. In
this situation arises pain and tingling along the nerve branches which pressure6. Dictionary
Mahar Priguna Mardjono and Sidhartha (1978) defines ischialgia as pain stems in the
lumbosacral area radiating to the buttocks and then to the posterolateral part of the upper
limbs, the lateral part of the lower leg, as well as the lateral part of foot6.
Lung cancer is a malignant tumor derived from primary lung or airway epithelial
bronkus8. The occurrence of cancer is characterized by abnormal cell growth, unlimited,
and destroy tissue cells normal8. Malignant process in the bronchial epithelium is preceded
by pre cancer8. The first change that occurred during the so-called precancerous squamous
1026
metaplasia is characterized by changes in the shape epitel8. Like most other cancers, the
cause of lung cancer is definitely not known, but prolonged exposure to inhalation of a
substance that is carcinogenic is a major causative factor in addition to other factors such as
the immune, genetic, etc8.
PERCENTAGE CASE
Mr. MI 23 years old, came to Dr.Mintohardjo hospital on June 10, 2014 with a
primary complaint of pain in the waist, spread to the left leg since a month ago. Patients
admitted to hospital on June 11, 2014 and June 24, 2014 came out with a doctor's note that
outpatient chemotherapy and subsequent action. Patients with a history of ulcer disease and
have had surgery on the left breast tumor, the left neck. Currently patients diagnosed with
the disease ischialghia.
LINE TREATMENT FOR LUNG TUMOR4
First line
Cisplatine / vinorelbine, cisplatin / gemcitabine, cisplatine / paclitaxel, carboplantin
/ gemcitabine (chemotherapy early stage, given the combination of the 2 drugs)
Second line
Docetaxel (Taxotere), pemetrexed, erlotinib and platinol (advanced stage that failed
previously treated with chemotherapy, administered with a single dose)
TREATMENT MANAGEMENT ISCHIALGIA1
1. Drugs: analgesics, NSAIDs, muscle relaxan, etc.
2. Program medical rehabilitation
a. Physical therapy: diathermy, electrotherapy, lumbar traction, manipulation
therapy, exercise.
b. Occupational Therapy: Teach proper body mechanic
c. Orthotic prosthetic: the provision of a lumbar corset, walkers
d. Advice

Avoid a lot of over bending.
1027

Avoid frequent heavy lifting.

Immediately break if have pain when walking or standing.

When sitting for long try disila foot alternately right and left, or use a small
seat for both legs rested.

When sweeping and mopping the floor use a broom handle or mop long so
that when sweeping or mopping the back does not bend.

If you want to take things on the floor, keep your back straight and bend
your knees to reach the goods.
3. Operation: Performed in severe cases or where the debilitating drugs and medical
rehabilitation programs do not help.
EVALUATION CLINIC2,3
The use of ceftriaxone injection is to overcome bacterial infections. Ketorolac for
the treatment of short-term post-surgical pain, paracetamol is used when necessary as an
analgesic and antipyretic. Mefenamic acid for mild or moderate pain, CTM to treat
symptoms of allergies. As for chemotherapy drugs given Taxotere (docetaxel) for the
treatment of lung cancer and a subsequent treatment failure when treated with previously
chemotherapy. Platinol (cisplatin) for the treatment of lung cancer. Zonal (epherison HCL)
for the symptomatic treatment of the circumstances related to musculuskoletal cramp
(muscle cramp).
DOSAGE AND METHOD OF USE
In the case of patients treated with injectable ceftriaxone 1 g administered for 7 days
2x1, 2x1 ketorolac 10 mg for 7 days, paracetamol 500 mg if necessary, mefenamic acid 500
mg for 7 days 2x1, 1x1 CTM 4 mg for 1 day on day three Taxotere (docetaxel) 20 mg,
Platinol (cisplatin) 10 ml, given on the eighth day as chemotherapy drugs and zonal 5 mg
administered on day 14.
RESULTS OF LABORATORY TESTS5
Results from laboratory tests on 12 June 2014 showed a decrease in the value of
urea 14 mg / dl (17-43 mg / dl) and impaired creatinine 0.7 mg / dl (0.9 -1.3 mg / dl), which
1028
indicates a decrease kidney function. On 18 June 2014 showed a decrease in the value of
leukocytes 4,700 u / l (5,000-10,000 U / l), hemoglobin 13.4 g / dl (14-48 g / dl), which is
caused by the use of chemotherapy drugs, and a decrease in creatinine values 0 , 8 mg / dl
(0.9-1.3 mg / dl), which indicates a decrease in kidney function.
DRUG RELATED PROBLEM
1.
Drug Interactions7
Mefenamic acid and ketorolac were equally increase the anticoagulant effect, used of
this drug should be monitored7.
2.
REQUIRES DRUG BUT DID NOT GET IT2
After chemo, patients complained a nausea but did not get anti-nausea drugs. Patients
who had chemotherapy should be given ondacetron to treat nausea after chemo2.
3.
DRUG SIDE EFFECTS3
Mefenamic acid and ketorolac have the same side effects that can irritate the stomach,
so that the necessary medication proton pump inhibitors such as omeprazole to
prevent an increase in gastric acid and stress ulcer3.
CONCLUSION
Based on the results of monitoring drug therapy in internal medicine wards at the
TNI AL Dr.Mintohardjo Hospital, then be concluded that the presence of Drug Related
Problems (DRP) in the form of drug interaction, but did not necessesary drug and drug side
effects. Results from laboratory tests showed a decrease in serum creatinine and serum
urea, indicates a decrease in renal function and impairment of leukocytes, hemoglobin,
creatinine, which is caused by the side effects of chemotherapy drugs.
REFERENCES
1. Anggriani. W. 2010. Physiotherapy Management In Ischialgia. Dr.Ramelan Hospital
Surabaya. Muhammadiyah University. Surakarta
2. BPOM. RI. 2008. Indonesian National Drug Information. Komperpom. Jakarta
3. Galileopharma. 2008. BNF Edition 56. Alexandria University
1029
4. Islamuddin. 2009. Systemic Therapy of Lung Carcinoma. Section of Internal Medicine.
Faculty of medicine. Andalas University. Field
5. Ministry of Health. RI. 2011. Guidelines For Clinical Data Interpretation. Jakarta
6. Markam. S. 1982. Neurology. Publisher. PT. EGC. Jakarta
7. Medscape. Drug Interactions. 2014
8. Siregar. L. 2006. Lung Cancer. University of North Sumatra.
1030
THE MONITORING OF DRUG THERAPY FOR CRF (Chronic Renal Failure)
PATIENT IN Dr. MINTOHARDJO, INDONESIAN NAVY MILITARY HOSPITAL
Ardiansyah1, Diana Laila Ramatillah2, Aprilita Rinayanti2
1
(UTA’45 Jakarta)
2
ABSTRACT
CRF (Chronic Renal Failure) is defined as abnormality of renal function which is marked
by the presence of protein in the urine (proteinuria) and the decline of renal function for 3
or more than 3 months which progressive to terminal renal failure1. Mrs. LD, 32 years old,
entered Dr. Mintohardjo hospital on June 22, 2014 with diagnosis CRF (Chronic Renal
Failure). Medical therapy for 5 days are Lasix injection, valsartan 80 mg, Amlodipine 10
mg, Cefoperazon 1 g, Dextrometorphan, Sodium bicarbonate, Folic acid, Aminoral,
Isosorbide Dinitrat 10 mg, Hydrochorthiazide 25 mg, and Lasix tablet. Based on the results
of clinical work practice in internal disease ward of Dr. Mitohardjo hospital, we can
conclude that DRP (Drug Related Problem) was high dosing and drug interaction.
Keywords: Chronic Renal Failure, Internal disease, Dr. Mintohardjo hospital
INTRODUCTION
Chronic renal disease is pathophysiological process with various etiology, it caused
progressive decline of renal function, and generally, it will be chronic renal failure in the
end. Chronic renal failure (CRF) is the decline of renal function which happen continuously
but slowly, it reversible because of the decline of glomerular filtration rate5. If renal could
not function well, there will be a cumulation of substances of metabolism residue inside the
body, so it caused toxic effects4. Chronic renal disease can expand so fast, in 2 – 3 months,
or slowly, in 30 – 40 years4.
End-stage renal failure is condition where the renal function of patient has declined,
which is measured by Klirens Kreatinin (KK) is not more than 15 ml/minute. Patient of
end-stage renal failure needs special therapy which is called renal replacement therapy6.
Renal replacement therapy consists of hemodialysis, peritoneal dialysis and renal
1031
transplant6. From some of replacement therapies above, Hemodialysis is the most applied in
Indonesia.
Based on The United States Renal Data System (USRDS) in 2009 end-stage renal
failure often found and its prevalence is about 10-13 %. In USA, the amount is 25 million
people, and in Indonesia is about 12,5 % or 18 million people7. According to the data of
Indonesian Renal Registry (IRR), total patients of end-stage renal failure which take
hemodialysis in Indonesia from 2007-2012 are 1885, 1936, 4707, 5184, 6951 and 91618.
Data of some research center in Indonesia, report that the cause of end-stage renal failure
who takes dialysis is glomerulonefritis (36,4%), obstruction and infection renal disease
(24,4%), diabetic renal disease (19,9%), hypertension (9,1%) and the other causes (5,2%)
PERCENTAGE OF CASES
Mrs. LD, 32 years old, entered Dr. Mintohardjo hospital on June 22, 2014 with diagnosis
CRF (Chronic Renal Failure) and Dyspepsia. Her complaint is she has limp for two days
before entering the hospital, dizzy a day before entering the hospital, nausea when eating,
defecate three times a day, it liquid ad black, low back pain and her right foot is limp when
she is walking. Results of laboratory tests showed that serum creatinine of patient was
increase and glomerular filtration rate is 13,30 ml/minute which indicate that the patient
suffer renal failure disease (dialysis).
CLINIC EVALUATION
The use of Lasix (furosemide) for edema heart, kidney and liver, valsartan and amlodipine
for hypertension therapy, cafoperazon as antibiotics because based on laboratory tests
result, leukocyte of patient has increase which indicate that there is infection,
dextrometorphan symptomatic therapy for non productive cough, folic acid for anemia and
renal failure, aminoral (keto acid) for chronic renal isufficiency, isosorbide dinitrat for
treatment nad prevention angina pectoris, hydroclhorthiazide for hypertension.
DOSE AND DIRECTION10,11.
In this case, patient was treated with lasix injection, 2x1 ampoule a day for two days ( 2223 June), valsartan 1x80 mg in 5 days (22-25 June), amlodipine 1x10 mg in 5 days (22-26
June), cefoperazon injection 2x1 g in 5 days (22-26 Juni), dextrometorpan 3x15 mg in 5
1032
days (22-26 June), sodium bicarbonate 3x500mg in 5 days (22-26 June) , folic acid 3x1 in 5
days (22-26 June), aminoral (keto acid) 3x2 in 3 days (22,25 and 26 June) , Isosorbide
Dinitrat 2x10mg in 3 days (23,24,dan 25 June), and hydrochorthiazide 1x25 mg in 5
days(22-26 June).
THE RESULT OF LABORATORY TEST
The result of hematology examination on 22 June 2014 showed the increasing of leukocyte,
it was 14.700/µL (5.000 – 10.000/ µL) it indicate that there was an infection, the increasing
of ureum, it was 90 mg/dl (17 – 43 mg/dl) and creatinine 6,2 mg/dl (0,6 – 1,1 mg/dl)
showed the decline of renal function. The decline of erythrocytes 3,59 million/ µL (4,2 –
5,4 million/ µL),hemoglobin 10,3 g/dl (12 – 14 g/dl) and hematocrit 31 % (37 – 42 %)
indicated that it was anemia.
GUIDE LINE OF CRF THERAPY10
LINE I
Antihypertention (ACE-Inhibitor) to decrease hypertention mitraglomerular and hypertofi
glomerular.
LINE 2
Diuretics to remove the excess fluid in the body.
According to National Kidney Foundation (NKF) Kidney Disease Outcome Quality
Initiative (K/000/) Guidelines Update in 2002, the definition of chronic renal disease are11:
a. Renal decay> 3 months, it is like as renal structure disorder, with or without the
decline of glomerular filtration rate which is marked by: pathology disorder, and
there is indication of renal decay, it could be blood or urine disorder, or radiology
disorder11.
b. Glomerular filtration rate <60 ml/minute/1,73m2 for >3 months, with or without
renal decay11.
DRUG RELATED PROBLEMS(DRPs)11
1. Too high dose
1033
The dose is too high in the distribution of valsartan it was 80 mg in a day. According to
BNF in 57th edition, 2009, if the glomerular filtration rate less than 20 ml/minute so the
distribution of valsartan begin with 40 mg, once a day.
2. Drug interaction
HCT and Lasix (Furosemid)
It has similar indication. Giving in the same time can caused hypokalemia, so that it
needs addition of KSR tablet.
CONCLUSION
Based on the results of clinical work practice in internal disease ward of Dr. Mintohardjo
hospital, we can conclude that the results of laboratory tests showed that serum creatinine
of patient was increase and glomerular filtration rate is 13,30 ml/minute which indicate that
the patient suffered renal failure disease (dialysis) and there is DRP (drug related problem)
it means the drug distribution with too high dose and there is drug interaction also.
BIBLIOGRAPHY
1. Putu,et al. 2007. Evaluasi penggunaan ACE Inhibitor pada Pasien Gagal Ginjal Kronik
di RSUP DrSardjito Yogyakarta. Pharmacy Faculty of Gajah Madah University
2. Bonner GF. 2006. Gastrointestinal evaluation related to the pelvic floor. London
3. Djojodiningrat, dkk.2006. Dispepsia fungsional. Buku ajar ilmu penyakit dalam. Edisi
ke-4. Ilmu Penyakit Dalam. Medical Faculty of Indonesia University.
4. Suwitra, K. 2009.Penyakit Ginjal Kronik. Interna Publishing.
5. Sekarwana N. 2011. Kompendium Nefrologi Anak. IDAI. Jakarta
6. Sharif, S. 2014.Asupan Protein, Status Gizi Pada Pasien Gagal Ginjal Tahap Akhir
yang Menjalani Hemodialisis Reguler. Medical Faculty of Hasanuddin University.
7. Suhardjono.2009. Penyakit Ginjal Kronik Adalah Suatu Wabah Baru (Global
Epidemic) Di seluruh Dunia. Annual Meeting of Association of Indonesian
Nephrology.
8. PERNEFRI. 2012. Report of Indonesian Renal Registry5th. Association of Indonesian
Nephrology.
1034
9. Prodjosudjadi, dkk.2009. End-Stage Renal Disease In Indonesia. Treatment velopment.
10. Faradilla.N. 2009.Gagal Ginjal Kronik (GGK). Medical Faculty of Riau University.
11. Burns, A. 2009. Renal Drug Handbook third edition. UK
12. BNF.2009. British National Formulary. BMJ Group. UK
1035
DIABETES MELLITUS TYPE II, and CHRONIC RENAL FAILURE
Arie Setiabudi Latif1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
Diabetes mellitus type 2 – formerly known as insulin-dependent diabetes mellitus (noninsulin-dependent diabetes mellitus-NIDDM) or adult-onset diabetes is a metabolic
disorder characterized by high blood glucose levels in the context of insulin resistanceand
relative insulin deficiency Caused GGK. 1 the most common are diabetes
andhypertension5.Mr. DS patient, age 38 years old, Dr. MINTOHARDJO RSAL Hospital
entered on June 15, 2014 with type II diabetes mellitus and with diagnosed of chronic renal
failure. Therapy treatment for 18 days of Intravenous Nefrosteril: RL 12 tpm, tpm, 12
Maltos Lasix Injection 2 x 2,3x6 ui, Novorapid Cefriaxone 2x1, Cefoperazone, Oral 2x1
folic acid 3x1, 3x1, CaCo3 Prorenal 3x1, 1x2, Bicnat 3x1 Cardace, Ranitidine, 2x1 Letonal
1x100 mg, Ondansetron,Omeprazole 3 x 1 2x1, Uripas 3x1, 4x1 Syr Season gr/day. Based
on the results of the practice of the clinician in the island of sangeang RSAL
Dr.MINTOHARDJO Hospital then can be drawn the conclusion that the existence of DRP
(DrugRelated Problem), in the form of indication without drugs, and drug interactions
(drug interaction).
Keywords: Diabetes Mellitus Type II, Chronic Renal Failure (GGK),
RSAL Dr. MINTOHARDJO
INTRODUCTION
Diabetes Mellitus is a disease in which levels of glucose (a simple sugar) in the blood is
high because the body cannot use insulin or release is adekuat. Blood sugar levels vary
throughout the day. Blood sugar will rise after a meal and returned to normal within 2
hours. Normal blood sugar levels tend to increase in a lightweight but progressive after the
age of 50 years, especially in people who are not active. 2
Classification:
1. type 1 Diabetes, which includes medical condition where cells was associated
with
Ketoacidosis to beta in the pancreas caused or cause autoimmunity, and idiopathic in
1036
nature. Diabetes mellitus with pathogenesis of cystic fibrosis, such as clear
ormitochondrial deficiency, is not included in this classification.
2. type 2 Diabetes, which is caused by a deficiency of insulin secretion, often
accompanied by insulin resistance syndrome.
DIABETES TYPE 2
Diabetes mellitus type 2 (language of the United Kingdom: adult-onset diabetes,obesityrelated diabetes, a non-insulin-dependent diabetes mellitus, NIDDM) is a typeof diabetes
mellitus that occurred not due to the ratio of insulin in the blood circulation, rather it is a
metabolic disorder caused by mutations in many genes,including those that express the β
cell dysfunction, impaired secretion of the hormone insulin, resistance of the cells to insulin
which is caused by a malfunction of the GLUT10with the hormon resistin that causes cell
cofactors network, especially in the liverbecome less sensitive to insulin and glucose
absorption RBP4 that suppress musclestriated but by increasing the secretion by the liver
blood sugar. The common gene mutation on chromo some 19 that is the most populous of
chromo somes that are found in humans 4.
Chronic renal failure (GGK) is defined as keabnormalan kidney function arecharacterized
by the presence of protein in the urine (proteinuria) and decreased kidney function for 3
months or more progressive to Terminal renal failure. The most commoncause of GGK is
diabetic and hypertension. 8
CASE OF PERCENTAGE
Mr. DS. patient age 38 years old in RSAL Dr. MINTOHARDJO Hospital on June 15,
2014. with a diagnosed of type II diabetes mellitus and chronic kidney Failure. A patient
come in with complaints of sore feet, can't sleep, body swelling, urination are few.
Laboratory examination results showed high levels of leukocytes indicates a high rate of
infection, ureum indicates CKD, the high levels of albumin and protein indicates CKD, the
high levels of creatinin indicates CKD, high blood sugar levels during indicate diabetes
mellitus.
1037
LINE TREATMENT OF DIABETES TYPE II.
The first line Sulfonurea group (increase insulin secretion), for example, glibenclamide,
glipizide, gliclazide, gliquidone, glimepiride, a sulfonylurea first used clinically are
tolbutamide and chlorpropamide.
Line two biguanide groups (increase glucose utilization in peripheral tissues and making
glukogan and inhibits gluconeogenesis), for example, Metformin.
Line three classes Alpha-glucosidase inhibitors, consisting of acarbose and voglibose; is
the enzyme alpha-glucosidase inhibitors (works by inhibiting the absorption of
carbohydrates from the intestine). 14
LINE TREATMENT OF CHRONIC RENAL FAILURE (CKD)
The first line antihypertensives (ACEI) to reduce glomerular hypertrophy and
hypertension intraglomerulus.
The second line Diuretics
The third line antidiabetes.13
CLINICAL EVALUATION
The use of Laxis to hypertension, edema, caused the failure of the heart and kidney disease,
Novorapid for therapy of diabetes mellitus type 1 and 2, Cefriaxone forinfection of the
respiratory tract, ENT, sepsis, meningitis. Bones, joints, Cefaperacone,genital tract
infections to breath, the genital tract, urinary tract, skin and mucosa,endometritis, folic acid
folic acid supplements to CaCo3, in order to prevent vitamin D deficiency, especially in
circumstances where the need for vitamin and calcium increases,chronic renal Insufficiency
for prorenal in association with a low calorie diet high inretention terkompensasi or not
terkompensasi.Cardace for additional therapy, hipetension a diuretic with or without
cardiac glycosides. To reduce the risk of myocardial infarction, stroke, death or the need for
KV Transmyocardial in diabetes patients,Ranitidine to eliminate symptoms of inability to
digest the sense of hot and sour on thesolar plexus, stomach ulcer and duodenal ulcer.
Letonal for essential hypertension,edem result: congestive heart pains, liver cirrhosis with
or without asites, nefrotiksyndrome, hiperaldosteronisme primary, ondansetron for nausea
1038
and vomiting aftersurgery, Easter keoterapi omeprazole for the treatment of active duodenal
ulcer short-term, gastroesofageal reflux disease, the State of hipersekresi patologik, Uripas
fordysuria, syr Season for peptikum ulcer and chronic gastritis.
DOSAGE AND USING2 4 .5
In the case of patient with treated (Ivs) Nefrosteril: RL 12 tpm for 6 days (12-17 June2014),
(Iv) Maltos 12 tpm subs 12 days (September 18 – June 29, 2014), (injection)Lasix
(Furosemid) 2 x 2 for 12 days (date 12-June 23, 2014), 6 3 x Novorapid ui for 11days (date
of 13-June 23, 2014), Cefriaxone 2 x 1 for 2 days (12-13 June20114)Cefoperazone, 2 x 1
for 11 days (date of 13-June 23, 2014), Folic Acid (Oral) 3 x 1 for 6 days (12-17 June
2014), CaCo3 3 x 1 for 6 days (12-17 June 2014), Prorenal 3 x 1 for 6 days (12-17 June
2014), Cardace (ramipril) 1 x 2 for 6 days (12-17 June2014), Bicnat 3 x 1 for 6 days (12-17
June 2014)Ranitidine, for 2 days (June 18-June 19, 2014), Letonal (Spironolactone) 1 x 1
(morning) for 12 days (date 12-June 23,2014), Ondansetron 3 x 1 for 3 days (date of June
18-20, 2014), Omeprazole 2 x 1 for 5 days (19-23 June 2014), Urispas (Flavoksat Hcl) 3 x
1 for 7 days (12-18 June 2014),Season Syr 4 x 1 gr/day for 2 days (on 20 and 23 June
2014).
Results Of Laboratory Examination
Parame
ter
Tanggal pemeriksaan
Hb
15
*
124
00
*
11,6
Ureum
*
192
Leukos
it
Albumi
n
Protein
16
*
14
1
*
2,
7
*
3,
6
17
*
159
00
*
11,4
18
*
145
00
*
11,7
19
*
190
00
*
11,7
*
232
*
198
20
*
193
00
*
10,1
21
*
198
00
*
9,9
22
*
120
00
*
6,6
23
*
164
00
*
10,8
24
*
190
00
25
Nilai
840
0
*
5,5
500010000
Pria :
14-18
*
215
17-43
mg/dl
*
2,6
3,55,2
*
5,5
6,68,8
1039
Kreatin
in
*
4
GDS
*
204
*
3,
5
*
18
8
*
4,6
0,91,3
*
304
*
276
*
169
*
178
80125
Description:
1. High levels of leukocytes indicates an infection. 12
2. Low Hb levels indicates CKD. 12
3. High levels of ureum indicates CKD. 12
4. the low levels of albumin and protein indicates CKD. 12
5. High levels of Creatinin indicates CKD. 12
6. the high blood sugar levels during indicate Diabetes mellitus 12
DRUG RELATED PROBLEM 4 .5
Drug Interactions
a. Urispas + Lasix (furosemid)
Effect: very nefrotoksik
Recommendation: stop using urispas (Flavoksat Hcl), because of the risk of nefrotoksik
b. Cefriaxone + lasix (furosemid)
Effect: increases the risk of nefrotoksit
Recommendation: replace the medicine cefriaxone with another drug that is still in a
group that does not give effect nefrotoksitas, in this case replaced with cefoperazone
c. Cardace (Ramipril) + Novorapid (insulin aspart)
Effect: increases the effect of novorapid
Recommendation: monitor blood glucose levels, the effect of this hipoglikemi it
is expected to lower the GDS that haven't been normal.
d. Cardace (Ramipril) + furosemid (lasix)
Effects: acute onset of hypotension and risky gagl kidney
1040
Recommendation: stop the use of ramipril for the antihipertensi the ACEi risk
nefrotoksik.
e. Cardace (Ramipril) + calcium carbonate (CaCo3) + Sodium bicarbonate (Bicnat)
Effects: calcium carbonate and bicnat can decrease the effect of ramipril.
Recommendation: the effect of ramipril therapy is inhibited by the presence of CaCo3
/bicnat, where bicnat is more necessary and CaCo3 in CKD patients. Results
ofmonitoring of blood pressure is also normal, so not needed antihipertensi again.
(ISOFarmakoterapi)
f. Cardace (Ramipril) + insulin aspart (Novorapid)
Effects: rapimril enhances the effect of Novorapid
Recommendation: it is recommended, however, because ramipril has been stopped,then
the maintenance of blood sugar insulin aspart work to help should use oralantidiabet
drugs.
CONCLUSION
Based on the results of the practice of the internal medicine, patient in RSAL Dr.
MINTOHARDJO Hospital then pull on theconclusion that the existence of DRP (Drug
Related Problem) is the presence of multipledrug interactions that occur are Lasix
(furosemid) + letonal (spironolactone), Cefriaxone+ lasix (furosemid), Cardace (Ramipril) +
Novorapid (insulin aspart), Cardace (Ramipril) + furosemid (lasix), Cardace (Ramipril) +
calcium carbonate (CaCo3) + Sodiumbicarbonate (Bicnat), Cardace (Ramipril) + insulin
aspart (Novorapid), urispas + Lasix(Furosemid)
REFERENCES
1. anonymous. 2008. Iso farmakoterapi. PT.ISFI Publishing: London.
2. anonymous. (2013) .ISO (information Drug spesialiten Indonesia). Volume 48.Jakarta:
Indonesia Pharmaceutical Degree Bond.
3. Dipiro JT ., et all, 2006. Pharmacotherapy Handbook Sixth Edition Appleton
and lange: Newyork.
1041
4. National
Kidney
Foundation.
2005.
K/DOQI
Clinical
Practice
Guidelines
forCardiovascular Disease in Dialysis Patients. New York.
5. Galileopharma. 2008, BNF edition 56, Alexandria University.
6. Suwitra, k. 2009. Chronic Kidney Disease. International Publishing.
7. Suhardjono. 2009. Chronic kidneydisease isa new plague (global epidemic)throughout
the world. Society Of Nephrology Annual Meeting Indonesia.
8. Prodjosudjadi dkk., 2009. EndStage Renal Disease In Indonesia. VelopmentTreatment.
9. BPOM.2008.nationaldrug Informatorium Indonesia (IONI). Jakarta: Sagung Seto.
10. Burns, a. 2009. Renal Drug Handbook third edition. New York: Oxford
11. http://emedicine.medscape.com
12. A.Y. Sutedjo, SKM. PocketBook ToKnow TheDisease ThroughThe LaboratoryExamin
ation Result.
1042
DRUG RELATED PROBLEMS ASSOCIATED OF TREATMENT UROLITHIASIS
DISEASE PATIENT IN PGI CIKINI HOSPITAL
Bioty Wong1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
Lecturer Pharmacy in Pharmacy Faculty University of 17 August 1945 Jakarta (UTA’45
Jakarta)
Email:[email protected]
ABSTRACT
Urolithiasis was a disease that occurs in hospital wards of PGI Cikini. Urolithiasis can be
occur anywhere in the urinary system1. Urolithiasis is a mineral efflorescence surrounding
the organic substance consisting of calcium salts (oxalate and phosphate) or magnesium
phosphate and uric acid 1. Case presentation: IS was a 41-year-old man admitted to the
wards for internal medicine. Patients diagnosed with urolithiasis. reclinical evaluation: in
this case need to be considered in this case study is the use of drugs that can cause
unwanted interactions in patients.
Keywords: Urolithiasis, RS PGI Cikini, Interactions
INTRODUCTION
In developed countries the disease is common upper urinary tract stones. This is due
to the influence of nutritional status and daily activities of the patient9. In the United States
5-10% of the population suffer from this disease, while in the entire world, there are an
average of 1-12% of people who suffer urinary tract stones9. This disease is one of the three
most prevalent diseases of urology in addition to urinary tract infections and prostate
enlargement benigna9.
Urolithiasis is a disease that occurs in the disease in hospital wards PGI Cikini.
Urolithiasis can occur anywhere in the urinary system1. Urolithiasis can be caused of a
mineral efflorescence surrounding the organic substance consisting of calcium salts
(oxalate and phosphate) or magnesium phosphate and uric acid 1.
Kidney stones can remain asymptomatic until it came out into the ureter and / or obstructed
urine flow, when the potential for kidney damage is acute10. This infection will increase the
1043
formation of organic substances
10
. Organic substances were surrounded by precipitated
1
minerals . This mineral deposition (due to infection) will increase the alkalinity of urine
and lead to precipitation of calcium phosphate and magnesium ammonium fosfat1. Other
factors associated with stone formation were antacid consumption in the long term, too
much vitamin D, and calcium carbonate 1.
The main symptom is an acute kidney stone or renal colic pain1. Location of pain depends
on the stone locations
10
. If the stone is in the renal pelvis, causing pain and pain is
hydronephrosis is not sharp, fixed, and is felt in the area of costovertebra corner1. If a stone
dropped into the ureter, the patient will experience severe pain, colic, and taste like
stabbed1. This pain is intermittent and caused by spasm (spasm) of the ureter and the
ureteral wall anoxia pressed by the stone. This pain spreads to the suprapubic area, external
genitalia, and lap1. Colicky pain may be accompanied by nausea and vomit1.
CASE PRESENTATION
IS was a 41-year-old man admitted to the wards for internal medicine. Patients
diagnosed with urolithiasis. Hospitalized patients PGI Cikini June 7, 2014, he was a new
patient in the PGI Cikini’s hospital. The patient cannot urinate 2 days ago, no urine during
straining, nausea, vomiting (+), fever (-), packed (-) before admission. History of present
illness 1 week ago when urinating out the stone, small stones mixed with blood urine. The
patient has a past medical history of drug allergy that causes the skin to blister genitals,
unknown type of medicine because at the time it was taking some kind of medication.
Clinical chemistry examination was increased alanine aminotransferase 64 U/L, urea at 96
mg/dL, creatinine 11.4 mg /dL and decreased sodium is 130 mEq / L and calcium of 8.4
mg/dL. While on hematological examination increased in erythrocyte sedimentation rate 69
mm / h, 12.3 10 ^ 3μL leukocytes, neutrophils segment of 81%, 9% monocytes, MCHC
37.9 g / dL and decreased in erythrocytes 4.16 10 ^ 6μL, hematocrit 34%, reticulocyte 7
permil, and neutrophils rods 0%.
GUIDELINE FOR UROLIHIASIS MEDICATION6,8,9,11
a. Conservative therapy
1044
Most ureteral stones have a diameter of <5 mm. As mentioned earlier, ureteral
stones <5 mm can come out spontaneously. Therapy aims to reduce pain, facilitate the
flow of urine by giving diuretics, such as:
1. Drink so diuresis 2 liters / day
2.
NSAIDs
Time limit is 6 weeks of conservative therapy. In addition to the size of the stone is
another requirement for the observation of the severity of the patient's complaints, the
presence or absence of infection and obstruction. The presence of recurrent colic or UTI
cause observation is not an option. So also with the presence of obstruction, especially
in certain patients (eg single kidney, kidney transplantation and decreased kidney
function) there is no tolerance for obstruction. Such patients should be done
immediately intervene.
b. ESWL (Extracorporeal Shockwave Lithotripsy)
With ESWL most patients do not need to be sedated, given only antidote to pain.
The patient will lie on a tool and will be subject to shock waves to break the stone Even
in last generation ESWL patients can be operated from a separate room. So, once the
location of the kidney is found, the doctor simply pressed a button and ESWL in the
operating room to move. Supine position of the patient himself could fit the position or
face down kidney stones. Kidney stones that have been broken will come out with the
urine. Usually patients do not need to be treated and can go home. ESWL is a kidney
stone crushing equipment using shock waves between 15-22 kilowatts. Although almost
all types and sizes of kidney stones can be solved by ESWL, still have to be reviewed
the effectiveness and efficiency of this tool. ESWL is only suitable to crush kidney
stones with a size less than 3 cm and located in the kidney or urinary tract between the
kidney and bladder (unless blocked by the pelvic bone). Another thing to consider is
whether the type of stone can be solved by ESWL or not. Hard rock (eg calcium oxalate
monohydrate) broke hard times and need some action. ESWL should not be used by
people with high blood pressure, diabetes, blood clotting disorders and kidney function,
pregnant women and children, as well as excess body weight (obesity).
c. Endourology
1045
Endourology action is minimally invasive techniques to remove urinary tract stones
which consisted of breaking stones, and then remove it from the urinary tract through the
instrument that is inserted directly into the urinary tract. The device is inserted through
the urethra or through a small incision in the skin (percutaneous). The process of
breaking rocks can be done mechanically, by means of hydraulic energy, the energy of
sound waves, or with laser energy.
d. Open Surgery
Clinics that do not have adequate facilities for the actions of endourology,
laparoscopy, or ESWL, stone retrieval was performed through open surgery. The open
surgery include: pielolitotomi or nephrolithotomy to pick up stones in the bile duct, and
for stones in the ureter ureterolitotomi. Not infrequently the patient should undergo
nephrectomy or taking action kidneys because kidneys are not functioning and contains
pus (pyonephrosis), the cortex already very thin, or may warp due to urinary tract stones
that cause obstruction or chronic infection.
e. installation Stent
Although not a primary treatment option, ureteric stenting sometimes play an
important role as an additional measure in the treatment of ureteral stones. For example,
in patients with sepsis is accompanied by signs of obstruction, stent use was necessary.
Also on ureteral stones attached (impacted).
f. Prevention of Recurrence After kidney stones removed
Prevention is done is based on the content of the elements which make up urinary
stones obtained from stone analysis. In general, prevention of this form:
1. Avoid dehydration by drinking enough and sought production of as much as 2-3
liters of urine per day.
2. Diet to reduce the levels of the substances the rock-forming components.
3. Daily activities are quite
Some diets are recommended to reduce the recurrence is:
a. Low protein, because the protein will stimulate urinary calcium excretion and cause the
urine to become more acidic atmosphere.
b. low oxalate
1046
c. Low salt, because it will spur the emergence natriuresis, hipercalsiuri
d. Low purine.
e. Low calcium diet is not recommended except in patients suffering from type II
absorptive Hipercalsiuri.
CLINICAL EVALUATION 3,7
Broadced (Ceftriaxone disodium) was used for urinary tract infections, Tramadol
(Tramadol HCl) for the treatment of acute and chronic pain, postoperative pain. Rantin
(Ranitidine HCl) used for hyperacidity, gastritis, peptic ulcer, chronic duodenitis,
pathological hypersecretion. Flagyl (Metonidazole) used for the prevention of postoperative
infections caused by anaerobic bacteria, especially Bacteroides species, and anaerobic
streptococci. Harnal (Tamsulosin HCl) used for symptoms of lower urinary tract disorders
associated with benign prostatic hyperplasia. Spasmium (Alverine citrate and
Chlordiazepokside) indicated for spasm pain / spasm, peptic ulcer. Sodium bicarbonate is
used to. Infusion of 0.9% NaCl is used to maintain electrolyte balance. NS infusion is used
to treat metabolic alkalosis due to fluid loss and mild sodium depletion.
DOSAGE AND DIRECTION3,7
For ten days in hospital care PGI Cikni Mr. IS getting 9 types of treatment. Patients
get Broadced (Ceftriaxone disodium) 2 grams for 10 days with a dose of 1 x 2 grams a day.
Tramadol (Tramadol HCl) ampoules administered for 10 days. On the first day until the
sixth day, the eighth day up to day 10 tramadol given at a dose of 3 x 1 day. On the seventh
day was given a dose of 1 x 1 a day. Rantin (Ranitidine HCl) ampoules in getting patients
for 3 days ie on day eight to ten with a daily dose of 2 x 1. Flagyl (Metronidazole)
suppository was given for 3 days ie on day eight to ten at a dose of 3 x 1 day. Harnal
(Tamsulosin HCl) 0.4 mg was given for 6 days from day five to ten with a daily dose of 1x
1. Spasmium (Alverine citrate and Chlordiazepokside) given for 6 days. Day five was given
at a dose of 1 x 1 a day. On day six to ten at a dose of 3 x 1 day. Sodium bicarbonate
capsules given for 6 days with dosi days to five 1 x 1 and on day six to ten 3 x 2 a day.
Infusion of 0.9% NaCl was given 6 days diving on the first day with a dose of 1x1, on the
1047
second day up to six at a dose of 2 x 1 day. NS infusion was given for 4 days, on seventh
day to tenth day.
DRUG RELATED PROBLEMS (DRPS)2,3,4,7
1. Drug Related Problem 1 (Drug Interaction)
a. Drug interaction 1
Spasmium and tramadol both increase sedation. Potential for interaction, monitoring
should be done.
Doctor’s Note: Tramadol is given to relieve acute or chronic pain or severe
postoperative pain due to kidney stones
Spasmium given to treat spasms of pain / spasm, peptic ulcer.
Pharmacist Intervention: Perform monitoring of the use of drugs that can interact.
Leave a space of drug use during 2 hours
b. Drug Interaction 2
Flagyl increases levels of harnal by affecting hepatic/intestinal enzyme CYP3A4
metabolism. Potential for interaction, Monitoring should be performed. Dose
reduction may be needed for coadministered drugs that are predominantly
metabolized by CYP3A
Doctor’s Note: Flagil used for urethritis and vaginitis, amubiasis, anaerobic
infections. Harnal given for symptoms of lower urinary tract disorders.
Intervention pharmacists: Advise the patient to give space around 2 hour to drugs
that interact with each other.
2. Drug Related Problem 2
On the seventh day ( June 13, 2014) patients require tramadol for pain suffered 3
times a day, but the patient was given once a day.
CONCLUSION
After the assessment of the patient's treatment, it can be concluded that patients diagnosed
urolithiasis. For drugs that interact give space 2 hours in the offering. Do rigorously
monitoring for drug-drug interaction.
1048
REFERENCES
1. Baradero, Mary,dkk.2005.Klien Gangguan Ginjal. Jakarta:Buku Kedokteran EKG.
2. Baxter, K. 2008. Stockley’s Drug Interaction Eight Edition. London.
3. BPOM.2008.Informatorium Obat Nasional Indonesia (IONI).Jakarta: Sagung Seto
4. Burns, A. 2009. Renal Drug Handbook third edition. New York : Oxford
5. Doenges, Marilynn.E,dkk. 2000. Rencana Asuhan Keperawatan edisi 3. Jakarta:Buku
Kedoktran EGC.
6. Hayes, Peter C. 2005.Buku Saku Diagnosis dan Terapi. Jakarta:Buku Kedokteran EGC.
7. MIMS. 2009. MIMS Indonesia Petunjuk Konsultasi. Edisi 9. Jakarta. PT. Bhuana Ilmu
Populer
8. Nugroho, Ditto. 2009. Batu ginjal. Jakarta: Buku Kedokteran EGC.
9. Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia. 2006. Buku Ajar Ilmu
Penyakit Dalam. Jilid I. Edisi IV. Pusat Penerbitan Departemen Ilmu Penyakit Dalam
FKUI. Jakarta.
10. Sabiston, C. Sabiston. 2005. Buku Ajar Bedah.Jakarta:Salemba Medika.
11. Tiselius HG, Ackerman D, Alken P, dkk. Guidelines on urolithiasis.
1049
STUDY OF PULMONARY DISEASES WARD PULMONARY TB BTA (+) LLKB
(The lesion Area new cases) on OAT kat II.
Junaedi, Chandra, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Tuberculosis (TB) is a disease caused by infection with Mycobacterium complex
tuberculosis1. Mycobacterium Tuberculosis rod-shaped, straight or slightly curved, not
capsule and spores. Tuberculosis (TB) disease of a lung to date is still a public health
problem1. Patient Mr. AH, age 37 years, 3 months, 7 days, W: 42 Kg, it was the friendship
on 02 Mach 2014 with the diagnosis of pulmonary TB BTA (+) LLBK (Broad new cases of
Lesion) on OAT category II. Therapy treatment for treated is. IV FD NaCl 0.9%,
Streptomycin Injeksi, Paracetamol, and OAT category II drugs (INH, Rifampin,
ETHAMBUTOL and Streptomycin, pirazinamid). Based on the results of the practice of
the Clerk's Ward on pulmonary disease clinic at the Friendship was then be drawn the
conclusion that the existence of the DRP (Drug Related Problem) is there a medicine
without any indication, the failure of patients in receiving medications and conditions that
need to be taken care of.
Keywords: Tuberculosis, BTA (+) LLKB, Pulmonary Disease
A. INTRODUCTION
Tuberculosis (TB) is a disease that it is caused by infection with Mycobacterium
tuberculosis kompleks1. Microbe Tuberculosis rod-shaped, straight or slightly curved, not
spores or not capsules1. These bacteria-sized width of 0.3 – 0.6 mm long and 1-4 mm. Wall
microbe is very complex, consisting of a layer of fat is quite high (60%)1. The main
constituent of the cell wall Microbe tuberculosis were micolat, wax complex (complex1050
wexes), thehalosa dimikolat called the cord factor and microbe sulfo lipids that play a role
in virulensi6.
The world's TUBERCULOSIS report by the WHO in 2006, that Indonesia as the
largest contributions number, three in the world after india and China with the number of
new cases is about 539.000 people per year. According to Notoatmodjo (2003) in addition
to the factor of environmental sanitation of houses, pulmonary TB disease occurrence is
also very concerned with the behavior and the amount of family income because most
patients with TB is a poor level of education rendah2. For examination of pulmonary
TUBERCULOSIS checked 3 specimens sputum within 2 days6. 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) 6. Whereas such checks photo thoracic, culture and
sensitivity test can be used as a support in diagnosis in accordance with the indications and
not justified in diagnosing TB6.
B. RESERVED
Patient Mr. AH, age 37 years, 3 months, 7 days, W: 42 Kg, it was the friendship on
02 Mach 2014 with the diagnosis of pulmonary TB BTA (+) LLBK (Broad new cases of
Lesion) on OAT category II. Friendship was signed on 2 March 2014. The patient came in
with the complaint that shortness of breath increased severe since 2 month SMRS. The
patient complained of shortness of breath during the 5 days of SMRS, claustrophobic not
reads ngik, shortness is felt throughout the day, shortness of breath, chest pain right side,
pain relapse during nighttime, losing weight and coughing at night.
The patients had previously received treatment for lung OAT category I at the
clinic, where patients had healed cause stopping his own treatment of OAT, OAT resistance
for category so I substituted OAT and category II. After treatment of OAT category II 5
days in diagnosis MDR TB patients (Multi Drug Resistant).
1051
C. EXAMINATION OF VITAL SIGN
Date Of
Examination
Blood
Pressure
(120/80
mmHg)
Pulse
circulation of
breath (1418x/menit)
body
temperature
2/3/2014
126/87 mmHg
108 x / menit
28.4 x / menit
36.8 ⁰C
3/3/2014
110/70 mmHg
90 x / menit
24 x / menit
36 ⁰C
4/3/2014
120/80 mmHg
88 x / menit
22 x / menit
36 ⁰C
5/3/2014
110/70 mmHg
84 x / menit
22 x / menit
36,7⁰C
6/3/2014
110/70 mmHg
84 x / menit
22 x / menit
36⁰C
(60100x/menit)
(36-37⁰C)
D. CLINICAL EVALUATION
Patient was given the drug OAT category II (Rifampin, Etambutol, INH, and
Pirazinamid) and injek Streptomycin for tuberculosis treatment. Patient to on paracetamol
to reduce short of breath and gave oxygen therapy 2 Lpm.
E. TUBERCULOSIS DRUGS AND MULTI DRUG RESISTANT7
Name
Doses
Pirazinamid
30-40
(Tablet, 500 mg)
mg/kg/day
Etambutol
1000
1750 mg
1750
2000 mg
2000
25 mg/kg/day 800
1200 mg
1200
1600 mg
1600
2000 mg
Kanamisin
15-20
500
(Vial, 1000 mg)
mg/kg/day
750 mg 1000 500
mg 1000 mg
Levofloksasin
750 mg day
750 mg
750 mg
(Tablet, 400 mg)
750-1000 mg
1052
(Kaplet, 250 mg)
Sikloserin
15-20
(Kapsul, 250 mg)
mg/kg/day
Etionamid
15-20
(Tablet, 250 mg)
mg/kg/day
PAS
150 mg/kg/day
500 mg
750 mg
750-1000 mg
500 mg
750 mg
750-1000 mg
8g
8g
8g
(Granula, 4 gr)
F. LINE TREATMENT For TBC6
Category I
Weight
The intensive phase of each day for
56 days
INH, rifimpisin, etambutol,
pirazinamid
2 tablet 4 FDC
3 tablet 4 FDC
4 tablet 4 FDC
5 tablet 4 FDC
The advanced stages, 3 times
a week for 16 weeks
Rifampisin, INH
The intensive phase of each day for
56 days
The advanced stages, 3 times
a week for 20 weeks
INH, Rifimpisin, Etambutol,
Pirazinamid, dan Injek Sereptomisin
Rifampisin, INH, Etambutol
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
30-37 kg
38-54 kg
55-70 kg
≥71 kg
2 tablet 4 FDC
3 tablet 4 FDC
4 tablet 4 FDC
5 tablet 4 FDC
Category II
Weight
1053
G. DOSAGE and MODE were USED3,4,5
The Name Of
Drug
Dose
Medicinal
indication
Usage
Common Dose
O2
2 Lpm
Short of breath
Inhalasi
2 Lpm
Parasetamol
3 x 500 mg
Analgetik
Oral
3-4 x 500 mg/day
Setreptomicin
1 x 750 mg
TBC
Injeksi
750mg /day
NaCl 0,9%
500 cc
Elektrolit
Injeksi
2 x/24 hour
4 FDC
1 x 3 tablet
TBC
Oral
3 tablet 4 FDC
H. THE VALUE OF LABORATORY
Table 1. The results of laboratory Examination
No. Lab : 140308-1796
No. Med Rec. 02-10-27-42
Name : Mr. A H
No
The name of
the test
Normal
Value
Units
Inspection Results
Leukosit
5 ~ 10
Ribu/mm3
14,29
16,88
Netrofil
50 ~ 70
%
74,1
77,3
Limposit
25 ~ 40
%
95
73
Monosit
2~8
%
7,9
6,1
Eosinofil
2~4
%
8,2
8,7
Basofil
0~1
%
0,3
0,6
Eristrosit
4,5 ~ 6,5
Juta/uL
5,18
5,98
02/03/2
014
03/0
3/20
14
04/03
/2001
4
05/0
3/20
14
06/03
/2014
Hitung Jenis
1054
Hemoglobin
13,0 ~ 18,0
g/dL
13,3
13,1
Hematrokrit
40 ~ 52
%
38
43
MCV
80 ~ 100
fL
73,7
77,9
MCH
26 ~ 34
Pg
25,7
24,0
MCHC
32 ~ 36
%
34,8
80,8
RDW-CV
11,5 ~ 14,5
%
17,0
16,20
Trombosit
150 ~ 440
Ribu/mm3
559
585
Na
135 ~ 145
Mmol/L
142,0
K
3.5 ~ 5.5
Mmol/L
4,20
Cl
98 ~ 109
Mmol/L
99
Ur
20 ~ 40
Mg/dL
18
Keratinin
0,6 ~ 1,6
Mg/dL
0,9
pH
7,34 ~ 7,44
PCO2
35 ~ 45
mmHg
43,3
PO2
85 ~ 95
mmHg
113,8
HCO3
22 ~ 26
Mmol/L
26,0
TCO2
23 ~ 27
Mmol/L
26,3
Std HCO3
2,5 ~ 26
Mmol/k
24,2
Saturasi O2
96 ~ 97
%
98,1
GDS
< 180
Mg/dL
98
Elektrolt
7,37
1055
Laju Endap
Darah
0 ~ 10
Mm
85
Protein
6~8
g/dL
8,2
Albumin
3,4 ~ 5
g/dL
3,9
Globulin
1,3 ~ 2,7
g/dL
4,3
Ast (SGOT)
0 ~ 37
u/L
25
Alt (SGPT)
0 ~ 40
u/L
4
I. DRUG RELATED PROBLEM
1. failed to receive medication
Patients failed to receive oral Paracetamol at 08.00 am on March 3,
2014. Suggestion to nurses and nurse's records list check performed periodically
and always cultivating the habit of giving information to his first patient-related
properties that are associated.
2. Condition to be note
The condition that need to be considered in these patient, in which
patient experience decreased in appetite so it should be given the addition of
vitamins to increase his appetite so it can improve the condition of the patient's
body in the face of illness and always check the function SGOT/SGPT patient at
regular intervals.
J. CONCLUSION
Based on the results of the practice in the Clerk's Ward on pulmonary
disease conclusion that the existence of DRPs (Drug Related Problems) is a
condition that needs to be noted and the patient's role in the failure to receive the
drug.
REFERENCES
1. PDPI, 2013. Pedoman diagnosis dan penatalaksanaan Tuberkulosis . Jakarta
1056
2. Herryanto, 2004, Riwayat pengobatan penderita TB paru Jurnal Kesehatan vol 3,
Bandung.
3. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung Seto
4. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford
5. Galileopharma. 2008, BNF edition 56, Alexandria University
6. Djojodibroto, Dr. R. Darmanto, Sp. P, FCCP. 2009. Respirologi (Respiratory
Medicine). Jakarta : EGC.
7. Nawas, Aarifin. 2014. Penatalaksanaan TB MDR dan Setrategi DOTS plus: Jakarta
1057
BRONCHOPNEUMONIA IN PULMONARY DISEASE WARD
Delius Wonda, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
In clinical, pneumonia is defined as an inflammation of lung caused of microorganisms
(bacteria, viruses, fungi, parasites)3. Pneumonia caused by Mycobacterium tuberculosis not
including while the lung inflammation caused by nonmikroorganisme (chemicals, radiation,
toxic material aspirations, drugs etc.) is called pneumonitis3. Mr. SY patients was 75 years
old and hospitalize at Gatot Subroto Army Hospital on 18 March 2014 with diagnosis is
bronchiectasis and bronchial asthma. Therapy treatment during hospitalized that is
Neurobion, furosemide, ceftriaxon, digoxin, ISDN, aspilet, allupurinol, nitrokaf, methyl
prednisolone, Ventolin. Based on the results of clinical practice in pulmonary disease ward
at Gatot Subroto Army Hospital, so can be concluded that presence of DRP (Drug Related
Problem) is happen drug interaction between furosemide interactions with digoxin and
aspirin with digoxin.
Key Word : Broncopneumonia, Pulmonary Disease, Gatot Subroto Army Hospital
INTRODUCTION
In clinical, pneumonia is defined as an inflammation of lung caused of
microorganisms (bacteria, viruses, fungi, parasites)3. Pneumonia caused by Mycobacterium
tuberculosis not including while the lung inflammation caused by nonmikroorganisme
(chemicals, radiation, toxic material aspirations, drugs etc.) is called pneumonitis3.
Streptococcus pneumoniae causes inflammatory exudate in large amount take a part
to helping bacteria invade through the pores that exist within alveoli until destroyed by
septum that separates lobes of the lungs2.
The origin of the pneumonia was the damage caused by the entry of particles
attacker in lower respiratory tract. The entryway frequent happen is inhalation of small
particles, but aspirations particles infection that larger in oropharyngeal spreads from
1058
distant infection focus or spread directly from surrounding tissues used as an entrance by
agents causing pneumonia4.
These particles can cause lung damage because they contain ingredients that can
cause an infection, disseminated through the air (water borne) when the infectious agent is
still active, and stay active while suspended in the air and then enter to tissue, and this
particles can cause infection. Combination of these conditions may help to explain why
pneumonia is less common happen and why some are more at risk than at other locations4.
CASE PRESENTATION
Mr. SY patients was 75 years old and hospitalize at Gatot Subroto Army Hospital
on 18 March 2014. Patients present with shortness of breath ± 1 week of cough with
phlegm, coughing, shortness of breath, sputum colored black. Ever seek treatment earlier
but no change. Past medical history of asthma last relapse was last week, Diabetes mellitus,
hypertension and stroke. The result of hematology laboratory tests that is ESR values has
increased 28 mm/hour, hemoglobin has decreased 11.6 g/dL, hematocrit has decreased
34%, erythrocytes has decreased 3.8 million/μL, leukocyte has increased 17200/μL, urea
has increased 62 mg/dL, creatinine has increased 1.7 mg/dL.
CLINICAL EVALUATION
Neurobion used for treatment of deficiency Vitamin B1, B6 and B12 such as beriberi and polineuritis. Furosemide used as a treatment of edema accompanying congestive
heart failure, cirrhosis of the liver and kidney disorders including nephrotic syndrome,
treatment of hypertension, either given alone or combination with antihypertensive drugs,
furosemide is very useful for situations that require a strong diuretic. Ceftriaxon used as
antibiotics due to bacterial infection. Digoxin used to treatment of acute congestive heart
failure and chronic and paroxysmal supraventricular tachycardia. ISDN used to prevent
chest pain caused by angina and heart failure left. Aspilet used to treatment and prevention
of angina pectoris and myocardial infarction. Allupurinol used to gout and hyperuricemia.
Nitrokaf used as a long-term prevention and treatment of angina pectoris. Methyl
prednisolone used as adrenocortical insufficiency acute and chronic primary. Ventolin used
1059
as treatment and prevention of asthma attacks. Routine management of chronic
bronchospasm that does not respond to conventional therapy; Acute severe asthma (status
asthmaticus).
DOSAGE AND DIRECTION
Therapeutic treatment given for 3 days that is Neurobion 5000 is administered
Intravena on days 2 and 3, furosemide administered orally on day 1 to day 3, ceftriaxon
given intravena on day 2 and day 3, digoxin administered orally on day 2 and day 3, ISDN
administered orally on day 2, aspilet administered orally on day 2, allupurinol administered
orally on day 2, nitrokaf-R administered orally on day 2, methyl prednisolone given
intravena on day 2, ventolin inhalation is given on day 2.
DATA LABORATORY VALUE
TIPE OF CHECK UP
HEMATOLOGY
REFERENCE VALUE
18/3
19/3
Erythrocyte
Sedimentation Rate
Routine Hematology
Hemoglobin
Hematocrit
Erythrocytes
Leukocyte
Platelet
MCV
MCH
MCHC
Total Bilirubin
Direct Bilirubin
Indirect Bilirubin
Fosfatase
SGOT
SGPT
y-GT
Total Protein
Albumin
Globulin
Total Cholesterol
< 20 mm/hour
28
28
13 – 18 g/Dl
40 – 52%
4.3 – 6.0 million/μ L
4,800 – 10, 800/ μ L
150,000 – 400,000/ μL
80 – 96 fl
27 – 32 pg
32 – 36 g/Dl
< 1,5 mg/dL
<0,3 mg/dL
<1,1 mg/dL
56-119
< 35 U/L
< 40 U/L
8-61 U/L
6-8,5 g/dL
3,5-5,0 g/dL
2,5 – 3,5 g/dL
< 200 mg/dL
11,6
34
3,8
17200
347000
88
30
34
1,92
0,86
1,06
85
54
33
50
6,5
4,0
2,5
147
1060
Triglyserida
HDL Cholesterol
LDL Cholesterol
Urea
Creatinine
Uric Acid
Fasting Blood Glucose
Blood Glucose (2 hours
PP)
Sodium
Potassium
Clorida
URINALYSIS
Complete Urine
Ph
PCO2
PO2
Bicarbonate
Bases Excess
Saturation
Specific Gravity
Protein
Glucose
Bilirubin
Nitrite
Ketones
Urobilinogen
Erythrocytes
Leukocyte
Cylinder
Cristal
Epithelial
Others
< 160 mg/dL
>35 mg/dL
<100 mg/dL
20 – 50 mg/dL
0.5 – 1,5 mg/dL
3.5 – 7.4 mg/dL
70 - 100 mg/dL
<140 mg/dL
62
1,7
66
54
80
61
2,2
117
118
135 – 147 mmol/L
3,5 – 5,0 mmol/L
95 – 105 mmol/L
131
3,5
97
137
3,7
97
4,6 – 8,0
33-44 mmHg
71-104 mmHg
22-29 mmol/L
(-2)-3 mmol/L
94-98 %
1010 – 1030
Negatif
Negatif
Negatif
Negatif
Negatif
Negatif – Positif 1
< 2 LPB
< 5/LPB
Negatif/LPK
Negatif
Positif
Negatif
7,483
23,1
126,4
17,5
-4,3
96,5
5,5
1015
-/Negatif
-/Negatif
-/ Negatif
-/ Negatif
-/ Negatif
Negatif
0-1-0
2-2-2
-/Negatif
-/Negatif
+/Positif 1
-/Negatif
GUIDELINE OF PNEUMONIA
Treatment consists of antibiotics and supportive treatment. Administration of
antibiotic in patients with pneumonia should be based on the data of microorganisms and
susceptibility test results, but for some reason that is3 :
1. Severe disease can be life-threatening.
2. Bacteria pathogens that can be isolated is not necessarily the cause of pneumonia.
1061
3. Results of bacterial culture takes time
Therefore, in patients with pneumonia can be administered empirical therapy. In general,
the selection of antibiotics based on bacteria that cause pneumonia can be seen as follows3 :
Penisilin sensitif Streptococcus pneumonia (PSSP)
� Group Penicillin
� Trimethoprim-sulfamethoxazole (TMP-SMZ)
� Macrolides
Penisilin resisten Streptococcus pneumoniae (PRSP)
� Betalaktam high oral doses (for outpatient)
� Sefotaxime, Ceftriaxone high doses
� New macrolides high doses
� respiratory Fluoroquinolone
Pseudomonas aeruginosa
� Aminoglycoside
� Seftazidime, Sefoperason, Cefepim
� Ticarsilin, Piperacillin
� Carbapenem : Meropenem, Imipenem
� Ciprofloxacin, Levofloxacin
Methicillin resistent Staphylococcus aureus (MRSA)
� Vancomysin
� Teikoplanin
� Linezolid
Hemophilus influenzae
� TMP-SMZ
1062
� Azitromysin
� Cefalosporin genes 2 or 3
� Respiratory Fluoroquinolone
Legionella
� Macrolides
� Fluoroquinolone
� Rifampin
Mycoplasma pneumoniae
� Doxycycline
� Macrolides
� Fluoroquinolone
Chlamydia pneumoniae
� Doxycycline
� Macrolides
� Fluoroquinolone
DRUG RELATED PROBLEMS (DRPs)
1. Interactions happened between digoxin and furosemide that is furosemide increases
effect of digoxin through pharmacodynamic synergism interactions that cause
hypokalemia.
2. When aspirin is given together with digoxin will increase levels of digoxin so that need
to dose adjustment or doing special tests to take a second these drugs. If the are used
need to be monitored closely and given the distance of at least 2 hours.
CONCLUSION
Based on a review of the patient's disease can be concluded that between giving
together digoxin and furosemide will cause furosemide can increase digoxin effects by
1063
pharmacodynamic synergism. When used simultaneously aspirin and digoxin will increase
digoxin levels should be monitored closely and should be spaced at least 2 hours of
administration of the drug.
REFERENCES
1. AHFS drug information 2004. McEvoy GK, ed. Methotrexate. Bethesda, MD:
American Society of Health-System Pharmacists; 2003:1082-9).
2. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A Pathophysiologic Approach 7th
Edition, McGraw Hill, New York.
3. PDPI, 2003. Pneuomonia Komuniti Pedoman Diagnosa dan Penatalaksanaan di
Indonesia. Jakarta.
4. Syamsuddin, 2013. Farmako terapi gangguan saluran pernafasan. Salemba medika.
Jakarta.
1064
DRUG RELATED PROBLEMS IN THE TREATMENT OF GUILLAIN-BARRE
SYNDROM DISEASE, ANTI PHOSPOLIPID SYNDROME AND DIABETES
MELLITUS TYPE 2
Dessy Karina L, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
2
(UTA’45 Jakarta)
1
ABSTRACT
Guillain Barre Syndrome and Anti Phospolipid Syndrome is an autoimmune condition and
its prevalence is very small at 2-3 cases in 100,000 people for a year and one of the patients
with this condition are treated in PGI Cikini hospital. Guillain-Barré syndrome is an
inflammatory disorder of nerve (nerves outside the brain and spinal cord) are attacked by its
own immune system. GBS is characterized by progressive muscle weakness and rapid. It
affects the nerves that signal muscles to contract and may impair the ability to walk, write,
breathe, talk, etc. Early symptoms are decreased sensation in the lower limbs which
developed into numbness and tingling. Can also occur severe back pain and leg weakness
in hands simultaneously, muscle pain, cramps, and shortness of breath. GBS symptoms
vary widely and in some cases can occur up to a total paralysis of respiratory muscles. APS
is a thrombophilic disorder in which antibodies are produced to various phospholipids.
Clinical manifestations in patients with APS is because phospholipids are an integral part of
the platelet and endothelial cell surface membrane, then the anti-phospholipid antibodies
will have a significant effect on platelets and vascular endothelial mechanism by inhibiting
the production of endothelial protasiklin, generating procoagulant effect on platelets, as
well as a decrease in fibrinolysis. Meanwhile other diagnosis of diabetes mellitus is a state
dysfunction and impaired glucose metabolism occurs in the form of impaired fasting
glucose and impaired glucose tolerance eventually occurs with type 2 diabetes mellitus.
Keywords: Guillain Barre Syndrome, diabetes type 2, PGI Cikini Hospital
1. Preliminary
Guillain Barre syndrome is an autoimmune disease that causes inflammation and
damage to myelin (fatty material, composed of fat and protein that forms a protective
sheath around some kind of peripheral nerve fibers). GBS is considered a rare disorder
with an incidence of about 2-3 cases in 100,000 people for a year
1
Symptoms of this
1065
disease is early weakness and numbness in the legs that quickly spread cause paralysis
(2). GBS is mediated by postinfectious. Cellular and humoral immune mechanisms may
play a role in its development. Most patients reported infectious disease in the weeks
before the onset of GBS. Many infectious agents are identified is expected to induce the
production of antibodies that cross-react with specific gangliosides and glycolipids,
such as GM1 and GD1b are distributed throughout the myelin in the peripheral nervous
system. GBS is a disease that usually occurs one or two weeks after a viral infection
such as sore throat, bronchitis, or the flu, after vaccination or surgical procedures.
Weakness and numbness in the legs are the first symptoms. These sensations can
quickly spread, eventually paralyzing the entire body 2.
Guillain-Barre may be triggered by 2 :
a. Campylobacter infection, the type of bacteria that is commonly found in food,
especially poultry
b. Operation
c. Epstein Barr Virus
d. Hodgkin's disease
e. Mononucleosis
f. HIV
g. Rabies or influenza immunization (rare)
1066
Guillain-Barre syndrome (GBS) Guidline 3
In 1986 the disease was introduced by Hughes Harris and Gharavi, Anti Phospolipid
Syndrome is a thrombophilic disorder in which antibodies are produced to various
phospholipids4. APS can be caused by lupus anticoagulant (LA) and anticardiolipin
antibodies (ACA), also called antiphospholipid antibodies5. Clinical manifestations in
patients with APS is because phospholipids are an integral part of the platelet and
endothelial cell surface membrane, then the anti-phospholipid antibodies will have a
1067
significant effect on platelets and vascular endothelial mechanism by inhibiting the
production of endothelial protasiklin, generating procoagulant effect on platelets, as well as
a decrease in fibrinolysis.
Guideline Antiphospolipid Syndrome 6
Diabetes mellitus is caused by glukotoksistas relative insulin deficiency results in
pancreatic
cell dysfunction and impaired glucose metabolism occurs in the form of
impaired fasting glucose impaired glucose tolerance and type 2 diabetes eventually
occurred7. It is essential in the management of Diabetes mellitus type 2 is a lifestyle change
that is a good diet and regular exercise. With or without pharmacologic therapy, a balanced
diet and exercise regularly (if not contraindicated) should still be carried out8
1068
Guidline Hyperglicemic Type 2 9
1069
2. Case Presentation
a. Patient Identity:
Patient Name
: EM
No
: Medical Records: 187 455
Dependents
: Alone
b. Anamnesis
Main Complaint: Limp
History of present disease: Weakness, defecate rather liquid, decreased appetite,
tingling and weakness in the hands, feet, and lips since 1 month ago.
Past medical history: The patient was known to have the same complaint with the
diagnosis of GBS, diabetes type 2, as well as from the APS in 2012 and had been
treated for 4 months in the Cikini hospital. Patients taking Metformin 500mg 2x
daily during and Simarc 1x2tab once every 2 days.
Family Disease History: None
c. General Examination:
Examination Vital sign: BP: 120/80, pulse: 74x/menit, R: 20x/menit, T: 36.5
d.
Clinical examination
Table 1. Examination Clinical Chemistry
No
Parameters
Clinical chemistry
1 Natrium
2 Kalium
3 Kalsium
4 Gula Darah Sewaktu
Value
Reference value
141 mEq/L
3,5 mEq/L
6,2 mg/dl *
186 mg/dl *
135-147
3,5-5,0
8,5-10,0
< 150 mg/dl
1070
e.
Examination During Treatment
Table 2. Examination Lab
2
June
2014
Parameters
1
Albumin
3,4 g/dl
2
Ferritin
0,84
*mg/ml
3
SGPT
26 u/L
4
Kreatinin
0,6 mg/dl
Glukosa darah
jam 06.00
Glukosa darah
jam 18.00
Glukosa darah
jam 24.00
Glukosa darah
jam 11.00
Glukosa darah
jam 16.00
Glukosa darah
jam 06.00
Glukosa darah
jam 11.00
Glukosa darah
jam 16.00
133
mg/dl
70-150
96 mg/dl
70-150
116mg/dl
70-150
6
7
8
9
10
11
12
13
Ureum
14
Natrium
15
Kalium
3 June
2014
5
June
2014
No
5
22-May14
29May14
21May-14
3,3
g/dl
6 June
2014
Reference value
3,4-4,8
Premenopouse :
6,9-282,5
Post : 14,0-233,1
Laki2 :
18-30 tahun :
18,7-323
31-60 tahun :
16,4-293,9
0-35
0,7
mg/dl
0,6-1,1
129
mg/dl
131
mg/dl
70-150
70-150
114
mg/dl
73
mg/dl
118
mg/dl
100
mg/dl
83
mg/dl
167 *
mg/dl
21
mg/dl
137
meq/L
4,2
meq/L
70-150
70-150
70-150
10-50
135-147
3,5-5,5
1071
16
Kalsium
17
Anti H. Pyllori
Kualitatif
8,4
*mg/dl
8,8-10,0
Positif
Positif
3. Clinical Evaluation
GBS is the main therapy to prevent and manage complications and provide
supportive care until symptoms begin to improve2. Mrs. EM treated with injection of
Methycobal for complaints peripheral neuropathy10. As is known Mrs. EM complain
circumstances tingling in hands, feet and lips. In the laboratory results are known Mrs.
EM ferritin levels below normal. Low ferritin levels indicate that the concentration of
iron in the body is low. Giving Sangobion caps to prevent anemia due to iron deficiency
and other minerals that contribute to the formation of blood cells. Mrs. EM using
metformin as monotherapy in controlling blood sugar levels and can be said to be
successful in controlling sugar levels seen in the laboratory results of blood sugar at a
time. Metformin monotherapy is rarely accompanied by hypoglycemia and metformin
can be used safely without causing hypoglycemia in prediabetes. Non glikemik effect of
metformin is important not cause weight gain or cause a little weight decrease7. Simarc2 (Warfarin-Na) is indicated for the state of thrombosis caused by APS syndrome with
Warfarin dose of 5-15 mg, the dose was increased by INR to be achieved (2.5 - 3.5) (10).
Provelyn (Pregabalin) is indicated in the neuropathic pain state11. At the starting dose
for nerve pain 75mg 2x a day and if well tolerated may be increased to 150mg after an
interval of 3-7 days, a maximum of 300 mg in the next week12. However, doctors
prescribe the use of 1x 50mg Provelyn only possibility is based on the severity of pain
experienced. Mrs. EM treated with lansoprazole and Inpepsa syrup for gastritis
treatment they experienced. Lansoprazole is a class of drugs for the treatment of ulcers
proton pump inhibitor which works by inhibiting the enzyme and produce energy to
remove HCl from the gastric parietal cell canaliculi while inpepsa works by forming a
layer of the stomach. Ondancentron given as an anti emetic treatment experienced
patients. Gammaraas (Plasma Immune globulin IV (human) 5%) is indicated to
1072
decrease the ability of the immune system attack body tissues in some cases disease
autoimmune13.
The next treatment is the administration of CaCO 3 in patients with the hope to
increase the value of low calcium on laboratory examination. Giving Laxadin and lacto
B is indicated to help the state of constipation that may be caused by the side effects of
the use Ondancentron and Inpepsa.
4. Drug Related Problems
Drug Interactions14
a. S ucralfate + lansoprazole
Sucralfat decrease levels of lansoprazole by inhibition of absorption GI
Suggestion: Separate multiple drug use for at least 30 minutes
b. Omeprazole + Warfarin
Omeprazole will reduce of Warfarin levels through the hepatic enzyme CYP1A2
Suggestion: Monitor usage and separate use of at least 2 hours.
c. DRP did not receive the drug
1. On 27 May 2014 Lacto B Patients should drink as much as 3 times a day but
only drink twice a day
2. On 28 May 2014 The patient should drink as much Sangobion caps 3x1 a day
but just taking 1 x 1 a day with record TAO
3. On the 29th May, 2014 (Thursday) the patient should drink only Simarc as
much 1x1tab, but the patient drink 1x2 tab. Whereas the dose of 1x1 tab on
Monday and Thursday
4. On 30 May 2014 Patients with Dyspepsia, doctor prescribed Inpepsa 3x1
tablespoon but just drink as much as 1x 1 a day.
5. On 31 May, 2014 and June 1, 2014 Patients should receive as much
lansoprazole 2x1 amp but just accept 1x1 amp.
6. On June 5, 2014 Patients should receive as much Methycobal 2x1 amp but only
received 1x1 amp whit the records TAO.
1073
7. On June 5, 2014 patients not taking prescribed Laxadin syr 2x1 tbsp with a
record OTM (os does not drink).
Suggestion: There should be more participation of pharmacists to ensure that
patients taking the drug according to the prescription as well as the role that should
be in addition to preventing potential DRP also solve the actual DRP.
5. Conclusion
Based on the practice of clinical work at the Cikini hospital with Patients Mrs.EM
suffering from GBS disease or APS. There is a record for drugs that interaction with
each other are spaced for 2 hours in the offering. Do strictly monitoring for drug
interaction and identification as well as the signing of the DRP Subscribe by local
pharmacists, especially in terms of the number of occurrences found DRP patients not
receiving the drug.
6. References
1. Muscular Dystropy Canada, 2007. Guillain-Barre Syndrome (GBS), Journal of
Muscular Dystropy Canada: Canada.
2. Inawati, 2013. Guillain-Barre Syndrome (GBS), Faculty of Medicine, University of
Wijaya Kusuma Surabaya.
3. BMJ, 2013. Guillain-Barre syndrome http://www.bmj.com/content/340/bmj.c2541
4. Levine et al, 2002. Antiphospholipid syndrome The. N Engl J Med. Retrieved July
8, 2014 date.
5. Saigal et al, 2010. Antiphospholipid Antibody Syndrome. Vol 58: 1 76-183.
Retrieved July 8, 2014 date.
6. The BMJ Diagnosis and management of the antiphospholipid syndrome in 2010
http://www.bmj.com/content/bmj/340/bmj.c2541/F3.large.jpg .
7. Arifin Augusta, 2011. Guide therapy Diabetes Mellitus Type 2 Current. Faculty of
Medicine, Section of Endocrinology and Metabolism UNPAD: Bandung.
8. American Diabetes Association, 2008. Standards of medical care in diabetes.
Journal of the American Diabetes Association: Diabetes Care S12-54.
1074
9. Canadian diabetes association 2013 pharmacologic Management of Type 2 Diabetes
http://guidelines.diabetes.ca/Browse/Chapter13
10. MIMS,2014.
Methycobal.
https://www.mims.com/INDONESIA/drug/info/
Methycobal / accessed date July 6, 2014.
11. Effendy, 2009. Antiphospholipid antibody syndrome Hematologic and Management
Aspects. Textbook of Medicine in volume II edisis V. Retrieved July 12, 2014 date.
12. MIMS, 2014b. Provelyn. https://www.mims.com/INDONESIA/drug/info/ Provelyn
/? type = brief . Retrieved date of July 6, 2014.
13. MIMS, 2014c. Gammaraas. http://www.webmd.com/cancer/tc/immune-globulinoverview . Retrieved date of July 6, 2014.
14. Medscape,
2014
d.
Drug
Interaction.
http://reference.medscape.com/drug-
interactionchecker . Retrieved July 9, 2014 date.
1075
STUDY IN DISEASE WARD CHRONIC RENAL FAILURE AND TYPE II
DIABETES MELLITUS
1
Deviyanti , 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
[email protected]
ABSTRACT
Chronic Renal Failure (CRF) is defined as a renal function abnormality characterized by
the presence of protein in the urine (proteinuria) and kidney function decline for 3 months
or more to progressive renal failure Terminal1. Causes of chronic renal failure is the most
common are diabetes and hypertension1. Patient Mrs. LS, aged 59 year old, entered the PGI
Cikini hospital on May 4, 2014 with a diagnosis of chronic renal failure and diabetes
mellitus type II. Therapy treatment for 9 days amlodipine 5 mg, lapibal 500 mcg, folic acid
1 mg, 30 mg gliquidone, captopril 12.5 mg and 1 g NaCl capsule. Based on the results of
their clinical practice in internal medicine wards in PGI Cikini hospital it can be concluded
that the presence of DRP (Drug Related Problems) form without drugs and indications of
improper drug selection.
Keywords: Chronic Renal Failure, Diabetes Mellitus Type II, Internal Medicine
INTRODUCTION
Chronic kidney disease is a pathophysiological process with diverse etiologies,
which resulted in a progressive decline in renal function, and generally end up with kidney
failure2. Chronic Renal Failure (CRF) is a global health problem with an increase in the
incidence, prevalence and morbidity3. According to data from the United States Renal Data
System (USRDS) 2009 end stage renal failure (GGTA) is common and the prevalence is
about 10-13%3. In the United States the number reached 25 million people, and an
estimated 12.5% in Indonesia or about 18 million people4. In Indonesia, the number of
patients with chronic kidney disease (CKD) increases rapidly with the incidence of endstage renal failure patients (GGTA) undergoing hemodialysis from 2002 to 2006 is 2077,
2039, 2594, 3556, and 43445. Data from several research centers spread throughout
Indonesia reported that the cause of end stage renal failure undergoing dialysis was
1076
glomerulonephritis (36.4%), kidney disease obstruction and infection (24.4%), diabetic
kidney disease (19.9%), hypertension (9.1 %), other reasons (5.2%)5.
Chronic renal failure is often associated with diabetes or hypertension is a serious
health problem and a public health problem in the world economy6. The number of patients
with chronic renal failure is increasing in the world, about 20-30% of patients with renal
impairment requiring renal replacement therapy6. Diabetes and hypertension are the two
most common causes and is associated with a high risk of death from cardiovascular
disease6.
Report of The United States Renal Date System (USRDS) in 2007 showed an
increase in population of patients with chronic renal failure in the United States compared
to previous years, where the prevalence of chronic renal failure patients reached 1,569
people per million population7. In Indonesia, the number of patients with kidney failure this
time is high, reaching 300,000 people but not all patients can be handled by the medical
personnel, only about 25,000 of those patients who can be treated, it means there is 80% of
patients with treatment untouched at all8. Treatment for patients with end stage chronic
renal failure, dialysis is done with therapy such as hemodialysis or kidney transplant which
aims to maintain the quality of life of patients 9.
CASE PERSENTATION
Patient Mrs. LS aged 59 year old, entered PGI Cikini hospital on May 4, 2014.
Patient was diagnosed with chronic renal failure and diabetes mellitus type II. Patient
present with a limp ± 11 hours before of hospital admission, mild headache, tingling of
fingers and swollen. Results of laboratory tests showed serum creatinine of patient has
increased and Glomerular Filtration Rate (LFG) calculation results in getting results 30.08
ml/min which indicates patient suffering from kidney failure 3 degrees.
CLINICAL EVALUATION
The use of amlodipine and captopril for the treatment of hypertension. Lapibal
(mecobalamin derivative of cyanocobalamin) for the treatment of peripheral neuropathy
and anemia. Folic acid as a therapeutic option to increase hemoglobin with values above
1077
11.5 g/dL for hemoglobin values between 10 g/dL - 11 g/dL of blood transfusion. The use
gliquidon for therapeutic treatment of type II diabetes mellitus, where as saline for the
treatment of hyponatremia and as therapy for anemia.
DOSAGE AND METHOD ARE USED10.11
In the case of patient treated with amlodipine 5 mg administered 5 mg 1x a day for 9 days,
lapibal 500 mcg given 2 x 500 mcg a day for 9 days, folic acid 5 mg administered 1 x 2
tablets a day for 9 days, 30 mg given 2 gliquidone x 30 mg a day for 9 days, captopril 12.5
mg given 2 x 1 tablet for 9 days and 1 g NaCl capsules given 3 x 1 g for 6 days later on the
7th day lowered the dose to 500 mg given 3 x 500 mg for 3 days.
DIAGNOSIS LABORATORIES VALUE12
Hematological examination results on May 4, 2014 showed adecrease in hemoglobin value
of 10.2 g/dL (12-14 g/dL) which indicated the occurrence of anemia, leukocyte 3.0 10
^3μL (5-10 10 ^3μL) and hematocrit 27% (37-43%) decreased that indicated of infection.
Creatinine value increased at 2.3 mg/dL (0.6 to 1.1 mg/dL) that it showed a decrease in
renal function, blood sodium decreased that indicated the occurrence of hyperkalemia and
blood sugar increated at 245 mg/dL (70 - 150 mg/dL), which indicated the presence of
diabetes mellitus.
DIAGNOSIS OF BLOOD GLUCOSE
Blood glucose test results on May 5, 2014 at three time the examination is at 06.00 pm (260
mg/dL), 11:00 pm (240 mg/dL) and 17:00 pm (234 mg/dL) increased from the normal
value of 70 -150 mg/dL, it indicated the presence of diabetes mellitus.
DRUG RELATED PROBLEM 10.11
1. Untreated Indication
Patient required antibiotic therapy for infection but did not get it. Patient also require
anti-inflammatory therapy for inflammation but did not get it.
2. Improper Drug Selection
1078
Election gliquidon therapy for type II diabetes mellitus in patient with chronic renal
failure are not recommended by the BNF edition 57, 2009.
CONCLUSION
Based on the results of their clinical practice at internal medicine ward PGI Cikini hospital
then pull in the conclusion that the results of laboratory tests showed serum creatinine value
and outcomes of patient experienced an increase in Glomerular Filtration Rate (GFR)
calculation in getting 30.08 ml/min which indicates that the patient has had the disease 3
degrees of renal failure and the DRP (Drug Related Problem) in the form of indications that
are not addressed and the presence of improper drug selection.
REFERENCES
1. Putu, et al., 2007.Evaluation of Use of ACE Inhibitors in Chronic Renal Failure
Patients at Dr Sardjito.Faculty of Pharmacy, University of Gajah Mada.
2. Suwitra, K. 2009.Chronic Kidney Disease.Interna Publishing.
3. National Kidney Foundation., 2005.K / DOQI Clinical Practice Guidelines for
Cardiovascular Disease in Dialysis Patients.New York.
4. Suhardjono.2009.Chronic Kidney Disease adal h an outbreak of a new (global
epidemic) throughout the world.Indonesian Society of Nephrology Annual Meeting.
5. Prodjosudjadi, dkk.2009.End-Stage Renal Disease in Indonesia.Treatment velopment.
6. Reikes, ST, 2000, Trends in endstage renal disease: epidemiology, morbidity and
mortality.Postgrad Med;108 (1): 124-142.
7. Warlianawati., 2007.Perceptions of Patients Against Nurses Role in Meeting the
Spiritual Needs in Chronic Renal Disease Patients on Hemodialysis Unit at the
hospital.PKU Muhammadiyah Yogyakarta : Patient Characteristics and Quality of Life
Patients Undergoing Chronic Renal Failure Hemodialysis Therapy.Faculty of Nursing
University of North Sumatra.
8. Aguwina, et al., 2012.Patient Characteristics and Quality of Life Patients Undergoing
Chronic Renal Failure Hemodialysis Therapy.Faculty of Nursing University of North
Sumatra.
1079
9. Brunner & Suddarth., 2002.Textbook of Medical Surgical Nursing.Jakarta: EGC.
10. Burns, A., 2009.R Enal Drug Handbook third edition.UK.
11. BNF., 2009.British National Formulary.BMJ Group.UK.
12. Sutedjo, AY., 2007.Disease Handbook Know Through Laboratory examination
results.Amara Books.Yogyakarta.
1080
COMBINED DRUG RELATED PROBLEMS IN THE TREATMENT OF
TUBERCULOSIS (TB) AND PLEURAL EFFUSION SINISTRA
Dewi Masyitha1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
Tuberculosis is a common disease and often occurs in internal medicine ward at PGI Cikini
Hospital. Classification of tuberculosis there are 2, namely pulmonary tuberculosis and
pleural effusion paru.7 extract also known as fluid in the chest is a medical condition
characterized by an increase in excess fluid between the two layers pleura8. Case
presentation: RM is a 30-year-old man hospitalized in internal medicine wards. Patients
diagnosed with tuberculosis and the left pleural effusion.Clinical evaluation: basically,
there are two interventions were found during the assessment of the patient's treatment, the
first patient did not receive the drug, and both isoniazid and rifampin as the combination of
anti-tuberculosis drugs that cause an interaction.
Keywords: Tuberculosis, Pleural Effusion, PGI Cikini Hospital
INTRODUCTION
Tuberculosis is a disease caused by the bacteria mycobacterium tuberculosis systemic
so it can be on all the organs of the body with the highest location in the lungs which is
usually the site of infection primer.6
Tuberculosis is an important public health problem in the world. In 1992 the World
Health Organization (WHO) has declared tuberculosis a Global Emergency. WHO report of
2004 states that there are 8.8 million cases with pulmonary tuberculosis showed clinical
symptoms include asymptomatic stage, the typical symptoms of pulmonary TB, then
stagnation and regression, eksaserbase worsening, symptoms recur and become chronic. On
1081
physical examination can be found among other signs mark infiltrates (dim, bronkhi bases,
bronhial), withdrawal signs of lung and mediastinum, secret canals and bronkhi breath,
breath sounds amforik due kafitas directly related to bronkus.7
Pleural effusion is a medical condition characterized by an increase in excess fluid
between the two layers of the pleura is a sac pleura.10 consisting of two layers covering the
lungs and chest wall, and separates it from the structures disekitarnya.10 There are two types
of pleural effusion: transudative pleural effusions are caused by fluid leaking into the
pleural cavity caused by low protein concentrations or high blood pressure, such as the state
of the left heart failure or cirrhosis of the liver, whereas other forms of exudative pleural
effusions are often the result of inflammation of the pleura, in circumstances such as
pneumonia and tuberculosis that causes the blood vessels become more permeable allowing
fluid to leak out and assembled between two layers pleura.2
CASE PRESENTATION
RM is a 30-year-old man was treated in the wards for internal medicine. Patients
diagnosed with tuberculosis and the left pleural effusion. Patients hospitalized PGI Cikini
dated March 30, 2014. Konsisi current patients is decreased. Patients feel shortness of
breath, coughing, weight decreased dramatically, fever, night sweats one week before
admission. Upon entering the hospital, the patient feels weak, fever, cough increasingly
become heavy, uncomfortable sleeping position.
The results of laboratory examinations of patients before treatment was given on
March 30, 2014 is for hematocrit, MCV, neutrophils rods, lymphocytes, sodium, calcium
and albumin lower than the normal value, while for the erythrocyte sedimentation rate,
erythrocytes, platelets and monocytes is higher than normal.
The results of laboratory examinations of patients after treatment given date May 6,
2014 is as follows, for MCV, neutrophils rods, lymphocytes and albumin value is still
lower than normal, while the erythrocyte sedimentation rate, erythrocytes, platelets, and
monocytes are still higher than normal values.
Based on the examination of the thorax was found: Lung looks right upper pulmonary
infiltrates and left, still looks hide left hemothorax. Ultrasound examination of the thorax:
1082
Looks effusion fleura pretty much left with a maximum of 6.4 cm into. Conclusion The
results: pulmonary tuberculosis effusion fleura duplex and the left.
As for the therapeutic treatment of patients on April 30, 2014 through to May 9,
2014 is as follows ceftriaxone as antibiotic, OBH as cough syrup, paracetamol as drug
fever, robumin used for albumin deficiency, rifampicin, isoniazid, pyrazinamide,
ethambutol is a combination of drugs for diseases tuberculosis, vitamin B complex, and
Lasix is used for edema.4, 5 Alloy tuberculosis treatment regimen used consisted of main
and auxiliary are as follows: 5
Lini 1
1. Categories 1, anti-tuberculosis drugs:
- Isoniazid
- Rifampicin
- Pyrazinamide
- Ethambutol
Lini 2
Categories 2 :
- Isoniazid
- Rifampisin
- Pirazinamid
- Etambutol
- Streptomisin
For 2 months (intensive phase) every day. Every day for 2 months and then
The next 4 months (continuation phase) with with isoniazid, rifampin, and
Rifampicin and isoniazid 3 times a week.
ethambutol for 5 months 3 times a
week.
2.
Fixed-dose
combination
(fixed
dose
combination).
- Type any additional medication
This fixed dose combination comprising :
(line 2):
- Four antituberculosis drugs in one tablet, namely - Kanamycin
rifampicin 150 mg, isoniazid 75 mg, - Quinolones
pyrazinamide 400 mg and 275 mg ethambutol.
- Other drugs are under
- Three antituberculosis drugs in one tablet,
investigation, macrolides
namely rifampicin 150 mg, isoniazid 75 mg and - Amoxicillin + clavulanic acid
400 mg pyrazinamide.
- Derivatives rifampicin and INH
CLINICAL EVALUATION
3.1 Drug Related Problem 1
Paracetamol is an antipyretic drug that is used as a fever. On May 5, 2014 the patient
complained of body heat or fever, but not given the drug to reduce fever of the patient.
Pharmacist Advice: best use of antipyretic drugs still given by the rules of the use of prn
(prorenata) ie if necessary or if the patient's fever.
1083
Pharmacist interventions: suggested to patients to get plenty of rest and eat foods that
contain protein, low fat, contains fiber, low-salt diet and the consumption of drinking 2
liters/day.
Isoniazid and rifampin is a combination of 4 types of Anti Tuberculosis Drugs (OAT) is
used to treat tuberculosis early phase of 2 months and 4 months of continuation phase.
Concomitant use of both types of OAT can cause significant interaction, which increases
the toxicity of isoniazid rifampin by increasing metabolism.
Pharmacist Advice: a combination of both types of Anti-Tuberculosis Drugs is still given to
patients for the treatment of the initial phase and continuation phase and avoid the use of
fixed-dose combination drug.
Intervention pharmacists: advise the patient to use the distance separating the two AntiTuberculosis drugs, to use rifampin sebaikknya morning and to isoniazid is used at night.
CONCLUSION
On May 5, 2014 the patient complained of body heat or fever, but not given the drug
to reduce fever of these patients, the use of antipyretic drugs should still be given to the
rules of use 3x daily or prn (prorenata) if the patient is febrile. Isoniazid and rifampin is anti
tuberculosis drugs as initial treatment phase and follow-up phase, because concurrent use of
isoniazid with rifampicin can cause significant interaction, the user should be given the
distance, which is used for rifampin and isoniazid morning used at night and avoid the use
of drug-dose combinations fixed. In patients advised to get plenty of rest and eat foods that
contain protein, low fat, contains fiber, low-salt diet and drink consumption 2 liters/day.
REFERENCES
1.
Baxter, K. (ed). 2008. “Stockley’s Drug Interaction”. Eight Edition. Pharmaceutical
Press, London and Chicago
2.
Bramardianto, 2014. “Penyebab, gejala dan pengobatan efusi pleura”. Jakarta
3.
Guyton & Hall. 2007. “Buku Ajar Fisiologi Kedokteran”. Edisi 11.Jakarta : EGC.
4.
Joint formulary comite, 2009 “Brithist National Formulary” BMJ Grop. London.
1084
5.
Konsensus TB Paru. 2013. “Pedoman Diagnosis dan penatalaksanaan TB di
Indonesia”. ISFI. Jakarta
6.
Mansjoer, A. 2000. “Kapita selekta kedokteran”. Edisi II. Jakarta : Media Aesculapius,
FKUI.
7.
Perhimpunan dokter paru indonesia, 2014. “Klasifikasi Tuberkulosis”. Jakarta
8.
Pudjo, Astowo. 2014. “perspective medical conditions disease efusi fleura. Jakarta
9.
Smeltzer, S.C & Bare,B.G.2003. “Buku Ajar Keperawatan Medikal Bedah” Brunner
& Suddart. Edisi 8. Jakarta: EGC.
10. Tjokronegoro,A & Utama, H.2004. “Rencana Asuhan Keperawatan”. Edisi III. Jakarta
: EGC.
1085
DRUG RELATED PROBLEMS IN TREATMENT HEMODIALYSIS
ON CHRONIC RENAL FAILURE
Esther Jeniaty1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Chronic renal failure is one disease that is common and often occurs in medicine
ward in PGI Cikini Hospital. Chronic Renal Failure consists of 5 stages, ie stage 1,stage
2,stage 3,stage 4and stage 5. Percentage of cases: Tn. EH is a 46-year-old man hospitalized
in internal medicine wards. Patients diagnosed with Chronic Renal Failure Stage V and
hypertension urgency. Clinical evaluation: Basically, there are two interventions were
found during the assessment of treatment the patient is the first use of a combination of 5
different Valsartan Antihypertensive, Captropil, bisoprolol and amlodipine and the second
is the interaction between calcium carbonate and bisoprolol causes a decrease in the effect
of bisoprolol.
Keywords: Chronic Renal Failure, antihypertensive, PGI Cikini
INTRODUCTION
Chronic kidney disease (CKD) is the inability of the kidneys to maintain the body's
balance and integrity appear gradually before dropping to phase decline stage renal final3.
Chronic kidney disease is a problem in the field of nephrology with a fairly high
incidence, etiology broad and complex, often with no complaints or clinical symptoms but
had entered the terminal stage and referred to as kidney disease terminal3.
Chronic renal failure occurs after kidney or channel experience a variety of diseases that
damage the kidney nephrons. Where the disease is more common in the renal parenchyma,
nevertheless abstraction lesions in the urinary tract can also cause chronic renal failure can
be divided into several 3.
1086
CASE PRESENTATION
EH is a 46-year-old man hospitalized in internal medicine wards. Patients diagnosed
with chronic kidney disease. Patients hospitalized PGI Cikini 13th June 2014, with past
history of CKD On Hd, Hypertension, and Heart. The patient's condition on admission
decreased, where patients feel weak for 30 minutes while the patient is on hemodialysis and
hemodialysis patients in the stop asking. Hemodialysis performed salama 1 hour 30
minutes. The patient feels tightness, heaviness in the chest radiating to the neck or left arm
when hemodialysis. Patient's blood pressure had risen so Captropil patients given 25 mg,
0.15 mg clonidine, but when taking Captropil, patients experience headache, dry cough. At
the time of entering the ED patients had productive cough with blood, and the patient
experienced severe chest tightness. Laboratory findings were as follows: for the erythrocyte
sedimentation rate, reticulocyte and creatinine higher than normal values, whereas
hemoglobin, leukocytes and erythrocytes is lower than normal values.
The results of examination of the blood pressure on admission was 220 mm Hg
systolic blood pressure and diastolic blood pressure 120 mm Hg indicates that the patient
had hypertension hypertensive urgency is without damage or complications minimum and
target organs. Blood pressure was lowered within 24 hours to the extent of requiring
parenteral therapy. Initial target blood pressure 160/110 mmHg within hours or days with
conventional oral therapy.
The treatment given for patients treated in the hospital is as follows: amlodipine
10mg once daily, 0.15 mg clonidine 3 times, three times a day Captropil 25mg, folic acid a
day 2 tablets, 3 times a day CaCO3 500mg, 1 tablet a day 5000mcg neorobion ,
omeperazole 1 capsule 3 times daily, valsartan 10 mg 2 times a day and 1 tablet daily
bisoprolol.
1087
Guidelines on the Treatment of Chronic Renal Failure patients Hipertensi5.
Management of Hypertension in CRF handling without diabetes is
recommended in adult patients with CRF and without Diabetes Urine albumin
excretion ≤ 30 mg / 24 hours (or satara) blood pressure ≥ 140 mmHg constant
systolic / diastolic ≥ 90 mmHg treated with blood pressure lowering drugs to
maintain blood pressure ≤ 140 mmHg constant ≤ 90 mm Hg systole and
diastole.
It is recommended that non-diabetic adult patients with CRF and urinary
albumin excretion 30-300 / 24 hours (or equivalent) that constantly blood
pressure> 130 mmHg systolic or> 80 mmHg diastolic were treated with drugs
to maintain blood pressure ≤ 130 mmHg constant systole or ≤ 80 mm Hg
diastolic.
Suggested non-diabetic adult patients with CRF and urine excretion> 300 mg
per 24 hours (or equivalent) is constant blood pressure> 130 mmHg systolic or>
80 mmHg diastolic were treated with blood pressure lowering drugs to maintain
blood pressure to maintain blood pressure konstn ≤ ≤ 130 mmHg systolic and
80 mmHg diastolic
It is recommended to use an ARB or ACE inhibitor in non-diabetic adult
patients with CRF and excretion of urine albumin 30-300 mg / 24 hours (or
equivalent) in the treatment with blood pressure lowering drugs.
Recommended that the use of ARBs or ACE inhibitors in non-diabetic adult
patients with CRF and urine albumin excretion ≥ 300mg/24 hours
(or
equivalent) who were treated with blood pressure medications.
.
CLINICAL EVALUATION
Drug Related Problems (DRPs)
1. Drug selection
5 The use of combinations of antihypertensive drugs: amlodipine, Captropil,
bisoprolol,valsartan and clonidine4.
1088
Pharmacist
Advice:
Avoid
concurrent
use
of
Ace-inhibitors
and
ARBs.
Intervention pharmacists: first choice hypertension and CRF is Ace-I, if the patient is
unable to tolerate, then another alternative is ARB4.
2. Drug Interactions
a) Bisoprolol and calsium carbonat
Significant interaction occurred between kalcium carbonate and calcium carbonate
bisoprolol which lowers the effect or efficacy of bisoprolol by inhibiting the
absorption of GI7.
Pharmacist advice: separate the two drugs with a distance of 2 hours
3 drug related problems7.
b) Bisoprolol and clonidin
Cardioselektiv use of beta blockers and centrally acting alpha agonists may lead to
rebound
hypertension
and
there
is
potential
for
interaksi1.
Pharmacist advice: To avoid interaction and rebound hypertension need to be
monitoring the use of both drugs1.
3. Dose regimen
Valsartan dose used by patients Tn.E H 80 mg twice daily for treating hypertension, but
the dose is not in accordance with the guidelines, treatment of hypertension and CKD
the dose should be lowered to 40 mg once a daily8.
Recommendation : doctors should be submitted to the lowered dose of valsartan.
CONCLUSION
After the assessment of the patient's treatment, it can be concluded that there are
five kinds of antihypertensive drugs with their respective functions that have been in use
from the group of patients that is Captropil Ace Inhibitor, Valsartan is an ARB class of
antihypertensive, beta-blocker bisoprolol of classes, class mlodipin is antihipertesi calcium
blockers chanal and the antihypertensive clonidine group of central α-2 agonists. The safest
hypertension medication for kidney patients is if ACEI not tolerated by the patient replaced
with ARB.4 Interaction between calcium carbonate and bisoprolol so in its use must be in
jailed 2 hours. The use of bisoprolol and clonidine can cause rebound hypertension while
1089
the sudden cessation of clonidine can cause rebound hipertensi1.Valsartan as
antihypertensive drugs, the dose should be given 80 mg twice daily lowered to 40 mg in
patients with Chronic Kidney Disease (CKD) on hemodialysis8.
REFERENCES
1. Baxter, K. 2008. Stockley's Drug Interaction Eight Edition. London
2. Joint Formulary Commite. 2009. British National Formulary. London
3. Saputra Ahmad. 2012. Gagal Ginjal Kronik. Jakarta
4. Badan Pom RI. 2008. Informatorium Obat Nasional Indonesia. Jakarta
5. K/DOQI. 2004. Clinical Practice Guadline on Hipertension and Antihypertensive Agent
in Chronic Kidney disease. Am J Kidney Dis. MA,USE.
6. 2003 World Health Organization (WHO) / International Society of Hypertension
Statement on Management of Hypertension. J Hypertens 2003;21:1983-1992.
7. Medscape. Drug Interactions. 2014
8. Caroline Ashley and Aileen Currie. 2009. The Renal Drug Handbook Third Edition.
Radcliffe Publishing Ltd 18 Marcham Road, Abingdon, Oxon OX14 1AA. United
Kingdom
1090
RELATED DRUG PROBLEM IN THE TREATMENT OF VERTIGO DISEASE
AND HYPERTENSION IN PGI CIKINI HOSPITAL
Fitriani1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
Abstract
Vertigo is any movement or sense of movement of the patient's body or objects around the
patient is concerned with balance system disorders (equilibrium)5. One factor is
hypertension systemic causes of vertigo2.
Patient Ms. YT is a female patient aged 53 years old was hospitalized at PGI Cikini on
April 29, 2014, the patient was diagnosed with vertigo and hypertension. Therapy treatment
for 8 days ie RL 20 TPM, Ranitidine 2x1, 2x1 g Ceftriaxone, Ondancetron 3x1, 3x1
Antacids, Valsartan 1x1, 3x1 Ibuprofen, Betahistin M 2x1, 3x1 Dramamin, Decolax 2x1,
3x1 Myonal. Based on the results of their clinical practice in internal medicine wards in
hospitals PGI Cikini it can be concluded that the presence of DRP (Drug Related Problem)
a drug interaction.
Keywords: Vertigo, Hypertension, RS PGI Cikini
1. Introduction
Vertigo is the sensation of movement or sense of motion of the body such as rotation
(twisting) without an actual sensation of rotation, can spin around or body that rotates
complaints most often encountered in practice8. Vertigo comes from the Latin "vertere"
ie turning 8. Vertigo included in balance disorders
manifested
as
headache,
dizziness, staggering, a sense of the world such as flying or somersaulting 8,5. Vertigo is
not a disease, but a symptom In short it can be said that the orientation space (spatial
orientation) we depend on three things, namely7:
1091
1. Input stronger sensation (sensation adequate input) through three of our five senses
are: sight, taste balance of the body, and sensibility.
2. Integration in the center (central integration)
3. Responses suitable motor (the motor proper response)
If the information received through the eyes does not match the information from the
labyrinth, then there will be Factors causing vertigo7.vertigo is caused by central
disorders associated with central nervous system disorders (serebrim cerebellar
cortex, brain stem or related to the vestibular system / otologik, in addition to the
factor of psychological / psychiatric and systemic factors such as aritmi heart,
hypertension, hypotension, congestive heart failure, anemia, hypoglycemia 2,6.
Patient Ms. YT is a 53-year-old admitted to the ward's disease internist PGI Cikini
Hospital, was diagnosed with vertigo and hypertension, patient admitted to hospital
since April 29, 2014 Patient with complaints of fever since two weeks before entering
the hospital with chills, dizziness, nausea, and abdominal pain.
Results of laboratory tests on the patient April 29, 2014 were:
examination
glucose during
leukocytes *
LED
hemoglobin *
hematocrit *
erythrocytes
platelets
urea
creatinine *
total cholesterol
AST *
SGPT
sodium
calcium
chloride
HDL Cholesterol
LDL Cholesterol
Results
122
12,600
2
11,5
34
3,91
234
22
12
170
35
29
144
4,5
103
65
98
Reference value
< 200 mg%
5,000-10,000/uL
0-15 mm/hour
12-16 a/dL
38-46%
3,6-5,2 million/mm3
150-400 thousand/mm3
17-43 mg/dl
0,6-1 mg/dl
<200 mg/dl
<31u/L
<31u/L
134-146 mmol/l
3,4-4,5 mmol/l
96-108 mmol/l
>65 mg/dl
<150 mg/dl
1092
The results of examination of the patient's vital signs on 29 April- May 6, 2014 is :
Examination
/ date
Blood
tension
pulse
breathe
29/04
30/04
01/05
02/05
03/05
04/05
05/05
06/05
160/8
0
80
20
130/8
0
80
20
120/8
0
80
20
130/8
0
80
20
150/8
0
80
20
130/9
0
80
20
130/9
0
80
20
130/9
0
80
20
3. Dosage
In this case the patient on therapy with intravenous fluids: RL 20 TPM for 5 days
(April 29,-May 3, 2014). Drug injection: Ranitidine (Ranitidine HCl) 2x1 25 mg for 4
days (April 29,-May 2, 2014), Ceftriaxone (Ceftriaxone disodium) 2x1g for 4 days
(April 29,-May 2, 2014), Ondancetron (ondancetronHCl) 0.1 3x1 -0.2 mg / kg for 5
days (April 29,-May 3, 2014). Oral medications: Antacids (Aluminum Hydroxide,
Magnesium Hydroxide) 3x1 1-2 g for 8 days (April 29,-May 6, 2014), 1x80 mg
valsartan for 8 days (April 29,-May 6, 2014), 3x1 Ibuprofen 200 mg for 2 days (April
29 to 30), Betahistin M (betahistinemesylat) 2x1 24-48 mg / day for 7 days (April 30May 6, 2014), Dramamin (Dimrnhydrinate) 3x1 50mg for 5 days (02-06 May 2014),
Decolax (Bisacodyl) 2x1 5 mg for 2 days (05-06 May 2014), Myonal (EperisoneHCl)
50mg 3x1 (05-06 May 2014).
4.
Clinical Evaluation 3.4
The use of Ringer lactate infusions to restore electrolyte balance, Ranitidine
(Ranitidine HCl) for antiulkus, Ceftriaxone (Ceftriaxone disodium) to treat respiratory
tract, Ondancetron (OndansetronHCl) for nausea and vomiting, Antacids (Aluminum
Hydroxide, Magnesium Hydroxide) to treat ulcers or interference acid digestion,
Valsartan for Hypertension, Ibuprofen for pain, Betahistinmesylat for treating vertigo,
dizziness, balance disorders in blood circulation. Dramamin (dimenhydrinate) to treat
vertigo, nausea or vomiting. Decolax (Bisacodyl) to overcome constipation. Myonal
(EperisoneHCl) for the symptomatic treatment of musculoskeletal spasm.
1093
5.
Drug Related Problem1
Of some drugs given drug-drug interaction, namely:
a. Antacids + Ranitidine
Effect: Antacids decrease the bioavailability of ranitidine, have to be careful with this
interaction because both drugs are often used together in the treatment of ulcers.
Recommendation: to prevent interactions using both drugs at intervals of ± 2 hours.
b. Antacids + Ceftriaxone
Effect: lowers the effectiveness of ceftriaxone Antasi
Recommendation: to prevent interactions using both drugs at intervals of ± 2 hours.
6.
Conclusion
Based on the results of clinician practice in internal medicine wards in the hospital in
patient PGI Cikini then the conclusion that the presence of DRP (Drug Related
Problem) in the form of the presence of several drug interactions that occured were
Antacids + Ranitidine and Antacids + Ceftriaxone.
7.
Bibliography
1. Baxter, 2008. K. Stockley’sDrug Interaction Eight Edition. London.
2.
Bashiruddin J. Vertigo Posisi Paroksismal Jinak. Dalam : Arsyad E, Iskandar
3.
N, Editor. Telinga, Hidung Tenggorok Kepala & Leher. 2008. Edisi Keenam.
Jakarta : Balai Penerbit FKUI.
4.
BPOM RI, 2008.“IONI”. SagungSeto Jakarta
5.
ISFI, 2009.“ISO Indonesia Vol. 44”. BerlicoMuliaFarma. Yogyakarta
6.
Joesoef Aboe Amar. 2000. Vertigo. In : Harsono, editor. Kapita Selekta Neurologi.
Yogyakarta: Gadjah Mada University Press
7.
Li JC & Epley J. Benign Paroxysmal Positional Vertigo. [online] 2009 [cited
20th]. Available from: http:// emedicine.medscape.com/article/884261-overview.
8.
Poerwad,
TroboesdanHerjantoPoernomo.
1994.:VertigodalamNeurologiKlinik.
Surabaya: FK UNAIR/RSUD Dr. Soetomo.
9.
Wreksoatmojo BR. Vertigo-Aspek Neurologi. [online] 2009 [cited 2009 May
1094
DRUG RELATED PROBLEM TREATMENT OF FEMORAL NECK FRACTURES
IN MINTOHARJO HOSPITAL
1
Fitriany JR , Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
A fracture is a break or continuity of bone and cartilage which is generally caused by
trauma, either directly or indirectly. Femoral neck fractures are intracapsular fracture that
occurs in the proximal femur including the femoral collum is starting from the distal
surface of the femoral head to the proximal part of the intertrokanter. 3 femoral neck
fractures often occur at the age of 60 years and more frequently in women, it This is caused
by a combination of bone loss due to aging processes and post-menopausal osteoporosis
which often can also be seen when the shortening of the left leg compared with the right,
the distance between the greater trochanter and the anterior superior iliac spine is shorter
because the trochanter is higher due to a cranial shift of the leg. 5 Patients Mr.. TS, aged 49
years, entered to hospital PGI Cikini on June 10, 2014 with a diagnosis of Femur Fractures
Collum. Therapy treatment for the treated ceftriaxone inj, remopain injection, ranitidine
injection, ketorolac injection, injection propranolol, amlodipine tab, Celexa, tabs, tab
ultracet, cal 95 tabs, tab oscal, alovell tab, novalgin inj, Rantin tab. Based on the results of
their clinical practice on general care in hospitals PGI Cikini it can be concluded that the
presence of DRP's (Drug Related Problem s) in the form of improper drug selection, the
indication is not handled as well as failed to receive the drug ranitidine inj, Rantin tab,
ultracet tab.
Keywords: Collum Fracture Femur, Internal Medicine and PGI Cikini Hospital.
INTRODUCTION
Femoral neck fractures are injuries that are often found in older patients and lead to
increased morbidity and mortality with health status and life expectancy, the incidence of
these fractures also increased. This fracture is a major cause of morbidity in older patients
due to immobile patient in bed. Rehabilitation takes for some months, causing
1095
immobilization of patients prefer to lie so susceptible to decubitus ulcers and lung
infections. Initial fracture mortality rate is about 10%. When untreated, these fractures
would worsen. 1 Magnetic ResonanceImaging (MRI) has been proven accurate in the
assessment of fracture and if made within 24 hours of injury, but this examination is
expensive. With MRI, fractures usually appear as a fracture line in the cortex surrounded by
a zone of intense edema in the medullary cavity. In a study by Quinn and McCarthy,
findings on MRI 100% sensitive, specific and accurate in identifying femoral neck fractures
4. Most fractures are caused by a sudden force and excessive, which can be a clash, beating,
crushing, bending or falling on his side, twisting or withdrawal when exposed to direct
force on a broken bone can be affected, it is definitely damaged soft tissue 2.
CASE STUDY
Patient Tn.TS, age 49 years was entered to hospital June 10 2014 PGI Cikini
Patients present with complaints of pain in the left groin, after the fall because of a slip and
fall while walking in the sitting position, the more painful when moved. A history of head
injury (-), fainting (-). The general condition of the patient at the time of hospital admission
was looked ill with a blood pressure of 160/108 mmHg, Nadi92 times / min, temperature 38
° C awareness CM. The patient had a history of hypertension.
CLINICAL EVALUATION
Therapy in the management of femoral neck fractures Tn.TS to suffer. Ceftriaxon
given to treat bacterial infections of gram-positive and gram-negative. Remopain
(ketorolac) is used for short-term treatment for post-surgical pain is moderate to severe and
Propranolol for hypertension as well as with Amlodipine for hypertension, angina
prophylaxis. Celexa (levofloxacin) for infection due to microorganisms Ultracet for shortterm therapy for moderate to severe acute pain. Oscal (alfacalcidol) is used for the
improvement of some symptoms (bone pain, bone lesions) while Alovell (Aledronat
sodium) for the treatment of osteoporosis confirmed the findings with low bone mass or by
the presence or history of osteoporotic fracture. Cal 95 is used for the treatment of
osteoporosis due to various reasons. Ranitidine is used for other conditions where gastric
1096
acid reduction will be beneficial and Novalgin (Metamizole Sodium) for pain relief after
surgery.
Dosage and how to use the drug in these patients on 13th June 2014 Ceftriaxon 2x1
grams used in injection with usual doses in severe infections 2-4 g / day. on the 13th of
June 2014 Remopain (ketorolac) is given 2x1 amp and on 14 June 2014 increased the dose
to 3x1 amp with standard dosing: initial dose, 10 mg, then 10-30 mg every 4-6 hours when
required. On 10 June 2014 given Ranitidine injection ampoules 1x1 failed to receive the
drug one time and date of 11-16 June 2014 2x1 ampoules Ranitidine injection is given at a
dose of common IM / Slow IV injection: 50 mg every 6-8 hours IV infusion: 25 mg / h for
2 hours, 6-8 hours, or for the prophylaxis of stress ulceration 125-250 mcg / kg / h. On 12
June 2014 granted 1x1 Ketorolac injection ampoules with standard dosing: Awal10 mg
dose, then 10-30 mg every 4-6 hours when required. On 11 June 2014 Propranolol was
given at a dose of 1x10 mg prevalent: the initial oral dose of 80 mg, 2 times daily. On 1119 June 2014 1 x Amlodipine 5 mg given with standard dosing: initial dose of 5 mg once
daily; a maximum of 10 mg once daily. On June 14-19, 2014 Celexa (levofloxacin) tablets
given 1 x 500 mg with standard dosing: oral, 250 mg-500 mg once daily for 7-14 days,
depending on the severity of the 14-17 June 2014 penyakit.pada given Ultracet 3 x1 tablet
and on December 13,18 and 19, failed to receive a one-time drug with standard dosing: 1-2
pain relief tablets every 4-6 hours up to 8 tablets a day, patients with creatinine clearance
<30 m / min ≤ 2 tablets every 12 hours . On 13-19 June 2014 awarded Cal 95 1 x 1 tablet
with a usual dose: 1-3 / tabs / day. On May 13-19 given Oscal (alfacalcidol) 1 x1 tablet
with the usual adult dose initially dose of 250 nanograms per day or 2 days, the usual dose
of 0.5-1 mcg per day. On 13 Alovell (Alendronate sodium) is given 1 x 1 tablet with a
usual dose of 10 mg once daily. On 13 given Novalgin (Metamizole sodium) intravenously
at a dose of 1cc usual 500 mg / ml. On 17 and 19 June 2014 given Rantin 2 x 1 tablet while
on the 18th June 2014 failed to receive the drug once.
1097
CLINICAL LABORATORY EXAMINATION RESULTS
In the laboratory test results dated 10 June 2014 entered patients obtained some
abnormal results include an increase in leukocytes 13,900 mm 3 with a normal value of 510 thousand mm 3, an increase in APTT of 38.4 seconds with a normal value of 26.4 to
37.5 seconds, a decrease in potassium 3.0 mEq / L with a normal value of 3.5-5.0 mEq / L,
and decreased calcium 8.2 mg / dl with normal values of 70-150 mg / dl 4.
DRUG RELATED PROBLEMS (DRP's)
1.
Improper drug selection 7
Of laboratory examination of patients found that higher patient APTT should get antipain patients who are not at risk of bleeding
2.
The indication is not handled 7
Judging from the value of potassium patients were dropped but the patient does not get
the drugs that may increase potassium.
3.
Failed to receive medication
On 14-17 June 2014 given 3 x1 Ultracet tablets and on December 13,18 and 19, failed
to receive the drug once, On 17 and 19 June 2014 given Rantin 2 x 1 tablet while on the
18th June 2014 failed to receive a one-time drug , and dated June 11-16 2014 2x1
ampulsedangkan Ranitidine injection is given on 10 June 2014 was given Ranitidine
injection ampoules 1x1 failed to receive the drug once.
4. Human Error
In the book list is sometimes nurses did not record drug medication that is administered
to the patient. So it is advisable to nurses to always take note of what has been given to
the patient. Do monitoring nurse notes on the book list of drugs.
CONCLUSION
Based on the results of their clinical practice in the treatment of pulmonary PGI
Cikini hospital, it can be concluded that the presence of DRP (Drug Related Problem) The
selection of a drug that is not appropriate because of the patient's laboratory tests found that
higher patient APTT should get anti-pain patients who are not at risk of bleeding,
1098
indications of untreated patients seen from potassium values are down, but the patient does
not get the drugs that can increase potassium, failed to receive the drug ranitidine inj,
Rantin ultracet tabs and tab.
REFERENCES
1. Rosenthal RE. Fracture and Dislocation of the Lower Extremity. In: Early Care of the
Injured Patient, ed IV. Toronto, Philadelphia: BC Decker, 2006.
2. Grace PA, Borley NR. Ataglance surgery. 3rd edition New York: McGraw; 2006.p.85
3. Kailis SG, Jellet LB, Chisnal W, Hancox DA. A rational approac h to the interpretati on
blood and urine of pathology tests. Aust J Pharm 1980 (April): 221-30.
4. Rasad, S. Diagnostic Radiology. 2nd edition of Jakarta, Faculty of Medicine Hall
Publishers; 2006.p.31
5. Snell RS. Clinical anatomy for medical students 6th edition Jakarta: EGC; 2004
6. Teaching staff of the Faculty of Medicine Jakarta surgery. Set of lecture surgery.
Jakarta: Center School of Medicine Publisher; 2004.p.484-7.
7. SM.BOH Stein "s Pharmacy practice manual: a guide to the clinical experience. 3rd ed.
2010 Lippincott Williams and Wilkins.
1099
PHYSIOTHERAPY STUDY ISCHIALGIA
Fitriani1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Ischialgia is a type of pain that is caused by the excitation of nervus ischiadicus1. Medical
dictionary defines ischias as thigh sores or pain in thigh area (nervus ischiadicus)2. The
patient, Ms. SL, age 32, came to RSAL Dr. Mintoharjo on June 9, 2014 with an ischialgia
diagnosis. Therapy for 8 days treatment is IVFD RL 500 ml, ketorolac injection of 3 x 1
ampoules, Dexamethasone injection 3 x 5 mg, Mefenamic Acid 3 x 500 mg, Diazepam 3 x
2 mg. Based on the results of the clinical practice in physiotherapy ward at RSAL
Dr.Mintohardjo, it can be concluded that there is DRPs (Drug Related Problems) such as
drug interactions and conditions that need to be considered.
Keywords: Ischialgia, RSAL Mintohardjo.
INTRODUCTION
Ischialgia is a pain which originates in the thigh lumbosacral area spreading to the
buttock and then to the posterolateral upper limb, the lateral lower leg, as well as the
lateral foot3. Nervus ischiadicus is located between the musculus piriformis and musculus
obturator internus4. For a person who’s actively running, joint that gets a lot of burden is
the hip joint, thus the bloodstream is concentrated in the area4. The bloodstream is
increased to provide oxygen therefore energy production can run smoothly, however the
bloodstream indeed causes swollen4. Swelling is also caused by a buildup of metabolic
waste results (myogelosis)4. Because of musculus piriformis and musculus obturatoris
internus are swollen, as a result nervus ischiadicus will be strangulated4.
Typical complaint is cramping or pain in the buttock or in the area of hamstring
muscles, ischialgia pain in the legs without back pain, and impaired sensory and motor
nerve that suits Nervus ischiadicus distribution5. Patients’ complaint can also be a pain that
1100
is getting severe pain when bows, sitting for too long, getting up from sitting, or when
internally rotate the thigh, also pain during micturition / defecation and dyspareunia5. This
occurs because some disease processes such as physical trauma, electrical, infections,
metabolic problems, and autoimun5. Ischialgia increases in frequency of doing so many
activities5.
There are several factors that lead this nerve strangulated, which include:
contraction / inflammation of the muscles in buttocks area, there is calcification of the spine
or circumstances referred to hernia nucleus pulposus (HNP)5. To know the main reason,
physical examination needs to do carefully by a doctor, or additional screening radiology /
X-ray of the spine if necessary5.
CASE PRESENTATION
The patient, Ms. SL, age 32, came to RSAL Dr.Mintohardjo on June 9th 2014. The patient
had pain complaint in the left groin since 3 days ago. Persistent pain and sometimes the
pain spread to waists. The patient also feels nausea without vomiting. The previous 2
months ago, the patient slipped with sitting position. The patient has dyspepsia past history.
The result of laboratory tests showed abnormalities, hematocrit 35% (normal value: 3742%), leukocytes 10,500 / µL (normal value: 5,000-10,000 / µL), LED 45 mm / hours
(normal value: < 20 mm / hour), HDL cholesterol 38 mg / dL (normal value: > 40 mg / dL),
Neutrophils stem 1% (normal value: 2-6%), neutrophils segment 81% (normal value: 5070%), lymphocytes 10% (normal value : 20-40%).
TREATMENT MANAGEMENT ISCHIALGIA6
1.
Drugs: analgesics, NSAIDs, muscle relaxant.
2.
Medical Rehabilitation Program
a. Physical therapy: Diathermy, Electrotherapy, lumbar traction, manipulation
therapy, Exercise.
b. Occupational Therapy: Teaching proper body mechanics.
c. Prosthetic orthotic: Giving lumbar corsets, a walker.
d. Advice:
1101

Avoid much bowing.

Avoid lifting of heavy goods frequently.

Take a break if get a pain when standing or walking.

When sitting for a long time, try to rotate feet alternately right and left, or use a
small seat for both of leg lean on.

When sweeping or mopping floors, use a handle broom or long mop therefore
the back does not bend.

If you want to take things on the floor, keep your back straight, but bend your
knees to reach the goods.

Do back exercising regularly, to strength back muscles thus can sustain the
spine nicely and optimally.
3.
Operation: perform in serious case / when it very disturbs the activities, where the
drugs and medical rehabilitation program do not help.
EVALUATION CLINIC7
The use of RL infusion aims to restore the balance of body fluids. Ketorolac
injection is used for short-term treatment for severe pain, Dexamethasone injection for antiinflammatory, Mefenamic Acid to cope with left groin pain that has experienced before by
the patient, diazepam to relax the muscles and to make the patient relax.
DOSAGE AND HOW TO USE7
In this case the patient is treated with 500 ml RL for 8 days, ketorolac injection is
given 3 x 1 amp for 8 days, Dexamethasone injection is given 3 x 5 mg for 8 days,
Mefenamic Acid is given 3 x 500 mg after meals for 8 days, and Diazepam is given 3 x 2
mg for 8 days.
THE RESULT OF LABORATORY TEST8
The result of laboratory test showed a decrease in hematocrit value of 35% (normal
value: 37-42%) indicates the occurrence of anemia, reduction in lymphocytes of 10%
(normal value: 20-40%) indicates the occurrence of anemia, reduction in HDL cholesterol
1102
38 mg / dL (normal value: > 40 mg / dL), reduction in neutrophils stem 1% (normal value:
2-6%), the value of leukocytes is increased 10,500 / µL (normal value: 5,000-10,000 / µL),
the value of LED is increased 45 mm / hour (normal value: < 20 mm / h), and neutrophils
segment is also increased 81% (normal value: 50-70%) that indicates there is an infection /
inflammation.
DRUG RELATED PROBLEM8,9
1.
Drug Interaction9
The patient is given ketorolac injection and mefenamic acid. The two of these can
lead ulcer irritation, and there is an interaction pharmacodynamicly (synergism)
where the ketorolac injection increases the effect of mefenamic acid, therefore the
proton pump inhibitor is recommended to be given which the purpose is to overcome
ulcer irritation and nausea that patient is suffered.
2.
The condition that needs to be considered8
Conditions that need to be considered in this patient where patient gets reduction in
hematocrit and lymphocyte values that indicates the occurrence of anemia, hence it
should be given vitamin blood booster to improve the patient's health.
CONCLUSION
Based on the results of the clinical practice in physiotherapy ward in RSAL
Dr.Mintohardjo, it can be concluded that there is DRPs (Drug Related Problems) in form of
a drug interaction, that requires the patient to get other drugs such as proton pump inhibitor
drugs to reduce stomach irritation that caused by the interaction of the two drugs (ketorolac
injection and mefenamic acid) and later that needs to get attention is the patient's condition
which is anemia that should get the blood booster drug therapy.
REFERENCES
1. Markam, Soemarmo. Neurologi, Jakarta: PT. EGC, 1982.
2. Kamali, A. Kamus Kedokteran, Jakarta: PT. Dian Rakyat, 1983.
1103
3. Mardjono M., and Sidharta P. Neurologi Klinis Dasar, Jakarta: PT. Dian Rakyat. 1978.
4. Sabotta. Atlas Anatomi Manusia Bagian 2, Jakarta. 1985.
5. Minaryanti, RN. Karya Tulis Ilmihah Penatalaksanaan Fisioterapi Pada Ischialgia
Dengan Short Wave Diathermy Dan Terapi Latihan Di RSUD Sreagen. Surakarta:
Universitas Muhammadiyah Surakarta. 2009.
6. Anggriani, W. Penatalaksanaan Fisioterapi Pada Ischialgia Dekstra di RS Dr Ramelan
Surabaya. Surakarta: Universitas Muhammadiyah Surakarta. 2010.
7. Agency for Food and Drug Administration. Information Obat Nasional Indonesia
(IONI). Jakarta: Sagung Seto. 2008.
8. Ministry of Health Indonesia. Pedoman Interpretasi Data Klinik, Jakarta. 2011.
9. Medscape. Drug Interaction. 2014.
1104
TREATMENT OF THE CHRONIC KIDNEY DISEASE (CKD) PATIENT IN THE
PGI HOSPITAL CIKINI JAKARTA
Francisca Linawati Moeljono1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
Email: [email protected]
ABSTRACT
Renal failure is usually divided into two broad categories namely chronic and acute.
Chronic renal failure is a progressive development of renal gagl and slow (usually lasting
several years), whereas acute renal failure occurs within a few days or a few weeks. 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. Ny.SS patients, aged 64 years, entered the hospital PGI Cikini on
June 2, 2014 with a diagnosis of CKD (Chronic Kidney Disease). Therapy treatment for the
amlodipine treated, levofloxacin, meropenem, mebo oint (Radix Extract Scullaria),
renxamin (amino acid), sumagesic (paracetamol). Based on the results of their clinical
practice in internal medicine wards in hospitals PGI Cikini it can be deduced that the
presence of DRP (Drug Related Problem) a correlation between drug therapy with clinical
conditions such as drug delivery is not as indicated, the dose is less than the actual drug and
failed to receive treatment .
Keywords
: CKD, Hypertension dan RS PGI Cikini
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.
1105
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 uremia3.
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 are:
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.
- 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.
1106
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 hormones6.
CASE PRESENTATION
Patients aged 64 years Ny.SS PGI Cikini hospitalized on 02 June 2014. Patients
present with swelling in the legs, heartburn, pain from tungkak right down, the patient does
not feel nausea or vomiting.
Patients experienced severe infections on the feet with increased white blood cells
and severely injured condition, and patients with impaired renal urea levels high. The
patient had a history of hypertension and CKD..
CLINICAL EVALUATION
The use of amlodipine to treat high blood pressure (hypertension) occurred in patients,
Levofloxacin as a broad spectrum antibiotic, is also used as an antibiotic Meropenem,
Sumagesic used to relieve pain in patients with swollen legs, and mebooint used for foot
ulcers of patients for skin ulcers . Therapeutic treatment is given of the date of June 2 to
June 11 by 2014.
DOSAGE AND USE1
No.
1.
Drugs
LEVOFLOXACIN
Giving method
PO
Dose
1X500mg daily
Indications
Antibiotic
2.
MEROPENEM
PO
3 x 500 mg daily
Antibiotic
3.
AMLODIPIN
PO
1 x 5mg daily
Hypertension
4.
SUMAGESIC
PO
3X1 daily
Painful
5
TRAMADOL
PO
If pain occurs
Painful
6
RENXAMIN
IV
1X1 daily
Electrolit
7
MEBO OINT
Topical
4-5
Wounded
1107
CLINICAL LABORATORY VALUES
Type of examination
Hemoglobin
Hematocrit
Leukocytes
Platelets
Reticulocyte
Type of examination
Freezing period
APTT
PT
INR
Fibrinogen
Total Protein
Albumin
Globulin
Urea
Creatinine
Urid acid
Sodium
Potassium
Result
11,8
*32
37600
199
*160.000
Result
10,11
53,7
14,2
1,2
271
Unit
g/dL
%
10^3 µL
10^3 µL
µg/L
Unit
minutes
second
second
Normal value
13,0-16,0
40-48
5,0-10,0
150-450
5 – 15
Normal value
10,0 – 16,0
26,4 – 37,5
11,0 – 14,2
mg/dL
180 – 350
5,9
2,1
3,8
132
4,1
6,5
129
3,6
g/dL
g/dL
g/dL
mg/dL
mg/dL
mg/dL
mmol/L
mEq/l
6,0 – 8,0
3,4 – 4,8
1,3 – 3,7
10 – 50
0,6 – 1,1
< 6,8
135 - 147
3,5 – 5,0
GUIDELINE PAIN
1108
MANAGEMEN OF TREATMENT CKD (CHRONIC KIDNEY DISEASE)
1. The drug is not suitable indication
The patient was having a medical problem that requires drug therapy but did not
get the medicine according to the indication. Found CKD diagnosis but received no
prescription for CKD indication, but more handlers to infections and hypertension, but
found that the supporting laboratory values refer to CKD.
2. Drugs Interaction
The use of the antibiotic levofloxacin tramadol drug must be in pause time
drinking because It can work to lower analgesic.
3. Administered dose was less
The patient was having a medical problem that requires drug therapy but the
appropriate drug therapy problem is given at a dose below the recommended dose
treatment is justified. Found the use of amlodipine 5 mg once daily with a blood
pressure of 158/80 mmHg or less but not dose increased to 10 mg once daily.
4. Failed receiving treatment
The patient was having a medical problem that requires drug therapy but can not
receive treatment with economic reasons, psychology, sociology, or for reasons of
1109
pharmaceutical. Found that the use of antibiotics meropenem administration is not
every day, for economic reasons, should be given 1x 3x or even not given.
5. Missing Right Drug Selection
The use of antibiotics should not directly use the antibiotic meropenem as an
antibiotic if this is the last line of antibiotic resistance occurs. And not scar tissue
culture examination.
CONCLUTION
Based on the results of their clinical practice in internal medicine wards in hospitals
PGI Cikini it can be deduced that the presence of DRP (Drug Related Problem) a
correlation between drug therapy with clinical conditions such as the presence of drug
delivery that are not appropriate indications and dose of drugs given to patients less than
that actually found the use of amlodipine 5 mg once daily with a blood pressure of 158/80
mmHg or less, but the dose was not increased to 10mg once a day and failed to receive
treatment.
ADVICE
Need for additional anticoagulation clinic because the laboratory tests found the
presence of a high APTT values.
REFERENCES
1. A. Price, Sylvia & M. Wilson, Lorraine. 2005. Edisi 6. Vol.2. Gagal Ginjal Kronik.
Patofisiologi Konsep Klinis Proses-proses Penyakit. Jakarta: EGC .
2. Aru W Sudoyo, dkk. 2009. Jilid 3. Edisi V. Penyakit Ginjal Kronik. Buku Ajar Ilmu
Penyakit Dalam. Jakarta : Interna Publishing
3. Doqi
Guidelines.2002.Clinical
Practice
Guidelines
on
Hypertension
and
AntyhipertensionAgents.USA
4. Jay H. Stein, MD. 2001. Panduan Klinik Ilmu Penyakit Dalam. Jakarta : EGC.
5. Smeltzer, Suazanne C. 2001. Edisi 8. Volume 2. Gagal Ginjal Kronik. Buku Ajar
Keperawatan Medikal-Bedah Brunner & Suddarth. Jakarta: EGC.
1110
6. Sibuea, W Herdin, dkk. 2005. Penanggulangan Gagal Ginjal Kronik. Ilmu Penyakit
Dalam. Jakarta : Asdi Mahasatya
7. The British Pain Society.2013.Understanding and managing pain:information for
patients, London
1111
DRUG RELATED PROBLEMS OF BLADDER CANCER SUSPECT IN
SURGICAL WARD PGI CIKINI HOSPITAL
Haerul Syam1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
Bladder cancer is one of the common diseases founded in internal disease ward at PGI
Cikini Hospital. Bladder is a hollow organ walls consist of smooth muscles called muscle
detrusol1. In some cases we will get a painless gross hematuria i.e the urine always red8.
Symptoms of bladder cancer such as blood mixed intermittent urination, feeling hot
urination, feeling to urinate, frequent urination, especially at night and on the next phase of
difficult urination, suprapubic pain that is constant, hot body and feel weak, low back pain
due to nerve pressure, pain on one side because hydronefrosis9.
Case presentation: SS is a 64 year old man hospitalized in internal disease wards. Patients
diagnosed with Bladder cancer disease. Preclinical evaluation: In this case must be
considered is the use of drugs which can be interact such as ketorolac may interact with
losartan and vitamin K with ketorolac.
Keywords : Bladder cancer suspect, Internal disease ward, PGI Cikini Hospital
Introduction
Bladder cancer is one of the common diseases founded in internal disease ward at PGI
Cikini Hospital. This cancer is usually a superficial tumor10. These tumors over time can
be held infiltration into the lamina phopria, muscle and perivesika fat which then spread
directly to the network around10. In some cases we will get a painless gross hematuria i.e
the urine always red8. Bladder is a hollow organ walls consist of smooth muscles called
muscle detrusol1. This muscle is composed of the fiber direction such that when contracted
causes the bladder to contract and shrink in volume. In distal part that close to the pelvic
1112
base (Diafgrama Urogenital) detrusor muscle forming tube and coating posterior urethral1.
Carcinoma of the bladder is still early superficial tumors2. These tumors can hold over time
infiltration into the lamina propria, muscle and fat perivesika which then spread directly
into the surrounding tissue2. Besides, the tumor can spread and hematogenous limfogen2.
The spread to the lymph glands limfogen perivesika, obturator, iliac and common iliac
ekterna, while the most frequent hematogenous spread to the liver, lungs and bones7. Many
factors influence the occurrence of bladder carcinoma include age, bladder carcinoma is
increased in the decade 60's, carcinogens, both derived from exsogen of cigarettes or
chemicals or endogenous metabolism of the results, another cause is suspected due to the
use of analgesics, cytostatic and chronic irritation by stones, sistomiasis or radiation7.
CASE PRESENTATION
SS is a 64-year-old man hospitalized in internal disease wards. Patients diagnosed
with suspected bladder cancer. Patients enter PGI Cikini hospital dated 30 April 2014.
Patient feels weak, hot body and bloody urine before enter hospital. Upon entering the
hospital, the patients feel back pain, fever, feeling tired and bloody urine. Clinical
chemistry examination has decreased calcium of 8.4 mg / dL, whereas in hematologic
examination, urine and parasitological increase in erythrocyte sedimentation rate 20 mm /
h, 2% basophil, eosinophil 13%, 10% monocytes, protombin past 14 , 3 seconds, the
bacteria in the urine 2362 / LPB and experienced a decrease in hemoglobin of 7.3 g / dL,
3.38 10 ^ 6μL erythrocytes, hematocrit 24%, 1% neutrophils rod, segment neutrophils 47%,
MCV 70 fL, MCH 21.6 pg, MCHC 30.8 g / dL, urine specific gravity of 1.010 g / mL.
Drug therapy given to patients include ceftriaxon given on day 3 to day 9 as antibiotics due
to bacterial infection, torasic (ketorolac) was given on day 3 to day 9 are used for short term
treatment of acute moderate to severe pain after surgical procedures, vomizole
(pantoprazole) was given on day 4 to day 9 was used as a pathological hypersecretion that
can not be treated orally, kalnex (tranexamic acid) administered on day 3 to day 9 is used to
prevent bleeding during surgery, vitamin K is given on day 3 to 9 days to be used for
deficiency of vitamin K, urecolin given on day 4 to day 9 for fluid retention before and
after surgery, cernevit given on day 3 to day 9 daily supplement, angioten (losartan) was
1113
given on day 4 to 9 days to be used for hypertension, tutofusin infusion given on day 3 to
day 9 as fluid and electrolytes before, during and after surgery, Asering infusion given on
day 3 to day 9 was given as a result of dehydration, trauma, acute gastroenteritis and
acidosis.
LABORATORY VALUE
Table 1. Laboratory of Hematology, Urine and Parasitology
Examination
Complete Peripheral
Blood
Erythrocyte
sedimentation rate
Hemoglobin
Leukocytes
Erythrocytes
Hematocrit
Retikolosit
Calculate Type
Leukocytes
Basophils
Eosinophils
Neutrophils Trunk
Neutrophils Segment
Lymphocytes
Monocytes
Platelets
MCV
MCH
MCHC
Bleeding Period (IVY)
Freezing period (LeeWhite)
Period protombin / INR
Protombin period (PT)
PT Patients
PT Control
Results
30 – 04 –
2014
Unit
Normal
Value
H 20
L 7,3
5,8
L 3,38
L 24
13
mm/ja
m
g/dL
10^3μL
10^6μL
%
Permil
0 – 10
13,0 – 16,0
5,0 – 10,0
4,50 – 5,50
40 – 48
5 – 15
H2
H 13
L1
L 47
27
H 10
213
L 70
L 21,6
L 30,8
3
11 – 12
H 14,3
12,8
1,2
%
%
%
%
%
%
10^3μL
fL
pg
g/dL
Menit
Menit
0–1
1–3
2–6
50 – 70
20 – 40
2–8
150 – 450
81 – 92
27,0 – 32,0
32,0 – 37,0
1–6
10 – 16
11,0 – 14,2
Detik
Detik
1114
INR
Examination
Complete Peripheral
Blood
Erythrocyte
sedimentation rate
Hemoglobin
Leukocytes
Erythrocytes
Hematocrit
Retikolosit
Calculate Type
Leukocytes
Basophils
Eosinophils
Neutrophils Trunk
Neutrophils Segment
Lymphocytes
Monocytes
Platelets
MCV
MCH
MCHC
Examination
Complete Peripheral
Blood
Erythrocyte
sedimentation rate
Hemoglobin
Leukocytes
Erythrocytes
Hematocrit
Retikolosit
Calculate Type
Leukocytes
Basophils
Eosinophils
Neutrophils Trunk
Neutrophils Segment
Results
01 – 05 –
2014
Unit
Normal
Value
H 43
L 7,3
8,1
L 3,52
L 25
12
mm/ja
m
g/dL
10^3μL
10^6μL
%
Permil
0 – 10
13,0 – 16,0
5,0 – 10,0
4,50 – 5,50
40 – 48
5 – 15
H2
H 15
L0
L 49
24
H 10
210
L 70
L 21,3
L 30,4
%
%
%
%
%
%
10^3μL
fL
pg
g/dL
0–1
1–3
2–6
50 – 70
20 – 40
2–8
150 – 450
81 – 92
27,0 – 32,0
32,0 – 37,0
Results
02 – 05 –
2014
Unit
Normal
Value
H 23
L 9,6
8,1
L 4,17
L 30
L7
mm/ja
m
g/dL
10^3μL
10^6μL
%
Permil
0 – 10
13,0 – 16,0
5,0 – 10,0
4,50 – 5,50
40 – 48
5 – 15
1
H 12
L0
65
L 14
8
237
%
%
%
%
%
%
0–1
1–3
2–6
50 – 70
20 – 40
2–8
150 – 450
1115
Lymphocytes
Monocytes
Platelets
MCV
MCH
MCHC
Examination
Complete urinalysis
Density
Color
Clarity
Leukocyte esterase
Nitrite
Blood
pH
Proteins
Glucose
Bilirubin
Urobilinogen
Ketones
Sediment
Leukocytes
Erythrocytes
Epithelial
Cylinder
Bacteria
L 72
L 23
32,1
10^3μL
fL
pg
g/dL
81 – 92
27,0 – 32,0
32,0 – 37,0
Results
01 – 05 –
2014
Unit
Normal
Value
L 1,010
Yellow
Clear
Negatif
Negatif
Negatif
7,0
Negatif
Negatif
Negatif
0,2
Negatif
g/mL
1,015 – 1,025
Yellow
Clear
Negatif
Negatif
Negatif
4,8 – 7,4
Negatif
Negatif
Negatif
< 0,2
Negatif
1
0
0
0
H 2362
/LPB
/LPB
/LPB
/LPK
/LPB
0–2
0–3
0–1
0–1
<5
Table 2. Examination of blood pressure
Date
30 april 2014
01 may 2014
02 may 2014
03 may 2014
Blood Pressure
Systole and Diastole
S
D
S
D
S
D
S
D
at
04.00
130
80
130
80
153
80
at
12.00
130
80
176
93
140
90
at
20.00
130
70
150
100
120
58
140
90
1116
S
D
S
D
S
D
S
D
S
D
04 may 2014
05 may 2014
06 may 2014
07 may 2014
08 may 2014
140
80
120
90
140
90
110
80
110
80
140
80
160
110
120
80
110
70
110
80
150
80
160
90
120
80
110
70
100
80
Table 3. Laboratory of Chemical clinic
Examination
Sodium, Potassium
Sodium (Na) blood
Potassium (K)
blood
Calcium (Ca)
Examination
Sodium, Potassium
Sodium (Na) blood
Potassium (K)
blood
Results
02 – 05 –
2014
Unit
Normal Value
142
4,1
mEq/L
mEq/L
135 – 147
3,5 – 10,3
8,4
mg/dl
0,8 – 10,3
Results
03 – 05 –
2014
Unit
Normal Value
142
3,8
mEq/L
mEq/L
135 – 147
3,5 – 10,3
8,4
mg/dl
0,8 – 10,3
Calcium (Ca)
Table 4. Profile Dispensing
Name of
Medication
Ceftriaxone 1
gram
Torasic 30 mg
Vomizole 2 x 1
flc
Date
30/4
-
1/5
-
2/5
2x1
3/5
2x1
4/5
2x1
5/5
2x1
6/5
2x1
7/5
8/5
2x1 2x1
-
-
2x1
2x1
2x1
2x1
2x1
2x1
2x1
-
-
2x1
2x1
2x1
2x1
2x1
2x1
2x1
1117
Kalnex 500 mg
-
-
3x1
3x1
3x1
3x1
3x1
3x1
3x1
Vit. K 2 x 1 amp
-
-
2x1
2x1
2x1
2x1
2x1
2x1
Cernevit 1 x 1
amp
Urecolin 2 x 1
tab
Angioten 25 mg
-
-
1x1
1x1
1x1
1x1
1x1
-
-
-
2x1
2x1
2x1
2x1
-
-
-
1x1
1x1
1x1
1x1
Folic iberet 3 x 1
tab
Infusion
tutofusin
Infusion asering
-
-
-
3x1
3x1
3x1
3x1
-
-
2 btl
2 btl
2 btl
2 btl
2 btl
2x
1
1x
1
2x
1
1x
1
3x
1
2 btl
-
-
1 btl
1 btl
1 btl
1 btl
1btl
1 btl
1btl
1x1
2x1
1x1
3x1
2 btl
CLINICAL EVALUATION
Drug Related Problem 1
Ketorolac is NSAIDs which can reduce pain5. The use of ketorolac when administered
concomitantly with losartan then ketorolac which is NSAIDs can reducing the synthesis of
prostaglandins may affect fluid hemostatic and can reduce the antihypertensive effect3,6.
Pharmacist Intervention: When ketorolac is still used in conjunction with losartan, better
the dose of losartan should be increased to optimize treatment.
Drug Related Problem 2
Vitamin K is used for deficiency of vitamin K5. The use of vitamin K when administered
concurrently with ketorolac will cause bleeding and reduced anticoagulants effect3,6.
Pharmacist Intervention: The use of vitamin K with ketorolac should be given a distance of
administration approximately 2 hours.
CONCLUSION
After the assessment of the patient's treatment, it can be concluded that the use of
ketorolac when administered concomitantly with losartan Ketorolac is NSAIDs which can
reduce pain. The use of ketorolac when administered concomitantly with losartan then
ketorolac which is NSAIDs can reducing the synthesis of prostaglandins may affect fluid
1118
hemostatic and can reduce the antihypertensive effect. So the dose of losartan should be
increased. The use of vitamin K when administered concurrently with ketorolac will cause
bleeding and reduced anticoagulants effects. So should be given a distance of
administration approximately 2 hours.
REFERENCES
1. Arief M.I. dkk. 2007. “Deteksi sel transisional karsinoma buli-buli dengan tes NMP-22
dan sitologi urine”. JURI.
2. Basuki B Purnomo. 2000. “Dasar-dasar Urology”, Ed I. penerbit CV Sagung Seto.
Jakarta.
3. Baxter, K. 2008. “Stockley’s Drug Interaction”. Eight Edition. Pharmaceutical Press,
London and Chicago.
4. Charles D.Hepler and Richard Segal. 2003. “Preventing Medication Errors and
Inproving Drug Therapy Outcomes”. CRC Press LLC.Boca Raton. Florida.
5. Depkes RI. 2008. “Informatorium Obat Nasional Indonesia”. Dirjen Pengawasan Obat
dan Makanan. Jakarta.
6. Medscape 2014. “Drugs Interaction Checker”.WebMLLC. Rheuters Helth Informaton.
7. Sjamsuhidayat R dan Jong WD. 1997. ”Buku Ajar Ilmu Bedah” . Ed 4.Penerbit Buku
Kedokteran EGC. Jakarta.
8. Tanagho EA dan McAnnch JW.1995. “Smith's General Urologi”. Ed 14. Appleton
Lange Medical Publication.
9. Wein AJ. 1998. “Urology 3” vol Ed 7.: W.B. Saunders. Philadelphia.
10. Wiley, Blackwell. 2009. “Nursing Dianoses Definition and Classification 2009-2011”.
United States of America: Mosby Elsevier.
1119
DRUG RELATED PROBLEMS ASSOCIATED AND TREATMENT FOR
CERVICAL CANCER IN INTERNAL MEDICINE WARD IN PGI CIKINI
HOSPITAL
Hendra Rahman1, Diana Laila Ramatilla2, Aprilita Rinayanti Eff2
1
Lectuter Pharmacy in Pharmacy Faculty University of 17 August 1945 Jakarta
(UTA ’45 Jakarta)
2
ABSTRACT
Cervical cancer is a cancer that attacks the cervix (mouth of the womb). Cervical cancer
begins in the lining of the cervix. The occurrence of cancer is very slow. First, some normal
cells turn into precancerous cells, then transformed into cancer cells. This change is called
dysplasia and usually detected with a pap smear test 3.6. Pain is a sensory and emotional
experience unpleasant result of actual tissue damage or potensia5. Patients Mrs.MM 39
years old, hospitalized PGI Cikini on June 23th 2014, was diagnosed of cervical cancer.
During hospitalized, she has received Vitamin K injection, Kalnex injection (tranexamic
acid), Alverin Citrate 30 mg and Klordiazepoksida HCl 5 mg, Ketorolac. Based on the
results of clinical secretariat at the ward of K in PGI Cikini hospital, it can be concluded
that the presence of DRPs (Drug Related Problems) is improper drug selection, Improper
use of drugs, Ketorolac is not used in accordance with the existing pain in patients.
Keywords: Cervical Cancer, Pain and RS PGI Cikini
INTRODUCTION
The cervix is the lower part of the uterus (womb). This is sometimes called the
uterine cervix. Body (the top) of the uterus, is where a fetus grows. The cervix connects the
body of the uterus to the vagina (birth canal). Part of the cervix closest to the body of the
uterus is called the endocervix. Following section to the vagina is exocervix (or ectocervix).
Majority of cervical cancers start in the transformation zone. Cervical cancer (also known
as cervical cancer) begins in the cells lining the cervix
7.3.
Cervical cancer at an early stage
does not show typical symptoms, even without symptoms. In later stages, the symptoms of
1120
cervical cancer include: bleeding post coitus, abnormal vaginal discharge, bleeding after
menopause, and abnormal discharge (yellowish, odorless and mixed blood) 3.
Two main types of cells lining the cervix are squamous and glandular cells. Most
cervical cancers start in the cells. These cells do not suddenly turn into cancer, and there are
some processes in its path. Normal cells in the cervix gradually changes from pre-cancer to
cancer. Doctors use several terms to describe the pre-cancerous changes, including cervical
intraepithelial neoplastic (CIN), squamous intraepithelial lesions (SIL), and dysplasia 6.
CASE PRESENTATION
Patients Mrs. MM, aged 39 years old came to PGI Cikini Hospital on June 23, 2014.
Patient felt pain in the right side of the waist. From the results of the diagnosis of cervical
cancer patients experience.
Patients are people with cancer of the cervix and had a hysterectomy, 1 year SMRs
(prior to hospital admission) the patient was said to have spread to the bladder occurred
approximately 2 months SMRs patient began to feel pain in the right hip, Patient radiation
recommended in RSCM and now waiting for the schedule . Patients taking anti-pain
medication SMRs ± 1 day, the patient felt a severe pain in the back right waist, nausea,
vomiting, post-micturition bladder is mounted hose from the kidney to the bladder.
EVALUATION CLINIC
The use of vitamin K for the treatment and prevention of bleeding1. Kalnex ampoule
(tranexamic acid) as cervical conization, hereditary angioneurotic edema, abnormal
bleeding after surgery
1.
Spasmium (Alverin Citrate 30 mg and Klordiazepoksida HCl 5
mg) for pain spasms / seizures
severe short-term (<5 days)
1.
1.
Ketorolac is used as the management of acute pain is
ketoprofen used for rheumatoid arthritis, osteoarthritis,
spondylitis, and acute articular disorder, fibrosis, cervical spondylitis, low back pain,
painful musculoskeletal conditions 3.
1121
Dosage and how to use the drug in patients is the first day of treatment was given
vitamin K on the second day of vitamin K consumption in stop and continued on the third
day to day with a dosage ten 3x1 ampoules, ampoules kalnex given one ampoule at The
first day and stopped on the second day and continued on the third day to day with a dosage
ten 3x1, spasmium in use on the sixth day with 1 tablet and on day seven to ten days at
doses used 3x1 tablet, the first day of RL (Ringer lactate) given concurrently with ketorolac
where RL given IV on day two RL and ketorolac use was discontinued and resumed on the
third day to the fifth day, the sixth day and seventh RL replaced with INS (Sodium
Chloride) and using ketorolac, on the eighth day until RL tenth day of re-use and ketorolac,
the ninth and tenth days of treatment therapies are added to profenid supposs (ketoprofen)
1x1.
CLINICAL DIAGNOSIS
EXAMINATION
NORMAL VALUE
Hemoglobin
12-16 g / Dl
Hematocrit
37-47%
Erythrocytes
4.3-6 million / mL
Leukocyte
4800-10800 / mL
Platelets
150.000-400.000/μL
FULL URINISASI dated 06.28.2014
Specific gravity
1015-1025
Color
Yellow
Clarity
Clear
Leukocyte esterase
Negative
Nitrite
Negative
Blood
Negative
pH
4.8 - 7.4
Proteins
Negative
Glucose
Negative
Bilirubin
Negative
Urobilinogen
<0.2
Ketones
Negative
23/6
9.7
28
20,700
592,000
1,010
Yellow
Clear
Negative
Negative
Negative
6.0
Negative
Negative
Negative
<0.2
Negative
1122
From the above data it can be concluded that an increase in platelet levels are where
normal values while the platelet 150.000-400.000/μL on clinical laboratory results showed
592,000 / ML. Supported by the value which the normal value 4800-10800 leukocytes / mL
and the results of clinical laboratory 20,700 / uL and it can be concluded that the patient
had cervical cancer.
Improper drug selection is Keterolac use an anti-inflammatory non-steroidal
heterocyclic acetic acid derivative that is used as an analgesic which is supposed to opiate
analgesics has experienced pain scale (VAS) 9.
CONCLUSION
Based on the results of clinical secretariat at the ward of K in PGI Cikini hospital, it
can be concluded that the presence of DRPs (Drug Related Problems) is improper drug
selection, Improper use of drugs, Ketorolac is not used in accordance with the existing pain
in patients.
REFERENCES
1. POM RI, 2008. Indonesian National Drug Information, Jakarta
2. Canavan TP, NR Doshi. Cervical cancer. Am Fam Physician 2000; 61:1369 -76.
3. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A pathophysiologic Approach 7
th
4. Hughes, J, 2008. Pain Management of, from basich to clinical practice
5. Menczer J. The low incidence of cervical cancer in Jewish women: has the puzzle
finally been solved? Isr Med Assoc J 2003; 5:120-3
6. Nurwijaya, H, dkk.2010.Cegah and Cervical Cancer Detection, Surabaya
7. D Turk and Melzack R. Handbook of pain as sessment. Guilford Press, New York,
1992.
1123
DRUG RELATED PROBLEMS IN ACUTE GASTROENTERITIS (GEA) AND
CORONARY ARTERY DESEASE (CAD)
Herna Barung1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Definition of acute gastroenteritis are diarrhea initially is a sudden and rapid, within a few
hours up to 7 and 14 days.3,8 First infection is a major cause of acute diarrhea, either by
bacteria, parasites or viruses. Other causes of vaccines and drugs, enteral nutrition followed
by prolonged fasting, chemotherapy, faecal impaction (overlow diarrhea).7 Coronary artery
disease in the desease is narrowing or blockage of the coronary arteries burrows because
the process of atherosclerosis.5 In atherosclerosis fatty occurs on the walls of the coronary
arteries that have occurred since a young age to old age.4
Case presentation: The patient is a 61 year old woman hospitalized in internal medicine
wards. Patients diagnosed with acute gastroenteritis (GEA) and Coronary Artery Disease
(CAD).
Preclinical evaluation: In this case study to consider the use of medications that can cause
such bisoprolol interaction with aspirin and warfarin with aspirin.
Keywords: Acute gastroenteritis and Coronary Artery Disease, PGI Cikini Hospital
INTRODUCTION
Definition of acute gastroenteritis are diarrhea initially is sudden and rapid, within a few
hours up to 7 or 14 days.3,8 First infection is a major cause of acute diarrhea, either by
bacteria, parasites or viruses. Other causes of vaccines and drugs, enteral nutrition followed
by prolonged fasting, chemotherapy, faecal impaction (overlow diarrhea).3
Potential
complications include diarrhea, cardiac dysrhythmia due to loss of fluid and electrolytes
were significantly (especially the loss of potassium), of urine less than 30 ml / hour for 2-3
days in a row, muscle weakness and parastesia. Hypotension and anorexia and sleepy
because blood potassium levels below 3.0 mEq / liter (SI: 3 mmol / L) should be
1124
reported.3,8 . Decreased levels of potassium cause cardiac dysrhythmias (atrial and
ventricular tachycardia, ventricular febrilasi and premature ventricular contractions) that
can cause death. Definition Coronary artery disease is a disease in which the coronary
artery narrowing or blockage of the coronary arteries burrows because the process of
atherosclerosis. In the process of atherosclerosis occurring fatty on the walls of the
coronary arteries and coronary arteries that have occurred at a young age to old age. This
process is generally normal in every person.4
CASE PRESENTATION
Mrs. SH is 61 year old woman hospitalized in internal medicine wards. Patients
diagnosed with acute gastroenteritis and coronary artery diseases entered Cikini hospital on
30 April 2014. Patient had nausea, vomiting, hot, watery bowel movements 20 times in 2
days before entering the hospital. The patient had a history of previous disease is CAD.
Patient fever and bowel movements are already 10 times, nausea, vomiting one time after
the patient is hospitalized. Echocardiographic examination has been carried out on
December 20, 2012 shows positive results. In the laboratory examination of stool complete
and all results are normal, this indicates patient include non-infectious diarrhea that are not
given antibiotics.
As for the therapeutic treatment of a patient on 30 April , 2014 through to 7 May,
2014 is amlodipine 5mg (class of calcium channel blockers) and bisoprolol 5mg (class of
beta blockers) for the treatment of hypertension. CCB and BB groups combined to achieve
effective results. Ascardia 80 mg (class of anti-platelet) for blood flow. Simarc 2mg and
heparin 25000UI is anticoagulant. Mechanism of action is very slow simarc could until a
few days there is a new effect that is replaced with the mechanism of action of heparin
25000UI faster, because at that time the patient had pain in the chest. Pain occurs due to
narrowing of the coronary arteries that supply oxygen to the heart a little. This pain is
called angina. New diatabs used for diarrhea and paracetamol 500mg tablets for antipyretic.
Gentamicin ointment for antibiotic because on May 3, 2014 patients have wounds in the
buttocks. Rantin injection ampoules are class H2 blockers for intestinal colic and nausea
1125
due on May 2 and May 4, 2014 the patient's nausea and vomiting. Simvastatin is a statin
used for cholesterol2.
Drug delivery profile in patient (Mrs.SH),starting from 30 th April - May 7, 2014 were:
Date
Name of drugs
30 April - 7 Mei 2014
30
1
2
3
4
5
Bisoprolol 50mg
√
√
√
√
√
√
Ascardia 80mg
√
√
√
√
√
√
Simarc 2mg
√
√
Simvastatin 10 mg
√
√
√
√
√
√
Ringer laktat
√
√
√
√
√
√
Amlodipin 5mg
√
√
√
√
√
√
Gentamicyn ointment
√
√
√
Rantin ampouls injection
√
√
Paracetamol 500mg
√
√
New diatabs
√
√
√
On the 30th of april conducted laboratory tests on patient ( Mrs.SH ):
Exemination
Hematokrit
Haemoglobin
Leukocytes
Platelet
Troponin I
Blood Sugar When
Complete Faeces
Color
Consistency
Mucus
Blood
Sodium
Potassium
APPT Patient
APPT control
6
√
√
√
√
√
√
-
Result/
30 April 2014
42%
*14,9
7,5
209
0,8
82
Unit
Normal Value
%
Gr/dl
10^3/ul
10^3/Ul
Mg/L
U/L
37-43
12,0-14,0
5,0-10,0
150-450
0-1
70-150
Brown
Muchy
None
None
139
3,8
33,3
33,6
Meq/L
Meq/L
Second
Second
brown/yellow
brown/yellow
None
None
135-147
3,5-5,0
26,4-37,5
7
√
√
√
√
√
√
√
-
Management of CAD or coronary heart disease, namely:3
1126
a.
Lifestyle Changes
Healthy and balanced diet, with more vegetables or fruits, it is important to protect our
heart arteries. Foods rich in fat, especially saturated fat, can lead to high cholesterol
levels, which is a major component collection that contribute to the narrowing of
heart arteries. Regular exercise is essential to maintain a healthy heart. Exercise helps
us to be fit and strong build circulation system. It also helps us lose weight. Obesity is
usually not healthy, because it resulted in the incidence of hypertension, diabetes
mellitus, and high fat levels become higher, all of which can damage the heart
arteries.
b.
Control
of
the
major
risk
factors
for
coronary
heart
disease
Diabetes mellitus, smoking, high cholesterol levels and high blood pressure are four
main
factors
that
lead
to
coronary
heart
disease
risk
is
higher.
Control of the four major risk factors vary in this well through lifestyle and / or
medication can help stabilize the progression of atherosclerosis, and lowering the risk
of complications such as heart attack.
c.
Medical therapy
Various drugs help patients with coronary artery disease, the most common include:
1)
Aspirin/Clopidogrel/Ticlopidine
These drugs thin the blood and reduce the likelihood of blood clots form at the end of
the narrowed heart arteries, therefore reducing the risk of heart attack.
2)
Beta-blocker(Atenolol,Bisoprolol,carvedilol)
This pharma helping to reduce heart rate and blood pressure, thereby reducing the
symptoms of angina also protects the heart
3)
Nitrates (Isosorbide dinitrate)
This prescription medication works open heart arteries, and then increase the blood
flow to the heart muscle and reduce symptoms of chest pain. Nitrates react quickly,
glyceryl trinitrate, is generally given in the form of a tablet or spray under the tongue,
normally used for rapid relief of chest pain
1127
4)
Angiotensin-Converting
Enzyme
Inhibitors
(Enalapril,
perindopril)
and
Angiotensin Receptor Blocker (Losartan,Valsartan)
These drugs allow blood flow to the heart more easily and also help lower blood
pressure.
5)
Drugs lipid-lowering drugs (fenofibrate, Simvastatin, Atorvastatin, Rosuvastatin)
This pharma reduce levels of "bad" cholesterol (Low-Density Lipoprotein), which is
one of the common causes for premature coronary heart disease or advanced.
CLINICAL EVALUATION
Drug Related Problems 11
Aspirin is an anti aggregate treatment of pathological conditions-where the activation or
platelet hyperactivity is a factor in the formation of prothrombin. Use of aspirin in
conjunction with bisoprolol may cause the effect of bisoprolol reduced and the use of both
drugs may increase potassium.
Intervention pharmacist: Need for strict monitoring because it has a very significant
interaction that needs to be given a minimum distance of 2 hours.
Drug Related Problem 21,2
Warfarin for the treatment of venous thrombosis and pulmonary embolism. Unstable
angina, prophylaxis in general surgery, myocardial infarction. The use of warfarin and
aspirin, warfarin and heparin may increase anti-coagulation, causing bleeding.
Intervention pharmacists: There needs to be monitoring closely for the use of both drugs
because it has a significant interaction that needs to be given a distance of at least 2 hours.
CONCLUSION
After the assessment of the patient's treatment, it can be concluded that the use of aspirin in
conjunction with bisoprolol may cause the effects of bisoprolol reduced and the use of both
drugs may increase potassium. Warfarin and aspirin, heparin and warfarin anticoagulation
may increase, causing bleeding so the need for strict monitoring to the use of either drug
because it has a significant interaction that needs to be given a distance of at least 2 hours.
1128
REFERENCES
1. Baxter, K. 2008. “Stockley’s Drug Interaction”. Eight Edition. Pharmaceutical Press.
London and Chicago
2. Medscape. Interaction. 2014.
3. Mansjoer Arif. 2001 "Capita Selecta Medicine". Three editions. Faculty of Medicine,
University of Indonesia. Jakarta
4. Sukandar Elin. 2011. ISO Pharmacotherapy 2 Indonesian Pharmacist Association.
Jakarta
1129
PERIODIC PARALYSIS OF HYPOKALEMIA FAMILIAL IN GENERAL CARE
WARD OF GATOT SUBROTO HOSPITAL JAKARTA INDONESIA
Iskandar Tajerimin1, Diana Laila Ramatillah2, Aprilita rinayanti2
1
(UTA’45 Jakarta)
2
ABSTRACT
Periodic Paralysis of hypokalemia familial is an inherited disorder autosomal dominant, is
characterized by episodic attacks of muscle weakness or flaccid paralysis due to movement
of potassium into the intracellular space of skeletal muscle. Clinical manifestations such as
weakness or intermittent episodic paralysis of the limbs, then spreading to the arm. The
attack came after sleep / rest and rarely occur during sleep, but may be triggered by
physical exercise. The diagnosis is made if you develop muscle weakness accompanied by
low plasma potassium (<3.0 mEq / L) and muscle weakness improved after administration
of potassium. Ms. Patient's, age 28 entered Gatot Subroto Hospital on March 13, 2014 with
complaints of weakness body. Therapy for the treatment of hospitalized ie 0.9% NaCl,
KCL 50 mEq, Rantin inj 50 mg, Ciprofloxacin 200 mg, Ondansetron 4 mg, 500 mg
sistenol, new diatab 2 tab. Based on the results of the clinical work practices in pulmonary
disease ward at Gatot Subroto Hospital it can be deduced that the presence of DRP (Drug
Related Problem) a correlation between drug therapy with clinical conditions such as lack
of proper drug selection in the selection of anti-emetic.
Keywords: Periodic Paralysis of hypokalemia familial, muscle weakness, potassium
INTRODUCTION
Hypokalemia may occur due to inadequate intake of potassium through diet,
potassium loss through the gastrointestinal tract or skin disorders, or due to a redistribution
of potassium into the extracellular fluid intraselular.3Hypokalaemic periodic paralysis
(PPH) is one of the clinical spectrum due to hypokalemia caused by redistribution of
potassium in acute into the liquid intraselular.4Hypokalaemic periodic paralysis can occur
familial / genetic or not affected by genetic.4PPH obtained can be found on the thyrotoxic
1130
state called thyrotoxicosis periodic paralysis whereas familial form of PPH is called
Hypokalemia may occur due to inadequate intake of potassium through diet, potassium loss
through the gastrointestinal tract or skin disorders, or due to a redistribution of potassium
into the extracellular fluid intraselular.3 hypokalaemic periodic paralysis (PPH) is one of
the clinical spectrum due to hypokalemia caused by redistribution of potassium in acute
into the liquid intraselular.4 hypokalaemic periodic paralysis can occur familial / genetic or
not affected by PPH genetika.4 obtained can be found on the thyrotoxic state called
thyrotoxicosis periodic paralysis whereas familial form of PPH is called Periodic Paralysis
of hypokalemia familial.3
Periodic Paralysis of hypokalemia familial is an inherited disorder autosomal
dominant, characterized by muscle weakness or flaccid paralysis due to hypokalemia due
process of moving potassium into the intracellular space of skeletal muscle.5 This disorder
can affect all races the most range in age of 10 years (the period peripubertas).5 Risk of
PPHF higher in Asians with the ratio of men: women is 2:1. PPHF incidence in Europe in
1994 to 1 in every 100,000 people. As many as 50% of men and women carrying the gene
have no symptoms or only mild symptoms.7 hypokalemia and paralysis symptoms are
common in children's emergency department. Need to understand the underlying cause,
whether due to the redistribution of potassium into intaselular space or due to excessive
excretion of potassium through the urine. Determine the cause of failure can cause
distribution error.8
\
CASE PRESENTATION
28 years old patient, Miss.Er entry Gatot Subroto Hospital on 13 March 2014.
Patients come with complaints of weakness body since last night. Last month the patient
had not been taking drugs KSR and repeatedly entered the hospital with the same
complaint. This has happened about 5 years.
CLINICAL EVALUATION
The used of KSR to prevent hypokalemia that occurs in patients from the first day in
the hospital is on the 13th of March 2014 to 18 March 2014, Rantin injection given to
1131
irritation of the stomach due to lack of food intake from outside, cifrofloxacin infusion
given as an antibiotic because at the time an increase in platelet laboratory tests, the use of
ondansetron as an antiemetic and to reduce the side effects of ciprofloxacin drug use,
sistenol tabs as anti-fever, and newdiatab to reduce diarrhea in patients naturally.
DOSAGE AND DIRECTION1.2
IVFD NaCl 0.9 + 50 mEq KCl was started on the first day ie on March 13, 2014
until the patient is check out on March 18, 2014 with dose 20 TPM by IV while the
maximum dose is 60 mEq. KSR 600 mg administered for patients treated namely on March
13, 2014 to 18 March 2014, while the oral dose of 3x1 maximum dosage is 1-2 tabs 2-3 per
days. Rantin inj 50 mg administered on the first day ie on 13 March 2014 to 18 March 2014
at a dose of IV 2x1 while the maximum dose of an intravenous infusion of 25 mg / hour for
2 hours; can be repeated every 6-8 hours.
Ciprofloxacin 200 mg administered on the second day of treatment namely on March 14,
2014 until March 18, 2014 by IV while the maximum dose intravenous infusion (over 3060 min, 400 mg over 60 minutes), 200-400 mg twice daily. Ondansetron 4 mg was given
only on the second day ie on March 14, 2014 by IV while the maximum dose of prevention
of postoperative nausea and vomiting, by mouth, with 8 mg. Sistenol Tab 500 mg on the
first day on March 13, 2014 while the oral maximal is 250-500 mg; This dose may be
repeated every 4-6 hours when necessary (max. 4 doses in 24 hours). New diatab tab given
on the third day of treatment namely on March 15, 2014 while the oral maximum dose
Adults and Children> 12 years: 2 tablets after every defecate, maximum of 12 tablets / day.
CLINICAL LABORATORY DIAGNOSIS
TYPE
EXAMINATION
HEMATOLOG
Y
Routine
hematology
Hemoglobin
Hematocrit
Erythrocytes
Leukocyte
RESULT
13/03/14 14/03/14 15/03/15 16/03/14 17/03/14
12,9
39
5,2
13740*
REFERENCE
VALUE
12 – 16 g/dL
37 – 47%
4.3 – 6.0 juta/μ L
4,800 – 10, 800/ μ
1132
Platelets
496000*
MCV
MCH
MCHC
CLINICAL
CHEMISTRY
SGOT (AST)
SGPT (ALT)
Calcium (Ca)
Magnesium (Mg)
Sodium (Na)
Potassium (K)
Chloride (Cl)
URINALYSIS
Complete urine
Ph
Specific gravity
Protein
76*
25*
33
L
150,000 –
400,000/ μL
80 – 96 fl
27 – 32 pg
32 – 36 g/dL
22
22
8.6*
2,29*
140*
2.5 **
111*
< 35 U/L
< 40 U/L
8,6 – 10,3 mg/dl
1,7 – 2,2 mEq/L
135 – 147 mmol/L
3,5 – 5,0 mmol/L
95 – 105 mmol/L
143
2,0**
108*
134 *
2.5 **
111 *
137
2.8 *
109 *
137
2.9 *
111 *
7,5
1.010
/Negative
/Negative
/Negative
/Negative
/Negative
4,6 – 8,0
1010 – 1030
Negative
Urobilinogen
Negative
Erythrocytes
Leukocyte
2-1-2
10-1515*
/Negative
/Negative
+
/Positive
/Negative
Negative –
Positive 1
< 2 LPB
< 5/LPB
Glucose
Bilirubin
Nitrite
Ketones
Cylinder
Crystal
Epitel
Etc
Negative
Negative
Negative
Negative
Negative/LPK
Negative
Positive
Negative
CLINICAL
1133
CHEMISTRY
Blood Gas
Analysis
pH
pCO2
pO2
Bicarbonate
(HCO3)
Base excess (BE)
O2 saturation
7.378
27.6
91.8
14.4*
7.400
25.8 *
109.2 *
16.1 *
7.353 *
26.4 *
109.6 *
14.6 *
7.37 - 7.45
33 - 44 mmHg
71 - 104 mmHg
22 – 29 mmol/L
-7.0
94.8
-6.6
96.9
-8.1
97.6
(-2) – 3 mmol/L
94 – 96 %
1. The appropriate choice of drug
Drug selection is less precise in the use of ondansetron as anti emetic. According BPOM
(IONI, 2008) and AHFS, 2004, ondansetron get over nausea that causes vomiting by
chemotherapy and radiotherapy. Are suggested to the doctor to review the accuracy in
drug selection. Do check list nurse records periodically.
2. Adverse effects of drugs
The use of antibiotics ciprofloxacin should revisit its use in which the use of
ciprofloxacin has the side effect of diarrhea and accelerate gastric emptying, This will
worsen the situation of patients who have previously experienced diarrhea.
3. Human Error
In the book of drug list, the nurses sometimes do not record the medication is given to
patients already. So it is advisable to nurses to always take note of what has been given
to the patient. Monitoring of nurses notes on the book of drug list.
CONCLUSION
Based on the results of their clinical practice in pulmonary disease ward at Gatot
Subroto Hospital it can be deduced that the presence of DRP (Drug Related Problem) a
correlation between drug therapy with clinical conditions such as lack of proper drug
selection in the selection of anti-emetic.
1134
REFERENCES
1. AHFS drug information 2004. McEvoy GK, ed. Methotrexate. Bethesda, MD: American
Society of Health-System Pharmacists; 2003:1082-9)
3. Tambunan T. Tubulopati. In: Alatas H, Tambunan T, Trihono PP, Pardede SO, editors.
Buku ajar nefrologi anak. Edisi ke-2. Jakarta: Balai Penerbit FKUI; 2002. p. 470-89.
4. Palmer BF, Dubose TD. Disorders of potassium metabolism. In: Schrier RW, editor.
Renal and electrolyte disorders. 7th ed. Philadelphia: Lippincott Williams & Wilkins;
2010. p. 137-64.
5. Sarnat BH. Neuromuscular disorder. In: Berhman RE, Kliegman RM, Jensen HB,
editors. Nelson textbook of pediatrics. 18th ed. Philadelphia: WB Saunders; 2007. p.
2531-40.
6. Hypokalemia periodic paralysis [Internet]. 2011 [cited 2011 Apr 20]. Available from:
http://www.hkpp.org.
7. Hypokalemia periodic paralysis [Internet]. 2011 [cited 2011 Apr 18]. Available from:
http://www.nlm.nih.gov/medlineplus/ency/article/000312.htm.
8. Lin SH, Chiu JS, Hsu CW, Chau AT. A simple and rapid approach to hypokalemic
paralysis. Am J Emerg Med. 2003;21:487-91.
1135
PANCREATIC TUMOR DISEASE
Ismail1, Diana Laila Ramatillah2, Aprilita rinayanti2
1
(UTA’45 Jakarta)
2
ABSTRACT
Pancreas is an organin the form of gland by length and thickness about12.5cm+2.5cm (in
humans), respectively.3It extends from the top to the large curvature of the stomach and it is
usually connected by two channels in to the duodenum, located on posterior wall of
abdominal behind the peritoneum so including retroperitoneal organ sexcept a small part of
cauda(nerve tail) located in lienorenalis ligament3. Patient Mr.N age 47 years entered the
PGI hospital Cikini on 23 April 2014, with initial diagnostic of diabetes mellitus and
hepatitis and based on the results of CEA and ERCP,patients diagnosed tumors or
pancreatic cancer as well as from the previous history of patient as diabetes mellitus
patient. Treatment therapy during hospitalization such as novorapid, rantin, cendantron,
neurobion, theragram, albumin25% and meropenam. Clinical evaluation, the medications
used have found the existence of DRP(Drug Related Problem) such failure to receive
medication and untreated indication.
Keywords: PGI Cikini Hospital, PancreaticTumors, Diabetes mellitus
1. Introduction
Pancreas is an organin the formof gland by length and thickness about12.5cm+2.5cm(in
humans), respectively. It extends from the top to the large curvature of the stomach and
it is usually connected by two channels into the duodenum3. In pancreas usually a rise
cells are tumor or cancer.Tumor is a disease caused by a berrant cell growth or
abnormal, rapid, and uncontrolled. Cell doing propagation but do not follow the rules of
propagation, resulting in damage to the body’s tissues and can cause death.
Generally,tumors or pancreatic cancer originated from the exocrine cells1.Pancreatic
cancer or pancreatic tumors amounted to only2% of all new cancer cases in United
States.However, this has become the fourth cause of death from cancer. Pancreatic
1136
cancer is rarely found in people with less than 50 years of age and the risk increases
with age6. Until now,the cause of cancer or pancreatic tumors is still not clear. The
research of epidemiology suggest the various risk factor that make it easier for someone
to suffer from cancer or pancreatic tumors: exogenous or environmental factors such as
smoking, alcohol, diet and endogenous factors such as age, obesity, diabetes mellitus
and chronic pancreatic and genetic factors and race.5
Patient Mr.N, 47 years old entered the PGI hospital of Cikini Jakarta on 23
April 2014 with major complication is the yelloweyes. Patient with Diabetes mellitus is
along time in which the body weight to lose drastically ±13kg in 2 months, and often
experience pain in the gut.
Table1.Results of Hematology Test
Inspection
Erythrocyte sedimentation
rate
Hemoglobin
Leukocyte
Erythrocytes
Hematocrit
Reticulocyte
Type Leukocyte Counts
Basophils
Eosinophils
Neutrophils Trunk
Neutrophils segment
Lymphocytes
Monocytes
Trombosit
MCV
MCH
MCHC
Result
Reference
Value
Unit
H 97
0 -10
mm/jam
L 10,8
H 12,7
L 3,38
L 29
H 34
12,0 - 14,0
5,0 -10,0
4,50 - 5,50
40 – 48
5 –15
g/dL
10^3/?L
10^6/?L
%
Permil
0
L0
L0
H 76
L 16
8
264
87
32,0
36,9
0–1
1–3
2– 6
50 – 70
20 – 40
2-8
150 – 450
81 – 92
27,0 - 32,0
32,0 - 37,0
%
%
%
%
%
%
10^3/?L
fL
Pg
g/dL
Figure1.Results of Endoscopic RetrogradeCholangiopancreatography(ERCP) Test
1137
Table 2. Results of Clinical ChemistryandImmunologyTests
Result
Inspection
Unit
Reference Value
Clinical Chemisty
SGOT
SGPT
Urea
Creatinine
Uric Acid
When Blood Glucose
Amylase
Lipase
Total Protein
Albumin
Total Bilirubin
Bilirubin Direk
Bilirubin Indirek
IMUNOLOGI
CA 19-9
CEA
HbsAg
Anti HBs
Anti HCV
H 135
H 189
31
0,7
4,6
H 443
H 143
H 1107
L 5,2
L 1,7
H 5,9
H 5,1
0,8
U/L
U/L
mg/dL
mg/dL
mg/dL
mg/dL
U/L
U/L
g/dL
g/dL
mg/dL
mg/dL
mg/dL
0 – 50
0 – 50
10 –50
0.6 - 1,0
3,0 – 7,0
70 – 150
<115
73 – 393
6,0 – 8,0
3,4 – 4,8
0,1 – 1,0
0,1 – 0,2
0,1 – 0,8
0,6
H 12,1
0,21
Negative
56,6
Non Reaktif
0,44
Non reaktif
U/mL
mg/mL
S/N
< 37
0,0 – 3,0
< 2,0 : Negative
> = 2,0 : positive
< 10,0 : Non Reaktif
>= 10,0 : Reaktif
< 1,00 : Non reaktif
> = 1,00 : Reaktif
mIU/mL
S/CO
1138
Table 3.Results of Feces Test
Inspection
Makroskopik
Color
Consistency
Mucus
Blood
Mikroskopik
Amoeba
Cyst
Leukocyte
Erythrocytes
Worms
Worm eggs
The rest of the
food
Starch
Fat
Fatty Acid Crystals
The rest of
Vegetables
Muscle fibers
blood Samar
Result
Unit
Reference Value
Brown
Mushy
Negative
Negative
Brown / Yellow
Mushy
Negative
Negative
not found
not found
--/LPB
0,1 / LPB
Negative
Negative
< 37
1–4
0–2
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
Negative
The treatment therapy givenby doctors toTn. N during the nursing care at the
hospital include Novorapid (insulin) given for 10 days too lower the blood glucose
levels of patients because the blood glucose levels test of patient are very high.
Ranitidine was administered for 6 days, starting from day1 to day 6 to treat pain in the
gut. Cendantron for 9 days to treat the patient’s nausea because before the patient come
to the hospital. He had experience of nausea,on day 2, the treatment of patients are not
getting Cendantron. Neurobion was administered for 9 days and Theragram
(VitA10,000iu,
vitaminB110mg,
vitamin
B2
10mg,
vitamin
B
65
mg, vitamin B125 mcg, vitamin C 200mg, vitamin D 400 iu, Fe 12mg, Mg 65
mg,Zn1.5 mg) administered for 6 days starting from day 4 to day 9,where in two drugs
administered as a multivitamin to enhance the patient’s appetite. Albumin 25% was
1139
administered for 3 days starting fromday 3 to day 5 because the examination results
which showed that albumin below the normal limit (under 1.7g/dL) or in other words
the patient has albumin deficiency. Meropenem was administered for 6 days starting
from day 4 to day 9 where meropenem is used as anantibiotic because the examination
results of patient’s leukocytes that experienced a decline that is expected any indication
of
infection.
However,the
use
of
meropenem
which
is
the
lastline
antibioticsinantibiotictherapyin patientsless appropriate in initial therapy.From patient’s
SOAPsaidthatfeces of black’s patient during 2 months marked the presence of bloodin
feces so indicatesMelena, butafterthe examinationof feces showed normal sodo
notdofollow-uptreatment.
Guideline of pancreatic cancer based on National Comprehensive Cancer
Network (NCCN) in 2009 which divided the pancreatic cancer based on stadium
whether the cancer is resectable of surgical or notas well, to determine when the
administration of chemotherapy and radiotherapy in patients. Moreover, not only
curative and palliative therapies required but also supportive therapyin terms of a strong
nutrition and emotional support from family and the medical management of pancreatic
cancer that is highly complex and requires a holistic handling of various party.
4. Drug Related Problems (DRPs)
a. Failure to receive medication
On 24 April 2014 patients did not receive cendantron.
b. Improper drug selection
The use of antibiotics should not be administered directly meropenem because this
antibioticis the last line if occur resistance to antibiotics.
5. Conclusions
Based on the examination result of patient Tn. Nw here patients are diagnosed
with pancreatic tumors and diabetes. Based on the monitoring resultof medication
therapy found several DRP namely on 24 April 2014 patient did not receive
1140
cendantronas well astheuse of antibiotics should not directly use meropenam antibiotics
because this antibiotics is the last line if occur resistance to antibiotics.
6. Recommendation
a. Continuously monitoring patient’s blood sugar levels
b. Provide medication counseling to patients regarding therapy
c. Recommend surgery to treat pancreatic tumor of patients.
7. References
1.
Arief, Hariana Drs. 2005. 812 ResepUntukMengobati 236 Penyakit. PenebarSwadaya :
Jakarta
2.
Hadi. S. 1997. Tumor Pankreas. Buku ajar IlmuPenyakitDalam, Jilid I, Edisi ke-3,
Editor Noer, H.M.S. BalaiPenerbit FKUI, Jakarta,
3.
ISFI, 2009. ISO Indonesia Vol. 44. BerlicoMuliaFarma : Yogyakarta
4.
ISFI, 2012. IsoFarmakoterapi. ISFI : Jakarta
5.
NCI(National Cancer Institute).2013. Pancreatic cancer. American cancer society
6.
Sudoyo, Aru W dkk. 2009. Buku Ajar IlmuPenyakitDalamJilid I. InternaPublishing :
Jakarta.
7.
Saif MW, 2010. Pancreatic cancer: Current & future therapy breakthroughs,
dalam:Pancreatic Awareness Day. New York: Columbia University Medical Center.
1141
PNEUMONIA AND MELENA PATIENT IN PULMONARY DISEASE WARD AT
GATOTSOEBROTO ARMY HOSPITAL JAKARTA INDONESIA
Isnan Yusuf Maswatu1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
Email :[email protected]
ABSTRACT
In clinical pneumonia was defined as an inflammation of the lung was caused by
microorganisms (bacteria, viruses, fungi, parasites). Pneumonia was caused by
Mycobacterium tuberculosis were not included. While lung inflammation caused by
nonmicroorganisms (chemicals, radiation, toxic material aspirations, drugs etc.) was called
pneumonitis, pneumonia can be caused by a variety of microorganisms, ie ; bacteria,
viruses, fungi and protozoa3. Of the local community literature pneumonia suffered by
many people abroad caused Gram-positive bacteria, whereas pneumonia in the hospital a
lot due to Gram-negative bacteria whereas aspiration pneumonia a lot was caused by
bacteria anaerob3. Patient Ms. SM, aged 46 years old, entered GatotSubroto Army Hospital
on March 9, 2014 was diagnosed of pneumonia in the former tuberculosis and anemia.
Therapy for the treatment of hospitalized was aminophylline, Combivent inhalation,
Neurobion, ceftriaxone, fluimucylsach, Omeprazole, Liv 52, Aminofluid, PRC transfusion
500 cc and IVFD RL. Based on the results of their clinical practice in pulmonary disease
ward at GatotSubroto Army Hospital it can be deduced that the presence of DRP (Drug
Related Problem) a correlation between drug theraphy with clinical conditions such as drug
selection mucus secretion was less precise in giving, a combination of antibiotics and
adverse effects drugs given.
Keywords: Pneumonia, melena,and RSPAD Hospital
INTRODUCTION
Pneumonia can be caused by a variety of microorganisms such as bacteria, viruses,
fungi and protozoa. Of the local community literature pneumonia suffered by many people
abroad caused Gram-positive bacteria, whereas pneumonia in the hospital a lot due to gram
negative bacteria whereas aspiration pneumonia were caused by anaerobic bacteria. Lately,
1142
reports from several cities in Indonesia showed that the bacteria found on the local
community pneumonia patient sputum examination was negative gram3.
Pneumonia is the result of the proliferation of microbial pathogens at the alveolar
level and the host response to pathogens. Microbial entry into the lower respiratory tract in
several ways. The most common way is via oropharyngeal aspiration4.
Mechanical defense factor is very important. Fur and nasal turbinates capture large
particles are inhaled before reaching the lower respiratory tract. The structure of the
tracheal bronchial capture particles carried by the breath then mucosiliari clearance and
local antibacterial factors cleanse or kill potential pathogens. Gag reflex (pharyngeal reflex)
and cough mechanism is an important protection from aspiration. In addition, the normal
flora binds to the cells of the oropharynx that can prevent binding of pathogenic bacteria to
the cells so as to reduce the risk of pneumonia caused by bacterial pathogens. When the
smaller microorganisms inhaled into the alveolar level, macrophages efficiently cleans and
kills pathogens. Macrophages has assisted by local protein (eg, surfactant proteins A and D)
that has the intrinsic properties of opsonizing or antibacterial / antiviral. After the magrofag
ingested and if it does not kill pathogens by macrophages, and then eliminated by
mucosiliari thus inhibited from transmission. However, when capacity is insufficient
alveolar macrophages to kill pathogens there will be pneumonia. Then macrophage
respiratory inflammatory response will begin to increase defense channel respiratory.
Inflammatory response of the proliferation of microorganisms is sufficient to trigger the
clinical syndrome of pneumonia. Secerti release of inflammatory mediator interleukin (IL)
1 and tumor necrosis factor (TNF) causes fever. Chemokines such as IL-8 and granulocyte
stimulating factor stimulates the release of neutrophils into the lungs, resulting in peripheral
leukocytes and increases the purulent secretion. Macrofag release of inflammatory
mediators and produce neutrophils cause capillary leakage equivalent despite the acute
respiratory distress syndrome in pneumonia, leakage is localized (early stage). Erythrocytes
across the alveolar capillary membrane with consequent occurrence of hemoptysis.
Capillary leak can be detected using radiography on auscultation and hypoxemia as a result
of being filled alveolar. Some bacterial pathogens causing emerging fluid-filled alveoli,
these disorders can lead to severe hypoxemia4.
1143
Increased respiratory impulse on systemic inflammatory response syndrome causing
respiratory alkalosis. The decrease in the respiratory system caused by capillary leakage,
hypoxemia,
increased
respiratory rhythm,
increased
secretion
and
occasionally
bronchospasm associated infections cause dyspnea. If severe enough, the changes in lung
mechanics may cause secondary death4.
CASE PRESENTATION
Patient Ms. SM 46 years old, was entered GatotSubroto Army Hospital on March 9,
2014. Patient present with shortness since 1 week entered hospital before. Patient suffering
from cough accompanied by phlegm and sometimes blood contained entered hospital
before. Patient feel claustrophobic every cough, shortness not accompanied by sound of
wheezing. The patient did not complain of chest pain. The patient had a high fever ± 1 days
and bloody entered hospital before.
The patient was treated inMentengAfia Hospital Public, associated with shortness of breath,
cough and fever. The patient had a history of TB disease 10 years ago, but the treatment
and declared cured completely.
CLINICAL EVALUATION
The used of Combivent inhalation to overcome severe shortness of breath that
occurs, ceftriaxone as a third generation cephalosporin antibiotic specific to gram-negative
bacterial infections, Liv52 as hepatoprotective. Fluimucyl as respiratory tract infections
with excess mucus secretion including bronchitis, emphysema and bronchiectasis,
prophylaxis and treatment of bronchopulmonary complications with mucostasis.
Omeprazole as a short-term treatment and duodenal ulcers were unresponsive to drugs and
H2 receptor antagonist short-term treatment of peptic ulcers. Neurobion as prevention and
treatment of disease due to deficiency of vitamin B1, B6, and B12 as peripheral neuritis,
neuralgia. Aminophylline was used to prevent and treat wheezing, shortness of breath, and
difficulty breathing caused by asthma, chronic bronchitis, emphysema, and lung disease
other. Aminofluid as supply of amino acids, electrolytes and water before and after surgery,
in individuals with hypoproteinemia or manutrisi light due to lack of oral intake.
1144
DOSAGE AND DIRECTION1
Drugs
IVFD RL
Giving
method
IV
Regimen
dose
20 tpm
Indication
Aminofilin
IV
1x0.4 mg
Combivent
Inhalasi
3x / Day
Neurobion
IV
1x1 / 3 ml
Ceftriaxon
IV
1x 2 g
Fill requirement
vitamine
B1,B6,B12
Antibiotic
FluimucylSach
PO
Adult and children > 12
years and childrens
with BB > 50 kg : 1 - 2
gram daily. At
chronicinfections
disease dose can be
increase until 4 gram
daily.
3x 200 mg Mucus secretion 200 mg daily
Liv 52
PO
3X2
Hepatoprotektor 3x1 daily
Omeprazole
IV
1x 40 mg
Peptic ulcers
20 – 40 mg daily
Aminofluid
IV
/12 hours
Electrolit
500/120 min IV
Transfusi PRC
IV
500 cc
Injection
PRC transfusion was
given when level HB >
8 g/dL, with normal
value 12-16 g/dL
Electrolit
Shortness of
breath
Bronchodilator
Usual Dose
500-1000 ml with
speed 300-500 ml per
hours ( 75-125 tpm)
Drip aminofilin in RL ;
0,5-1 mg/kgBB/hours
3-4 kali daily 2,5 ml
1 x 3 ml daily
1145
CLINICAL LABORATORY VALUES
Type of examination
HEMATOLOGY
LED
Routine hematology
Hemoglobin
Hematocrit
Erythrocytes
Leukocyte
Trombosit
MCV
MCH
MCHC
Total Bilirubin
SGOT
SGPT
Total Protein
Albumin
Globulin
Total Cholesterol
Triglycerides
HDL Cholesterol
LDL Cholesterol
Ureum
Creatinine
Uric acid
Fasting blood
glucose
Blood glucose (2
hours PP)
Sodium
Potassium
Chloride
Normal Value
09/3
11/3
13/3
6,2
24
4,3
14800
613000
9,5
33
5,1
8200
478.000
11,0
38
5,8
5100
434000
55
15
26
65
19
20
66
19
29
>20 mm/hours
12 – 16 g/dL
37 – 47%
4.3 – 6.0 juta/μ L
4,800 – 10, 800/ μ L
150,000 – 400,000/
μL
80 – 96 fl
27 – 32 pg
32 – 36 g/dL
< 1,5 mg/dL
< 35 U/L
< 40 U/L
6-8,5 g/dL
3,5-5,0 g/dL
2,5 – 3,5 g/dL
< 200 mg/dL
< 160 mg/dL
>35 mg/dL
<100 mg/dL
20 – 50 mg/dL
0.5 – 1,5 mg/dL
3.5 – 7.4 mg/dL
70 - 100 mg/dL
75
20
21
38
0,8
<140 mg/dL
135 – 147 mmol/L
3,5 – 5,0 mmol/L
95 – 105 mmol/L
10/3
0,66
26
17
8,1
3,5
4,6
78
99
20
38
28
0,8
4,6
131
103
134
4,0
98
136
3,8
91
1146
Ceftriaxon the treatment of choice with the use of third generation antibiotics,
specifically in gram-negative bacteria. Can be combined with macrolide antibiotics such
as azithromycin claritromisin or 1 g IV daily then 500 mg daily3,5.
Flumuicyl an adjunctive therapy for patient with abnormal mucus secretion in
acute and chronic bronchopulmonary condition, while patient with a history of peptic
ulcer disease/stress ulcer, because acetyl cysteine was caused nausea and vomiting that
increase the risk of gastrointestinal haemorrhage; disrupt the gastric mucosal barrier
mukolitic7.
2. Drug interactions
There is a drug interaction between omeprazole may decrease the levels or
effects of aminophylline on hepatic enzyme CYP1A2 metabolism. Recommended to be
given in the use of distance9.
3. Adverse effects of drugs
The used of antibiotic ceftriaxone should be combined with group macrolide,
ceftriaxone also prone to bleeding, recommended by the addition of vitamin K as an
anticoagulant3.
4. Human Errors
In the book the list of drugs the nurses sometimes do not record the medication
that was given to the patient. So it is advisable to nurses to always take note of what has
been given to the patient. Monitoring of nurses notes on the book list of drugs.
CONCLUSION
Based on the results of their clinical practice in pulmonary disease ward at
GatotSoebroto Army Hospital it can be deduced that the presence of DRPs (Drug Related
Problems) a correlation between drug theraphy with clinical conditions such as the
presence of the selection of antibiotics should be combined with group makrolide.
fluimucyl was used that should be replaced with ambroxol, and the used of ceftriaxone
should be administered with vitamin K.
1147
Result laboratory data shows that the condition of patient decreased hemoglobin 6.2 g / dL,
indicating patient bleeding because melena that required a blood transfusion. As well as the
patient's condition at baseline leukocyte entry 14800 indicating increased bacterial
infection.
REFERENCES
American Society of Health-System Pharmacists; 2003:1082-9)
2. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A Pathophysiologic Approach
7thEdition, McGraw Hill, New York.
3. FeketyRobert,M.D 1990, Safety of Parenteral Third Generation Cephalosporins, The
American Journal Medicine,Vol 88,Michigan USA.
4. PDPI,
2003.
PneuomoniaKomunitiPedomanDiagnosadanPenatalaksanaan
di
Indonesia,Jakarta
5. Joseph Loscalzo et all, 2010 Harrison’s Pulmonary and Critical Care Medicine 17th
Editions, The McGraw-Hill Companies, Inc., New York
6. Kasper L, Dennis., et al, 2010, Harrison’s Infectious Diseases, The McGraw-Hill
Companies, Inc., New York.
7. Koda-Kimble et al., 2009, Applied Therapeutics: The Clinical Use of Drug 9th Edition,
Lippincott Williams & Wilkins, USA.
8. Lacy, F.C., Armstrong L.L., Goldman, M.P., Lance L.L.et al, 2010, Drug Information
Handbook,Lexi-Comp, American Pharmacist Association.
9. Medscape 2014. Drugs Interaction Checker.WebM,LLC, Reuters Health Information.
1148
COMBINED DRUG RELATED PROBLEMS IN DISEASE TREATMENT FOR
DYSPEPSIA IN INTERNAL MEDICINE WARD IN PGI CIKINI HOSPITAL
Jenie1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABTSRACT
Dyspepsia is a common disease and often occurs in internal medicine ward in PGI Cikini
Hospital. Dyspepsia is a collection of complaints or clinical symptoms consisting of
discomfort or pain, full flavor and heat in the upper abdomen that persist or relapse
complaints of pain and heart burn 4.. Case presentation: MS is a 23-year-old woman
hospitalized in internal medicine wards. Patients diagnosed with dyspepsia. Preclinical
evaluation: basically, there is one intervention that was found during the assessment of
treatment of patients, ie about drug interactions Inpepsa (Sucralfate) with Renatac
(Ranitidine), and Sharox (Cefuroxime) and Renatac (Ranitidine).
Keywords: Dyspepsia, Pain, PGI Cikini Hospital
1. Introduction
Dyspepsia syndrome, better known as the general public ulcer disease even though
less precise, because the ulcer is derived from the Dutch language, which means the
stomach.5 Complaints that appear on ulcer disease does not always come from the stomach.
The prevalence of the disease varied, most of the research shows nearly 25% of adults
experience symptoms of dyspepsia at some time in their lives 5.
A survey of states, approximately 30% of patients who went to a general
practitioner due to a gastrointestinal disorder mainly dyspepsia and 40-50% of patients
presenting to specialist caused due to indigestion, especially dyspepsia 6.
Changes in irregular eating patterns, drugs that are not clear, substances such as
nicotine and alcohol, and the presence of psychiatric conditions of stress, food intake
becomes less so the stomach will be empty, void can lead to gastric erosions in the stomach
due to friction between the walls of the stomach, such conditions may lead to increased
production of HCL that will stimulate the acidic conditions of the stomach, so that
1149
stimulation in the medulla oblongata carry impulses vomiting that can not be accepted by
the digestive tract completely. This is what causes vomiting 7.
2. Presentation Case
"MS" is a 23-year-old woman hospitalized in internal medicine wards. Patient
diagnosed with dyspepsia. Patient entered in PGI Cikini Hospital on 5th June 2014. The
patient feels dizzy, nausea, vomiting, and weakness one week before admission. Upon
entering the hospital, the patient feels dizzy, weakness, nausea, and decreased appetite.
Laboratory tests that have been carried increased erythrocyte sedimentation rate, decreased
hematocrit, and decreased neutrophil.
As for drug therapy given to Ms."MS" covers Sharox (Cefuroxime) is used as an
antibiotic for skin and soft tissue infections.4Renatac (Ranitidine) is used for the treatment
of gastric ulcers, duodenal ulcers, hyperacidity, Zollinger-Ellison syndrome, gastristis and
reflux esophagitis
4.
Narfos used to treat nausea and vomiting induced by cytotoxic
chemotherapy drugs and radiotherapy, prevention of postoperative nausea and vomiting
4.
Mylanta is used to reduce the symptoms associated with excess stomach acid, gastritis,
gastric ulcer, duodenal ulcer with symptoms such as nausea, stomach pain and heartburn
4.
Inpepsa short-term treatment (up to 8 weeks) in a duodenal ulcer, which serves to coat the
ulcers or sores are present in the stomach 4.
3. Evaluation Clinic
Inpepsa (Sucralfate) and Renatac (Ranitidine) is a combination that is often
used in the treatment of gastric ulcer and duodenal ulcer
drugs can cause interactions
1.
1.
Concomitant use of both
Inpepsa can reduce the absorption or bioavailability of
Renatac (Ranitidine) so that the drug should be administered distance giving about 2
hours 1.
1150
Concomitant use Sharox (Cefuroxime) and Renatac (Ranitidine) can cause
significant of interaction, where Renatac (Ranitidine) will decrease the effects of Sharox
by increasing gastric pH.
Intervention pharmacists: Advise the patient to use the distance separating the two drugs,
for Renatac in consumption before meals while sharox consumed after eating
1.
To avoid
interaction, monitoring is necessary to use both drugs 1.
4. 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
gastric ulcer and duodenal ulcer. Concurrent use of both drugs may reduce the absorption
or bioavailability of Renatac (Ranitidine) so that the drug should be given a distance of
about 2 hours of administration. Concomitant use Sharox (cefurox cefuroxime) and Renatac
(Ranitidine) may decrease the effects of Sharox by increasing the pH of the stomach, so
Renatac consumed before a meal while Sharox consumed after meals and after use of the
drug for gastric ulcer dyspepsia patients otherwise it can not be addressed properly.
5. 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, accessed on May 9,
2014
6. Reeves J Charlene. Keperawatan Medikal Bedah. Jakarta. 2001
7. Syahputra, Wawan. 2013. “Dispepsia”. http://www.wawanssblogspot.com, accessed
on April 10, 2014
1151
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
1152
CHRONIC OBSTRUCTION PULMONARY DISEASE (COPD)
Junita Labendi1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Chronic Obstructive Pulmonary disease (COPD) is achronic lung disease characterized by
airflow resistancein the airways that are progressive nonreversible or partially reversibel5.
The patients Mr.Swd, age 74 years, entered Gatot Subroto Army Hospital on March 17,
2014 with a diagnosis of acute exacerbation of COPD. Treatment during the hospitalized
were IVFD aminophylline, methylprednisolone, ranitidine, Lasal expectorant, neb
Combivent, Pulmicort neb, clarithromycin, Aptor, and ISDN. Based on the results oftheir
clinical practice on the wards of lung disease in Gatot Subroto Army Hospital (RSPAD), it
can be concluded that the presence of DRP (Drug Related Problem) are the drug interaction
(methylprednisolone and clarithromycin), and improper dosing regimen in using ranitidine
(drug doseis too low)
Keywords :
Acute exacerbation, pulmonary disease and RSPAD Gatot Soebroto.
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is achronic lung disease
characterized by airflow resistancein the airways that are progressive nonreversible or
partially reversible. COPD consists of chronic bronchitis and emphysema, or a combination
of both5.
Acute exacerbation of
COPD means the onset of worsening compared to the
previous condition. Exacerbations can be caused by infection or other factors such as air
pollution, fatigueor the onset of complications. Symptoms of exacerbation istightness
increases, increased sputum production and change insputum color5.
Airway obstruction in COPD is irreversible and occurs due to structural changes in
the small airways inflammation, fibrosis is a major cause of airway obstruction6.
1153
CASE PRESENTATION
The patients Mr. Swd, age 74 years entered Gatot Subroto Army Hospital (RSPAD)
on March 17, 2014. The patient cameto the Emergency Room with a complaint shortness of
breath since 2 days before hospital admission, the complaints with fever, cough with
phlegmcould come outgreenish white color. Patients had been heart surgeryin 1997 patients
have a history of asthma and cardiac.
CLINICAL EVALUATION
The use of Combivent nebuliser to reduce mucus secretion. Pulmicort nebuliser to
over come the tightness. Aminophylline as long-term maintenance, especially in moderate
and severe to over come the acute exacerbation. Methylprednisolone is used when there is
an acute exacerbation that serves to suppress inflammation that occurs. Ranitidine for
peptic ulcers and duodenal ulcers. Lasal expectorant serves as a diluent sputum.
Clarithromycin for antibiotics. ISDN for jantung1,5.
The Patients during treatment at Gatot Subroto Army Hospital (RSPAD) have drug
therapy: IVFD aminophylline with by drip, aminophylline indicated for acute exacerbation.
Methylprednisolone
Injection
of
3x62.5
mg
the
prevalent
dose
10-500
mg,
methylprednisolone indicated for inflammatory. Lasal expectorant 3x1C orally, is indicated
for cough. Injection of 2x50 mg ranitidine, usual dose of 3x50mg, ranitidineis indicated for
gastric and duodenal ulcers. Clarithromycin 2x250 mg orally, prevalent dose 250 mg,
clarithromycin is indicated for antibiotics. Combivent nebuliser 4 x/day, a dose prevalent 34 x/day, is indicated to reduce the secretion of mucus. and Pulmicortnebulizer 2x/day, a
dose prevalent 2x/day, indicated for cope tightness.
LABORTORY VALUE
Parameters
Platelet
pCO2
Value
17-03-2014
146000*
47.8*
Normal value
150000-400.000/μL
33-44 mmHg
1154
Bikarbonat (HCO3)
41.4*
22-29 mmol/L
1. Dose regimens
Dose of the drug is too low, in the prescription ranitidine 2x50 mg a day, according to
the literature Renal Drug Handbook (2009), should have been 3x50 mg daily.
Suggested to the doctor to re-evaluate the use of therapeutic doses of ranitidine. Do a
check list of nurses notes.
2. Drug interaction
- Clarithromycin+methylprednisolone3
Clarithromycin will increase methylprednisolone effects by affecting the
metabolism o fthe CYP3A4 enzyme.
CONCLUSION
Based on the results of their clinical practice in pulmonary diseases wardat Gatot
Subroto Army Hospital (RSPAD), it can be concluded that the presence of a drug
interaction between DRP methylprednisolon and clarithromycin (non-significant), and
improper dosing regimen in the use of ranitidine (drug doseis too low).
REFERENCES
1.
BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung Seto.
2.
Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford
3.
David S. Tatro, 2003 A to Z Drug Facts and Comparisons.
4.
Martin, J., Jordan., B,. Macfarlane, C,R,. et el,. 2008. BNF-56. London: British
Medical Association.
5.
PDPI. 2003. Penyakit Paru Obstruktif Kronik (PPOK). Pedoman Diagnosis dan
Penatalaksanaan Di Indonesia : Jakarta
6.
Sudoyo, Aru W., et al. 2006. Buku Ajar Penyakit Dalam. Jakarta : Departemen Ilmu
Penyakit Dalam Fakultas Kedokteran Universitas Indonesia.
1155
CASE STUDY OF CKD (CHRONIC RENAL DISEASE) IN PGI CIKINI
HOSPITAL
Junitha Pritama Duwila1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Chronic kidney disease (CKD) is defined as kidney damage that occurred more than 3
months, in the form of structural or functional abnormalities, with or without decreased
glomerular filtration rate (glomerular filtration rate / GFR) with pathological manifestations
of abnormalities or there are signs of kidney disorders, including abnormalities in the
chemical composition of blood, or urine, or radiographic abnormalities3. Mr. Y 56 years
old, was diagnosed of non-functioning right kidney. He has received ceftriaxone, vitamin k,
torasic (ketorolac), caprol (pantoprazole), ca gluconas. Based on the results of clinical
practice kepanitraan hospital ward in PGI Cikini disease, it can be concluded that the
presence of DRP (Drug Related Problem) drug interaction is the interaction between
ceftriaxone with ca gluconas and ketorolac with vitamin k.
Keywords: Chronic Renal Failure, Internal Medicine, Hospital PGI Cikini.
INTRODUCTION
Chronic kidney disease (CKD) is defined as kidney damage that occurred more than 3
months, in the form of structural or functional abnormalities, with or without decreased
glomerular filtration rate (glomerular filtration rate / GFR) with pathological manifestations
of abnormalities or there are signs of kidney disorders, including abnormalities in the
chemical composition of blood, or urine, or radiographic abnormalities3. Decreased renal
function causes the end product of protein metabolism (which is normally excreted into the
urine) accumulate in the blood 3. Resulting in uremia and affects every system of the
body6. The more heap garbage products, the symptoms will be more severe6. Fluid and
sodium retention as a result of the decline in renal function may lead to edema, congestive
heart failure / CHF, and hypertension6. Hypertension can also occur because of the activity
of the renin-angiotensin axis and cooperation both increase secretion of aldosterone6. CKD
1156
also causes metabolic acidosis caused by the kidneys are unable to secrete acid (H)
excessive6. Decrease ekresi phosphate and other organic acids may also occur6. In
addition, CKD also causes anemia that occurs because of inadequate erythropoietin
production, shortened red blood cell age, nutritional deficiencies, and a tendency to bleed
due to the status of uremic patients, especially of the digestive tract6. Eritropoitein
produced by the kidneys, stimulates the bone marrow to produce red blood cells decreased
erythropoietin production if it results in severe anemia accompanied by fatigue, angina, and
shortness of breath6.
CASE PRESENTATION
Mr. Y 56 years was dagnosed with back pain and a limp. Hematology laboratory
tests LED has increased 23 mm / h, 45% lymphocytes, total protein 8.1 g / dL, globulin 3.9
g / dL, creatinin 1.7 mg / dL and laboratory values decreased neutrophil stem 1%, 46%
neutrophils segment, calcium 8.7 mg / dL.
Examination
Complete peripheral blood
Erythrocyte sedimentation
rate
hemoglobin
leukocytes
erythrocytes
hematocrit
reticulocyte
Leukocyte count
basophils
eosinophils
neutrophils stem
neutrophils segment
lymphocytes
monocytes
platelets
MCV
MCH
MCHC
Hemostatic
Freezing period
Result
12
mei
2014
Unit
Normal
Value
*23
15,8
9,4
5,27
44
12
mm/hour
g/dL
10^3μL
10^3μL
%
Permil
0-20
12-14
5-10
4-4,5
37-43
5-15
0
1
*1
*46
*45
7
280
83
30,0
36,0
%
%
%
%
%
%
10^3μL
fL
pg
g/dL
0-1
1-3
2-6
50-70
20-40
2-8
150-450
81-92
27-32
32-37
1112
34,0
32,1
minute
second
second
10-16
26,437,5
1157
APTT patients
APTT control
Prothrombin future
PT patients
PT control
INR
Fibrinogen
D-dimer
Total protein
Albumin
Globulin
SGOT
SGPT
Urea
Creatinine
Sodium, Potassium
Sodium
Potassium
Calcium
Phosphorus
13,0
12,5
1,0
306
H 8,1
4,2
H 3,9
22
32
30
H 1,7
135
L 3.3
L 8,7 mg/dL
L 1,4
second
second
11-14,2
mg/dL
μg/L
g/dL
g/dL
g/dL
U/L
U/L
mg/dL
mg/dL
180-350
0-500
6,0 - 8,0
3,4 - 4,8
1,3 - 3,7
0 - 35
0 - 35
10 - 50
0,6 - 1,1
mEq/L
mEq/L
mg/dL
135
147
3,5 - 5,0
8,8
10,0
2,5 - 5,0
EVALUATION CLINIC
Ceftriaxon use as a result of bacterial infection antibiotics are used in injection for 9 days
from the 12th to the 20th, vitamin C ampoule used due to deficiency of vitamin K for 8
days starting from April 13 to May 20, torasic (ketorolac) ampoules used for acute pain
management short-term use for 8 days starting from April 13 to May 20, caprol
(pantoprazole) is used for stomach ulcers used orally for 1 day on the 13th, ca gluconate
ampoules used due to lack of calcium and also used for allergies, as well as the shock due
to arsphenamin case of poisoning by timbale, karbonatertraclorida and potassium used for 3
days starting from April 14 to May 16.
GUIDELINE CHRONIC RENAL FAILURE
1. ACP does not recommend screening asymptomatic chronic kidney disease in adults
without risk factors for chronic kidney disease. Despite its prevalence increases with
age, chronic kidney disease have a relatively low prevalence in the general population
1158
without risk factors. The main risk factors for chronic kidney disease, such as diabetes,
hypertension, and cardiovascular disease.
2. ACP does not recommend the examination of proteinuria in adults with or without
diabetes who recently taking angiotensin-converting enzyme inhibitors (ACE
inhibitors) or angiotensin II-receptor blocker (ARB). It is unknown whether there are
additional benefits of the examination of proteinuria in patients already taking an ACE
inhibitor or ARB.
3. ACP recommends that clinicians choose pharmacologic therapy that includes ACE
inhibitors or ARBs in patients with hypertension and chronic kidney disease stages 1-3.
Evidence shows that treatment with ACE inhibitors or ARBs reduce the risk of ESRD
(end stage renal disease) in patients with chronic kidney disease stages 1-3.
4. ACP recommends that clinicians choose governance statin therapy for LDL (low density
lipoprotein) in patients with chronic kidney disease stages 1-3. Evidence showed statins
reduce the risk of all-cause mortality and also lowers the risk of myocardial infarction,
stroke, and most cardiovascular outcomes in patients with chronic kidney disease stages
1-3.
1.
Interaction between ceftriaxone with Ca gluconas the use of ceftriaxone with Ca
glukonate can increase particulate fluid in the lungs and kidneys 2.
2. The use of ketorolac with vitamin K anticoagulant effect of vitamin K resulted in
decreases. If the remains are used need to be monitored closely and given the distance
at least 2 hours 2.
CONCLUSION
Based on the assessment results of the patient's disease can be inferred by the use of
ceftriaxone with Ca glukonate can increase particulate fluid in the lungs and kidneys. The
use of ketorolac with vitamin K anticoagulant effect of vitamin K resulted in decreases. If
the remains are used need to be monitored closely and given the distance at least 2 hours.
1159
REFERENCES
American Society of Health-System Pharmacists; 2003:1082-9).
2. Baxter, K. 2008. “Stockley’s Drug Interaction”. Eight Edition. Pharmaceutical Press,
London and Chicago.
3. Bertram G.Katzung, 2012. “Farmakologi Klinik Dasar” ed.10. Buku Kedokteran.
EGC.
dan Makanan. Jakarta
6. Sudiyono, 2006. “Buku Ajar Ilmu Penyakit Dalam”. FK UI Jakarta.
1160
STUDY OF DRUG RELATED PROBLEMS (DRPS) ASSOCIATED WITH THE
PATIENT TREATMENT MILIARY TUBERCULOSIS (TB) AT INTERNAL
MEDICINE WARDS PGI CIKINI HOSPITAL
Lestin Allo Paillin1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Tuberculosis (TB) is contagious infection disease caused by the bacterium Mycobacterium
tuberculosis, an aerobic bacilli resistant to acid, which is transmitted through the air
(airborne). Miliary TB is disseminated TB, although always the lung, but included in the
Extrapulmonary Tuberculosis (ETB) group because many organs are attacked. Patient’s
Ms. LS, aged 62 years, entered the PGI Cikini Hospital on May 1, 2014 with was diagnosed
of anemia, febris H2 and dyspepsia and miliary TB final diagnosis. Therapy for the
treatment of hospitalized were Cefotaxime, Rantin (Ranitidine), Paracetamol, Omeprazole,
Rifampicin, Isoniazid, Pyrazinamide, Ethambutol, Vitamin B6, Musin (Sucralfate),
Fluimucil (Acetylcysteine), and Amlodipine. Based on the results of their clinical practice,
found Drug Related Problems (DRPs) a correlation between drug therapy with clinical
conditions such as weight loss as a result of had difficulty eating, microcytic anemia and
hypoalbuminemia form of indications without drug. Improper dosage regimens in the used
of Rifampicin and Pyrazinamide form of drug dose was too low. Existence of interactions
some drugs that was Rifampicin and Amlodipine; Rifampicin and Isoniazid; Rifampicin
and Paracetamol; Omeprazole and Paracetamol; Isoniazid and Paracetamol; Isoniazid and
Ethambutol.
Keywords
: Tuberculosis, Dosage, PGI Cikini Hospital
INTRODUCTION
Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium
tuberculosis, an aerobic bacilli resistant to acid, which is transmitted through the air
(airborne)1. Pulmonary Tuberculosis (PTB) covers 80% of the overall incidence of
1161
tuberculosis disease, while the remaining 20% is Extrapulmonary Tuberculosis (ETB ) is
TB that attacks the organs other than the lung such as the pleural, limpe gland, spinal joints,
urinary tract, central nervous system and stomach. Often the diagnosis of ETB becomes
difficult because the symptoms are not specific5.
Miliary TB is a form of TB with varying severity, in the form of small tubercles on a
variety of different organs due to dissemination of bacilli throughout the body via the blood
stream6. Miliary TB is also disseminated tuberculosis, although almost always the lung, but
included in the ETB group because many organs are attacked9.
According to WHO, in the year 2012 an estimated 8.6 million people infected with
TB and 1.3 million died, including 320.000 deaths included People with HIV/AIDS
(PWHA). Southeast Asia and the Western Pacific Region collectively accounted for 58% of
TB cases in the world in the year 20128.
Number of patients with TB in Indonesia is still relatively high. The number of TB
patients in Indonesia was ranked fourth highest worldwide after China, India, and South
Africa. The prevalence of TB in Indonesia in the year 2013 was 297 per 100.000 population
with new cases each year reached 460.000 cases. Thus, the total number of cases up to the
year 2013 reached approximately 800.000-900.000 cases of TB7.
TB disease is the cause of deaths of the three numbers after heart disease and acute
respiratory disease in all the ages so that good TB control is very necessary5.
CASE PRESENTATION
Ms. LS 62 years old, was entered PGI Cikini Hospital on May 1, 2014. Patient
present with fever since the day before hospitalized. One day before hospitalized, the
patient began malaise, cough with sputum is difficult to remove. The patient felt nauseated
and had difficulty eating, so that weight loss
± 2 kg in one week.
Based on complaints and the examination results of hematology patient, the doctor
diagnosed anemia, febris H2, and dyspepsia. After examination of Acid Fast Bacilli (AFB)
negative results obtained, as well as photo thorax examination also found abnormalities in
the pulmonary infiltrates and nodules which look fine on both lungs to avert any miliary
1162
specific process. From the results of the examination doctors diagnosed patient suffering
from miliary TB.
The patient has a past medical history of hypertension as a result of not taking the
medication regularly.
CLINICAL EVALUATION 4
Used of Cefotaxime 1 g injection was given 3 times daily to used treat respiratory
tract infections. Rantin (Ranitidine) 50 mg/2 mL injection was given 2 times daily to used
treat peptic ulcers and duodenal ulcers. Paracetamol 500 mg tablet was given 3 times daily
to used reduce fever. Omeprazole 40 mg injection 1 daily to used treat gastric ulcers and
duodenal ulcers. Rifampicin 450 mg tablet and INH 300 mg tablet was given 2 times daily
used as an anti tuberculosis, Pirazinamide 500 mg tablet and Ethambutol 500 mg tablet was
given 2 times daily used as an anti tuberculosis. Vitamin B6 10 mg tablet was given 3 times
daily to used prevent peripheral neuritis. Ambroxol 30 mg tablet was given 3 times daily
used as secretolytic. Mucin (Sucralfate) 500 mg tablet was given 4 times daily to used treat
peptic ulcers and duodenal ulcers. Fluimucil (Acetylcysteine) syrup 10 mL was given 3
times daily used as therapy hypersecretion viscous mucus. Amlodipine 5 mg tablet was
given 2 times daily used as an anti hypertension.
DATA LABORATORY
Based on laboratory test obtained hematology patient results Hemoglobin 7.8 g/dL,
Erythrocytes 4.83 10^3μL, Hematocrit 27%, MCV 55 fl, MCH 16.1 pg, MCHC 29.3 g/dL,
reticulocyte 19 permil, and Albumin 2.5 g/dL.
1163
TREATMENT REGIMEN
ATD (Anti Tuberculosis Drugs) alloys used by the Indonesian Government in the
National TB Control Program5, following as :
Type
Intensive Phase
Continued
Advanced Stage
Category 1
2HRZE
-
4H3R3
Category 2
2HRZES
HRZE
5H3R3E3
Category 3
2HRZ
-
4H3R3
Description:
2HRZE
: Used for 2 months, ATD (HRZE) were given every day.
4H3R3
: Used for 4 months, ATD (HR) were given 3 times a week.
2HRZES
: Used for 2 months, ATD (HRZES) were given every day.
HRZE
: Used for 1 month, ATD (HRZE) were given every day.
5H3R3E3
: Used for 5 months, ATD (HRE) were given 3 times a week.
2HRZ
: Used for 2 months, ATD (HRZ) were given every day.
Where:
H= Isoniazid; R= Rifampicin; Z= Pyrazinamide; E= Ethambutol; S= Streptomycin
Treatment according to the categories defined by the criteria of patients5, following as :
Category 1
New cases pulmonary TB of AFB positive
New cases pulmonary TB of AFB negative, rontgen positive severe pain
Patients with severe extrapulmonary, including meningitis, miliary, pericarditis, peritonitis,
pleurisy eksudativa bilateral, spinal tuberculosis, intestinal tuberculosis, TB urinary tract
and genitals.
Category 2
Patients with pulmonary tuberculosis relapse
Patients with pulmonary tuberculosis with therapy failure
Patients with treatment after default
Category 3
New cases of AFB negative and rontgen positive mild pain
1164
Patients with extrapulmonary TB include mild lymph node TB, pleurisy eksudativa
unilateral, bone (except spine), joint and adrenal glands.
Correlation between Medicine Therapy with Disease
There is indication without drugs, where patient experience weight loss as a result
of difficulty eating. It is recommended to provide additional therapy in the form of a
supplement that can increase the appetite such as Vitamin zinc or Vitamin B complex and
monitoring of the patient's nutritional state. Value hematologic examination of patient seen
a decrease in the value of Hemoglobin, Erythrocytes, Hematocrit, MCV, MCH, MCHC
indicates that overall microcytic anemia. It is also seen with an increase in the value of
Reticulocyte patient. It is recommended to provide additional oral iron therapy and
periodically check the Hemoglobin, Erythrocytes, Hematocrit, MCV, MCH, MCHC and
Reticulocyte. Patient experience hypoalbuminemia, it is seen with albumin value decreases,
but the patient did not received Albumin therapy.
Dose Regimen
Rifampicin drug dosage given was too low at 1 x 450 mg, which according to Dr.
Aine Burns (Renal Drug Handbook, 2009) should have been administered dose is 600-1200
mg daily within 2-4 divided doses. Pyrazinamide drug dose given was also too low at 2 x
500 mg daily, which according to Dr. Aine Burns (Renal Drug Handbook, 2009), should
the dose given was 1.5 g – 2 g daily. Suggested to the doctor to re-evaluate therapeutic dose
Rifampicin and Pyrazinamide. Checking patient medication records on a regular basis.
Drug Interaction2
Drug interactions between Rifampicin and Amlodipine was Rifampicin will
decreased the effect of Amlodipine by increasing the isoenzyme cytochrome P450
CYP3A4. Giving Rifampicin and Isoniazid concurrently will decreased bioavailability of
Rifampicin. Rifampicin and Paracetamol given concurrently will decrease the effectiveness
of Paracetamol by increasing metabolism of Paracetamol. For Omeprazole and Paracetamol
1165
which Omeprazole can induces CYP1A2, and possibly increased formation of metabolites
hepatotoxic Paracetamol. Isoniazid and Paracetamol which Isoniazid will increase the
toxicity of Paracetamol by inhibiting metabolism Paracetamol. The use of Isoniazid and
Ethambutol concurrently there was known evidence that Ethambutol does not affect serum
Isoniazid levels significantly, but there is also some evidence to suggest that optic
neuropathy and Ethambutol can be increased with the use concurrently with Isoniazid.
CONCLUSION
Based on the results of their clinical practice at Internal Medicine Ward PGI Cikini
Hospital can be concluded that the presence of Drug Related Problems (DRPs) a correlation
between medicine therapy with clinical conditions such as weight loss as a result of a
correlation between drug therapy with clinical conditions such as weight loss as a result of
had difficulty eating, microcytic anemia and hypoalbuminemia form of indications without
drug. Improper dosage regimens in the use of Rifampicin and Pyrazinamide form of drug
dose is too low. Existence of interactions some drugs that is Rifampicin and Amlodipine;
Rifampicin and Isoniazid; Rifampin and Paracetamol; Omeprazole and Paracetamol;
Isoniazid and Paracetamol; Isoniazid and Ethambutol.
REFERENCES
1. Asih, Niluh G.Y dan Christantie Effendy. 2004. Keperawatan Medikal Beda : Klien
dengan Gangguan Pernapasan Cetakan Pertama. Jakarta: EGC
2. Baxter, Karen. 2010. Stockley’s Drug Interactions Ninth Edition. London :
Pharmaceutical Press.
3. Burns, Aine. 2009. Renal Drug Handbook Third Edition. New York : Oxford
4. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta: Sagung Seto.
5. Direktorat Bina Farmasi Komunitas dan Klinik. 2005. Pharmaceutical Care Untuk
Penyakit Tuberkulosis. Jakarta: Departemen Kesehatan Republik Indonesia.
6. Dorland, W.A. Newman. 2012. Kamus Saku
Kedokteran Edisi 28. Translate by
Albertus Agung Mahode, et al. Jakarta : EGC.
1166
7. Kartika, Unoviana. 2014. Indonesia Peringkat 4 Pasien TB Terbanyak di Dunia,
(Online), (http://health.kompas.com/read/2014/03/03/1415171/ Indonesia. Peringkat . 4
. Pasien. TB. Terbanyak. di. Dunia), Date Accessed on Maret 3, 2014.
8. Reksoprodjo, Mariani. 2014. Rekomendasi Pertemuan ke-2 Forum Stop TB Partnership
Kawasan Asia Tenggara, Pasifik Barat dan Mediterania Timur, (Online),
(http://www.stoptbindonesia.org/2014/04/rekomendasi-pertemuan-ke-2-fstpi.html),
Date Accessed on April 28, 2014.
9. Syamsuri, Wizhar, et al. 1998. Tuberkulosis Milier. Padang: Faculty of Medicine,
Andalas University.
1167
DRUG RELATED PROBLEM ON DISESASE THERAPY
MANAGEMENT COMPLICATIONS STROKE WITH FEW
COMPLICATIONS TYPE II DIABETES, HYPERLIPIDEMIA AND
HYPERTENSION
Muhammad Fauzi1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
Stroke is a major reduction in the nervous system suddenly that lasted for 24 hours and
thought to originate from the blood vessels. There are 2 strokes : ishkemik stroke (stroke
caused by blockage) and hemorrhagic stroke (stroke caused by bleeding)1.
Stroke cases in Indonesia showed good trajectory in terms of mortality, incidence, and
disability. According to the MOH Riskesdas, mortality by age was of 15.9% (age 45-55
years), 26.8% (age 55-64 years) and 23.5% (age> 65tahun). The incidence of stroke
according Soertidewi was 51.6 / 100,000 population and 1.6% of disability4.
Case presentation : Mrs. ST 59 year old came to the hospital PGI Cikini. Patient diagnosed
with stroke with few complications DM of type II diabetes, hyperlipidemia and
hypertension.
Clinic Evaluation: there are basically 3 intervention studies found scuba treatment of stroke
patient with less complications of type II diabetes mellitus, hyperlipidemia, and
hypertension is the first drug administration drug administration HCT second and third
simvastatin administration of antiplatelet.
Keywords : Stroke, type II diabetes mellitus, hyperlipidemia, hypertension, RS PGI Cikini
1. Introduction
Stroke is a major reduction in the nervous system suddenly that lasted for 24 hours
and thought to originate from the blood vessels. There are 2 strokes: ishkemik stroke
(stroke caused by blockage) and hemorrhagic stroke (stroke caused by bleeding). Some
88% of all stroke is ischemic stroke, which is caused by the formation of a thrombus or
embolism that inhibit cerebral artery. The end result of thrombus formation or arterial
1168
embolism is a bottleneck and decrease cerebral blood flow. Cerebral blood flow in
normal circumstances is 60ml / 100g of brain tissue per minute. Ischemia occurs when
drah flow to the brain <20ml / 100g of brain tissue per minute, where the energy of
ATP produced will be reduced due to the change from aerobic to anaerobic metabolism
and impaired homeostasis of ions, resulting in disruption of activity and reactivity
lsitrik neurons progressively.
Chronic hypertension is a risk factor for stroke because it may lead to endothelial
dysfunction. Endothelial nitric oxide function remove (NO) which will play a role set
dilation and constriction of blood vessels in a balanced way, NO produced from
endothelial dysfunction levels will be reduced so that there will be effects of
proinflammatory, procoagulant and prothrombotic can change the structure of blood
vessel walls. Hypertension also activates enzymes that can increase oxidative stress on
blood vessels. The combination of endothelial dysfunction and oxidative stress will
further accelerate the process of atherosclerosis that narrows the lumen of blood vessels
and lead to the formation of plaque that intracerebral neuronal cells more susceptible to
ischemia and plaque as an embolus causing risk of ischemic stroke 2.
In the diabetes or the state will result in severe hyperglycemia glycosuria.
Glycosuria this will result in osmotic diuresis that increases urine output (polyuria).
When the body loses fluids then had blood concentrations that make blood clot or
thrombosis in other words. Thrombosis associated with atherosclerosis processes which
can result in narrowing of the blood vessels leading to brain6. Dyslipidemia be risk
factors for ischemic stroke because of the role of low-density lipoprotein (LDL) in the
process of atherosclerosis. LDL can cause inflammation resulting in endothelial
dysfunction.
A female patient aged 59 years old, came to the PGI Cikini Hospital on May 2,
2014 with complaints of weak-side motion to the left since 1 day before entering the
hospital. Patients sometimes feel dizzy. Results of physical examination showed a
general awareness Compos mentus (fully conscious). Blood pressure 160/100 mmHg.
1169
Laboratory tests at admission showed GDR 399 mg%. Meanwhile, laboratory results on
May 3 shows the results: GDN: 161 mg%, GD 2 hours PP: 188 mg%, Ur: 64 mg%, Cr:
1.3 mg,; uric acid: 7.1 mg%, total cholesterol: 322 mg%, HDL cholesterol: 27 mg%,
LDL cholesterol: 245.4 mg%, triglycerides 248 mg%. Based on the results of tests
carried out, the patient was diagnosed with ischemic stroke with few complications
such as diabetes mellitus type II, hyperlipidemia and hypertension.
Therapy in the acute phase are given in ischemic stroke patients includes treatment
of acute stroke in general, such as the stabilization of the airway and hemodynamic
stabilization, as well as specialized therapy, such as fluid and electrolyte management,
management of thrombolysis, blood pressure management, and management of blood
sugar. For airway stabilization given oxygen on the state of the oxygen saturation
<95%. In this case the patient is receiving oxygen therapy in the emergency department
until the fifth day of treatment. Acute ischemic stroke patients are mostly located in the
state of hypovolemia or euvolemi. The state of hypovolemia in patients with acute
stroke may lead to hypoperfusion and result in ischemic brain. Administration of
isotonic fluids such as 0.9% saline is recommended in order to maintain euvolemi. In
this case, pesien has received fluid therapy in the form of NaCl 0.9%.
Thrombolysis is done by providing tissue plasminogen activator (alteplase)
intravenously within 3 hours after onset. Alteplase working on plasmin enzyme that can
break down fibrin in blood clots, which can destroy the thrombus. In this case the
patient does not get thrombolysis therapy. This happens because the patient did not
meet the inclusion criteria for thrombolysis, namely stroke onset of less than 3 hour4.
The decrease high blood pressure in acute stroke is not recommended as a routine
action, because the possibility can worsen neurological output. In most patients, the
blood pressure will go down by itself within the first 24 hours after the onset of the
attack stroke 4. Decreased blood pressure in the acute phase only needs to be done when
the patient's blood pressure exceeds 220/120 mm Hg or MABP> 130 mmHg. And drugs
that must be given is a combination of a diuretic with ACE inhibitor 2. Patient's blood
pressure at admission was 160/100 mmHg and IGD his MABP was 140 mmHg, and the
patient only received an ACE inhibitor antihypertensive drug classes (Ramixal® /
1170
Ramipril). On the fourth day of treatment then patients received antihypertensive drugs
diuretics (HCT) and the ARB group (Lifezar® / Losartan). On the fifth day of treatment
the patient also received additional antihypertensive drug clonidine 2x1. Administration
of antihypertensive drugs with four combinations still showed a decrease in blood
pressure as desired as recommended by Perdossi (2011) that a decrease in blood
pressure of 15-20% each drug administration. Then on the day of treatment the patient
keenan get more additional classes of antihypertensive drugs CCB (amlodipine 1 x
10mg). 1,3mg% of patients creatinine levels and uric acid levels were 7.1 mg% of
patient showed both state> normal indicating that patient has impaired renal function,
whereas patient receiving HCT therapy, which is largely excreted through the kidneys it
can aggravate the kidney. So according to our group HCT election in this case is less
precise, and should be replaced with Furosemide.
Patient received metformin at a dose of 2x500 mg / day. Pembrian aims to lower
patient’s blood sugar levels that are above normal (GDR 399 mg% at the time of entry).
From interviews with patient, patient often consume sweet tea every day and just knew
had diabetes mellitus at the time admitted to the hospital. Metformin administration of
this therapy is also combined with other oral antidiabetic medications (glimepiride)
which aims to achieve the desired therapeutic. So on the second day of a patient's blood
sugar levels can drop far enough. After the second day, the blood glucose level was
measured to be 161 mg% GDN, GD 2 hours PP 188 mg%. For treatment of high
cholesterol simvastatin given 1x1. Lowering blood cholesterol with statins can reduce
the risk of ischemic stroke. However, administration of simvastatin less help to decrease
triglyceride levels and increase HDL levels. Thus, it is recommended that patient are
given drugs known as fibrates (fenofibrate) that are useful for high levels of
triglycerides and HDL were rendah 3.
After getting acute therapy, subsequent management component that needs attention
is the prevention of deterioration of neurological conditions or medical complications.
For prevention of deterioration of neurological conditions, patient given antiplatelet.
Giving aspirin (tromboaspilet) as antiplatelet given at a dose of 325 mg for the initial
attack gained 24-48 jam4. However, patient only receive treatment with a dose of
1171
tromboaspilet at a dose of 80 mg was first given. Thus, in this case the patient did not
receive drug therapy with an appropriate dose. As for other medical complications, such
as stress ulcer, giving H2-receptor blockers or proton pump inhibitors should give 4. In
this case the patient was given Ranitidine injection at a dose of 2 x 1 ampoule. Giving
Nevradin E (vitamin B complex) aims to help prevent an increase in homocysteine is a
risfactor for stroke indapenden and other cardiovascular diseases.
3.1 Drug Related Problems
HCT is a diuretic antihypertensive drug classes. Judging from the patient's creatinine
levels 1,3mg% and uric acid levels were 7.1 mg% of patient showed both state> normal
indicating that patient had impaired renal function, whereas patient receiving HCT
therapy where the drug is largely excreted through the kidneys this can aggravate the
kidneys.
Intervention pharmacists: advise patient to replace the diuretic HCT drug therapy by
using drug class diuretic Henle loop is furosemide.
For treatment of high cholesterol simvastatin given. Lowering blood cholesterol with
statins can reduce the risk of ischemic stroke. However, administration of simvastatin
less help to decrease triglyceride levels and increase HDL levels.
Intervention pharmacists: recommend that the patient is given drugs known as fibrates
(fenofibrate) that are useful for high triglycerides and low HDL.
After getting acute therapy, subsequent management component that needs attention is
the prevention of deterioration of neurological conditions or medical complications. For
prevention of deterioration of neurological conditions, patient given antiplatelet. Giving
aspirin (tromboaspilet) as antiplatelet given at a dose of 325 mg for the initial attack
obtained jam4 24-48. However, patient only receive treatment with a dose of
tromboaspilet at a dose of 80 mg was first given. Thus, in this case the patient did not
receive drug therapy with an appropriate dose.
1172
Intervention pharmacists : suggest to the patient to replace the antiplatelet drug with
larger doses in accordance with the prescribed dose is difficult to achieve the desired
therapeutic.
4. Conclusion
After the assessment of the patient's treatment, it can be concluded hypertensive therapy
for patient who have kidney deficiency is not HCT furosemide, to decrease high
triglycerides with low HDL therapy is the right treatment drugs known as fibrates,
namely fenofibrate, antiplatelet agents used for blood thinning must be the correct
dosage as set out above.
5. References
1. American Society of Health-System Pharmacist (ASHP). 2011. AHFS Drug
Information. Bethesda : American Society of Health System Pharmacist.
2. Dipiro, J. T., Talbert, R.L., Yee, G.C., Matzke G.R., Wells, B.G. & Posey L.M. 2008.
Pharmacotheraphy : A Pathophysiologic Approach (7th Ed). New York : McGrawHill.
3. Gazette. 2013. In Health : Divisi Pelayanan Obat. Jakarta
4. Pokdi Stroke Perhimpunan Dokter Spesialis Saraf Indonesia (PERDOSSI). 2011.
Guideline Stroke 2011. Jakarta : PERDOSSI.
5. Uchino, K., Pary, J., Giotta J. 2007. Cambridge Pocket Clinians : Acute Stroke Care.
UK : Cambridge University Press.
6. World Health Organitation (WHO). 2006. The Who Step wise Approach to Stroke
Surveilance. Geneva :WHO.
1173
A CASE STUDY CHRONIC KIDNEY DISEASE STAGE V ON HEMODIALYSIS
Magriatin1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
Chronic kidney disease (CKD) is a malfunction of the kidney (nephron units) or chronic
decrease in kidney function where the kidneys are not able to maintain the internal
environment of the development of progressive kidney failure, irreversible and slowly in
the long term and permanent causing accumulation of residual metabolic (uremic toxic) that
lead kidneys does not work and cause pain response5. Patient Mrs. NH 54 years old was
diagnosed with CKD on HD, Anemia and Melena. During hospitalized, she has received
treatment of medicine, those were Cefotaxime, Paracetamol, Transamin, folic acid, Vitamin
K, Vitamin B12, CaCO3, Na.bicarbonate, Lactulax, Omeprazole, PRC transfusion,
Furosemide, Diphenhydramine, Calcium gluconas, Sucralfate, NaCl 0.9%, D 40%,
Somatostatin. The clinical evaluation, folic acid in the treatment of anemia is improper,
because it is not caused by a deficiency of folic acid showed with normal MCV (date 18/3
= 81: Normal 80-96 FL) 4.
Keywords: Gatot Soebroto Army Hospital, Chronic Renal Disease
INTRODUCTION
Chronic kidney disease (CKD) is a malfunction of the kidney (nephron units) or
chronic decrease in kidney function where the kidneys are not able to maintain the internal
environment of the development of progressive kidney failure, irreversible and slowly in
the long term and permanent causing accumulation of residual metabolic (uremic toxic) that
lead kidneys does not work and cause pain response5.
Diagnosis of chronic kidney disease done in case of kidney damage for more than 3
months, the abnormality of structure or function of the kidney with or without decreased
glomerular filtration rate by pathologic abnormalities or indication kidney damage like
1174
proteinuria. Beside it, the value of glomerular filtration rate <60 ml/minute/1,73m ² for> 3
months with or without kidney damage 2.
NKF-KDOQI CKD submit grouping into five stages, began from stage 1 (the
lightest) to stage 5 (most severe) by the value of glomerular filtration rate (GFR) per body
surface area. First stage of Kidney damage with normal or increased GFR (≥ 90
ml/minute/1.73 m2). The second stage of Kidney damage with mild GFR (60-89
ml/minute/1.73 m2). Third stage of Kidney damage with GFR moderate (30-59
ml/minute/1.73 m2). Stage four Kidney damage with severe LFG (15-29 ml/minute/1.73
m2). Stage 5 renal failure (<15 ml/minute/1.73 m2) 8.
CASE PRESENTATION
Mrs. NH 54 years old was diagnosed with CKD stage V (end-stage), anemia and
melena. Patient complained of weakness since 6 hours SMRs, lazy to talk, decreased
appetite, dark stool. Change pampers 3-4 times a day with a past history of hypertension
but no description of the use of drugs.
EVALUATION CLINIC 1,6,11
Giving Cefotaxime as an antibiotics, treated infections. Paracetamol used to relieve
mild and moderate pain, fever treatment. Calcium gluconas to treated hypocalcaemia.
Natrium bicarbonate to treated dyspepsia and acidosis. Omeprazole and Sucralfat to treated
ulcer. Laktulac to treated constipation and bleeding in portal vein caused by difficult to
remove stool. CaCO3 to prevent hiperphosphate through binding to phosphate in food
intake, causing reduced phosphate absorption. Transamin, Vitamin K and Somatostatin for
treatment of bleeding. In this case Somatostatin given only once on 23/3 related to patients
experiencing vomiting blood. Folic acid, Vitamin B12, Transfusion PRC (Packed Red
Cells) using to treated anemia. Red blood cell transfusion is an option in the treatment of
anemia of chronic renal disease that required when acute bleeding, ESAs resistance, or
when the patient's hemoglobin level below 7 g / dL. The clinical evaluation, folic acid in
the treatment of anemia is improper, because it is not caused by a deficiency of folic acid
showed with normal MCV (date 18/3 = 81: Normal 80-96 FL). Furosemide to control blood
1175
pressure, edema resolve, increasing the excretion of K+. Diphenhydramine, of allergic
reactions to blood or plasma. NaCl 0.9% and D 40% as salt electrolyte solutions, nutrition
and fluids of body
DOSAGE AND DIRECTION 1
Dosage and method to used cefotaxime injection of 3 x 1 gram dose as an
antibacterial therapy in patients with HD 1 g every 8-12 hours. 3 × 500mg paracetamol
used to relieved mild and moderate pain and fever with dose in patients with HD therapy
500 mg - 1 g every 6-8 hours. Natrium bicarbonate 3 × 500 mg in the treatment of
dyspepsia, metabolic acidosis with dose in patients with HD therapy Oral: 0.5-1.5 g three
times a day (or more if needed). Calcium gluconas injection of 10 ml to resolved with a
dose of hypocalcaemia in patients with HD therapy depend on the indication of acute
hypocalcaemia: 10-20 ml of 10% calcium gluconas (2.25 to 4.5 mmol calcium) slowly
injection over 3 -10 minutes. On March 21st the laboratory test showed a decreased in
calcium level of 6.1 mg / dl, normal 8.6 to 10.3 mg / dl, so given intravenous Calcium
gluconas. Omeprazole injection of 2 × 40 mg to pressing gastric acid secretion by inhibiting
the "acid (proton) pump" with doses in patients with HD therapy IV: 40 mg once daily for
up to 5 days, patients with bleeding during endoscopy: 80 mg followed by 8 mg / hour for
72 hours (British Society of gastroenterology). Sucralfat 3 × 15 cc to protecting mucosa
from acid attack pepsin in gastric and duodenal ulcers with dose in patients with HD
therapy 2-4 g daily. Oral Lactulac 3 × 5 ml for Laxative with dose in patients with HD
therapy initially 15 mL twice daily; adjustment doses needed. 3 × 500 mg CaCO3 to
prevent hyperphosphatemia by binding to phosphate in food intake with dose in patients
undergoing HD treatment dose is adjusted with serum phosphate and calcium levels. Use of
oral folic acid 1 × 1 mg to treat anemia, folic acid deficiency associated with dose in
patients with HD therapy 5 mg daily for 4 months, then weekly according to response.
Vitamin B12 3 × 50 mcg to resolved deficiencies associated anemia vitamin B12. PRC
transfusion injection of 2 bags / day to treated anemia. Transamin injection of 3 × 500 mg
for the treatment of bleeding caused by excessive dose fibrinolysis in patients with HD
therapy: 5 mg / kg every 12-24 hours. Vitamin K injection of 3 × 10 mg, for the treatment
1176
of the second hypoprothrombinemia with conditions that limiting absorption or synthesis of
vitamin K prophylaxis with doses in patients HD therapy iv: 5-40 mg daily. Somatostatin
injection of 2 cc / hour for esophageal bleeding. Furosemide injection of 1 × 20 mg / ml for
the control of blood pressure, resolved edema, increase the excretion of K+ with a dose
therapy in patients undergoing iv: 20 mg - 1.5 g daily. Diphenhydramine injection of 1 × 10
mg / ml for allergic reactions to blood or plasma. NaCl 0.9% injection 500cc / 24-hour to a
solution of salt and electrolyte replacement fluids lost IV: severe deficiency of 2-3 liters
means 2-3 hours then reduced. D 40% injection of 50 cc of a solution of electrolytes and
nutrients.
LABORATORY TEST 9
In the laboratory test showed abnormal results include a decrease in Hb (date 17/3 =
4.7: date 18/3 = 6.0: date 19/3 = 5.2: date 20/3 = 6.5 : date of 21/3 = 4.2: date 22/3 = 5.1:
date 23/3 = 5.2: Normal 12-16 g / dl), hematocrit (date 17/3 = 14: date 18/3 = 18: date 19/3
= 16: date 20/3 = 18: date 21/3 = 12: date 22/3 = 14: date 23/3 = 15: Normal 34-47%) and
erythrocytes ((date 17 / 3 = 1.9: date 18/3 = 2.2: date 19/3 = 2.0: date 20/3 = 2.3: date 21/3
= 1.5: date 22/3 = 1, 8: date 23/3 = 1.8: Normal 4.3 to 6.0 million / mL). This indicated of
anemia caused by decreased production of the hormone erythropoietin by the kidney
medulla that important in erythropoiesis in the bone marrow. Anemia in CKD cases also
caused by reduced the life time of red blood cells as a result of uremia. In patients with
CKD stage V lifespan of red blood cells is only 60 days from the normal4. Shown also an
increase in the number of leukocytes to 14470 / μ, the normal 4800-10800 / μ that indicated
the presence of an acute inflammatory process or infection. Electrolyte abnormalities
shown from the decreased sodium 129 mmol / l (normal 135-147mmol / l) and calcium 6.1
mg / dl (normal 8.6 to 10.3 mg / dl), also an increase in potassium of 5.4 g / dl (normal 3.55.0 g / dl) and phosphorus 6.3 mg / dl (normal 2.5-5.0 mg / dl), where it is associated with
reduced renal function to manage the balance electrolytes through the process of excretion
and reabsorption.
In addition, laboratory result were not normal include urea (date17/3 = 247; normal
20-50 mg / dl) and creatinin (date17/3 = 7.3: normal 0,5-1,5 mg / dl) which indicates
1177
kidney function. From the calculation formula of Cockroft-Goult, CrCl or GFR showed
patient were 7,2 (<15 ml/minute/1, 73m2), including in CKD stage V requiring
hemodialysis therapy. There hyperkalemia (date 17/3 = 5.4: date 18/3 = 5.4: date 19/3 =
6.3: date 21/3 = 6.9: Normal 3.5-5.0 g / dl ) that harm patient because it can improve
cardiac ventricular repolarization phase
4
. Hyperkalemia conditions associated with
acidosis, as acidosis when the body did hemostasis mechanism to move the excess H + ions
in the blood to the intracellular. To maintain the electrical neutrality of K + ions released
from the cells that can lead to hyperkalemia 9. Condition of acidosis is also seen from the
patient's respiratory rate more than 20 times / min. The high RR can be caused by
conditions of acidosis with a low O2 levels stimulates the medulla oblongata to increase
breathing frequency on respiratory system 10.
1. The Relation Between Drug with Disease
Therapeutic treatment for Mrs. SH, medication is given according medical indication.
2. Improper Drug Selection 4
Folic acid in the treatment of anemia is improper, because is not caused by a deficiency
of folic acid showed with normal MCV (date 18/3 = 81: Normal 80-96 FL).
3. Doses Regimen
Doses were given according to the dose adjustment in patients with CKD stage V
4. Duplication of Drugs
There is no indication of therapeutic duplication
5. Allergy or intolerance
Patients not suffered allergic or intolerant to one drug (or chemicals associated with
treatment).
6. Adverse Drug Reaction
There are no symptoms or medical problems indicated.
7. Interactions and Contraindications 7
• CACO3 + lactulose
1178
CACO3 decreases effects of lactulose (PH decrease colon) by pharmacodynamics
antagonism, significant interaction possible, monitor closely
• Omeprazole + Vit.B12
Omeprazole reduces the effect of B12 levels through inhibition of the GI absorbs;
apply if both are oral. Minor or insignificant interactions.
• Cefotaxime + Furosemide
Cefotaxime increase the toxicity of furosemide through pharmacodynamics synergism,
increasing the risk of interactions nephrotoxic minor or insignificant.
• Furosemide + .float acid
Furosemide lowers folat acid with increased renal clearance. Interaction of minor or
insignificant.
• Furosemide + Ca.glukonat
Furosemide lowers ca.glukonat with increased renal clearance. Interaction of minor or
insignificant.
• Furosemide + Ca.karbonat
Furosemide reduces levels of CaCO3 with increased renal clearance.
Minor
interaction or insignificant.
CONCLUSION
Based on the result of the practice of clinic secretariat at the Gatot Soebroto, it can
be conclude that there was DRPs (Drug Related Problems) such as, the selection of folic
acid in the treatment of anemia is improper, because anemia is not caused by folic acid
deficiency as indicated by normal MCV values (date 18/3 = 81: Normal 80-96 FL) 4.
Actually the therapeutic management of anemia in CKD is the injection of erythropoietin
(epoetin alfa 21.6 mg IV every week) 3, but it cannot be done because the price is
expensive, so the PRC transfusion is right choice to treat severe anemia patient.
ADVICE
1. CaCO3 tablets chewed after the first bite to eat (along with eating), related to its
function as a phosphate binder in food intake.
1179
2. CaCO3 decreases effects of lactulose (PH decrease colon) by pharmacodynamics
antagonism, significant interaction possible, monitor closely 7. So
you can do to
minimize the interaction with giving interval to take medication, at least 2 hours.
REFERENCES
1. Ashley,C., Currie, A. 2009. The Renal Drug Handbook 3th Edition, Electronic Version.
New York: Radcliffe Publishing Oxford
2. Chonchol. 2005. Recommendations for the Screening and Management of Patients with
Chronic Kidney Disease. Nephron Dial Transplant Suppl .
3. Chrisholm-burns,M.A.,
Wells,B.G.,
Schinghammer,T.L.,
et
all,
2008,
Pharmacotherapy principles and Practice, New York: McGraw-Hill
4. Dipiro, J., T., 2005, Pharmacoteraphy, Sixth Edition, McGraw Hill : USA.
5. Hudson, J.Q., 2008, Chronic Kidney Disease: Management of Complications, in Dipiro,
J. T., Talbert, R. L., Yee., G. C., Matzke, G. R., Wells, B. G., & Posey, M. L.,
Pharmacotherapy: A Pathophysiologic Approach, 7th Ed, McGrawHill, New York.
6. Martin, J., Jordan, B,. Macfarlane, C,R,. et all,. 2008. BNF-56. London: British Medical
Association.
7. Medscape.com. 2014. http://www.medscape.com/druginfo/ druginterchecker. accessed
on 30 Juni 2014
8. National Kidney Foundation. 2006. KDOQI Clinical Practice Guidelines and Clinical
Practice Recommendations for Anemia in Chronic Kidney Disease. AJKD Vol 47, No 5,
Suppl 3, May 2006.The Official Journal Of The National Kidney Foundation.
9. Pagana, K.D., Pagana, T.J., 2002. Mosby’s manual of diagnostic and laboratory tests,
2nd edition. Missouri:mosby inc
10. Soeparman, Sukaton u.,Waspadji, s. 1990, Phatology vol. II Jakarta: FKUI
11. Tatro D.S, 2003. A to Z Drug Facts, Electronic Version. Facts and Comparisons San
Franscisco
1180
CKD (CHRONIC KIDNEY DISEASE) AND ANEMIA
Marni1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
CKD or chronic renal failure is a patofiologi process with various etiology, which causes
the reduction of kidney function that progressive and generally end with kidney failure1. In
the next stage, chronic kidney failure can cause anemia with symptoms of weakness,
fatigue, lethargy and shortness of breath2. Patients Mrs. K 55 years old, entered the Navy
Hospital Dr. Mintohardjo on June 16, 2014 and diagnosed CKD (Chronic Kidney Disease)
and Anemia. She got treatment teraphy for 5 days with RL 500 ml, 3x10 units Novorapid
injection, 10 mg of amlodipine, valsartan 80 mg, lasix injection, Bic. Sodium, Folic Acid 1
mg, Pro Renal, Glimepiride 2 mg, metformin 500 mg, and Lasix capsules. Based on the
result of their clinical practice in internal medicine wards at the Navy Hospital Dr.
Mintohardjo, it can be concluded that the causes of DRP (Drug Related Problem) is the
drugs interaction and inappropriate drug selection.
Keyword : CKD (Chronic Kidney Disease), Anemia, Medicine
INTRODUCTION
Chronic renal failure is kidney damage that occurs for more than 3 months, based
on pathologic abnormalities or markers of kidney damage such as proteinuria3. In chronic
renal failure, the decline of kidney function occurs slowly3. The process of decline in renal
function can continue for months or years until the kidney can not function at all (end stage
renal disease)3.
In the early stages of chronic renal failure. Perhaps, we can not find the clinical
symptoms because the kidneys are still able to adapt its functions3. In advanced stages,
chronic kidney failure can cause anemia with symptoms of weakness, fatigue, lethargy and
shortness of breath. In the accumulation of body fluids, it causes more swelling of the
whole body3. Some patients show the symptom that caused by the uremic condition (the
level of urea in blood is increase) that is nausea, vomiting and altered mental status
1181
(encephalopathy), with electrolyte imbalance. Renal ultrasound examination can be helpful
in diagnosing chronic renal failure3.
Major cause of CKD (Chronic Kidney Disease) in the United States 1995-1999 is
DM Type 1 (7%), diabetes mellitus type 2 (37%), hypertension and large vessel disease
27%, 10% glomerulonephritis, interstitial nephritis 4%, cysts and other congenital diseases
3%, systemic disease (lupus and vasculitis) 2%, 2% neoplasms. Based on Indonesian
Society of Nephrology (Pernefri) of 2000, the most common cause of kidney failure are
glomerulonephritis, diabetes mellitus, hypertension, obstruction and infection4.
The factors of chronic renal failure risk is with the patients of diabetes mellitus or
hypertension, obesity or smoking, age over 50 years, and individuals with a history of
diabetes mellitus, hypertension, and kidney disease in the family5. The preventing action
toward the chronic kidney disease should have been done at the early stadium of chronic
kidney disease5. Various preventing action have prove its benefit to prevent kidney disease
and cardiovascular, namely the treatment of hypertension (the lower the blood pressure the
smaller the risk of decline in kidney function), blood sugar control, blood lipids, anemia,
smoking surcease, increased physical activity and weight control5.
CASE PRESENTATION
Mrs. K, 55 years old entered the Navy Hospital Dr. Mintohardjo on June 16, 2014
was diagnosed of CKD (Chronic Kidney Disease) and Anemia. Patient came to hospital
with a limp since 2 days ago before entered hospital, dizziness 1 day ago before entered
hospital. Patient is queasy while eating, 3x1 bowel movements a day, liquid, black, low
back pain, right leg felt weak when walking. Result of laboratory tests showed creatinine
serum and the increased of patient urea and the result of calculation of glomerular filtration
rate (GFR) in getting the results of 38.5 ml / min which indicates kidney disease stage-3,
decreased hemoglobin, increased blood pressure, and sugar fasting blood (GDP) and when
blood sugar (GDS) has increased.
CLINICAL EVALUATION 6
The using of RL to return the electrolyte balance in dehydration, Novorapid injections for
diabetes mellitus, Amlodipine for hypertension. Valsartan for hypertension, Lasix injection
1182
for cardiac edema, kidney and liver, Bic.Natrium for metabolic acidosis, Folic Acid for
anemia and kidney failure, Renal Pro for chronic renal insufficiency, Lasix capsules for
cardiac edema, kidney and liver, Glimepiride and Metformin for diabetes mellitus type 2.
In the case of patients treated with 500 ml RL for 4 days, Novorapid injections 3x10
unit for 4 days, Amlodipine 10 mg 1x10 mg administered daily for 4 days then lowered the
dose to 5 mg administered 1 x 5 mg daily, Valsartan 80 mg was given 1 x 80 mg daily for 5
days, Lasix injection is given 1 x 1 a day for 3 days, Bic.Natrium given 2 x 1 daily for 4
days, Folic Acid given 2 x 1 for 4 days, Pro Renal given 3 x 2 daily for 4 days ,
Glimepiride 2 mg given 1 x 2 mg daily on days 5 and Metformin 500 mg given 3 x 500 mg
daily on day 5.
RESULTS OF LABORATORY TESTS8
Hematological examination results on June 16, 2014 shows a decrease in
hemoglobin value of 5,8 g / dL (12-14 g / dl), hematocrit 1,9% (37-42%), and erythrocytes
2,55 mL (4,2 – 5,4 mL), which indicates the occurrence of anemia, leukocytes 12,300 mL
(5000-10000 mL) indicate the presence of infection. Increased creatinine value of 1.3 mg /
dL (0,6 to 1,1 mg / dL) and urea 52 mg / dL (17-43 mg / dL) showed a decrease in kidney
function. The increase in fasting blood glucose 184 mg / dL (70-110 mg / dL) and blood
sugar as 165 mg / dL (<110 mg / dL) indicates the presence of diabetes mellitus.
LINE TREATMENT FOR CKD (Chronic Kidney Disease)9
Line 1
Antihypertensives (ACEI) to decrease intraglomerulus hypertension and glomerular
hypertrophy.
Line 2
diuretics
Line 3
1183
Antidiabetic, example: Glimepiride, Insulin, Glipizide. Avoid the use of metformin and
sulfonylurea drugs with a long service life.
DRUG RELATED PROBLEMS (DRPs)6,10,11,12,13,14
-
The patient was given Lasix injection (Furosemide) and Novorapid injection
(Insulin). There are several reports showing that furosemide can decrease the
effects of insulin and increase the level blood glucose, and according to Drug
Interactions 1989, effects of diabetes medicine at the opponent, as a result of blood
sugar levels may remain too high (hyperglycemia).
-
Patients are given metformin and lasix capsules (Furosemide). Furosemide can
increase the concentrations of Metformin serum, it can reduce concentration of
furosemide serum.
2. Selection of Inappropriate Medication
Patients get Metformin medicine. It is contraindicated with kidney disease because it
can cause hypoglycemia. According to the Pharmacotherapy and Medical Terminology
2008, in the state of decreased renal function, avoid Acarbose, Asetohexamid,
chlorpropamide, glyburide, metformin. Consider Glipizide, Glimepiride, Tolazamid,
tolbutamide, Insulin, Repaglinide, Glitazon.
CONCLUSION
Based on the result of their clinical practice in internal medicine wards at the
Navy Hospital Dr. Mintohardjo, we can conclude that the presence of DRP (Drug Related
Problem) is caused by the interaction of drugs and improper drug selection. The result of
laboratory tests showed creatinine serum and the increased of patient urea and the result of
calculation of glomerular filtration rate (GFR) in getting the results of 38.5 ml / min which
indicates kidney disease stage-3, decreased hemoglobin, increased blood pressure, and
fasting blood glucose (FBG) and when blood sugar (BS) has increased.
1184
REFERENCES
1.
Putu, et al. 2007. Evaluation of Use of ACE Inhibitors in Chronic Renal Failure
Patients at Dr Sardjito. Faculty of Pharmacy, University of Gajah Mada.
2.
Suwitra, K. 2009. Chronic Kidney Disease. Interna Publishing.
3.
Fritiwi, DH, et al. 2010. Chronic Renal Failure. University of North Sumatra.
4.
Society of Nephrology Indonesia. 2000. Chronic Kidney Disease and Glomerulopati:
Clinical Aspects and Pathology Renal Hypertension Management Today. Jakarta.
5.
National Kidney Foundation (NKF). 2009. K/DOQI Clinical Practice Guidelines for
Cardiovascular Disease in Dialysis Patients. New York.
6.
BPOM. 2008. Indonesian National Medicine Information (IONI). Jakarta : Sagung
Seto
7.
Burns, A. 2009. Renal Drug Handbook third edition. New York : Oxford
8.
Sutedjo, AY. 2007. Disease Handbook Know Through Laboratory examination results.
Amara Books. Yogyakarta.
9.
Faradilla, N. 2009. Chronic Renal Failure. Faculty of Medicine, University of Riau
10. Baxter, K. 2008. Stockley's Drug Interactions eighth edition. London: Pharmaceutical
Press.
11. Galileopharma. 2008. BNF edition 56. Alexandria University.
12. Harkness, R. 1989. Drug interactions. New York: Publisher ITB.
13. Priyanto. 2008. Pharmacotherapy and Medical Terminology. Publisher : Institute for
the Study and Consultation Pharmacology.
14. Kluwer, W. 2012. Drug Interaction Facts. Facts and Comparisons
1185
DRUG RELATED PROBLEMS ASSOCIATED WITH THE
TREATMENT FOR TUBERCULOSIS (TB) IN PERSAHABATAN
HOSPITAL
Mumar1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Tuberculosis (TB) infection is acute or chronic, caused by the bacteria Mycobacterium
tuberculosis. The infection is acquired from individuals who have active TB over the air
(airborne)6. Mr. MS 35 years old, was diagnosed of pulmonary TB. He has received 4FDC,
sucralfat, ceftriaxone, ranitidine, streptomycin. Based on the results, it can be concluded
that there was DRPs (Drug Related Problems) such as untreated indication, subtherapeutic
dosage, drug interactions and failure to received medication.
Keywords: Tuberculosis, Lung Diseases, DRPs
1.INTRODUCTION
Most people with TB are productive population aged between 15-55 years, and the
disease is the third cause of death after heart disease and acute respiratory illness in all the
ages4.
Tuberculosis (TB) is an acute or chronic infection caused by the bacteria
Mycobacterium tuberculosis6. The infection is acquired from individuals with active TB
through the air (airborne)6. Pulmonary tuberculosis includes 80% of the overall incidence
of tuberculosis, while the remaining 20% is extrapulmonary tuberculosis5. It is estimated
that one third of the world's population infected with the bacteria never M.tuberculosis5.
An increasing number of patients with TB is caused by a variety of factors, namely
the lack of patient adherence to treatment level and take medicine, the price of expensive
drugs, the emergence of double resistance, lack of host resistance to mycobacteria, reduced
1186
power bactericidal drugs existing drugs, the increasing cases of HIV / AIDS and economic
crisis.
2.PERCENTAGE OF CASES
Mr. MS 35 years old, was diagnosed of pulmonary TB. He came with complaints of
shortness of breath, coughing blood since 10 months SMRS. He has received 4FDC,
sucralfat, ceftriaxone, ranitidine, streptomycin
3.CLINICAL EVALUATION
Used of 4 FDC as antituberculosis. Sucralfate to treatment peptic ulcers. Ceftriaxone to
treatment
infections.
Ranitidine
to
treatment
peptic
ulcer. Streptomycin as
antituberculosis in combination with other drugs.
4.DRUG RELATED PROBLEMS (DRPs)
1. Untreated indication
There are untreated indication, where patients has decrease inappetite. He could getting
vitamin B complex.
2. Subtherapeutic dosage
Such
as
ranitidine
50
mg
2
time/day,
according
to
Dr.Aine
Burns
(Renal Drug Handbook, 2009), it is supposed to be 3 x 50 mg a day.
Rifampin increases the toxicity of INH by increasing metabolism. The use of rifampin
and pyrazinamide simultaneously will increase the toxicity of one more with
synergistic farmacodinamic interaction (additive hepatotoxicity). Using of INH and
ethambutol simultaneously known experimental evidence that the ethambutol does not
affect levels of INH serum, but there is also some evidence to suggest that optic
neuropathy can be enchanced by the use of ethambutol along with isoniazid. Using of
INH and pyrazinamides imultaneously can increase the toxicity of one more
synergistic interactions with farmacodinamic are minor or no significant interaction
(additive hepatotoxicity).
1187
4. Failed to received medication
Patients failed to receive the injection of drugs on February 1, 2014 and injection
ranitidine 06.00 pm. Ask
the
nurse and
nurse’s
records list check
performed periodically.
7.CONCLUSION
Based on the results, it can be concluded that there was DRPs (Drug Related Problems)
such as untreated indication, subtherapeutic dosage, drug interactions and failure to
received medication.
8. REFERENCE
1. Anonymous. 2005. Stocley's DrugInteractions. The Pharmaceutical Press.
2. BPOM. 2008. National Drug Informatorium Indonesia. Jakarta: Sagung Seto.
3. Dr. Aine Burns. 2009. The Renal Drug Handbook third edition. New York: Oxford.
4. The Directorate of community development and Community Famasiclinic. 2005.
Pharmaceutical Care For Tuberculosis Disease. Jakarta : Ministry of Health of
Indonesia
5. Djojodibroto,
Darmanto, Sp. P.,
FCCP. 2009. Respirologi (Respiratory
Medicine). Jakarta: EGC.
6. Morgan, Geri and Hamilton, Carole. 2009. Obstetri and Ginekologi. Jakarta: EGC.
1188
DRUG RELATED PROBLEMS IN THE COMBINATION OF TREATMENT OF
TYPE 2 DIABETES MELLITUS AND CAD (CORONARY ARTERY
DISEASE)/CORONARY ARTERY DISEASE
Mutmainnah KS1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
Diabetes mellitus type 2 formerly called insulin-dependent diabetes mellitus or adult-onset
diabetes is a metabolic disorder characterized by high blood glucose in the context of
insulin resistance and insulin dedisiensi relatif2. Kororner blood vessels are blood vessels
that take full responsibility in meeting all the needs of nutrients and oxygen to the heart 4.
Shortage of supply of nutrients and oxygen to the heart (ischemia) will cause disruption of
the function and heart work4. Case presentation: AM is a 64 years old man was treated
internal medicine word. Patient diagnosed with Type II Diabetes Mellitus and CAD or
coronary artery disease. Clinical evaluation: Basically, there are two interventions were
found during the assessment of treatment of patients, which is the first of ranitidine dosage
is too small of a usual dose, the second increase in total cholesterol and decreased levels of
HDL than the normal value of patient-related and disease.
Keywords: Diabetes mellitus, Coronary artery disease, PGI Cikini Hospital
1. Introduction
Diabetes mellitus (DM) is defined as an illness or a chronic metabolic disorder with
multiple etiologies characterized by high blood sugar levels is accompanied by impaired
metabolism of carbohydrates, lipids and proteins as a result insufusiensi insulin2 function.
Diabetes mellitus increases the risk of heart disease kororne, especially when blood sugar
levels are not controlled by not good2.
1189
Coroner artery disease also known as arteriosclerosis cardiovascular disease,
coronary heart disease, or ischemic heart disease is a disease that occurs when there is a
blockage of blood flow pasrsial to heart3. This problem can affect the buildup of plaque in
the arteries where plaques of inflamed cells, proteins and calsium3.
This is called arteriosclerosis which is blood hardening3. lack of blood supply due to
narrowing of the coronary arteries resulting in chest pain called angina, which usually
occurs when bereaktivitas elderly physic or experiencing stress. Coronery heart disease can
also lead to weakened heart pump power. There are several risk factors for coronary heart
disease are two of them are high blood pressure, high blood pressure which increase the
work of the heart so that the heart wall to thicken/rigid and increases the risk of heart
disease koroner3.
Mr. AM 64-years-old man was diagnosed of CAD (coronary artery disease).
Patients hospitalized PGI Cikini 9th May 2014. Patients complain would not eat since 1
week ago. Upon entering the hospital, the patient felt nausea, vomiting when there is food
in, fatigue, reduced appetite, sore tongue, cough since one week ago and no phlegm, BAK
is not smooth. The patient has a past medical history of hypertension and asthma is. Results
laboratory examination of patients before treatment was given on 29 May 2014 tenggal as
follows; lymphocytes 16% \, sodium 132 mmol / I is less than the normal value, on
examination of blood endapp rate 54 mm / hour. 23% eosinophils, monocytes 11%, uric
acid 13.5 mg / dI, 224 pp blood sugar than normal.
The results of laboratory examinations of patients after treatment is given checks
total cholesterol 117 mg / dI which exceeds the normal values and levels of HDL 26 mg /
less than normal value.
Thoracic examination results: CTR> 50% impression enlarged left heart, embedded
apex, aortic elongation and not widened mediastinum, trachea and hilar well with the
conclusions cardiomegaly, elogasi aorta, right pulmonary tuberculosis suspects.
The drug delivery therapy patients from 29 April-8 May 2014, namely, 1 g cefotaxim
indicated to treat infections due to sensitive bekteri bekteri gram positive and gram
1190
negative, Ranitidine injection for the treatment of duodenal ulcer, chronic dyspepsia
episodes, penururnan stomach acid. Aspilet to cope with pain in the chest and as
antiplatelet. Clopidogrel therapy in the prevention of atherosclerotic peripheral arterial
disease. Allopurinol for prophylaxis of gout and uric acid, Captopril weeks to cope with
mild to moderate hypertension. Metformin for diabetes mellitus, Rindopump to cope with
duodenal ulcer and dyspepsia, Ondansentron injection to treat nausea and vomiting.
As for drug therapy against lipids and lipoproteins are as follows :
Drug
TG
KT
VLDL
LDL
1.Dammar-damar
- Kolestiramin
+
-+
-- Kolestipol
+
-+
-2.Asam nikotinat
- Acipimox
--3.Fibrat
- Klofibrat
-Ο
-- Bezafibrat
-Ο
-- Simifibrat
-Ο
-- Fenofibrat
-Ο
-- Bezafibrat
-Ο
-- Gemfibrozil
-4.Statin
- Lovastatin
----- Pravastatin
---- Simvastatin
+
---- Atorvastatin
+
---- Fluvastatin
+
---- Rovusastatin
+
---TG = trigliserida, ,KT= kolesterol total
Ο = netral
+ = Increased ++ = strong increase, --- = Strong decline once
HDL
+
Ο
Ο
Ο
Ο
Ο
++
+
+
+
+
+
+
3. Clinical evaluation
Ranitidine is a drug indicated for the treatment of gastric disorders. In the
administration of ranitidine injection, the dose given is too small ie 50 mg every 12 hours
or 2 times a day so that the problem can not be resolved the patient's stomach, while
according to the literature BNF usual dose of ranitidine is for adults and children> 12 yr 50
mg every 6-8 hours or 3 times a day.
1191
Pharmaceutical Interventions: to overcome the disorder of the stomach of patients
who cause nausea and vomiting ranitidine dosage should be increased to 50 mg every 6-8
hours per day.
In laboratory tests indicated that total cholesterol levels in excess of the normal
value and HDL less than normal, where it can cause an increased risk of heart disease, but
for patients treated patients did not receive drug treatment antihiperkolesterolemia.
Pharmacist Advice: The need for anti-cholesterol drug delivery in patients.
Intervention pharmacists: advise patients to monitor the rise in blood sugar levels which
can lead to decreased levels of HDL.
4. Conclusion
After the assesment of the patient's treatment, it can be concluded that ranitidine is a
drug that is indicated to overcome stomach disorders. The dose of ranitidine were given 50
mg every 12 hours or 2 times a day, the dose should be increased from the initial dose
should be 50 mg every 6-8 hours per day or 3 times a day for gastric irritation experienced
by patients can be overcome. Antihiperkolesterolemia due to the necessity of granting
increasing levels of total cholesterol and decreased levels of HDL, should be given drug
antihyperkolesterolemia fibrates like Gemfibrozil group.
5. References
1.
Baxter, K. “ Stockley Drug Interaction Eight Edition”. London.2008.
2.
DEPKES RI.”Diabetes Mellitus”.Jakarta 2007.
3.
Reeves J Charlene.”Keperawatan Medikal Bedah”. Jakarta.2001.
4.
Hillman, “Penyakit jantung koroner”. Jakarta, 2012.
5.
Salma.”Penyakit jantung koroner” Jakarta,2012.
6.
ISFI. “Iso Farmakoterapi”. ISFI Jakarta, 2012.
7.
Dinas Kesehatan Provinsi Sumatera Barat. “Cara mudah meningkatkan HDL” sumber
2013.
8.
Ria Qodaria Arief,” Konsultan kolesterol total”. Jakarta 2014.
1192
9.
Tjay Tan Hoan.”Obat-Obat Penting”. Pt Elex Media Compotindo Jakarta, 2008.
10. Guyton JR. “Pertimbangan Keamanan Dengan Terapi Niacin”.American journal of
cardiologi, 2007.
1193
DRUG RELATED PROBLEMS IN TYPE II DIABETES MELLITUS
Nurhania Rasyid1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
According to the American Diabetes Association (ADA) in 2010, Diabetes mellitus is a
group of metabolic diseases with characteristic hyperglycemia that occurs due to abnormal
insulin secretion, insulin action, or both. Patients Ny. G, age 40, entered Gatot Subroto
Army Hospital on March 7, 2014 with a diagnosis of diabetic ketoacidosis, hipotyroid.
Therapeutic treatment who used patient are insulin Levemir, insulin novorapid,
levofloxacin, ampicillin sulbactam, omeprazole, Aspar, CaCO3, Ca Gluconas, thyrax,
ketorolac, ascardia and vip albumin. Based on the results of their clinical practice on the
ward floor V General Treat Room at RSPAD Gatot Soebroto it can be deduced that the
presence of DRP (Drug Related Problem) in the form of improper drug selection that
ketorolac can cause bleeding and increase gastric acid, recommended the selection of
analgesics is tramadol stomach would be safe because of using that drug and pain will be
reduced. Using of Levemir insulin and Novorapid insulin had given on December 18, 19
and March 20, 2014 it made blood glucose be lower than average value (< 50 mg/dl). It
made the patient be hypoglycemia, there would be hypoglycemic, Novorapid with dosage 7
IU / 7 IU / 7 UI, Levemir with dosage 20 mg / dl IU5. Adverse drug effects, the using of
insulin in patients is out of normal, so it made worst patient condition (hypoglycemic) .
Patients showed a critical figure in blood sugar levels that is 58 mg / dl. Significant
interaction occurred between levofloxacin and insulin (pharmacodynamic synergism
interaction) where lovofloxacin enhance the effects of insulin2.
Keywords: Diabetic ketoacidosis, Hipotyroid, Gatot Subroto Army Hospital
INTRODUCTION
According to the American Diabetes Association (ADA) in 2010, Diabetes mellitus is
a group of metabolic diseases with characteristic hyperglycemia that occurs due to
abnormal insulin secretion, insulin action, or both. Ketoacidosis is an acute complication of
diabetes that is characterized by elevated blood glucose levels are high (300-600 mg / dL),
along with the signs and symptoms of acidosis and strong plasma ketone (+).
1194
The classic symptoms of DM with while plasma glucose 200 mg / dL (11.1 mmol /
L), while plasma glucose is result during an examination for a moment on one day without
regard to time of last meal, fasting plasma glucose 126 mg / dL (7.0 mmol / L) , mean
fasting patients did not receive additional calories at least 8 hours, 2 hour plasma glucose
level in oral glucose tolerance (Oral Glucose Tolerance Test) 200 mg / dL (11.1 mmol / L),
OGTT (Oral Glucose Tolerance Test) conducted by the WHO standard , using a glucose
load equivalent to 75 g of glucose anhidrus dissolved into the water.
To handle type 2 diabetes mellitus in Indonesia, we need a guideline to improve the
efficacy and efficiency of therapy, as well as prevent complications which was made by a
consensus of endocrinology Indonesian unity.
The main goal of therapy is to achieve DM good metabolic control in order to prevent
long-term complications. But unfortunately, the data in Indonesia on the quality
management of patients with type 2 diabetes are still not sufficient.
Guideline for clinical therapy is used as a reference in selecting among various drug
therapies available to treat type 2 diabetes in order to provide appropriate treatment
decisions in specific circumstances. However, the facts on the ground suggest there are still
many mismatches selection of treatment with clinical treatment guidelines due to various
obstacles.
CASE PRESENTATION
Mrs. G 40 years old entered Gatot Subroto Army Hospital on March 7, 2014.
Patients present with a letter of introduction from Dr hospitals. BOB H. Bazar, SKM
Lampung with type II diabetes, the patient complained of nausea (+), vomiting for 3 days.
The patient was hospitalized in the Hospital Dr. BOB H. Bazar, SKM Lampung for
1 week starting 1-6th May 2014 and with complaints of pain in the left leg, nausea and
vomiting, body weakness and restlessness. Until now still limp and felt pain in the left leg.
The patient had a history of diabetes mellitus type II and hipotyroid.
1195
CLINICAL EVALUATION
The use of insulin and insulin Levemir novorapid to cope with diabetes mellitus.
Ampicillin sulbactam and levofloxacin in the treatment of bacterial infections. Omeprazole
for the treatment of peptic ulcers. Aspar (I-aspartate Potassium) for hipokalium therapy.
CaCO3 and Ca Gluconas to calcium therapy. Thyrax (L-thyroxine Na) for hypothyroid
treatment. Ketorolac for pain. Ascardia (acetylsalicylic acid) as an antiplatelet. Vip albumin
to overcome hipoalbumin.
Dosage and method of using of insulin novorapid 3x300 mg dose which is usually
subcutan, individual doses. Levemir Insulin typically 1x300 mg dose subcutaneously
which, individual doses. Levofloxacin 1x750 intravenously, with the usual dose of 1x750
mg every 24 hours. Ampicillin sulbactam 4x1, 5 intravenously, usually 2 times daily dose
of 375-750 mg. Omeprazole 1x40 intravenously at a dose of 20 mg once daily prevalent for
2-4 weeks. Aspar (Potassium I-aspatat) 3x200 mg orally at a dose of 1-3 tabs 3xsehari
prevalent. CaCO3 3x500 orally at a dose of 1-3 tabs common / hr. Ca gluconas 2x1 amp
intravenously at a dose of 1-2 grams prevalent. Thyrax (L-thyroxine Na) 1x50 mg orally at
doses commonly begins 0.05-0.1 mg / hr. 3x30 mg ketorolac intravenously at a dose of 30
mg prevalent every 6 hours to a maximum of 120 mg / hr. Ascardia (acetylsalicylic acid)
3x80 mg orally at a dose of 80-160 mg daily prevalent. Vip albumin 3x2 mg orally at a
dose of 3x2 mg with doses commonly prevalent 3xsehari 2 capsules.
CLINICAL DIAGNOSIS LABORATORY
Laboratory tests in patients with abnormal results obtained hyperglycemic which
occurred on March 17, 2014 which is when the blood glucose 403 mg / dl above normal
and on March 21, 2014 while blood glucose 207 mg / dl, and blood glucose 2 hours pp is
395 mg / dl . Under normal circumstances, on 18, 19, 20th March, 2014, this indicates that
patients had diabetes mellitus. Calcium increased on March 17th, 2014 ie 7.7 mg / dl, dated
March 18, 2014 ie 8.0 mg / dl and dated March 20, 2014 was 7.3 mg / dl, indicating
patients had hypercalcemia. Potassium decreased on March 18, 2014 at 2.8 mmol / L, dated
1196
March 20, 2014 at 2.8 mmol / L, and dated March 21, 2014 is 3.1 mmol / L, indicating
patients had hipokalemia.
Ketorolac can cause bleeding and increase gastric acid, recommended the selection of
analgesics is tramadol stomach would be safe because of using that drug and pain will
be reduced.
2. Dose regimen
Using of Levemir insulin and Novorapid insulin had given on December 18, 19 and
March 20, 2014 it made blood glucose be lower than average value (< 50 mg/dl). It
made the patient be hypoglycemia, there would be hypoglycemic, Novorapid with
dosage 7 IU / 7 IU / 7 UI, Levemir with dosage 20 mg / dl IU5.
3. Adverse drug effects
The use of insulin in patients too much. The addition of Levemir for patients effects of
hypoglycemia in patients. Patients showed a critical figure in blood sugar levels is 58
mg / dl.
Significant interaction occurred between levofloxacin and insulin is pharmacodynamic
(synergism interaction) where lovofloxacin enhance the effects of insulin and patient
was hypoglycemia because of that2.
5. Human
error
In Medical Records, nurses sometimes do not record the medication that is given to the
patient. So it is advisable to keep records of the nurse who had administered the drug to
the patient. Monitoring of nurses notes on medical records.
CONCLUSION
Based on the results of their clinical practice in the general ward floor RSPAD
Gatot Suebroto can be deduced that the presence of DRP (Drug Related Problem) in the
form of improper drug selection that ketorolac can cause bleeding, and increase gastric
acid, recommended the selection of analgesics is tramadol stomach would be safe because
1197
of using that drug and pain will be reduced. Using of Levemir insulin and Novorapid
insulin had given on December 18, 19 and March 20, 2014 it made blood glucose be lower
than average value (< 50 mg/dl). It made the patient be hypoglycemia, there would be
hypoglycemic, Novorapid with dosage 7 IU / 7 IU / 7 UI, Levemir with dosage 20 mg / dl
IU5. Adverse drug effects, the using of insulin in patients is out of normal, so it made worst
patient condition (hypoglycemic) . Patients showed a critical figure in blood sugar levels
that is 58 mg / dl. Significant interaction occurred between levofloxacin and insulin
(pharmacodynamic synergism interaction) where lovofloxacin enhance the effects of
insulin2
REFERENCES
1. POM RI, 2008. Indonesian National Drug Information. Jakarta
2. Baxter, Karen, 2008. Stockley’s Drug Interactions. Pharmaceutical Press: London
3. BNF 61, 2011. British National Formulary. Pharmaceutical Press: London
4. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A pathophysiologic Approach 7th
Edition, McGraw Hill.New York.
5. Nathan, Buse, Davidson, et al. 2009.Medical Management of Hyperglycemia in Thype 2
Diabetes: A Consensus Algorithm for the Initiation and Adjustment of Therapy.
Diabetes Care 32, 193-203
6. N K. E, Wayuni, et al, 2012. Efektifitas Usage Fees and OHO Insulin combination
therapy in patients with Type II Diabetes Mellitus in the
Hospital
Outpatient
Wangaya.enny. Accessed 10 March 2013
7. Perkeni. , 2011. Consensus Control and Prevention of type 2 Diabetes Mellitus in
Indonesia 2011. Perkeni PB. Jakarta.
8. Tan, Pinem, et al, 2012. Appropriateness Of Oral hypoglycemic Prescribing Drugs in
Type 2 Diabetes Mellitus Consensus Perkeni According To
Clinic Of Abdul Moeloek Hospital Dublin 2012.
2011
In
Outpatient
Retrieved 11 March 2013
9. UK Renal Pharmacy Group, 2009, Renal Drug Handbook Third Edition, Oxford
Radcliffe publishing. New York
1198
DRUG RELATED PROBLEMS IN REGIMEN OF DOSE FOR
TUBERCULOSIS (TB) PATIENT AT INTERNAL WARD RSUP
HOSPITAL
Noviani Nongkang1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
E-mail: [email protected]
ABSTRACT
Tuberculosis (TB) is an infection caused by mycobacterium tuberculosis complex1.
Mycobacterium tuberculosis is straight or slightly curved, not spores and not encapsulated.
Tuberculosis is still becoming public health problem1. Patient MR. ARB, 62 years old,
entering RSUP Persahabatan on March 11, 2014 and diagnosed with Pulmonary
Tuberculosis Acid Fast Bacillus (AFB/BTA) (+), LKKPO (extensive Lesions dropped
case/extensive lesions breaking the treatment), dyspepsia syndrome, and hypoglycemia.
Medical treatment therapy are IVFD NaCl 0,9%, Azithromycin, sucralfate, antacid,
ceftazidime, omeprazole, and Anti Tuberculosis Drug (OAT) category II. (Rifampicin,
Isoniazid (INH), Pyrazinamide, Ethambutol and Streptomycin). Based on the result of
clinic administrative clerk on Pulmonary ward in RSUP Persahabatan we can conclude that
there is DRP (Drug Related Problem) consist of Drug without indication, low doze drug,
failed to receive medication, and condition that need to be considered.
Key Word : Tuberculosis, Pulmonary, Dyspepsia Syndrome
INTRODUCTION
Tuberculosis (TB) is an infection caused by mycobacterium tuberculosis complex1.
Mycobacterium tuberculosis is straight or slightly curved, not spores and not encapsulated
1
. The bacteria is 0.3-0.6 microns wide and 1-4 microns in length. Wall of mycobacterium
is very complex, consisting of a layer of fat is quite high (60%)1. The main constituent of
the cell wall of mycobacterium tuberculosis is mycolic acid, wax complex (complex1199
waxes), trehasole dymicolate called cord factor and mycobacterial sulpholipids that play
role in virulence6. Clinical symptoms are cough in two weeks, bloody cough, shortness in
breath, chest pain, and other fever6. TBC report from WHO placed Indonesia in the third
largest after India and China with new number of case ± 539.000 people in a year2.
According to Notoadmojo (2003) beside home sanitation environment, the existence of TB
also related to attitude and family income because most of victims of TB are poor people
with low education2. TB examination is held with 3 sputum specimen in two days that is in
Spot-Next Day-Spot (SPS) 6. Based on National TB program guidelines, the diagnosed
pulmonary of adult people is based on the existing of TB germs (AFB/BTA) 6.
CASE PRESENTATION
MR. ARB, 62 years old, entered RSUP Persahabatan on March 11, 2014. The
patient came by complaining his massive shortness breath since 2 months before entering
the hospital. Patient complain his shortness breath 3 days, patient usually sleeps in supine
and wake up because his shortness breath, cough in phlegm with white color.
Patient used to take medical because of cough, with Sputum AFD/BTA (+), patient is given
anti Tuberculosis drug category II without injection. Patient complains nausea, vomit since
3 days, no meal, pain in heartburn, weight loss 3 kg in a month, fever (-) and sweat in the
night.
LINE TREATMENT FOR PEPTIC ULCER 7
Line I
Antacid (neutralize the acid, not absorbed by digestive system)
Line II
Receptor Antagonist H2
(to obstruct/block acid secretion by obstructing the bound between histamine and its
receptor)
1200
Line III
Proton pump inhibitor obstructs/blocks enzyme work K+ /H+ -AT phase which break K+ /H+
-. ATphase produces energy that used to release acid from parietal cell canal into acid
lumen, example omeprazole.
LINE TREAMENT FOR TB 6
Category I
Weight
30-37 kg
38-54 kg
55-70 kg
≥71 kg
Intensive phase
Every day in 56 days ( 2 month)
Rifampicin,
Isoniazid
Pyrazinamide, Ethambutol
2 tablets 4 FDC
3 tablets 4 FDC
4 tablets 4 FDC
5 tablets 4 FDC
Continuation phase
3 times a week for 16 weeks
(4 months)
(INH), Rifampicin, Isoniazid (INH)
2 tablets 4 FDC
3 tablets 4 FDC
4 tablets 4 FDC
5 tablets 4 FDC
CATEGORY II
Weight
30-37 kg
38-54 kg
55-70 kg
≥71 kg
Intensive phase
Every day in 56 days ( 2 month)
Rifampicin,
Pyrazinamide,
Streptomycin
2 tablets 4 FDC
3 tablets 4 FDC
4 tablets 4 FDC
5 tablets 4 FDC
Continuation phase
3 times a week for 16 weeks
(4 months)
Isoniazid
(INH), Rifampicin, Isoniazid (INH),
Ethambutol, Ethambutol
2 tablets 4 FDC
3 tablets 4 FDC
4 tablets 4 FDC
5 tablets 4 FDC
CLINICAL EVALUATION
The used of sucralfate, antacid, and omeprazole is for dyspepsia syndrome. In this
case the patient that receives omeprazole injection when his stomach acid increased will
caused the patient cannot have meal or even swallow it. Next, after the patient feel better,
he was given medical therapy with antacid and sucralfate to relieve the stomach pain. On
the other hand, for Tuberculosis medical treatment, the patient was given Anti Tuberculosis
1201
treatment (OAT) category II (Rifampicin, Isoniazid (INH), Pyrazinamide, Ethambutol and
Streptomycin). The patient received medicine without indication like Azithromycin and
ceftazidime antibiotic that cause gastrointestinal disorders. Where azithromycin antibiotic
will prevent the streptococcus to impair the respiratory tract and ceftazidime is a good
solution for meningitis treatment which prevents pseudomonas bacteria.
DOSAGE AND DIRECTIONS TO USE 3,4,5
In this case, the patient was given therapy with 500mg azithromycin 1 x 500 mg in four
days, antacid was given 3 x CI a day before eat for 4 days. Sucralfate was given 3 x CI an
hour after having meal and it is given 1 x 40 mb in 2 days, while for Tuberculosis treatment
the patient was given anti tuberculosis drug (OAT) in day fifth.
RESULT OF LABORATORY TESTS 8
The laboratory test result on March 08, 2014 show there was a decrease of hematocrit
values about 32 % (37-43 %) that indicated there was infection. The increasing of
creatinine values was 1,7 mg/dL (0,6-1,5 mg/dL) indicated the decrease of renal/kidney
function. The increasing value of SGOT (serum glutamic oxaloacetic transaminase) was 53
mg/dL (0-37 mg/dL) indicated there was impaired liver function, sodium of blood was
decrease indicated hypercalemia that was 133 (135-145 mg/dL).
DRUG RELATED PROBLEM 4,5
1.
Drug without indication
Patient received azithromycin antibiotic and ceftazidime. According to BNF in 2008,
azithromycin is indicated to streptococcus bacteria to impair the respiratory tract and
ceftazidime is for meningitis treatment which prevents pseudomonas bacteria.
2.
Dosage regimen
The low dose of drug in sucralfate recipe which was 3 x 1 CI/day should be 4
gram/days in 2-4 dose according to Dr. Aine Burns (Renal Drug Handbook, 2009). It
suggest to the doctor to reevaluate the dose therapy of sucrafte used.
1202
3.
Fail to receive the drug
The patient failed to receive ceftazidime injection on 12.00 WITA on 11 and 13 March
2014. Asking to the nurse and it is written in periodically/regular nurse record
4.
Condition need to be considered
Condition need to be considered is the patient loss of appetite and should be given
extra vitamin in order to increase appetite so it can improve the patient body in facing
the illness.
CONCLUSION
Based on the result of scribe clinic practice in pulmonary ward in RSUP
Persahabatan, we can conclude that there are DRP consist of Drug without indication where
the patient receive azithromycin and ceftadizime antibiotic, drug low dose, Condition need
to be considered Failure of patient in receiving the drug
REFERENCES
1. PDPI, 2013. Guidelines for the diagnosis and management of tuberculosis. Jakarta
2. Herryanto, 2004, the treatment of patient with pulmonary TB History Health Journal
vol 3, London.
3. National authorities. , 2008. Indonesian National Medicine Information (IONI). Jakarta:
Sagung Seto
4. Burns, Dr.. Aine. , 2009. Renal Drug Handbook third edition. New York: Oxford.
6. Djojodibroto,Dr.R.Darmanto,Sp.P, FCCP.,2009.Respirology (Respiratory Medicine).
Jakarta: EGC
7. Priyanto, 2008. F armakoterapi and Medical Terminology. Jakarta.
8. Sutedjo, AY. , 2007. Disease Know Interest Books Through Examination Results
Laboratorium. Amara Books. Yogyakarta.
1203
DRUG RELATED PROBLEMS IN HIV-AIDS PATIENT
Novitalia Tonapa1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
HIV(Human Imunodeficiency Virus) is a virus that can only infect humans, multiply in
human cells, thus decreasing human immunity against infectious diseases4. If the
progression of HIV infection is not inhibited bydrugs that now exist and not accompanied
by a healthy life style in the10-15years to develop into AIDS (Acquired Immune Syndrome
deficiency)4. Mr. OH 23-years old went into PGI Cikini hospital on May 3, 2014 and was
diagnosed with HIV-AIDS by checking the value of CD4 and anti-HIV. Therapy for the
treatment of hospitalized was ceftriaxon, ranitidine, ondasentron, paracetamol, Ventolin,
KCl, Cotrimoxazole, Mycostatin, Amoxan, Duviral and neviral. Clinical evaluation of
drugs obtained reveal anymultiple drug interaction between Paracetamol and Ranitidine,
Paracetamol and Duviral, Duviral and Ranitidine.
Keywords: PGI Cikini Hospital, HIV-AIDS, Antiretroviral Drugs
I. INTRODUCTION
HIV (Human Imuno deficiency Virus) is a virus that can only infect humans,
multiply in human cells, thus decreasing human immunity against infectious diseases4.
According to research, 80% of injecting drug users have hepatitis B or C and 40-50%
HIV-AIDS4.
Drug abuse , HIV infection, prostitution and sex behavior are three problems
associated with each other4. Indonesia is a country that is prone to HIV/AIDS, this was
due to ease traffic in habitants with neighboring countries that have the level of HIV
/AIDS is high.4 If the progression of HIV infection is not inhibited by drugs that now
exists and is not accompanied by a healthy lifestyle in the10-15 years to develop into
AIDS (Acquired Immune Deficiency Syndrome)4. AIDS is a collection of signs and
symptoms of diseases which is caused by the loss or deterioration of a person's immune
1204
system because of HIV infection acquired. HIV-AIDS diagnosisis made on clinical,
immunological examination and virological examination5.
2. CASE PRESENTATION
Mr.OH 23 years old, entered the hospital with a chief complaint 2weeks before
admission fever, cough phlegm, tightness, nausea, vomiting, abdominal pain in the pit of
the stomach, decreased appetite, movements. Past medical history, history of allergic
disease and nofamily history of disease. On admission was given ranitidine injection,
ondansentron, paracetamol and ventolin. On the second day, based on physical
examination and the results of additional anti-HIV therapy given were ceftriaxon and
Mycostatin, and on the third day after CD4 given additional therapy was kotrimoxazol,
and on the sixth day of blood transfusion. After 1 week of therapy cotrimoxazole
adjunctive therapy for antiretroviral drugs given were Duviral and neviral.
3. GUIDELINE
HIV AIDS treatment guideline
People With HIV AIDS:
a. Eligible ARVS :

if no opportunistic infections start ARV therapy5 .

if any opportunistic infections do treatment ofopportunistic infection for 2
weeks, then start ARV therapy5 .
b. Not eligible ARV :
 provide treatment plans and the provision of ARV therapy5.
 Vaccination when the patient is able to5 .
 Start ARV if people with Hiv Aids already qualifiedARV therapy5 .
c. persons with Hiv/Aids there are constraints of compliance:
Search for compliance related solutions team up
topeople
with
Hiv/Aids canbe wayward and get accessARV therapy5.
For the provision of ARV Therapy and Kotrimoxazol:
a.
Preventive Medicine cotrimoxazolis recommendedfor :
1205

When not available the number of CD4 cells of thecheckup, all patients were
given kotrimoksasol soon after declared HIV positive.5

PersonswithHIV AIDSwere symptomatic(clinical stage 2, 3, or4), including
pregnantwomenandlactating.5

PersonswithHIV
AIDSwith
CD4
countbelow
200cells/mm3(if
availableinspectionandthe results ofCD4).5
For
people
with Hiv/Aids that
will
initiate ARV therapy
in
a CD4
count below 200 cells/mm3. It is recommended to give Kotrimoksasol (1x960mg as
the prevention of opportunistic infections) 2 weeks before the ARV therapy.5
b.
ARV therapy

Startingantiretroviraltherapyin
all
patientswith
CD4
counts<350
cells/mmregardless ofclinicalstage.5

Antiretroviraltherapyis recommendedin all patientswithactive TB, pregnant
womenandhepatitisBco-infectionregardless ofCD4 count.5
4. CLINICAL EVALUATION
On the first day the patient was given injections of ranitidine because patient had
complaints have decreased appetite so given ranitidin einjection in order to inhibit
gastric acid secretion. Ondasentron also given to treat nausea and vomiting patient.
Given paracetamol for fever overcome, ventolin was given because the patient
experienced shortness of where the patient also had a history of pneumonia, with the
composition of ventolin salbutamol is a short-acting bronchodilator medication. After
laboratory examination on the second day of the antibiotic ceftriaxone given patient
because the patient also had a history of pneumonia and leukocytes of patient very low
at 0.610^3/μL where normal leukocytes is 10^5.0-103/μL, given paracetamol drip
because on the second day after the examination, the patient temperature rise was
40.10C. Mycostatin was given medication for oral thrush, and also PRC transfusion. On
May 8 KCl administered by laboratory examination on May 7 in which the patient low
potassium 2.6 mEq/L where the normal potassium is 3.5-5.0mEq/L. The patient was also
diagnosed with HIVAIDS of CD4. Examination showed CD4 immune status of patient
1206
with HIV-AIDS on the results of CD4 helper T lymphocit very less 20 where the
absolute CD4 and normal values 410-1590cells /mL where normal values are 31-60%,
and also examination showed anti-HIV positive. Amoxan therapy given after the
administration was stopped Ceftriaxon. Based on the laboratory results of the patient
was given additional drug therapy cotrimoxazole where the management of HIV patient
issued by the Ministry of Health of the Republic of Indonesia patient with HIV will be
given when treatment with antiretroviral drugs will first be treated with cotrimoxazole
where cotrimoxazole dose used is1x960mg,Tn.OH was given antiretroviral drug therapy
on the 9th of May 2014 neviral and duviral. Duviral is a FDC of AZT+3TC, AZT
(zidovudine) and lamivudine(3TC) which is aclass of antiretroviral drugs Nucleoside
Reverse Transcriptase Inhibitors (NRTIs), and neviral (nevirapin) which is aclass of anti
retroviral drugs Non Nucleoside Reverse Transcriptase Inhibitors (NNRTIs).
5. DRUG REALETED PROBLEMS (DRPS)
Drug interactions

Paracetamol + Ranitidin
Ranitidine can inhibit the oxidative metabolism of paracetamol by cytochrome P450
isoenzymes, resulting in decreased hepatotoxic metabolite.3

Paracetamol + Duviral
PharmacologicaleffectsofDuviralwould decrease.7

Duviral + Kotrimoksazol
Cotrimoxazole, alone orasco-trimoxazolein combination with thetrimetoprin reduce
renal clearance duviral.3
6. CONCLUSION
 If ranitidinebe given together with the possibility of paracetamol can cause a
decrease inthe effect of paracetamol that feveris not resolved, the two drugs should
separated.
1207

If given together paracetamol and Duviral can cause pharmacological effects of
Duviral will decrease, so the need separate dorconsider increasing the dose of
Duviral.7

If Duviral provided with cotrimoxazole, duviral can cause toxicity so that the user
need separated.
7. SUGGESTIONS

Monitor the patient blood pressure and respiratory patient during treatment.

Monitor the use of antiretroviral drugsin patient

Monitor the patient condition as susceptible to bleeding
REFERENCES
1. Badan POM RI, 2008. Informasi Obat Nasional Indonesia. Badan POM; Jakarta.
2. BNF 61, 2011, Britsh National Formulary.Pharmaceutical press: London.
3. Baxter, Karen. 2008. Stockleys Drug Interactions eighth edition. Pharmaceutical Press;
London
4. Harlina,LM. 2008. Peran Orang tua Dalam Mencegah dan Menanggulangi
Penyalahan narkoba. Balai Pustaka; Jakarta.
5. Kementrian Kesehatan RI,2011. Pedoman Nasional Tatalaksana Klinis Infeksi HIV dan
Terapi Antiretroviral Pada Orang Dewasa. Kementrian Kesehatan RI;Jakarta
6. Lacy, CF, dkk. 2008. Drug Information Handbook. 17th edition, American Pharmacists
Association; USA
7. Tatro, DS, dkk. 2009. Drug Interaction Facts. Drug Information Analyst ; San Carlos,
California
8. Yulinah, Se, dkk. 2009. ISO Farmakoterapi. ISFI: Jakarta
1208
TREATMENT FOR CHRONIC KIDNEY DISEASE (CAD) STAGE III
WITH DIABETES MELLITUS (DM) TYPE II
Nurhayati Alimudin1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Chronic Kidney Disease is one of the common diseases in the PGI Cikinihospital internal
medicine ward. Chronic Kidney Diseaseconsists of 5stage, that is stage 1, stage 2, stage 3,
stage 4, andstage 5. Diabetes Mellitus (DM) is defined as a disease orchronic metabolism
disorderwith multiple etiologies characterized by high levels of sugar accompanied by
disorders of carbohydrate, lipid, and protein metabolism as a result of insulin function
insufficiency. Case presentation : SS is a 52 year admitted to the internal medicine ward.
Patient was diagnosed with CKD stage IIIdan Diabetes Mellitus Type II. Clinical
Evaluation :Basically, there are 3 interventions that have been done during the clerking of
this patient. One is regarding the decreased levels of allopurinol, the second of
metilprednisolne side effects associated with the patient’s disease, and the third of the
termination gliquidonthat untreated clinical condition.
Keywords: Chronic Kidney Disease, Diabetes Mellitus,PGICikini Hospital
1. INTRODUCTION
PGI CikiniHospital known, especially in the medical field kidney3.Chronic
Kidney Disease or end stage renal disease is a progressive deviation of kidney function that
can not be recovered where the body’s ability to maintain metabolic balance, fluid and
electrolyte failure, resulting in uremia. This condition may be caused by chronic
glomerulonephritis, pielonephritis, uncontrolled hypertention, hereditary lesionsin diseases
1209
such as polycystic, vascular abnormalities, urinary tract obstruction, kidney disease
secondary to systemic disease (diabetic), infection, drugs or mixture toxic5.
Chronic Kidney Disease (CKD) has now become a serious health problem in the
world. According to WHO (2002) and Burden of Disease, renal and urinary tract disease
has caused the death of 850.000people annually7. This suggest that the disease is ranked
number 12 highest mortality7. Chronic Kidney Diseaseconsists of 5 stage, that is stage 1
with GFR rate of more than 90, cause minimal damage to the kidney, stage 2 at a rate of
60-89 GFR, led to slightly decreased kidney function, stage 3at a rate of 30-59 GFR, cause
a mild decrease in kidney function, stage 4at a rate of 15-29 GFR, cause a severe decrease
in kidney function, and stage 5with GFR rate of more less 15, cause of end stage kidney
failure7.
Diabetes Mellitus (DM) is defined as a disease orchronic metabolism disorderwith
multiple etiologies characterized by high levels of sugar accompanied by disorders of
carbohydrate, lipid, and protein metabolism as a result of insulin function insufficiency2.
Insufficiency caused by impaired insulin function or deficiency of insulin production by the
beta cells of Langerhans of the pancreas gland, or due to the lack of responsiveness of the
body’s cells against insulin2.
SS is a man with 52 years old admitted to the internal medicine ward. Patientwas
diagnosed with CKD stage III dan Diabetes Mellitus Type II. Patient entered in PGI Cikini
Hospital on March 24th2014. This patient is a patient transfer and referral of Kramat
Hospital. Patient kidney function is now greatly decreased. The patient feels dizzy, nausea,
vomiting, and body weakness one week prior to admission hospital. The patient has a past
medical history of diabetes mellitus.After come in hospital, the patient felt headchace and
their body weak, the patient felt fever and hot in their waist, especially in the afternoon.
Patient felt his hand cramps, pain in the feet and hand, especiallyin the left arm.After doing
examination patient’s rate of GFR, where a decrease GFR 32,37 ml/minute/1,73 mm 2.
Beside that, decreasdureum, creatinine, uric acid and decrease calcium in the body.
1210
The results of laboratory examinations of patients before treatment was given on
March 24th2014.
Examination
Peripheral Blood
Hemoglobin
Leukosit
Eritosit
Liver Function
SGOT 37oC
SGPT 37oC
Renal Function
Uric acid
Urea
Creatinine
Glucose
During glucose
Result
Unit
Reference value
9
8,89
3,15
g%
10^3μL
10^3μL
13-16
5-10
4,5-5,5
39
59
U/I
U/I
<35
<35
14,1
93
2,5
mg/dl
mg/dl
mg/dl
<6,8
10-50
0.6-1,1
209
mg/dl
80-180
The result of laboratory patien’t examination after gift drugs
Examination
Peripheral Blood (29/3/2014)
Hemoglobin
Leukosit
Hematokrit
Erythrocyte sedimentation rate
Eritosit
Retikulosit
Trombosit
MCV
MCH
MCHC
Liver Function (10/4/2014)
SGOT 37oC
SGPT 37oC
Renal Function (10/4/2014)
Urea
Creatinine
Elechtrolyte (7/4/2014)
Sodium
Potassium
Phosphate
Calcium
Glucose(3/4/2014)
Result
Unit
Reference value
8,6
9,7
26
72
3,16
15
275
83
27,2
32,8
g%
10^3μL
%
mm/jam
10^3μL
permil
10^3μL
fL
pg
g/dL
13-16
5-10
37-43
0-10
4,5-5,5
5-15
150-450
81-92
27,0-32,0
32,0-37,0
26
43
U/I
U/I
<35
<35
92
4,3
mg/dl
mg/dl
10-50
0.6-1,1
138
4,6
4,4
2,8
mmol/l
mEq/l
mEq/l
mg/dl
135-147
3,5-5,5
2,5-4,8
8,8-10,3
1211
N blood glucose
PP blood glucose
06.00 blood glucose
13.00 blood glucose
16.00 blood glucose
142
210
142
210
267
mg/dl
mg/dl
mg/dl
mg/dl
mg/dl
<110
<140
70-150
70-150
70-150
As for drugs theraphy which give to Mr. SS take in bicnatthrought oral for fixed
the situation of metabolic acidosis and urine alkhalinesation. Gliquidon 30 mg gived in oral
for decrease blood glucose rate.Allopurinol 100 mg gived in oral for decrease uric
acid.Betaserc (betahistinHCl
8 mg) gived
in
oral
for nausea
and vomiting
treatment.Metilprednisolon 4 mg gived in oral for inflammatory treatment.
3. CHLINICAL EVALUATION
Allopurinol is drugs which used to indication gout, kidney stones and gout, decrease gout.
Using allopurinol with natrium bicarbonate and calcium carbonate can effected decrease
allopurinol from the gastrointestinal absorbtion1. Using both of natrium bicarbonate and
allopurinol or calcium carbonate and allopurinol at the same time should be giving interval
about 2 hours. Allopurinol is bether to be drunk after a meal. To get the effect of
allopurinol, after the initial dose of 100 mg, allopurinol dose should be further increased to
200-300 mg.
Methyilprednisolonis one of the drugs known as corticosteroids are indicated for the
treatment
of
inflammation,
allergies,
rheumatic
disease,
and
skin
disease.
Methylprednisolonhas the side effect of osteoporosis especially in elderly and diabetes
mellitus, whereas this patient has the diabetes mellitus disease, resulting in increased levels
of blood glucose in the body is called hyperglycemia. In addition, methylprednisolonalso
need to be consired in elderly patients and renal disorders, because methylprednisolone
causes the suppression of renal. Suppression of renal by methylprednisoloncaused due to
suppression of the adrenal glands, increased reabsorbtionNa+, and excretion K+ and H+ in
1212
the tubuli distal. Consequently, there is sodium retention with expantion of extracellular
fluid volume, hypokalemia, and alkalosis6.
Gliquidonis one of the oral anti-diabetic drugs known as sulfonilurea are indicated for the
treatment of Non Insulin Dependent Diabetes Mellitus (NIDDM) treatment or Diabetes
Mellitus Type II. On March 29 to April 2 2014 discontinued the use gliquidone, though the
patient’s blood glucose increased up to 267 mg/dl. The use of oral anti-diabetic is
indispensable due increase in blood glucose levels and to the use methylprednisoloncan
cause hyperglycemia.
4. CONCLUSION
After the study it can be concluded that allopurinol is the drug of choice for lowering uric
acid levels of patients. Due to the use of allopurinol with sodium bicarbonate and calcium
carbonate cause interactions, allopurinol should be the distance between the two drugs
should be separated at least 2 hours. If necessary the dose of allopurinol may be increased
to 300 mg. Methylprednisolonis a drug that is indicated for the treatment of inflammatory.
Due to the use of methylprednisoloncausing harmful side effects in patients, should use
other anti inflammatory medications and blood glucose levels need to be monitored. On
March 29 to April 2 2014, blood glucose is increasing, but patient not give continue oral
anti diabetic because gliqudinstoped. Use of metilprednisolon can increase level blood
glucose caused hyperglycemia.
REFERENCES
1. Baxter, K. Stockley’s Drug Interaction Eight Edition. London. 2008
2. DEPKES RI. Diabetes Mellitus. Jakarta. 2007
3. HutagalungPoltak,
Sirait
Amir,
NadeaxMoxa.
100
Tahun
RS
PGI Cikini,
denganSentuhanKasih. 1997. Jakarta
4. Joint Formulary Commite. British National Formulary. London. 2009
5. Reeves J Charlene. KeperawatanMedikalBedah. Jakarta. 2001
6. Sabri Muhammad. Kortikososteroid. Jakarta. 2012
1213
7. Saputra Ahmad. Chronick Kidney Disease. Jakarta. 2012
8. StafPengajar FK universitasSriwijaya. Kumpulan KuliahFarmakologi Ed. 2. EGC
:Jakarta. 2009
9. Tjay Tan Hoan. Obat-ObatPenting. Elex Media Komputindo : Jakarta 2007
1214
DRP ASSOCIATED WITH TREATMENT OF MELENA DISEASE
WITH D.M TYPE II AND PARKINSON HISTORY
Octaviana M. Luan1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRAK
Melena is the appereance of stool accompanied by blood (aften colored is
black),foul smelling through the rectum.Melena is caused by bleeding lines top of
absorption(7).Mr.MS age 69 years, entering RSAL Dr. Mintohardjo hospital on june
14,2014 at.10 o'clock with a complains limp, can't walk,nausea and vomiting since the early
morning of 5 hours before entering hospital and black-colored of defecate in the morning
entering the hospital,and he get melena diagnosed. The patient have a history of DM type
II since 2008 and parkinson since 2011. Drugs that patients routinely used at home for as
long as it is Hexymer (Trihexypenidil HCL), Metformin, Leparson(Levodopa,Benserazide
HCL) , Aspilet (Acetylsalicylic Acid), Ripinirole(Ropinirole HCL). The new drugs used
now in hospital is Vitamin k, Transamin, Ranitidin, Ondansetron, Lactulax (Laktulosa) and
Dulcolax (Bisokodil). Based on the results of the observation then it can be infered that in
the provision of therapy for the treatment of inpatients of the possibility of drug interaction
that can be positive or negative impact. Such drug interaction between Metformin and
Ranitidin(increasing level of Metformin because of the competition while elimination
cleareance in renal with ranitidin). Lactulax and dulcolax (both of which can increase the
laxative effects and potentially lead to diarrhea and dehydration), Aspilet (Acetylsalicylic
Acid) and Vitamin K (Phitomenadyon) (aspilet inhibit of vitamin K works), Aspilet
(Acetylsalicylic Acid) and Traneksamat Acid (the presence of Aspilet acid inhibits the
work of Traneksamat acid), levodopa and ripinirole (both of which can increase the effects
of dopaminergik), Trihexypenidil and levodopa (at high dose of i-dopa effects
trihexypenidil can lose by delaying absorption).5
Keywords
: Melena,Diabetes Melitus type II and Parkinson.
1215
INTRODUCTION
Melena is the appereance of stool accompanied by blood (aften colored is black),
foul smelling through the rectum. Melena is caused by bleeding lines top of absorption.
Dark red or black color of feses come from the conversion of HB into hematin by bacteria
after 14 hours. The source of bleeding is usually also comes from the line top if absorption.
Melena usually accompanied by hematemesis. (7)
According to the American Diabetes Association (ADA) of the year 2010, Diabetes
melitus ia a metabolic disease group with characteristic hyperglikemia that occurs due to
abnormalities of insulin secretion, insulin activity, or both.
Pakinson is a disease characterized by tremor at rest, rigiditas, bradikinesia and loss
of pastural reflexes,the pathology of degenaration of pigmented neurons neuromielanin
especially in the pars kompakta nigra which commensurate inclusion cell neuronss
eusinofilik.(6)
PRESENTATION CASE
Mr.MS aged 69 years, entered the hospital on june 14,2014 at 10 o'clock with a
limp complaint,and nausea,vomiting since the early morning at 5 o'clock and black colored
bowel movements this morning. He get a melena diagnosed.
Patient were treated until june19,2014.The patient has a history of type II DM since
2008 and parkinson since 2011.
CLINICAL EVALUATION
The routine treatment used by patient at home it is Hexymer, Ripinirole , Leparson
(Levodopa) as parkinson therapy, Metformin as Diabetes Melitus type II therapy. Aspilet
(Acethylsalicylic Acid) is a non opiat
analgesic and painkillers can be used for the
prevention of the occurence of angina pectoris and miocard infark. RL is given for
electrolytes alternative. Vit K injection and transamin injection is a injections to stop the
bleeding. Ranitidin injection as H2 blockers in order to prevent gastric hipersekresi gastric
acid. Traneksamin injection contains traneksamat acid can stop the bleeding. Ondansetron
injection as antiemetic and vomiting. Lactulax syrup and Dulcolax as a laxative.1
1216
TREATMENT DATA
At the time of hospitalised patients given 20 tpm Ringer Laktat,Vit K injection,
Transamin injection, Ranitidin injection. Ringer Lactat given to the patient returns home,
Vitamin K injection (3x1) and Transamin injection (3x1) used for 2 days on 14 june and 15
june. Ranitinidin injection (2x1) used for 3 days and stoped at 17 june and subsequently
replaced by ranitidin tablet (2x1). Ondancetron injection given only on the first day when
patients enter the hospital. On june 16 the patient starts given lactulose syrup for
constipation, up to 19 june. And the patient also given the Dulcolax supossitoria only on 17
june. During treatment at hospital the patient still using the usual drug consumed at home
i.e Metformin as therapy of Diabetic Melitus type II, Hexymer (Trihexypenidil HCL),
Leparson(Levodopa,Benzerazide HCL), and Ropinirole (Ropinirole HCL) for parkinson
theraphy and Aspilet (Acethylsalicylic Acid) is a non opiat analgesic and painkillers can be
used for the prevention of the occurence of angina pectoris and miocard infark. In the case
the use of Aspilet (Acethylsalicylic Acid) should be discountinued because,according to the
study based on the patient's medical record drug Aspilet (Acethylsalicylic Acid) not need
not be prescribed to patients.
RESULT OF LABORATORY EXAMINATION
EXAMINAT NORMAL
ION
VALUE
14/6
15/6
16/6
17/6
18/6
19/6
Leukosit
5000-10000
11500*
9000
8200
6300
8200
6500
Eritrosit
4,6-6,2
3,55*
2,79*
2,62*
5,33
3,5*
3,73*
Hemoglobin
14-16
10,9*
8,5*
8,1*
14,6
10,5*
11,1*
Hematokrit
42-48
31*
24*
23*
41*
30*
31*
Trombosit
150000450000
248000
199000
189000
148000
124000
222000
SGOT
< 35
23
SGPT
< 41
17
-
-
-
-
-
1217
Ureum
17-43
102*
-
-
-
-
-
Kreatinin
0,9-1,3
1,2
-
-
-
-
-
Asam urat
3,6-8,2
-
5,5
-
-
-
-
Trigleserida
60-170
-
180*
-
-
-
-
Kolesterol
total
HDL
< 200
-
127*
-
-
-
-
>40
-
29*
-
-
-
-
LDL
<130
-
62
-
-
-
-
Na
136-146
-
144
-
-
-
-
K
3,4-4,5
-
4,3
-
-
-
-
Cl
96-108
-
10,8
-
-
-
-
From the above date,we can known that liver function and electrolytesin the body of
the patient are at the limit of normal. Ureum value (renal function)on june 14 has a value of
above normal.Leukosit value higher than normal reference,this indicated a suspected
infection. Eritrosit, hemoglobin and hematokrit is lower than normal reference, and this
indicated the patient has a anemia so it makes a patient limp. The patient suffered anemia
can be caused by bleeding on the canal absorption.
DRUG RELATED PROBLEMS ( DRP )
1. Selection of remedies
Since the prescribing metformin, patients often complained of gastrointestinal
disorders and constipation. This is a side efect of metformin.Metformin side efects if
use in long term therapy with high doses can inhibit the absorption of viatmin
B12Defisiensi of vitamin B12 can cause anemia. Acute side effects occur in as many
as 30% of patients treated with metformin. Side effect include primarily GI complaints,
such as diarrhea, abdominal discomfort, nausea, anorexia, and metallic taste. GI side
1218
efects are usually transient and dose related and can be mitigated by giving the drug
just before meals, initiating therapy with small doses and slowly increasing the dosage
but is rarely associated with anemia. Metformin reduces serum vitamin B12 levels in
approximately 7% of patients. Vitamin B12 deficiency anemia can be treated with
vitamin B12 supplementation or by discontinuing metformin.Diminished vitamin B12
absorption and transport can be improved with oral calcium suplementation. We
recommend eating patterns and time consumption of metformin need to be reviewed.
The addition of B12 of Folic acid suplements also should be given to patients taking
metformin as a therapy of diabetes.(4)
2.
Adverse Drug Effects
The use of aspilet in a long time causes gastrointestinal disorders and contra indication,
so that it can be said that aspilet was one of the causes of the occurrence of melena in
patients. It is recommended that stopped uses of Aspilet (Acethylsalicylic Acid)
because the indications do not comply with the patients suffered disease. Levodopa
(leparson) and ropinirole both of witch can increase dopamin so that should be
monitored.(5)
3. Human Eror
Sometime a nurse does not record a drug that has been given to the patient in the
medical record. And nurses to aften forget to write down the complaints of patients
because it is considered not related to the patient disease. But this is a side effect from
using the drugs. So it is advissable to nurses to always record a drug that has been
given to the patient .
CONCLUSION
After a study of treatment then, it can be concluded that the use of aspilet in the long
time by patients is one of indicators that lat to melena in patients . It is recommended that
stopped uses of Aspilet (Acethylsalicylic Acid) because the indications do not comply with
the patients suffered disease. And the use of metformin in a long time has resulting in a
deficiency of vitamin B12 so that patients should reproduce the consumption of foods
containing vitamin B12 such as meat , eggs, milk and yeast, and consumed metformin 1
1219
hour after eating. The addition of suplement B12 or acid folid also should be given to
patients taking metformin as a therapy of diabetes.(4)
REFERENCES
1. Badan POM RI, 2008. Information Obat Nasional Indonesia, Jakarta
2. BNF 61, 2011. Britsh National Formulary 61 March 2011
3. Dipiro, J.T et al 2009 Handbook Of Pharmacoterapy 7 thEdisition. USA : McGraw-Hill
Medical
4. Handbook of Clinical Drug of Data-Pdf,hal 649
5. http://reference.medscape.com/drug-interactionchecker
6. Sunaryanti,T.Penyakit Parkinson,defenisi,etiologi,patologi,patogenesis dan manifestasi
klinis.diambil dari :
7. http://elib.fk.uwks.ac.id/asset/archieve/jurnal/voll.no2.Juli2011/PENYAKIT%20PARK
INSON_old.pdf. Diakses tanggal 20 juni 2014
8. J.A Britto,.M.J.R.Dalrymple.Nay.1996.Kisi-kisi menembus masalah Bedah : jakarta.
Buku Kedokteran EGC.
1220
TUBERCULOSIS DISEASE AT CIKINI HOSPITAL
Oktovina Tulak1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
Tuberculosis, TB brevity is an infectious disease that most often occurs in the lungs 8.
Causes of pulmonary tuberculosis is an acid-resistant gram-positive bacilli with very slow
growth, namely Mycobacterium tuberculosis 8. Mr. Z.N 23 year old with a body weight of
50 kg admission PGI Cikini hospital on the 12th April, 2014 and was diagnosed with
pulmonary tuberculosis by chest x-ray and sputum. Therapy for the treatment of
hospitalized ie ceftriaxon, Panadol, omeprazole, transamin amp, vitamin k amp, rifampin,
isoniazid, ethambutol and pyrazinamide. Clinical evaluation of drugs obtained discovered
the presence of several drug interactions between rifampicin and paracetamol, INH and
rifampin, ethambutol and INH, isoniazid and paracetamol, INH and pyrazinamid.
Keywords: PGI Cikini Hospital, pulmonary TB, Treatment
1.
INTRODUCTION
Tuberculosis, TB brevity is an infectious disease that most often (approximately
80%) occurs in the lungs 7. Causes of pulmonary tuberculosis is an acid resistant gram
positive bacilli with very slow growth, which is Mycobacterium tuberculosis5.
Tuberculosis is classified into two, namely pulmonary tuberculosis (tuberculosis
that attacks the lung tissue, excluding the pleura) and extra-pulmonary tuberculosis
(tuberculosis that attacks the organs other than the lungs, such as the lymph nodes, the
lining of the brain, bone, kidney, urinary tract)5.
The diagnosis of tuberculosis can be established based on clinical symptoms,
physical examination/physical, bacteriological examination, radiological and other
1221
investigations. Tuberculosis treatment is divided into two phases, namely the intensive
phase (2-3 months) and a continuation phase 4 or 7 bulan7.
2.
CASE PRESENTATION
Mr. Z.N is 23 years with a body weight of 50 kg. Admitted to hospital with
complaints of 2 weeks complaining of high fever, intermittent, does not improve with
medication, cough, sputum, chest pain, heartburn. Past medical history and no family
history. On admission was given ceftriaxone, omeprazole, Panadol, transamin amp, vit K
amp. On the third day, the results of the investigation showed BTA (++) and patient
diagnosed with pulmonary tuberculosis. Additional medications given were rifampin,
ethambutol, pirazynamid, and INH.
3.
GUIDELINE TREATMENT OF TB
Tuberculosis treatment is divided into two phases, namely the intensive phase (2-3
months) and a continuation phase 4 or 7 months 7.
a. The main drug types (line 1) used is
 INH
 Rifampisin
 Pirazinamid
 Streptomisin
 Etambutol
b. Type any additional medication (line 2)
 Kanamisi
 Amikasin
 Kuinolon
4.
DRUG RELEATED PROBLEMS
a
Drug Interaction
 Rifampisin + Paracetamol
Rifampin increases the metabolism of paracetamol
1222

INH + Rifampicin
Bioavailability of rifampicin can be reduced by isoniazid
 Etambutol + INH
Ethambutol did not seem to affect serum levels of isoniazid. However, it seems
that the optic neuropathy caused by ethambutol can be increased by isoniazid.
 Isoniazid + Paracetamol
Isoniazid will increase the level or effect of acetaminophen by CYP2E1 affect
liver enzymes during metabolism. Significant interaction possible, closely monitor
 INH + Pyrazinamid
A study in 19 TB patient found that pyrazinamide did not affect serum levels of
isoniazid
5.
CLINICAL EVALUATION
On the first day, the patient was given medication Ceftriaxon, Panadol,
omeprazole, transamin, and vitamin K. The patient was given antibiotics Ceftriaxon
because of hematologic examination, some results indicate that patients infected with the
bacteria. Ceftriaxon is a third-generation cephalosporin antibiotic that is effective against a
broad spectrum of gram positive and negative bacteria. Given Panadol (paracetamol)
because of a high fever. Dose of Panadol (paracetamol) is given does not exceed 4000 mg /
day (according to ISO Pharmacotherapy)8. Given omeprazole for heartburn experienced.
Patient was also given Transamin (tranexamic acid) and vitamin K because of Epitaksis.
Epitaksis or nosebleeds occur because of a tear in the wall of blood vessels in the nose2.
The cause of epistaxis can vary such as trauma, irritation of the nasal mucosa because of
low humidity, the presence of inflammation in the nasal mucosa due to sinusitis, blood
clotting disorders, to the presence of a tumor 2. Nosebleeds because of a high fever make
the walls of blood vessels dilate and thin so easy to tear if there is pressure or friction
around the nasal mucosa. Transamin an antifibrinolytic drug that inhibits dissolution of
fibrin threads. Used for prophylaxis and treatment of bleeding due to excessive fibrinolysis.
Vitamin C is a vitamin that is used to prevent / overcome bleeding due to vitamin K
deficiency. On the third day, the results of smear positive patient. According to the
1223
literature, including category 1 patient was new patient smear positive pulmonary
tuberculosis treated with INH, rifampin, pyrazinamide and ethambutol for 2 months and 4
months of intensive phase berikunya maintenance phase7.
6.
CONCLUSION
 If rifampicin and paracetamol paracetamol given at the same effects may not be
achieved so that the patient fever was not come down immediately, separate the use
of two drugs3.
 Isoniazid may reduce the bioavailability of rifampicin, its use needs to be separated3
 Vision problems caused by ethambutol be enhanced with INH2
 INH will enhance the effect of paracetamol, so the need to use hepatoprotective.
Monitor closely3
7.
ADVICE

The use of combinations of antibiotics on TB patient should not be broken during
the initial phase of 2 months for the next 4 months and for the maintenance phase,
so that the entire treatment period covers 6 months7
REFERENCES
1. Badan POM RI, 2008. Informasi Obat Nasional Indonesia. Badan POM; Jakarta.
2. Baughman, DC dan Hackley, JC, 2000. Keperawatan Medikal Bedah. EGC: Jakarta
3. Baxter, karen, 2008. Stockley’s Drug Interactions. Pharmaceutical Press: London
4. BNF 61, 2011, British National Formulary. Pharmaceutical press: London
5. Hoan, TT dan Kirana, R, 2007. Obat- Obat Penting. Gramedia: Jakarta
6. Laban, Yohannes Y, 2008. TBC. Kanisius: Yogyakarta.
7. Perhimpunan Dokter paru Seluruh Indonesia, 2006. Pedoman dan Diagnosis
Penatalaksanaan di Indonesia: Jakarta
8. Yulinah, SE dkk, 2009. ISO Farmakoterapi. ISFI: Jakarta
9. Somatri, Irman, 2007. Asuhan Keperawatan Pada Pasien dengan Gangguan Sistem
pernafasan. Salemba Medika; jakarta
1224
DRUG RELATED PROBLEMS IN STROKE NON HEMOROGIK
DISEASE
Ratih Antasari1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
Jakarta)
ABSTRACT
Stroke or brain attack is a clinical syndrome that early onset of sudden, progressive, fast,
and a focal neurological deficit or global, which lasted for 24 hours more or immediate
cause of death and solely caused by circulatory disorders of the brain non-traumatic. Nonhemorrhagic stroke is defined as a cerebrovascular disorder caused by blocked blood vessel
caused by certain diseases such as ateroklorosis, arteritis, thrombus and embolus. Risk
factors for stroke include non hemorogik hypertension, diabetes mellitus (DM), heart
disease, and smoking hiperkolesterolemi. Presentation case, a man 72 years present with a
limp on the right foot, on Friday June 13, 2014 and grew weak from last night when
Saturday morning, the patient vomited 3 times with food. Physical examination revealed
BP 130/80 mmHg, right leg redness and limp body. Laboratory showed that uric acid and
cholesterol levels increased. From the doctor's diagnosis of patients known to suffer from
non-hemorrhagic stroke 4.
Key words: risk factors, non hemoroagik stroke, focal neurologic
INTRODUCTION
Stroke or brain attack is a clinical syndrome that early onset of sudden, progressive,
fast, and a focal neurological deficit or global, lasting 24 hours or more or immediate cause
of death and solely caused by the interference of non traumatic brain blood circulation.
Stroke is defined as a set of non hemorogik clinical signs that developed by vascular
causes. This Gejalah lasts 24 hours or more in general lifeboat due to reduced blood flow to
the brain, which causes disability or death 5 .According WHO estimates, as many as 20.5
million people in the world have been infected with a stroke in 2011 and, of that 5.5 million
1225
people had died. High blood pressure or hypertension, donated 17.5 million cases of stroke
in the world. In Indonesia, the disease is ranked third after heart disease and cancer where
as much as 28.5% of patients died and the rest suffered partial or total paralysis Only 15%
are able to sembut total disability from stroke and 8. Based on the pathophysiology of
stroke is composed of non-hemorrhagic stroke and hemorrhagic stroke. Non Haemorrhagic
stroke is the most frequent type of stroke occurs, nearly 80% of all strokes are caused by a
clot or other blockage in the arteries that flow to the brain 5. The weakness of the brain in
patients with motion, and parese nerve VII and XII and leads to non-hemorrhagic stroke
that required immediate treatment to avoid further complications
2
.Terdapat some risk
factors of non hemorrhagic stroke, such as advanced age, hypertension, diabetes, heart
disease , hypercholesterolemia, smoking and vascular abnormalities of the brain
3
.
Neurologic symptoms that arise as a result of circulatory disorders of the brain depends on
the severity of the disorder and the location. The main symptoms of non-hemorrhagic
stroke is a sudden onset of neurologic deficits, preceded by prodromal symptoms, occurs at
rest or sleep and waking consciousness is usually not decreased by 2.
CASE PRESENTATION
Mr. patients. JB 72 years old came to Mintohardjo Hospital on June 14, 2014
Patients with keluhaan go limp on the right foot on Friday, June 13, 2014 and the limp on
Saturday morning, the patient vomited 3 times with food and complained of dizziness. Past
history; Hypertension, cholesterol and uric acid.
EVALUATION CLINIC
Mr. JB in RL infusion therapy with 20 drops / aims minutes to restore the balance of
body fluids. Ranitidine injection of 2 x 1 amp, used intravena with usual dose IM / Slow IV
Injection: 50 mg every 6-8 hours, for anti-vomiting. Citicolin injection of 2 x 1 amp, used
intravenously at a dose commonly 250-500 mg / day intravenously up to 1 g / day, to
reduce damage to brain tissue. Betahistin 2 x 1 tabs, used orally at a dose of 16 mg three
times a normal day, for adults 24-48 mg per day, preferably with food, as medicine vertigo.
Piracetam 3 x 1 tab used orally at a dose of common 7.2 g / day, in divided doses 2-3 times,
1226
for memory decline, asthenia (fatigue), psikomotorik disorder (brain nerve). Neurobion 1 x
1 tab used orally for the treatment of peripheral nerve disorders and vitamins. Simvastatin 1
x 10 mg tab used orally at a dose of 10 mg daily prevalent evenings, to reduce LDL
cholesterol in total. Ceftriaxone injection is used in intramuscular injection or intravenous
bolus infusion with standard dosing of 1 g / day in a single dose, in severe infections 2-4 g /
day single dose, for skin and tissue infections. Gabapentin 1 x 1 tab used orally at a dose of
0.9-1.2 g daily prevalent, for neuropathic pain. Sodium diclofenac 2 x 50 mg tab used
orally at a dose of 25-50 mg prevalent in 15-60 minutes, to reduce pain.Meloxicam 1 x 15
mg taken orally at a dose of 7.5 mg daily common meals together, if necessary to raise the a
maximum of 15 mg once daily, for pain. Allopurinol 3 x 1 tab used orally at a dose of 100
mg prevalent as a single dose, the account after eating, gradually increase for 1-3 weeks
according to the uric acid levels in plasma or in urine, up to about 300 mg a day, for gout.
Aspilet1 x 1 tab used orally at a dose of 300-900 mg prevalent will needed every 4-6 hours;
maximum of 4 g per day, for antiplatelet 9.
LABORATORY RESULTS
On 14 June 2014, conducted laboratory tests in which obtained Leukosit 14,800
(normal value 5.000-10.000μL), it indicates the presence of infection or acute inflammation
that given antibiotics ceftriaxone injection. On 15 June 2014 found total cholesterol 263
(normal value: <200μL) and LDL cholesterol 195 (normal value: <130μL) and given an
increase in drug simvastatin tablets. On 15 June 2014 found Uric Acid 8.5 (normal value:
<5.2 mmHg) an increase that was given Allopurinol tablets.
1. Indication without drug 9
On 14-22 June 2014 the patient experienced an increase in uric acid that needs to be
given medication allopurinol therapy but new patients get allopurinol therapy on 23
June 2014.
2. Duplication Therapy 2
1227
Duplication of a given drug in the anti-pain medication diclofenac sodium and
meloxikam, should be given a pain medication alone. This happens because the patient
has not given allopurinol while, which causes pain in patients with uric acid previously
untreated patients.
3. Human Error 6
In the book list is sometimes nurses did not record drug medication that is given to the
patient so the nurse advised to keep records of what has been given to the patient. Do
the monitoring nurse notes on the book list of drugs.
CONCLUSION
Based on the results of their clinical practice on the island numfort care RSAL
Mintohardjo fourth floor can be concluded that the presence of DRP (Drug Related
Problem) form, without medication indication, where patients have elevated uric acid,
allopurinol treatment should be given therapy and the anti-pain treatment should be given
only one anti-pain medication .
REFERENCES
1. Dipiro, Joseph T., et. al., 2008, Pharmacoterapy: A pathophysiologic Approach 7 th
Edition, McGraw Hill, New York
2. Lacy, FC, Armstrong LL, Goldman MP, Lance LLet al, 2010, Drug Information
Handbook, Lexi-Comp, the American Pharmacist Association.
3. Mardjono M. 2006 Mechanism of CNS Vascular Disorders In Clinical Neurology
Association, eleventh edition. Dian people. 270-93
4. Unila medulla, Volume 2, Number 3, March 2014 59
5. PERDOSSI. In 2007. Konsensusnasionalpengelolaan stroke in Indonesia. Jakarta: 3-7.
6. Prasetya Y. 2006 Faktorrisiko vow that berpengaruhterhadapkejadian non hemorogik
stroke. UniversitasDiponegoro.
7. SA Price and LM Wilson. 2006 Patofisologi, konsepklinis penyakitjilid processes 2.
Jakarta: EGC. 2006: 1110-19.
8. Stroke Association Stroke Counsil. Stroke. 37: 1583 -1633
9. MIMS 105th Annual Indonesian edition 2006/2007
1228
DRUG RELATED PROBLEMS IN TREATMENT OF BRAIN TUMOR
DISEASE ACCOMPANIED TB
Ruslina Simangunsong1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
A Brain Tumor is one of the diseases that are common and frequent in the ward of disease
in PGI Cikini hospital. Brain Tumor disease malignancy is the number two most prevalent
after the leukemia in the children, and the tumor is the most common solid tumor in this
age group. A Brain Tumor can appear at any age, but each is likely to have an incidence
peak age. A Brain Tumor that lazin was metastastik in adults but relatively rare in
children.Case presentation: AN 19-year-old man is hospitalized in the ward for ailments
inside. The patient was diagnosed with a Brain Tumor diseases.Clinical evaluation: in this
case it should be noted in this case that the study on the use of medicines and tuberculosis
which can cause unwanted side effects patients.
Keywords: Brain Tumor, tuberculosis, PGI Cikini Hospital
INTRODUCTION
A Brain Tumor is one of the diseases that are common and frequent in the ward of
disease in RS PGI Cikini. Brain Tumor disease malignancy is the number two most
prevalent after the leukemia in the children, and the tumor is the most common solid tumor
in age group2. A Brain Tumor can appear at any age, but each is likely to have an incidence
peak age. A Brain Tumor metastastik are common in adults but relatively rare in
children2.Metatastasis tumor reaches the brain through the blood stream (hematogen) and
generally occurs after metastasis at paru5. Tumors in the lung and breast tumors are the
most common tumors metastatic to the otak5. Tumors of the gastrointestinal tract (though
1229
more rare) may also undergo metastasis to the brain, but generally these tumors invade the
liver and lung, hipernefroma and melanoma metastasis is the source of the order an
important central nervous, but these tumors are rare. Karsioma prostate, a tumor that often
occurs in uasia further, seldom metastasis to otak5.Pulmonary tubercolosis is an infectious
disease directly caused by TB germs (Mycobacterium tuberculosis) 7.
CASE PRESENTATION
AN 19-year-old hospitalized in the ward for ailments inside. The patient was
diagnosed with a Brain Tumor diseases. PGI Cikini HOSPITAL inpatients may 11, 2014.
The patient feels pain in the head before entering the HOSPITAL, sudden pain behind the
head, pain accompanied by nausea, throwing up spray. Laboratory examination has been
carried out.
LABORATORY EXAMINATION RESULTS DATA
Type
of
Examination
Hematology
Sedimentation
rate Hemoglobin
Leukocytes
Erythrocytes
Hematocrit
Reticulocyte
Basophils
Eosinophils
Neutrophils stem
Neutrophils
stegmen
Lymphocyte
Monocytes
Platelets
MCV
MCH
MCHC
Result
Normal Value
Unit
*46
0-10
mm/jam
*12.1
7.7
*4.35
*35
*36
0
1
*0
13.0-16.0
5.0-10.0
4.50-5.50
40-48
5-15
0-1
1-3
2-6
g/dL
10^3/µL
10^6/µL
%
Permil
%
%
%
*71
50-70
%
*18
*10
358
*80
27.8
20-40
2-8
150-450
81-92
27.0-32.0
%
%
10^3/µL
fL
pg
1230
Type
Examination
of
Result
Normal Value
Unit
13
28
18
0.8
138
4.2
8.8
0-50
0-50
10-50
0.6-1.1
135-147
3.5-5.0
8.8-10.3
U/L
U/L
mg/dL
mg/dL
mEq/L
mEq/L
mg/L
0.21
0.13
0.14
<1:negativ
>1:reaktif
<1 non reaktif
34.7
32.0-37.0
Clinical Chemistry
SGOT
SGPT
Urea
Creatinine
Sodium
Potassium
Calcium
Immunology
HBsAg
Anti HCV
Anti HIV
g/Dl
TUMOR DISEASES TREATMENT GUIDELINE BRAIN6
Surgery
Surgery is the most common treatment for the tumor otak6. The goal is to raise as much of
the tumor and minimize as much as possible opportunities to lose brain function.The
operation to open the bones of the skull are called kraniotomi. This is done with general
anesthesia.
Stereotactic Radiosurgery
Stereotactic Radiosurgery is the technical "knifeless" to destroy brain tumors without
opening the skull. A CT scan or MRI is used to determine the exact location of the tumor in
the brain. High levels of radiation energy is redirected to tumor from various angles to
destroy tumor.
Radiotherapy
Radiation therapy uses x-rays to kill tumor cells. A large machine directed at tumors and
adjacent tissues. Maybe sometimes radiation directed to the whole brain or spinal nerves to
the back.
1231
Chemotherapy
Chemotherapy is the use of one or more of the drugs to kill cancer cells. chemotherapy is
administered orally or by intravenous infusion to the rest of the body. the drugs usually
given in 2-4 cycle which covers the period of treatment and recovery period
DISEASE TREATMENT GUIDELINE TB7
Treatment for TB disease are divided into several categories, namely:
1. Category I (2HRZE/4H3R3)
Category I is new cases with positive sputum and sufferers with severe conditions such as
meningitis, TB milier, perikarditis, pleuritis, peritonitis massif or bilateral, spondiolitis with
neurological disorders, and patients with negative sputum but his widespread abnormalities,
intestinal TB, TB urinal tract, and so on. For the past 2 months of taking the drug INH,
rifampin, ETHAMBUTOL and pirazinamid every day (intensive stage), and 4 months later
taking the drug INH and rifampincin three times in a week (advanced stage).
2. Category II (HRZE/5H3R3E3)
Category II is a case of a relapse or fail with sputum remain positive.
awarded to:
o patients with relapse
o Patients fail therapy
o patients with negligent treatment after taking the drug.
3. Category III (2HRZ/4H3R3)
Category III is the case of sputum is negative but not his extensive abnormalities and
pulmonary TB cases outside other than those referred to in category I.
4.
Category IV
Category IV is for chronic tuberculosis. Priority treatment is low because of the likelihood
of success is low once.
Medicines anti tuberkulostatik
1. Isoniazid (INH)
2. Rifampicin
1232
3. the Pyrazinamid
4. Ethambutol
5. Streptomycin
CLINIC EVALUATION
As for the drugs given for Tn'S 10-day treatments include phenitoin injection (3 x 1
ampules) for the prevention and treatment of seizures that occur during or after
neurosurgery, loratadin 10 mg (2 x 1 tablet) given orally for allergy symptoms such as
fever, rifampicin (1 x 300 mg) for tuberculos, leprosy, ethambutol (1 x 1000 mg) for
tuberculosis in combination with other drugs, INH (300 mg 1 x) for tuberculosis in
combination of other drugs, pyrazinamide (1x1000mg) for tuberculosis in combination of
other drugs, stugeron tablets for impaired balance, impaired blood circulation in the brain,
peripheral circulation disorders, cernevit daily multivitamin supplement for injection for
patients with parenteral nutris, laxadine syrup (3 x 1 tablespoon) to constipation.
Judging from the results of laboratory values above normal hematokrit patient
showed indications of the presence of thrombus that can interfere with blood flow, but the
patient does not get the medication for antiplatelet.
Note: Physicians monitoring strictly in administering medication especially tuberculosis
drugs.
CONCLUSION
After a study of the treatment of patient, it can be concluded that the patient was
diagnosed with a brain tumor. Additional drugs required for the laboratory results of
antiplatelet patients where values above normal hematokrit, for drugs interacting in
interspace 2 hours in his deed. Done rigorously monitoring for drug-drug interactions.
REFERENCES
1. Baxter, k. Stockley's Drug Interaction Eight Edition. London. 2018
2. Behrman, k. Arvin.Ilmu Kesehatan Anak . 2000 in Jakarta.
1233
3. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta: SagungSe
4. Fransisca b. Batticaca. Asuha Keperawatan pada Klien dengan Gangguan Sistem
Persarafan. Jakarta.2008
5. Howard, b. Weiner. Neurology. Jakarta.2001
6. H. Mohamad Isa,Perawatan Penyakit Dalam dan Bedah. Jakarta.2008
7. Sudoyo, Aruw. 2006. Buku Ajar Ilmu Penyakit Dalam jilid 2 Edisi IV. Jakarta:
Departemen Ilmu Penyakit Dalam FKUI.
1234
COMBINED DRUG RELATED PROBLEMS IN TREATMENT
MENINGITIS TUBERCULOSA, HEMIPARESIS THE RIGHT,
PULMONARY TUBERCULOSIS, PNEUMONIA, VASCULITIS, AND
ENCEPHALITIS, IN PGI CIKINI HOSPITAL, CENTRAL JAKARTA.
Sahran Asabe1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Tuberculosis Meningitis is inflammation of the lining of the brain due to complications of
primary tuberculosis9. In this case to consider the use of tuberculosis drugs that can cause
unwanted side effects patients. Mr. MT is a 29 year old male diagnosed with meningitis
Tuberculosa, Hemiparesis The right, pulmonary tuberculosis, pneumonia, vasculitis, and
encephalitis. Patients present with abdominal pain, my body limp and his right leg and right
hand can not move, blood pressure 130/80 mmHg. Initially 16 days ago patients
hospitalized Merauke because of complaints of nausea and severe vomiting 3 days before,
while being treated MT had loss of consciousness 1 day, then regained consciousness up
and down during the treatment of fever, dry cough (+),shortness of breath (+) felt up and
down, especially at night. Past medical history gland Tuberculosis (+), incomplete
treatment, anti-tuberculosis drug withdrawal. From the results of the chest x-ray looks
perselubungan bilateral left and right lung. And from the results of a CT scan with or
without IV contrast seems infarction or cerebral crus of the internal capsule and the
posterior parietal sinistra with moderate-severe prognosis. Drug therapy given to Mr. MT
physicians include standard therapies to treat tuberculosis meningitis, namely, isoniazid,
rifampicin pyrazinamide, ethambutol, and streptomycin. Additional drug therapy given to
Mr. MT physicians include Dexamethasone, Omeprazole, Ranitidine, Inpepsa, Brainact,
Citicoline, Clopidogrel, and Ascardia. Based on the clinical outcome of patients, it can be
deduced the existence of DRP (Drug Related Problem) form the indication is not handled,
not handled drug reactions, drug interactions, the treatment given to Mr. MT.
Keyword : Treatment Meningitis Tuberculosa, Hemiparesis The right, pulmonary
tuberculosis, pneumonia, vasculitis, and encephalitis, In RS. PGI Cikini, Central Jakarta.
1235
1.
INTRODUCTION
Meningitis is an infection of the central nervous system that affects the membrane
lining of the brain and spinal cord are also referred to as the meninges8. Meningitis can be
caused by various types of microorganisms such as bacteria, viruses, fungi and parasites8.
Tuberculosis meningitis belong to the meningitis caused by the bacterium Mycobacterium
tuberculosis8. The bacteria spread to the brain from other parts of the body8. Tuberculous
meningitis is one of the complications of primary tuberculosis8. Morbidity and high
mortality of this disease and the prognosis is poor8. Complications of tuberculous
meningitis occur every 300 primary untreated tuberculosis8. The CDC reported in 1990 of
tuberculosis meningitis morbidity 6.2% of extrapulmonary tuberculosis8. The incidence of
tuberculosis meningitis comparable with primary tuberculosis, usually depending on the
socio-economic status, public hygiene, age, nutritional status and genetic factors that
determine a person's immune response8. Predisposing factor for the development of
tuberculosis infection is malnutrition, use of corticosteroids, malignancy, head injury, HIV
infection and diabetes mellitus8. This disease can affect all ages, children more often than
adults, especially in the first 5 years of life. Rarely found in under 6 months of age and
almost never found in under 3 months of age8. The right Hemiparesis is weakness on one
side of the body and usually occurs right side paralysis of the arms and legs12. Pulmonary
tuberculosis is a disease of inflammation of the lung parenchyma due to bacteria
mycobacterium tuberculosis infection11. Pulmonary tuberculosis is one of pneumonia,
which is pneumonia caused by mycobacterium tuberculosis11. Pulmonary tuberculosis
includes 80% of all tuberculosis, while the other 20% is extrapulmonary tuberculosis11.
Pneumonia is an inflammatory condition of the lungs that primarily affects the microscopic
air sacs known as alveoli11. This condition is usually caused by a viral or bacterial infection
and more rarely other microorganisms, certain medications, and other conditions such as
autoimmune diseases11. Vasculitis is inflammation of blood vessels11. CNS vasculitis
menyebapkan headache, behavioral changes, impaired memory, impaired consciousness
and generalized seizures11. Encephalitis is an infection of the central nervous system
(CNS), which was caused by a virus or other microorganism that non-purulent13. The most
common cause of encephalitis is the herpes simplex virus later, arboviruses, and rarely was
1236
caused by entero viruses, Mump, and adeno virus13. Encephalitis may also occur after
measles infection, influenza, varicella, and post-vaccination pertussis13.
2.
CASE PRESENTATION
Mr. MT 29-year-old was diagnosed with Meningitis Tuberculosa, Hemiparesis The
right, pulmonary tuberculosis, pneumonia, vasculitis, and encephalitis. Hospitalized
patients PGI Cikini dated May 22, 2014. The patient is moving and referrals from hospitals
Merauke. Patients present with abdominal pain, my body limp and his right leg and right
hand can not move, the patient seemed to grimace and holding his stomach, blood pressure
130/80 mmHg. Initially 16 days ago Mr. MT Merauke hospitalized because of complaints
of nausea and severe vomiting 3 days earlier, when the treated patients had a decrease in
consciousness 1 day, then regained consciousness, fever up and down during the treatment,
dry cough (+), Shortness of breath is felt up and down, especially at night (+).Since at home
weight loss (+),urinating with a catheter since treatment, weight loss treatments many
current. Mr. MT since of Merauke has received anti-tuberculosis drugs. Past medical
history of tuberculosis gland (+), incomplete treatment, Anti-tuberculosis drug withdrawal.
3.
DISCUSSION
Based on clinical data and laboratory test results, Mr. MT in the diagnosis of
meningitis Tuberculosa, Hemiparesis The right, pulmonary tuberculosis, pneumonia,
vasculitis, and encephalitis. From the results of the chest x-ray looks perselubungan
bilateral left and right lung. And from the results of a CT scan with or without IV contrast
seems infarction or cerebral crus of the internal capsule and the posterior parietal sinistra
with moderate-severe prognosis.
Laboratory tests have been carried out. From the results of clinical chemistry
examination increased SGOT and SGPT namely, SGOT 90 U/L and SGPT 98 U/L (an
increase by more than 2 times the normal value indicate liver dysfunction), decreased
albumin 2.8 g/dl (indicate a liver disorder and can affect the discharge toward the vascular
network resulting in oudema), globulin increased at 3.8 g/dl (indicates the resistance of the
body against infections that occur in the body)10. From the results of immunological
1237
examination there was an increase of complement C4, anti-HSV-1 IgG increased as high as
3.78 are positive (presence of anti-HSV which means once or happens HSV infection)10.
From the results of hematology, increased erythrocyte sedimentation rate is quite high at 65
mm / h (indicating an increase in globulin and fibrinogen levels due to acute infection, and
is used as a means of monitoring the success of therapy such as rheumatoid artris and
tuberculosis)10. Hemoglobin, hematocrit, MCV, MCH, and MCHC decreased indicating the
patient has anemia, or because they use drugs eg rifampicin10. From the result of an
increase in leukocyte counts segments namely 74% neutrophils and 10% monocytes
indicate inflammatory diseases, tissue damage (AMI), Hodgkin's disease, acute pancreatitis,
viral or parasitic infections, monocytes lukemia, cancer, and collagen diseases10. While the
examination of the levels of leukocyte count decreased levels of neutrophil rod that is 0%
and 4% lymphocytes, indicating the presence of a viral infection, leukopenia,
agranulocytosis, aplastic anemia, iron deficiency anemia10. On examination of the levels of
leukocyte count decreased levels of 0% indicates that eusinofil hyperfunctioning
adrenocortical, stress, and shock4. On examination the patient's prothrombin time is 10.9
seconds decline indicates a myocardial infarction, pulmonary embolism or due to the use of
the drug rifampicin4. D-dimer levels experienced an increase in the 13590 mg / L would
indicate a thrombotic disorder. And has conducted urine and parasitological examination
and positive nitrite results obtained, namely leukocyte eksterase 3 + / 500 cells / mL,
leukocyte ie 2289 / LPB, erythrocytes at 23 / LPB, and the epithelium is 8 / LPB,
accompanied by positive bacterial examination of 29 522 / LPB on microscopic sediment
indicates a urinary tract infection (UTI)4. These results were confirmed by examination of
urine clarity and obtained a positive result indicates the presence of blood turbid, nana or
crystals indicates the presence of inflammation in the kidneys4. Reinforced by the presence
of crystals of calcium oxalate that findings +2. On examination of protein in the urine was
found that the presence of protein 2+ /100 mg/dL (+). The presence of blood is reinforced
by the findings of the blood that is 3+ / 200 cells / uL. And the parasitological examination
of urine and urobilinogen levels seen that 1.0 indicate impaired liver function, bile duct or
excessive haemolysis processes that occur in the body10.
1238
Drug therapy given to Mr. MT physicians include standard treatment for TB
meningitis, namely, Isoniazid, Rifampicin, Pyrazinamide, Ethambutol, and Streptomycin.
Isoniazid has bactericidal properties with the ability to penetrate the CSF with 20% of
normal meninges and meningeal inflammation in 90% of plasma levels, doses of isoniazid
were given to patients with the diagnosis of tuberculous meningitis is 300 mg / day and
should be monitored toxicity in the liver, and to prevent occurrence of peripheral neuritis
due to pyridoxine deficiency as a result of the use of isoniazid given vitamin B62.
Rifampin has bactericidal properties or against intracellular and extracellular organisms
with penetration into the CSF with meningeal inflammation in 10% of plasma levels2. The
dose of rifampicin to tackle TB meningitis is 600 mg / day and liver toxicity should be
monitored, rifampicin can interact with protease inhibitors on HIV infection2. Pyrazinamide
is bakterisid the penetration ability to CSV with normal meninges together with plasma
levels, doses given to treat tuberculosis meningitis is 20-30 mg / kg and need to be
monitored on liver toxicity2. During the treatment the patient is getting the right therapy
associated with a disease in a patient suffering2. Ethambutol is bacteriostatic by pressing
mycobacteria multiplication by interfering with the synthesis of RNA, 80% absorption in
the body, and distributed throughout the body, concentrated in the kidneys, lungs, saliva
and red blood cells, relative to the CSS adequate diffusion with or without inflimasi,
reaching levels 50% in the CNS2. Streptomycin is bacteriostatic or able to fight
extracellular bacterial organisms, where streptomycin has the ability to penetrate the CSF
with inflammation of the meninges that 25% of the levels in plasma, sterptomisin dose
given at 15 mg / kg and the need to monitor toxicity in vesibuler and auditory function 2. In
patients with tuberculous meningitis in addition to antibiotic therapy, corticosteroid
medications are also given2. Corticosteroids such as dexamethasone in patients with
tuberculous meningitis began two days hospitalized and damage in the long term2.
Evaluation parameters expected that the response of treatments, complications of treatment,
and neurological damageThe duration of corticosteroids in patients with tuberculous
meningitis is for 12 weeks at a dose dexametasone of 0.3 mg / kg / day increased up to 1
mg / day2. Additional drug therapy given to Mr. physician. MT include omeprazole,
ranitidine and inpepsa used to treat peptic ulcers, brainact and citicoline used for disorders
1239
of consciousness which accompanies damage / cerebral injury, cerebral trauma, brain
surgery and cerebral infarction. Clopidogrel and ascardia used for the prevention of further
atherothrombotic events where in the know on the CT scan looks crus cerebri posterior
infarction of the internal capsule and right parretalis. Tramadol is used to treat pain suffered
by patients (used only in the event of pain)3. Rhinos are used to reduce allergy symptoms
suffered by patients3. Albumin 20% is used to cope with hypoalbuminemia. NaCl 0.9 is
used to restore the electrolyte balance in the circumstances of dehydration3.
4.
DRUG RELATED PROBLEM (DRP)
4.1 Drug Related Problem 1 (Failed to receive medication).
Judging from the treatment of the patient profile Mr MT on May 22, 2014 the patient
does not get the drug Rifampin because there is no drug.
4.2 Drug Related Problem 2 (Indications that are not addressed).
From the results of laboratory tests hemoglobin, hematocrit, MCV, MCH, and MCHC
decreased indicating the patient has anemia, or because they use drugs eg rifampicin3, 4.
4.3 Drug Related Problem 3 (unwanted drug reactions).
The patient complained of nausea, dizziness, and abdominal pain caused due to the use
of rifampicin3.
4.4 Drug Related Problem 4 (drug interactions).
1) There is some evidence that optic neuropathy caused by ethambutol with isoniazid can
be improved, and any effect finish slower after using one of isoniazid. 2-5 groups of
authors suggest that both ethambutol and isoniazid should be discontinued in case of
severe optic neuritis. They further recommended that isoniazid should be discontinued
if less severe optic neuritis and do not improve within 6 weeks after stopping
ethambutol1.
2) Evidence showed that the pharmacokinetics of cimetidine and ranitidine nor interact
with isoniazid1.
3) The use of anti-tuberculosis drugs RHZ together causing toxins increased from others
with pharmacodynamic synergy, the possibility of serious interactions or lifethreatening.
1240
4) The use of omeprazole with omeprazole vitamin B6 lead to lower levels of vitamin B
by inhibiting gastrointestinal absorption. Applies only to the form of a second oral
agent. Small or insignificant interactions1.
5) The use of streptomycin in patients with impaired liver function are at risk of damage
to the auditory and vestibular nerves2.
6) The use of antiplatelet clopidogrel and ascardia eg in liver function disorders can
menyebapakan bleeding2.
5. CONCLUSION
1) Mr. MT patients at diagnosis of meningitis Tuberculosa, Hemiparesis The right,
Pulmonary Tuberculosis, pneumonia, vasculitis, and encephalitis.
2) Found the presence of a failed drug related problems (DRP) receive the drug,
indications that are not addressed, adverse drug reactions are not desired, and drug
interactions.
3) Need further examination to obtain a diagnosis of cerebrospinal fluid examination
upright example that can help diagnose meningitis tuberculosa.
4) Therapy treatment for patients is irrational because it is found Drug Related Problems
(DRP).
REFERENCES
1. Baxter, K. 2008. “Stockley’s Drug Interaction”. Eight Editions. Pharmaceutical Press,
London and Chicago.
2. Lacy, C.F., Armstrong, L.L., Goldman, M.P., lance, L.L., 2009. Drug Information
Handbook., APha., amerika
4. Sutedjo, AY., 2009., Buku Saku Mengenal Penyakit Melalui Hasil Pemeriksaan
Laboratorium., Amara books., Yogyakarta.
1241
5. Qazi, S.A., Khan, M.A., Mughal, N., Ahmad, M., Joomro, B., Sakata, Y., Kuriya, N.,
Matsuishi, T., Abbas, K.A., Yamashita, F., Dexamethasone and bacterial meningitis in
Pakistan., Archives of Disease in Childhood., 75:482-488
6. Mohamad Isa, 2008. “Perawatan Penyakit Dalam & Bedah”. Pusat Pendidikan
Pegawai Departemen Kesehatan RI: Jakarta.
7. Anonim, 2010., Pedoman Diagnosa dan Terapi Staf Medis Fungsional Ilmu Penyakit
Saraf/Laboratorium Ilmu Penyakit Saraf., Fakultas Kedokteran Universitas Brawijaya.,
Malang.
8. Israr, Y.A., 2008. Meningitis, universitas Riau. Pekanbaru.
9. Retno Asti Werdhani., 2011., Patofisiologi, Diagnosis, dan Klafisikasi Tuberkulosis.,
fkui., Jakarta.
10. Pagana, K.D., 2002., Mosby’s Manual of Diagnostic and Laboratory Test., Mosby inc.,
America.
11. Djojodibroto darmanto. 2009. Respirologi. Jakarta : Penerbit buku kedokteran EGC.
12. Weiner, Howard L., Levitt, Laurence P. 2001. Buku Saku Neurology. Edisi 5. Jakarta:
Penerbit buku kedokteran EGC.
13. Muttaqin, Arif. 2008. Buku Ajar Asuhan Keperawatan Klien Dengan Gangguan Sistem
Pernafasan. Jakarta : Salemba Medika
Appendix
Table 1. Therapy was given to patients
drug
Omeprazole
route
dose
day care
1
2
3
√
√
√
IV
1x1 flc
PO
capsul
Ranitidin
IV
1 Amp
√
Inpepsa
IV
500 mg
√
Rhinos
PO
2x1 cps
√
√
√
4
5
6
comments
7
√
√
√
√
√
√
√
√
8
9
10
√
√
√
Used to prevent
stress ulcers as
patients bedrest
√
√
√
anti-allergy
1242
Dexametasone
IV
3x1 amp
√
Brainact
IV
2x500mg
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
3X500mg
4x500mg
Reduce
neurological
sequel
Peripheral
vasodilators and
cerebral
activators in
dealing with
cognitive decline.
Citicoline
IV
3x500mg
√
√
√
Tramadol
IV
1x400mg
√
√
√
As an opioid
analgesic
Clopidogrel
PO
1 x75 mg
√
√
√
antiplatelet
Askardia
PO
1 x80 mg
√
√
√
Anti platelet
Streptomisin
IM
1x750mg
√
√
IM
1 x 1 gr
Curcuma
PO
3x1 tab
√
√
√
Hepa balance
PO
3 x 1 cps
√
√
Vit B6
PO
1 x 1 tab
√
Rifampicin
PO
1x450mg
INH 400 mg
PO
1x300mg
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
-
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
√
Pirazinamid
PO
1 x 1 gr
√
√
√
√
√
√
√
Ethambutol
PO
1x1g
√
√
√
√
√
√
√
Albumin 20%
IV
1x100cc
√
√
√
NaCl 0,9%
Infus
1x1 infus
√
√
√
√
√
√
√
√
√
√
As a class of
aminoglycoside
antibiotics for
tuberculosis
infection.
Treatment of
liver dysfunction
hepatopretektor
Prevent adverse
effects from the
use of INH.
Antibiotics to
treat infections of
tuberculosis
therapy of
hypoalbuminemia
As resustisasi
fluid
1243
Table 2. Examination Results of Blood Pressure Patients
Date
22 Mei 2014
23 Mei 2014
24 Mei 2014
25 Mei 2014
26 Mei 2014
27 Mei 2014
28 Mei 2014
29 Mei 2014
30 Mei 2014
31 Mei 2014
Systolic and
diastolic
blood
pressure
S
D
S
D
S
D
S
D
S
D
S
D
S
D
S
D
S
D
S
D
Time
04.00
Time
08.00
Time
12.00
Time
16.00
Time
20.00
Time
24.00
130
80
130
80
140
80
120
80
130
80
120
80
120
80
140
80
120
90
130
80
150
100
110
90
130
80
130
80
-
130
90
120
100
130
90
130
90
130
80
140
90
110
80
110
80
120
90
130
80
110
90
-
110
70
110
90
120
80
120
90
130
90
130
80
110
80
140
90
130
90
120
100
-
Table 3. Examination of patients Clinical Chemistry Laboratory
Examination
CLINICAL
CHEMISTRY
SGOT
SGPT
Ureum
Kreatinin
Asam urat
Natrium, Kalium
Natrium (Na) blood
Kalium (K) blood
Results
22 – 05 –
2014
Unit
Reference Value
H 90
H 98
24
0,6
5,3
U/L
U/L
mg/dL
mg/dL
mg/dl
0 – 50
0 – 50
10 – 50
0,6 – 1,1
3,0 – 7,0
L 133
3,6
mEq/L
mEq/L
135 – 147
3,5 – 10,3
8,9
mg/dl
0,8 – 10,3
1244
Calcium
Blood sugar during
134
mg/dl
IMMUNOLOGY
HbsAg
0,15
Negatif
0,10
Negatif
S/CO
0,09
Non Reaktif
S/CO
Anti HCV
Anti HIV
Anti HIV (Elisa)
Anti Toksoplasma
IgM
S/CO
0,311
Negatif
0,1
Negatif
IU/mL
Anti Toksoplasma
IgM
Examination
CLINICAL
CHEMISTRY
SGOT
SGPT
Protein Total
Albumin
Globulin
IMMUNOLOGY
Complement C4
Examination
CLINICAL
CHEMISTRY
Protein Total
Albumin
70 – 150
< 1,0
>=
< 1,00
>=
: Negatif
: 1,0 Positif
: Negatif
: 1,00 : Positif
< 0,90
: Non
Reaktif
0,90 – 0,99 : Greyzone
>=1
: Positif
Negatif
: <= 0,499
Equivokal : 0,500 –
0,599
Negatif
: >= 0,600
Negatif
: < 2,0
Equivokal : 2,0 – 2,9
Negatif
: >= 3,0
Results
26 – 05 –
2014
Unit
Reference Value
39
H 111
6,6
L 2,8
H 3,8
U/L
U/L
g/dL
g/dL
g/d L
0 – 50
0 – 50
6,0 – 8,0
3,4 – 4,8
2,3 – 3,7
H 45,60
mg/dL
16,5 – 38,0
Results
28 – 05 –
2014
7,9
3,7
H 4,2
Unit
g/dL
g/dL
g/Dl
Reference Value
6,0 – 8,0
3,4 – 4,8
2,3 – 3,7
1245
Globulin
Examination
IMMUNOLOGY
Anti HSV 1 IgG
Anti HSV 1 IgM
Results
28 – 05 –
2014
3,78
Positif
0,32
Negatif
Unit
Reference Value
Negatif
: <= 0,90
Equivokal : 0,91 – 1,09
Negatif
: >= 1,10
Negatif
: <= 0,90
Equivokal : 0,91 – 1,09
Negatif
: >= 1,10
Table 4. Hematology laboratory examination
Results
21 – 05 –
Examination
Unit
2014
COMPLETE PERIPHERAL
* 65
mm/ja
BLOOD
Erythrocyte Sedimentation
*12,0
m
Rate
5,8
g/dL
Hemoglobin
5,24
10^3μL
Leukosit
*37
10^6μL
Eritrosit
13
%
Hematokrit
/ mL
Retikolosit
0
2
%
Calculate Type Leukocytes
Basofil
*0
%
Eosinofil
*74
%
Neutrofil Batang
*4
%
Neutrofil Segmen
*10
%
Limfosit
259
%
Monosit
*71
10^3μL
Trombosit
*22,9
fL
MCV
32,4
pg
MCH
g/dL
MCHC
Results
27 – 05 –
Examination
Unit
2014
Reference Value
0 – 10
13,0 – 16,0
5,0 – 10,0
4,50 – 5,50
40 – 48
5 – 15
0–1
1–3
2–6
50 – 70
20 – 40
2–8
150 – 450
81 – 92
27,0 – 32,0
32,0 – 37,0
Reference Value
1246
COMPLETE PERIPHERAL
BLOOD
Laju Endap Darah
Hemoglobin
Leukosit
Eritrosit
Hematokrit
Retikolosit
Calculate Type Leukocytes
Basofil
Eosinofil
Neutrofil Batang
Neutrofil Segmen
Limfosit
Monosit
Trombosit
MCV
MCH
MCHC
HOMOSTASIS
Freezing Period (Lee-White)
APTT
APTT Patients
APTT Control
Prothrombin Time / INR
Protrombin Time (PT)
PT Patient
PT Control
INR
Fibrinogen
D-Dimer
Examination
*38
*11,3
6,9
4,8
*36
*23
0
*0
*0
*78
*12
*10
344
*75
*23,3
*31,1
mm/hour
s
g/dL
10^3μL
10^6μL
%
/ mL
%
%
%
%
%
%
10^3μL
fL
pg
g/dL
12 – 13
0 – 10
13,0 – 16,0
5,0 – 10,0
4,50 – 5,50
40 – 48
5 – 15
0–1
1–3
2–6
50 – 70
20 – 40
2–8
150 – 450
81 – 92
27,0 – 32,0
32,0 – 37,0
10 – 16
Minutes
33,7
30,9
*10,9
11,6
0,9
324
13590
Results
28 – 05 –
2014
26,4 – 37,5
Seconds
Seconds
11,0 – 14,2
Seconds
Seconds
mg/dL
μg/L
Unit
HEMMATOLOGY
Lupus Anti Coagulant
LA 1
LA 1 Patients
LA 1 Control
49,80
40,70
Detik
Detik
LA 2
LA 2 Patients
30,20
Detik
180,0 – 350,0
0 – 500
Reference Value
1247
LA 2 Control
Ratio (patients / control)
Ratio (R. LA1 : R. LA2)
33,80
0,89
1,37
Detik
<1,2
: (-)
1,2 – 1,5 : (+) mild
1,5 – 2,0 : (+)
moderat
>2,0
: (+) severe
Table 5. Immunology laboratory examination
Examination
ANA
Results
:
negatif
Reference value :
negatif
Anti Ds-DNA
HBsAg
Results
04 – 06 –
2014
Unit
Reference Value
14,8
Negatif
10 / mL
0,7
Negatif
MPL
Negatif
: 0 – 200
Equivocal
: 201 - 300
Positif lemah : 301 - 800
Positif kuat
: >800
Negatif
: <12,5
Indeterminate
: 12,5 20
Positif lemah - sedang : 20 - 80
Positif tinggi
: >80
4,8
Negatif
GPL
S/N
2,4
2,1
SMU
SGU
ACA IgM
Anti IgG
Anti B2 GP1 IgM
Anti B2 GP1 IgG
0,68
Negatif
Anti CMV IgM
1,69
Positif
Anti CMV IgG
Negatif
: <15
Indeterminate
: 12,5 20
Positif lemah - sedang : 20 - 80
Positif tinggi
: >80
0 – 20
0 - 20
Negatif
: <= 0,90
Equivokal : 0,91 – 1,09
Negatif
: >= 1,10
Negatif
: <= 0,90
Equivokal : 0,91 – 1,09
Negatif
: >= 1,10
1248
Table 6. Examination of urine and parasitology
Examination
Urin and
Parasitology
Berat jenis
Warna
Kejernihan
Esterase leukosit
Nitrit
Darah
PH
Protein
Gulukosa
Bilirubin
Urobilinogen
Keton
Results
07 – 06 –
2014
1,025
Kuning
Keruh
3+ / 500
Positif
3+ /200
5,5
2+ / 100
Negatif
Negatif
1,0
Negatif
H 2289
H 23
H8
Sediment
Leukosit
Eritrosit
Epitel
Silinder
Bacteria
H 29522
Cristal
kalsium
oksalat (+2)
Lain-lain
Unit
Reference Value
g/mL
1,015-1,025
Kuning
Jernih
Negatif
Negatif
Negatif
4,8-7,4
Negatif
Negatif
Negatif
<0,2
Negatif
sel/
μL
sel/
μL
mg/dL
0–2
0–3
0–1
0–1
<5
/LPB
/LPB
/LPB
/LPK
/LPB
Table 7. Examination of allergy and immunology
Examination
Allergies and
Immonology
Limposit (CD45+)
absolut
Sel T (CD3+) persen
Sel T (CD3+) absolut
Sel T (CD4+) persen
Sel T (CD4+) absolut
Results
07 – 06 – 2014
L 935
77
724
44
L 409
Unit
Reference Value
/μL
%
sel/μL
%
sel/μL
1000 – 4000
55 – 84
690 – 2540
31 – 60
410 - 1590
1249
THE EVALUATION OF DRUG RELATED PROBLEMS (DRPs)
ASSOCIATED WITH THE TREATMANT FOR ACUTE
EXACERBATION OF COPD IN GATOT SOEBROTO HOSPITAL
Selviani Sumalong1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
Student of Pharmacist Program, Faculty of Pharmacy UTA'45 Jakarta
(UTA’45 Jakarta)
[email protected]
ABSTRACT
COPD is a chronic lung disease characterized by air flow resistance in the respiratory tract
that is progressive or reversible partial nonreversibel 7. COPD consists of chronic bronchitis
and emphysema or both 7. Patient Mr. SBT, age 72 years, entered Gatot Subroto Army
Hospital on March 13, 2014 with a diagnosis of pneumonia accompanied with acute
exacerbations of COPD. Therapy for the treatment of hospitalized ie IVFD D5%, IVFD
RL, aminophylline, methylprednisolone, omeprazole, levofloxacin, fluimucyl, azitromicin,
Combivent, paracetamol. Based on the results of their clinical practice in pulmonary
disease ward at Gatot Subroto Army Hospital, it can be concluded that the presence of DRP
(Drug Related Problem) a lack of proper drug selection in overcoming excess mucus, the
side effects of drugs that cause an increase in blood glucose levels of patients.
Keywords: Acute exacerbations of COPD, Pulmonary Disease, Gatot Subroto Army
Hospital
INTRODUCTION
Chronic Obstructive Pulmonary Disease (COPD) very little known in the
community. In the United States in 1991 there were an estimated 14 million people suffer
from COPD, increased by 41.5% compared to 1982, while mortality was ranked the fourth
most common cause is 18.6 per 100,000 population in 1991 and the death rate increased
32.9% from the year 1979 to 1991 5.
According to the Global Initiative for Chronic Obstructive Lung Disease (GOLD),
COPD is a disease with characteristic airway limitation that is not fully reversible. The
1250
airway limitation is usually progressive and connected to the inflammatory response due to
harmful material or gas 2. COPD is one of the major non-communicable diseases, which is
rather seldom exposed because of the lack of information provided 5.
Chronic Obstructive Pulmonary Disease (COPD) is a systemic disease that has
relationship between the involvement of metabolic, skeletal muscle, and molecular
genetics. Activity limitations are common complaints of patients with COPD that greatly
influences the quality of life. Skeletal muscle dysfunction is the main thing that plays a role
in COPD patients with activity limitations. Systemic inflammation, weight loss, increased
risk of cardiovascular disease, osteoporosis and depression is a systemic manifestations of
COPD 3.
COPD will give negative impact for the quality of patients life, including patients
aged> 40 years will lead to disability sufferers. In this case, they are still in the group of
productive age but can not work optimally because of the chronic shortness of breath 4.
COPD Diagnosis is made based on the presence of symptoms - symptoms include cough,
sputum production, dyspnea, and a history of exposure to a risk factor. Meanwhile, the
respiratory tract obstruction it should be confirmed by spirometry6.
CASE PRESENTATION
Patient Mr. SBT, 72 years old was enter to Gatot Subroto Army Hospital on March
13, 2014. Patient was delivered with his family’swhere is the condition of weakness,
shortness of breath for ± 3 days since he entered to the hospital, cough (+), fever (+).
Routine control of poly lung. Tightness is not the first time, if intermittent cold air. Routine
treatment for lung poly each month. The patient had a history of asthma. The patient is a
smoker when he was youth.
CLINICAL EVALUATION
Aminophylline for the use of reversible airway obstruction, acute severe asthma.
Methylprednisolone for suppression of inflammation with allergic disorders. Omeprazole
for stomach ulcers and duodenal ulcers. Levofloxacin for infections due to sensitive
microorganisms in acute maxillary sinusitis bleak, acute bacterial exacerbations of chronic
1251
bronchitis, community-acquired pneumonia, and complicated urinary tract infections.
Fluimucyl for respiratory tract infections with excess mucus secretion including bronchitis,
emphysema and bronkiekstasis. Azitromicin for infections caused by susceptible
microorganisms, ARI, bronchitis, pneumonia. Combivent for the treatment of diseases
associated with pulmonary obstruction disease. Paracetamol to cope with mild to moderate
pain, pyrexia 1.
LINE TREATMENT FOR COPD 7
a.
Bronchodilators
Given alone or a combination of all three types of bronchodilators and adapted to the
classification of disease severity. The selection of the preferred drug inhalation,
nebulizer is not recommended in the long-term use. In severe degree preferred
sustained release drug delivery (slow release) or medications affect the long (long
acting).
Kind of - kind of bronchodilators:
1.
Class of anticholinergic
Used in mild to severe, as well as bronchodilator also reduce mucus secretion
(maximum of 4 times per day).
2.
Beta agonist class - 2
Form of inhalers used to treat spasms, increase in number can use as a monitor
onset of exacerbation. Should be used as a maintenance drug that affects the long
form of tablets. Shape nebulizer can be used to overcome the acute exacerbation,
not recommended for long term use. Subcutaneous injection or drip shape to
cope with severe exacerbations.
3.
Combination of anticholinergics and beta agonists - 2
The combination of these two drug classes will strengthen the effect of
bronchodilation, because both have different workplace. Besides, the use of drug
combinations simpler and easier for the patient.
4.
Group xanthine
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In a slow-release form as a long-term maintenance treatment, especially in
moderate and severe. Regular tablets or powders to overcome shortness (Nasal
congestion), bolus injection or drip shape to cope with acute exacerbation. Longterm use of aminophylline blood levels of inspection required.
b.
Antiinflammatory
Used in the event of acute exacerbations in the form of oral or intravenous injection,
serves suppress inflammation that occurs, selected group of methylprednisolone or
prednisone. Inhalation as a form of long-term therapy is given if the test proves
positive corticosteroid that there were improvements pascabronkodilator VEP1
increase> 20% and a minimum of 250 mg.
c.
Antibiotic
Only given when there is an infection. Antibiotics are used:
First line
: - Amoxicillin
- Macrolides
Line Two : - Amoxicillin and clavulanic acid
- Cephalosporins
- Quinolone
- Makrolid new
Hospital care, can be selected:
-
Amoxicillin and clavulanate
-
II & III generation cephalosporins injection
-
Oral quinolones
coupled with the anti-pseudomonal
d.
-
Aminoglikose per injection
-
Quinolones per injection
-
The fourth-generation cephalosporins per injection
Antioxidants
1253
Can reduce exacerbations and improve the qualities of life, used N - acetylcysteine.
Can be administered in COPD with frequent exacerbations, the administration is not
recommended as a routine
e.
Mucolytic
Only given mainly in acute exacerbation because it will accelerate the improvement
of exacerbations, especially in chronic bronchitis with viscous sputum. Reduces
COPD exacerbations in chronic bronchitis, but not recommended as a routine
administration.
DOSAGE AND DIRECTION1, 2
The therapy provided during care that IVFD D5%, IVFD RL, aminophylline,
methylprednisolone, omeprazole, levofloxacin, fluimucyl, azitromicin, Combivent and
paracetamol. IVFD D5% is given while the patient was still in the ER, RL IVFD given at
the time the patient was transferred to the infirmary. Where indications as electrolyte,
administered intravenously. Aminophylline was given 1 ½ ampoule / 12 hours, the
indications for chronic obstructive pulmonary disease and asthma, administered
intravenously at a dose of 250-500 mg prevalent (5 mg / kg). Methylprednisolone was
given 3 x 62.5 mg, as the suppression of inflammatory indications, administered
intravenously at a dose of 500 mg prevalent. Omeprazole was given 1 x 40 mg, are
indicated for peptic ulcers, administered intravenously, with the usual dose of 40 mg.
Levofloxacin was given 1 x 750 mg, are indicated for bacterial infections, administered
intravenously, with the usual dose of 750 mg / day. Fluimucyl given 3 x 1, indications for
excess mucus secretion, administered orally, with the usual dose of 3 x 1 sach / day.
Combivent given 4 x / day, the indication as a bronchodilator, with the usual dose of 4x
daily maximum spray 12 spray 2 x 24 hours. Paracetamol was given 3 x 500 mg,
indications as analgesic and antipyretic, administered orally, with the usual dose of 0.5-1 g
every 4-6 hours up to a maximum of 4 g per day. Azitromicin given at the time the patient
will go home with a dose of 1 x 1, indicated for bacterial infections, administered orally,
with the usual dose of 500 mg.
1254
LIST OF THERAPY TREATMENT
The list of therapies for patient treated at the Gatot Subroto Army Hospital, where
on December 13 thirds of patient entered in the ER, given IVFD D5% + 1 ½ aminophylline
intravenous ampoules, at a dose of 10 TPM (drops per minute). Date 13/3 given
omeprazole injection at a dose of 1 x 40 mg and methylprednisolone injection at a dose of 3
x 62.5 mg intavena. After the treatment the patient was transferred chamber and given some
medication therapy. Date 14/3 to 17/3 patients given aminophylline 1 IVFD RL + ½
ampoule with intravenous doses of 15 TPM (drops per minute). Antibiotics levofloxacin
given 1 x 750 mg intravenously starting on 14/3 to 16/3. Date 14/3 Fluimucyl patients
administered orally at a dose of 3 x 1 sach. Combivent Inhalation given 4 x / day starting on
14/3 to 17/3. Azitromicin prescribed at the time the patient will go home with a dose of 1 x
500 mg.
LABORATORY VALUES
Clinical chemistry laboratory results on 14 March 2014, shows the value of fasting
blood glucose and blood glucose 2 hours PP has increased. Where the patient's fasting
blood glucose value is 184 mg / dL of normal value 70-100 mg / dL and 2-hour blood
glucose PP is 206 mg / dL of normal values <140 mg / dL. And clinical chemistry
laboratory results on 16 March 2014, showed an increase in leukocytes of patients that
14400/μL of normal values from 4.800 to 10.800 / mL. This shows there is an increase in
leukocyte infections.
1.
Selection relatively safe drug
Drug selection is less precise in the use Fluimucyl (Acetylcysteine) for respiratory
tract infections with excess mucus secretion. According to the BNF 56 (2008), one of
the side effects of acetylcysteine may cause nausea and vomiting. Given a patient
with a history of peptic ulcer disease and GI disorders. Then recommended /
suggested to the doctor to review the accuracy in drug selection. Can be given
1255
ambroxol, where the side effects of ambroxol for mild gastrointestinal disturbances so
as to minimize gastrointestinal side effects.
2.
Side effects of drugs
An increase in fasting blood glucose and blood glucose 2 hours PP allegedly due to
administration of methyl prednisolone (glucocorticoids) because according to A to Z
drug facts (2003), one of the side effects of methyl prednisolone may cause
hyperglycemia. Recommended / suggested to the doctor for examination to determine
the patient HbA1c diabetes positive or not, conduct monitoring of blood glucose and
fasting blood glucose 2 hours PP patient and saw a sign-a sign of the patient physical.
CONCLUSION
Based on the results of their clinical practice in pulmonary disease ward at Gatot Subroto
Army Hospital it can be deduced that the presence of DRP (Drug Related Problem) a lack
of proper drug selection in overcoming excessive mucus, and side effects of drugs that
cause an increase in blood glucose levels of patients, where from the medical records of
patients not previously known to have a history of diabetes mellitus.
REFERENCES
1. National authorities., 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta:
Sagung Seto
2. National Institutes of Health, National Heart, Lung and Blood Institutes., 2001, the
Global Initiative for Chronic Obstructive Lung Disease. NHLBI / WHO workshop
report.
3. Agustin, H & Yunus, F., 2008, Metabolic processes in COPD., J Re spir Indo vol 28,
no 3.
4. Agusti AGN, et al., 2003.Systemic Effects of COPD, Eur Respir J.
5. Oemiati, Ruth. 2013.Study Epidemoiologi Chronic Obstructive Pulmonary Disease
(COPD).
6. Ikawati Zullies, 2007, Pharmacology Respiratory System Diseases. Yogyakarta:
Pustaka clean city.
1256
7. PDPI, 2003, Chronic Obstructive Pulmonary Disease (COPD) Guidelines for
Diagnosis and Penatalaksaan in Indonesia. Jakarta.
8. Galileopharma. , 2008. BNF edition 56. Alexandria University.
9. David S. Tatro, 2003. A to Z Drug Facts. Facts and Comparisons.
1257
DRUG RELATED PROBLEM ON THE TREATMENT A SIMPLE
FEVER SEIZURE
Singgih Ardian Prabudi1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
A fever seizure is a seizure which occurred at body temperature rise (rectal temperature of
>38 ° C) caused by a process other than brain7. Simple fever seizure lasts a short time, less
than 15 minutes and will generally stop itself10. The General form of seizure tonic and
clonic movements, without a focal and not recurring within 24 hour2.7. Patient 's DDP, age
2 years 8 months old, entered RSPAD Gatot Soebroto on 12 March 2014 with a simple
Fever Seizure diagnosis. Therapy treatment of Paracetamol supposutoria, Paracetamol
tablets, Farmadol injection, Diazepam supposutoria, Ambroxol syrup, Ondancetron
injection, Amoxicillin injection and Dexanta syrup, Infusa D5 FD ¼ volume . Based on the
results of the practice of the registrar of clinics on child care RSPAD Gatot Soebroto then
can be drawn the conclusion that the existence of the DRP (Drug Related Problem) in the
form of inappropriate dosage regimens in the use of Paracetamol tablets and Amoxicillin
injection (dose of medication is too low).
Keywords: simple fever Seizure, child care, Amoxicillin injection and Paracetamol
INTRODUCTION
From the study, the incidence of seizures on its own is not too big a fever which is
about 2-5%, meaning that of 100 children with a fever there is about 2-5 who experience
seizures. Fever seizures occur at ages 6 – 60 months and most occur at ages 17-23
months2.
A fever seizure is a seizure which occurred at body temperature rise (rectal
temperature of > 38 ° C) caused by a process other than brain7. A simple fever seizure lasts
a short time, less than 15 minutes and will generally stop itself10. The General form of
seizure tonic and clonic movements, without a focal and not recurring within 24 hour2.7.
1258
Fever seizures occur in children at a time in their development when the seizure threshold
is low. This happens when the children are susceptible to infections such as upper
respiratory tract infections, otitis media, syndrome virus and they respond with comparably
more high temperatures10.
CASE PRESENTATION
Patient Mr. DDP, age 2 years 8 months entered RSPAD Gatot Soebroto on 12
March 2014. A patient comes in with complaints of fever since 2 days before entering the
hospital, the body temperature measured 38,4 0C at the moment hospital, accompanied a
seizure this morning lasted approximately 10 minutes, the patient complained out patches
of redness on the head (face), chest, arms, stomach and lower limbs, no nausea and
vomiting, no coughs and colds.
The patient is a reference from Daan mogot Tangerang Hospital, bringing results
photo thoraks with impression suspect bronchopneumonia. The therapy has ever given in
the previous hospital is Erithromicyn 250 mg, Ponflu syrup, Humafog syrup, Ibuprofen
syrup, Diazepam.
A history of the patient's disease is fever seizure in 1 year ago and there is no family
history of the disease.
CLINICAL EVALUATION
The use of paracetamol to fever treatment11. Ambroxol as secretolitic on acute
respiratory tract disorders and kronis5. Ondancetron as an antiemetic to combat nausea and
vomiting at children8. Diazepam for muscle relaxes on fever seizures and epileptic8.
Dexanta to prevent hyperacidic5. Farmadol injection to overcome hyperpirexia (> 400C).
Amoxicillin an antibiotic broad spectrum infections to Gram-positive and negative
microorganism sensitive as in community-acquired pneumoniae3.9.
1259
ADMINISTERING THERAPY
Drug’s
Paracetamol tablets
-
Paracetamol
supposutoria
Ambroxol syrup
Dosage
4 x 250
mg
1 x 250
mg
3 x 1 cth
Indication
Analgesic,
antipiretic
Analgesic,
antipyretic
Secretolitic
-
Dexanta syrup
3x1cth
Antihyperacidicis Oral
-
Ondancetron
Injection
4mg/ml IV
-
Amoxicillin
3 x 4 Antiemetic
mg
1 x 750 Antibiotics
mg
Injection
-
Diazepam
1 x 10 Muscle relaxes
mg
Rectal
30mg/Kg
Body
weight every 8
hour
>10 years 10 mg
dosage
-
Route
Oral
Rectal
Oral
Absolute Dosage
10-15
mg/Kg
Body weight/daily
10-15 mg/ Kg
Body weight/daily
15mg/5ml 3 times
daily ½ cth (5ml)
RESULTS OF LABORATORY EXAMINATION
Diagnostic
Reference value
12/3/2014
- Haemoglobin
12-16 g/dL
12,2
- Hematocrit
37-47 %
36
- RBC
4.3-6 juta/μL
4,7
- WBC
4800-10.800 / μL
* 12.500
- Trombosit
150.000-400.000/μL
300.000
- MCV
80-96 fL
77
- MCH
27-32 pg
26
- MCHC
32-36 g/dl
34
Dosing Regimens
A dose of paracetamol given orally to control increase body temperature has not
been appropriate. In these patients given paracetamol tablets with a dose of 250 mg once
1260
daily at 3 times daily and according to literature should be given a dose of 10-15 mg/Kg
every 4-6 hour7,10,11.
Calculation of the dose of paracetamol: 26 kg x 10-15 mg = 260-390 mg
A dose of paracetamol given: 250 mg
From the above calculation should be the minimum dose of paracetamol is given of
260 mg up to 390 mg
Dosage amoxicillin given in injection to tackle respiratory infections have not been
appropriate. In these patients were given amoxicillin injections with a dose of 750 mg once
and according to literature that the dose of amoxicillin which must be given to a child with
bacterial infection by S.pneumoniae that is 30 mg/kg every 8 hour3.
Calculation of the dosage of amoxicillin injection: 26 Kg x 30 mg = 780 mg
Amoxicillin injection dose given: 750 mg
From the above calculation should be the minimum dose of amoxicillin injection is
given at least 780 mg.
Ambroxol dose given orally as a secretolitic not yet appropriate. In these patients
were given doses ambroxol 3 times daily 1 cth measures (5 ml) and according to literature
that the dose must be given to the ambroxol children 2-6 years old is 3 times daily ½ cth
measures (2, 5 ml)5.
CONCLUSION
Based on the results of the practice registrar clinics on child care at the RSPAD Gatot
Soebroto then it can pull in the conclusion that the existence of DRP (Drug Related
Problem) that have dose regimens not yet to be right is paracetamol oraly dosing is low if
adjusted to the weight of the patient, dosing amoxicillin low if calculated based on the
weight of the patient and dosing ambroxol more based on the literature.
REFERENCES
1.
American Academy of Pediatrics Steering Committee on Quality Improvement and
Management, Subcommittee on Febrile Seizures. Febrile seizures: clinical practice
1261
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. David S. Tatro, 2003 A to Z Drug Facts Facts and Comparisons 2003
7. IDAI, 2006 Konsensus Penatalaksanaan Kejang Demam,Unit Kerja
Koordinasi
Neurologi, IDAI 2006
8. ISFI , 2008
ISO Farmakoterapi Cetakan Pertama. 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. RSPAD Gatot Soebroto, 2012 Standar Pelayanan Medik Kejang Demam Sederhana
11. 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.
12. Tatro DS (ed). Drug Interaction Facts 2004. Facts and Comparisons, St. Louis, MO.
2004
1262
DRUG RELATED PROBLEMS ON DISEASE MANAGEMENT OF
DYSPEPSIA IN GERIATRIC PATIENT IN THE INTERNAL
MEDICINE WARD PGI CIKINI HOSPITAL
Siska Nola Dewi1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Dyspepsia is one of the common diseases found in the internal medicine ward of PGI
Cikini Hospital. Dyspepsia is more common in geriatric patients compared with younger
patients is usually caused by peptic ulcer, there are 2 types of dyspepsia: 1. Organic
Dyspepsia 2. Non-organic dyspepsia or previously called Functional Dyspepsia.
Presentation of cases : the patient with initial SM is 85-years-old woman hospitalized in
internal medicine wards, patient was diagnosed with dyspepsia. Clinical Evaluation:
basiclly, there were 2 interventions couse of dyspepsia which were found during the
assessment of patients treatmant, namely the administrations of meloxicam, domperidone
with paracetamol simultaneously orally ans the last one, Captopril with food.
Keywords : Dyspepsia, Geriatric Patient, PGI Cikini Hospital
1. INTRODUCTION
Dyspepsia is a syndrome or collection of symptoms that Consist of pain or
discomfort in the epigastrium, nausea, vomiting, bloating, feeling full earlier than
expected when eating, upper abdomen fullnest, and burping2. In elderly patients
dyspepsia, peptic ulcer disease is more common than younger patients3. Peptic ulcer in
the elderly is often more serious than the same case at a younger age due to the risk
factors ulcers is more complain in the elderly3. Another factor affecting the prognosis of
peptic ulcer in the elderly is co-morbidity, polyfarmacy, NSAID administrations and
1263
malnutrition3. One of the symptoms or syndromes, dyspepsia can be caused by various
diseases, whether they are organic or functional2.
2. PRESENTATION OF CASE
Mrs. SM 85-years-old patient hospitalized in internal medicine wards. Patient
was diagnosed with dyspepsia and enter hospital since April
22,
2014. Patient
complainted nausea and vomiting one time since 4 days before hospital admission and
was decreased appetite since 1 week before entering the hospital.
Physical examination discovered BP 150/80 mmHg, Heart rate 78-88 x / min,
Temperature of 36-37 oC, Respiratory 18-20x/min.
Laboratory examinations on April 22, 2014: Blood Sedimentation Rate (40 mm/hour),
Hemoglobin (6.2 g/dL), Leukocytes (4.8 10^3/μL), Erythrocytes (2.58 10 ^ 6/μL),
Hematocrit (18%), Reticulocyte (23 mile), Platelets (85 10 ^ 3/μL), MCV (70 fL),
MCH (24 pg), Calcium (7.3 mg / dL) .
After treatment the laboratory result on April 27, 2014: Blood Sedimentation
Rate (120 mm / h), Hemoglobin (7.6 g / dL), Leukocytes (6.6 10^3/μL), Erythrocytes
(3.19 10^6/μL), Hematocrit (23%), Retikulocyte (19 mile), Platelets (109 10 ^ 3/μL),
MCV (71fL), MCH (23.8 pg).
The profile of the patient's treatment was Rantin 50 mg injection to treat ulcers,
Episan to protect the gastric mucosa, domperidone 10 mg to prevent and treat nausea
and vomiting, Captopril 12.5 mg to lower blood pressure, Sangobion to treat anemia,
Alprazolam 5 mg as a sedative, Panadol to reduce fever, Meloxicam 7.5 mg to relieve
the pain, Ceftriaxone 1gr as antibiotics, Ca. gluconate to fix electrolyte problem and
Cavit D3 to prevent osteoporosis in postmenopausal patient.
Meloxicam is a Non-Steroid Anti-inflammatory Drug class (NSAID) which was
used to relieve the pain, the patient complained of pain in both legs on April 28, 2014,
1264
but the usage of NSAIDs in patient with dyspepsia could deteriorate because of
NSAIDs is a drug that can cause dyspepsia.
Pharmacist advice :
Giving NSAID in geriatric patient should be administered with proton pump inhibitors
to prevent peptic ulcer.
3.2 Drug Related Problem
Domperidone was used to prevent nausea and vomiting, paracetamol to reduce
fever. When the two drugs were administered orally simultaneously will cause drug
interactions that will increase the absorption of paracetamol.
Captopril was used to lower blood pressure when administered with food the
absorption of Captopril in the gastrointestinal tract is lowered and so is the effect in
blood pressure, although this drug interactions is not very significant.
Pharmacist advice : Give a lag time of at least 2 hours between intake of domperidone
with paracetamol and give Captopril one hour before eating.
Pharmacist Intervention: It was recommended to patient to get plenty of rest and eat
foods that contain high protein, low fat, contains fiber, low sodium diet and water
consumption 2 liters / day.
4. CONCLUSION
After the assessment of the patient's treatment, it could be concluded that
meloxicam is a class of Non Steroid Anti-inflammatory Drug (NSAID) was used to
relieve pain, the patient complained of pain in both legs on April 28, 2014 but the
administratins of NSAIDs in patient with dyspepsia may harm patient because NSAID
class of drugs is one of the drugs that could induce dyspepsia. In order to prevent side
effects of NSAID administration in geriatric patient, NSIDs should be given with
proton pump inhibitors. Domperidone was used to prevent nausea and vomiting,
paracetamol was used for the fever, the administration of Domperidone simultaneously
with Paracetamol, can increase the absorption of paracetamol in the gastrointestinal
tract, Give a lag time of at least 2 hours between intake of domperidone with
paracetamol.
1265
Captopril was used for lowering blood pressure and when Catopril is given together
with food will reduce Captoprils absorbsm food, Captopril should given one hour
before meals.
REFERENCES
1. Baxter, 2008. K.Stockley’s Drug Interaction Eight Edition. London.
2. Djojoningrat D. 2010. Dispepsia Fungsionaldalam: Sudoyo AW, Setyohadi B, Alwi I,
Simandibrata M, Setiati S. Buku Ajar IlmuPenyakitDalamjilid I edisi 5. Interna
Publishing. Jakarta.
3. LinderJD, Wilcox CM. 2001. Gastrointestinaldisorders in the elderly: acid peptic
disease inthe elderly. GastroenterolClinNorth Am.
4. Montalto M, Santoro L, et al. 2004. Functional dyspepsia: definition, classification,
clinical and therapeutic management. Article in Italian. AnnItal Med Int.
5. Pilotto A, Franceschi M, et al. 2004. Proton-pump inhibitors reduce the risk of
uncomplicated peptic ulcer w elderly either acute or chronic users of aspirin/ nonsteroidal anti-inflammatory drugs. Aliment Pharmacol&Ther.
1266
DRPs (DRUG RELATED PROBLEMS) ASSOCIATED WITH
TREATMENT TO FEBRILE OBSTRUCTION PATIENT IN PGI
CIKINI HOSPITAL
Siti Erlina Wahyuningsih1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Febrile/Fever is a condition of increased body temperature more than 380C. Fever is
biological response to disease by cytokines and is characterized an increase in body
temperature and activity of immune. The symptoms of febrile viral infection are usually
fever, increased temperature> 380 C, chills, lethargy, restless and cranky as well as trouble
sleeping, sweating, red face watery eyes and lower the appetite. Patient Mr. H goes to PGI
Cikini hospital on 9th June 2014 with the diagnosis of febrile.Patient has received
medicines to 10 days as vitamin B complex, Folic acid, Panadol, Curcuma / Hepamax,
Ondansetron. Based on the result of the clinic secretariat at the ward of K in PGI Cikini
Hospital, it could be concluded that there was DRPs (Drug Related Problem) such as
improrer drug selection, untreated indication, ADR, and drug used without indication.
Keywords:
Febrile
Obstruction,
Internal
Medicine,
PGI
Cikini
Hospital.
INTRODUCTION
Febrile/Fever is a condition of increased body temperature more than 380C. Fever
is biological response to disease by cytokines and is characterized an increase in body
temperature and activity of immune. The body has developed adefense system against
infection and elevation of body temperature gives an optimal job opportunities for
bodydefense system. Fever occurs due to the release of pyrogen from leukocytes that had
previously been stimulated by exogenous pyrogens can be derived from a microorganism or
an immunologic reaction that results are not based on a infection5. Pyrogen is a protein that
it is identical to interkulin-1, in the hypothalamus stimulates to releasearachidonic acid and
1267
these substances result in an increase prostaglandin E2 synthesis which can directly lead to
a pireksia4. Effect of autonomic regulation will result in peripheral vasoconstriction and
decreased heat dissipation so that the patient had a fever. Body temperature may increase
due to the increased metabolic activity also resulted in the addition of heat production and
distribution due to inadequate surface then increase fever4. Efforts to overcome the
"undiagnosed fever" is the ad juvantivustreatment. The principle is the implementation a
drug that it is used should be based on a strong indication of the appropriate local
experience and must have spesification5.
CASE PRESENTATION
Mr.H has gone to the PGI Cikini hospital on June 9 th2014 was diagnosed of
febrile obstruction and viral infections. Patient present with febrile (fever).
CLINICAL EVALUATION1
Using of vitamin B complex to treated nausea and vomiting as a hepatoprotective.
The using of ondansetron for nausea and vomiting. Folic acid for anemia. Using of
Curcuma or hepamax to treated liver function (hepatoprotective). Panadol to treated fever.
DOSAGE AND DIRECTION1, 3.6
During hospitalized in PGI Cikni Hospital, Mr. H was treated 5 medicine. The first
day the patient got Panadol tablets for four days. On the first day was given at a dose of 1 x
1 (500 mg) a day, and Panadol on second day given at a dose of 2 x 1 (500 mg) a day. And
on third and fourth day was given at a dose of 3 x 1 (500 mg) tablets. Vitamin B complex 3
x 1 was given for 9 days. Folic Acid 1 x 2 was given for 9 days. Curcuma or hepamax only
given twice in 10 days with a dose 3 x 1while ondansetron given only 4 days in 10 days
with the dose of 2 x 4 mg.
DRPs (DRUG RELATED PROBLEMS)
1. Improper durg selection
1268

Patients received ondansetron for nausea and vomiting, patient was also assigned the
vitamin B complex,Vitamin B complex is quite effective for the treatment of nausea
and vomiting of patients. Ondansetron is usually used for patient with severe nausea
and vomiting (post-surgery).

Patient got folic acid for the treatment anemia, but the results of laboratory shown that
patient did not have indication in decreasing of Hb.

Patient actually have to get albumin therapy, it based on laboratory data that it showed
the lower of albumin patient, but patient didn’t get it.

Patient was requiring antibiotic therapy on that time but he did not get it. Antibiotic
therapy was required because laboratory results showed the lower value of leukocytes,
also some laboratory results shown the presence of bacteria in the patient urine.

Patient also need vitamin K to prevent bleeding, it was seen from patient laboratory
data that it showed a low values of platelet.
3. Drug used without indication
Patient received Panadol to overcome the fever, but Panadol have hepatotoxic effects
that can increase the value of SGOT / SPGT in patients. So it is advisable for patient to
changed Panadol with other drugs that do not have hepatotoxic effects or provide
sistenol (Paracetamol + acetilcysteine).
4. ADR (Adverse Drug Reaction)
Using of Panadol in patients with SGOT / SGPT were high, it can cause increasing of
SGOT / SGPT patient.
CONCLUSION
Based on the result of the practice of clinic secretariat at the ward of K at PGI
Hospital Cikini, it can be conclude that there was DRPs (Drug Related Problems) such as
improrer drug selection, untreated indication, ADR, and drug used without indication.
REFERENCES
1. BPOM. , 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta: SagungSeto
1269
2. Burns, A. 2009. Renal Drug Handbook third edition. New York: Oxford
3. BNF. 2009, British National Formulary. BMJ Group. UK
4. TamsuriAnas. , 2006. Vital Sign. Jakarta; EGC Book Medical Publishers, Matter. 2738
5. Priyanto. , 2008. Pharmacotherapy and Medical Terminology. Institute for Studies and
Consultation Pharmacology. Jakarta. Matter 769-773
6. MIMS. , 2009. MIMS Indonesia Edition 9. Jakarta. PT. BhuanaIlmuPopuler
7. Sutedjo, AY. , 2007. Buku Saku Mengenal Penyakit Melalui Hasil Pemeriksaan
Laboraturium. Amara Books. Yogyakarta
1270
BRONKIEKTASIS (BE) AT LUNG INFECTION WARD RSUP
HOSPITAL
Siti Suhartini1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Bronkiektasis is a disease that is signed by the presence of dilatation (ecstasies) and the
distortion of local Bronchus which has pathologic characteristic and run chronically,
persistently or irreversible7. The deviation of bronchus is caused by the changing in
bronchus’s wall such as the destruction of elastic elements, smooth sinew of bronchus,
cartilage, and vascular7. The patient Mr. NWW, aged 75, entered RSUP Persahabatan on
2nd of March 2014 with the diagnosed of infected BE, dyspepsia syndrome and ISK (kidney
stone). The therapy treatment during the treatment is paracetamol, ambroxol, antasida,
ranitidine, levofloxacin and IV FD NaC1 0,9%. Based on the result of clinic secretariat
practice at the ward of lungs disease at RSUP Persahabatan it can be concluded that there is
a DRP (Drug Related Problem) such as the correlation between the medicine therapy in
clinical condition like the reducing of appetite (the indication without medicine), the
inappropriate in choice of medicine in choice of anti emetic, dose of regimen on the use of
ranitidine (the dose of the medicine is too low) and the failure of the patient in receiving the
medicine.
Key words : Bronkiektasis, infected of BE, lungs disease and RSUP Persahabatan
INTRODUCTION
Bronkiektasis is a kind of disease that is signed by existence of a dilatation (ecstasies)
and distortion (ecstasies) and bronchus local distortion that has pathology characteristic and
run chronically, persistently or irreversible (do not change to first form)7. The deviation of
bronchus is caused by the changes in bronchus wall like the destruction of elastic element,
the smooth sinew of bronchus, cartilage, and vascular7. The classical symptom is the
productive cough with sputum purulent4. Half of the patients will produce the daily sputum,
1271
it is also followed by hemoptisis and the progressive decrease of inhalation function, the
worn out of the patient condition is influenced by the air temperature that is cold
temperature that will increase the serious condition of the disease4.
Bronkiektasis sometimes is categorized in a group of infected inhalation line disease
with the diagnose of infected bronkiektasis3. In Bronkiektasis occurs the abnormal
dilatation from bronchus and secondary bronchioles to the infection and inflammation
which is happened repeatedly5. Bronchioles are clogged up because the cracks of epitel
from mucosa bronchus, so this problem can cause the formation of fibrosis tissue5.
Obstruction and infection is the main cause of bronkiektasis6. In obstruction occurs the
accumulation secret that has been infected until the inflammation, necrosis, fibrosis and
dilatation of inhalation line happened that is irreversible6. Aspergilosis bronkopulmoner
alergika ( the reaction hypersensivity to Aspergillus fumigatus with the serious
inflammation that rich of eosinofil at inhalation line) can oppressive the cystic fibrosis
condition and also asthma and bring the bronkiektasis 6.
CASE PRESENTATION
The patient Mr. NWW, age 75 entered RSUP persahabatan on 2nd of March 2014. The
patient came with the painful stomachache gripe that was suddenly happened when he was
depriving the grass about 4 days before entered the hospital. The patient had coughed
gripped in the morning about 2 weeks before entering the hospital. The color of the sputum
cough is white. The patient has never cough with blood. The patient felt tight every time he
cough, tighten without ngik sound. The tight is not influenced by the weather or activity.
The patient was not complaining about the pain in his chest and he was not complaining
about the sweat at night. The patient had been in a fever on one day before entering the
hospital and cared at clinic. The patient complained that he did not want to eat with the
deriving of body weight about 5 kg at the latest month.
The patient had been caring in RSUP Persahabatan on ± 4 months ago with the
complaint of blood in his urine and he had been caring for almost 2 weeks and planned to
follow the surgery but it was canceled because the patient was afraid. Now the urine of the
1272
patient is normal (there is no blood). The patient has been a smoker since he was young.
The patient has a history of asthma, DM and dyspepsia.
CLINICAL EVALUATION
The use of paracetamol is for curing the light to medium pain, pyrexia. Ambroxol is as
the sekretolitik at distraction of inhalation line chronic especially in eksaserbasi of
bronchitis chronic and bronchitis asthmatic and asthma bronchial. Antasida is used for
dyspepsia syndrome; ranitidine is for sore flank and sore duodenum. Ondansetron is for
queasy at medium level. Levofloxacin for infection caused by sensitive microorganism
such as in acute maxillary sinusitis, acute bacterial exacerbations of chronic bronchitis,
community-acquired pneumonia, dan complicated urinary tract infections 1.
DOSES AND INDICATION 2
Name of the
drugs
Parasetamol
Prescription
dose
3 x 500 mg
Ambroxol syr 3 x 1 c
Antasida syr
3x1 c
Ranitidin
2 x 50 mg
Levofloxacin
1 x 750 mg
NaCl 0,9%
500 cc
Commonly
dose
250-500
mg
every 4-6 hours
if it needed
2-3x 45 mg/15
ml
7-14 ml 3-4
times
30
minutes
before eat
50 mg every 68 hours
750 mg every
24 hours
Indication
The usage
Analgesik and Oral
atipiretik
Productive
cough
Dyspepsia
Oral
oral
Sore cavity and Injection
and duodenum
Bacterial
Injection
Infection
Electrolyte
Injection
1273
LABORATORY RESULT
No.
1
2
3
4
5
6
7
8
Parameter
Leukosit
Netrofil
Eosinofil
Hematokrit
MCV
MCH
MCHC
RDW-CV
Value
Hematology
02-3-2014
24,6 ribu/mm3
86,8 %
0,2 %
37 %
57,8 fL
20,9 pg
36,1 %
15,5 %
Normal
Value
5 - 10
50 – 70
2–4
40 - 52
80 - 100
26 - 34
32 - 36
11,5-14,5
1.
Untreated medication.
There is an indication without medicine, where the patient felt the reducing of the
appetite. It is suggested for giving the additional therapy like vitamin B complex and there
is a monitoring of the appetite of the patient.
2.
Improper drug selection.
The chosen of unsuitable medicine that is used on ondansentron as the antiemetic.
According to BPOM (IONI, 2008), ondansentron cures the queasy vomit which caused by
chemotherapy and radiotherapy. The choice of antiemetic is based on BPOM (IONI, 2008)
on the first time, is the domperidon with the indication to cure the chronic queasy vomit. It
is suggested for the doctor to observe again the précising of the chosen of the medicine. Do
the check list note of the nurse continuity.
3.
Regimen dose
The dose of the medicine is too low that is in the ranitidine prescription 2 x 50 mg
for a day, according to Dr. Aine Burns (Renal Drug Handbook, 2009), it should be 3x50
mg in a day. It is suggested to doctor to evaluate again the dose of the therapy of the usage
of ranitidine. Do the checklist note of the nurse continuity.
4.
Failure to receiving medicine
1274
The patient failed in receiving the medicine such as the ranitidine injection at 06.00
WIB and 18.00 WIB at 3rd of March 2014. It is suggested to the pharmacist to ask to the
nurse about the drugs that has been given and do the checklist note of the nurse continuity.
CONCLUSION
Based on the result of the practice of clinic secretariat at lungs ward at RSUP
Persahabatan, it can be concluded that there is a DRP (Drug Related Problem) such as the
correlation between the therapy of the medicine with clinical condition like the reducing of
appetite ( indication without medicine), the chosen of the medicine that is not appropriate in
anti emetic, regimen dose which is not appropriate in the use of ranitidine (the dose is too
low) and the failure of the patient in receiving the medicine.
REFERENCES
8. BPOM. 2008. Informatorium Obat Nasional Indonesia (IONI). Jakarta : Sagung Seto.
9. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford.
10. Djojodibroto, Dr. R. Darmanto, Sp. P, FCCP. 2009. Respirologi (Respiratory
Medicine). Jakarta : EGC.
11. Gleadle, J. 2007. At A Glance Anamnesis. Jakarta : Erlangga.
12. L, Kee Joyce dan R, Hayes Evelyn. 1996. Farmakologi. Jakarta : EGC.
13. Mitchell,. Kumar,. Abbas,. Fausto. 2008. Buku Saku Dasar Patologis Penyakit robbins
dan cotran edisi 7. Jakarta : EGC.
14. Sudoyo, Aru W., et al. 2006. Buku Ajar Ilmu Penyakit Dalam. Jakarta : Departemen
Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Indonesia
1275
DRUG RELATED PROBLEMS PNEUMONIA DISEASE
Suci Ramadhan Sulaeman1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Pneumonia is defined as lung inflammation caused by microorganisms (bacteria, viruses,
fungi, parasites). Pneumonia caused by Mycobacterium tuberculosis is not included
whereas lung inflammation caused by nonmicroorganism (chemicals, radiation, toxic
material aspirations, drugs etc.) is called pneumonitis 3. Patient Mrs. R, aged 80 years,
entered the Gatot Subroto Army Hospital March 9, 2014 with a diagnosis of pneumonia.
Therapy treatment for the treated IVFD 0.9% NaCl, ventolin expectoran, Rantin inj, inj
ceftriaxon, flumucyl tab, (iron II gluconate, manganese sulfate, folic acid, vitamin b12
tabs), Combivent inhalation. Based on the results of their clinical practice on general
maintenance at Gatot Subroto Army Hospital, it can be concluded that the presence of DRP
(Drug Related Problem) a correlation between drug therapy with clinical conditions such as
decreased appetite, and hypoalbuminemia (indication without drug), can be replaced with
the use of fluimucyl ambroxol to minimize gastrointestinal side effects. Antibiotic therapy
should be combined with group makrolide if the long-term use. The addition of vitamins K
as an anti-coagulant.
Keywords: Pneumonia, Pulmonary Disease and Gatot Subroto Army Hospital.
INTRODUCTION
Lower tract infection remains a major health problem in both developing countries
and advanced. Causes of pneumonia are hard to find and it takes several days to get results,
whereas pneumonia can cause death if not immediately treated, then the initial treatment of
pneumonia are given antibiotics empirically 3. Pneumonia can be caused by a variety of
microorganisms, namely bacteria, viruses, fungi and protozoa. From the literature
community pneumonia suffered by foreign peoples caused many Gram-positive bacteria,
whereas pneumonia in the hospital a lot due to Gram-negative bacteria, while a lot of
aspiration pneumonia caused by anaerobic bacteria. Lately, reports from several cities in
1276
Indonesia showed that the bacteria recovered from patients with pneumonia community
sputum examination is negative Gram 3. Pneumonia is the result of the proliferation of
microbial pathogens at the alveolar level and the host response to pathogens. Microbes
enter the lower respiratory tract in several ways. The most common way is via
oropharyngeal aspiration.
CASE PRESENTATION
Patients Mrs. R, 80 years old was entered into Gatot Subroto Army Hospital March
9 2014. Patient presents with family escorted the body weakness, cough with phlegm
approximately 1 week before entering the hospital, packed (-), nausea (+), vomiting (-),
fever (+), the last 2 days decreased appetite. Routine control to poly heart. The general
condition of the patient at the time of hospital admission was looked ill with a blood
pressure of 120/80 mm Hg, pulse 88 beats / min, 37 ° C, awerness as CM. The patient has a
history of diabetes mellitus, hypertension and HHD. Treatment history Aptor 1 x 80 mg,
Nitrokaf 2 x 2.5 mg, 1 x 80 mg Micardis, teronac 1 x 25 mg.
EVALUATION CLINIC
Mrs.R therapy for the management of pneumonia suffered. Ventolin tabs expectoran
given to treat shortness of breath that works as a beta II receptor agonist with a beta
receptor activation of multiple injections . Rantin used which is used to prevent an increase
in the excess stomach acid due to stress ulcers in patients. Ceftriaxone for killing bacteria
pneumonia and mucus hypersecretion therapy Fluimucyl is thick and heavy in the
respiratory tract that serves to dilute the phlegm. Sangobiad usually given to patients with
deficiencies of vitamins and minerals and the formation of red blood Combivent inhalation
therapy is used in patients with severe shortness happened.
Dose of medication to patients on 10-15 March 2014, is ivfd 0.9% NaCl at a dose of
20 TPM is used by injection to substitute loss of body fluids, so that the body has the usual
dose of energy back from 2.5 to 11.5%. on 9-14 March 2014 2x 50 mg ranitidine injection
1277
is used to prevent ulcers steerz the usual dose of im / slow iv injection: 50 mg every 6-8
hours iv infusion: 25 mg / hour for 2 hours 6-8 hours or for sterz ulceration prophylaxis
125-250 mcg / kg / hour and date 9-14 March 1x 2 g of ceftriaxone injection is used to kill
bacteria that cause pneumonia with the usual dose of 250 mg, 2-3 times a day, increasing to
a maximum dose of 3 grams a day. and on 10,13,14 March 2014 sangobiad 1x1 tab taken
orally which is used for blood booster vitamins and on 9-15 March 2014 5cc for tree times
day expectroran Ventolin nebulizer used to overcome spasms. on 10-15 March 2014
flumucyl 3 x 300 mg taken orally for the treatment of viscous mucus hypersecretion and
airway thickness at the usual adult dose of 200 mg and 100 mg child. on 15 March 2014
Combivent inhalation 3 x / day used by inhalation for the treatment of severe shortness.
No.
Parameter
Tgl
1
2
3
4
5
9-3-2014
Albumin
Natrium
Hemoglobin
Eritrosit
Leukosit
Value
Normal Value
Clinical Chemistry
3,1 g/dL
120 mmol/ L
9,1 g/dL
3,2million/µL
16300/µL
3,4 – 5
135 – 147 mmol/ L
12 - 16 g/dL
4,3 – 6,0/ µL
4,800 – 10,800/ µL
1. The correlation between drug therapy with disease
There is no indication of drugs, which the patient has decreased appetite. Are suggested
to provide additional therapy such as vitamin B complex or curcuma tab and perform
monitoring of the state of the patient's appetite. Patients had hypoalbuminemia with
albumin value of 3.3 g / dL and albumin therapy.
2. Selection of drugs

antibiotics ceftriaxon 1 x 2 g is right (Single dose of l - 2 gr time 12-24 hours), but must
be combined with macrolide antibiotics such as azithromycin, claritromisin or 1 g IV
1278
once then 500 mg once a day5. Recommended for adding Vitamin K therapy as an anticoagulant for Ceftriaxon.Di recommended for use in the given distance in therapy.

Flumuicyl treatment an additional indication for patients with abnormal mucus
secretion / viscous under conditions of acute and chronic bronchopulmonary. Patients
The problem will aggravate symptoms of nausea disease patients increases the risk of
gastrointestinal haemorrhage so; disrupt the gastric mucosal barrier mukolitik 7.
Recommendation: Ambroxol Hcl Disorders .Ambroxol have mild side effects on the
gastrointestinal tract sa, allergic reactions 8.
3. Human Error
In the book list is sometimes nurses did not record drug medication that is administered
to the patient. So it is advisable to nurses to always take note of what has been given to
the patient. Do monitoring nurse notes on the book list of drugs.
CONCLUSION
Based on the results of their clinical practice in the treatment of lung at Gatot
Subroto Army Hospital, it can be concluded that the presence of DRP (Drug Related
Problem) a correlation between drug therapy with clinical conditions such as decreased
appetite, and hypoalbuminemia (indication without drug), can be replaced with the use of
fluimucyl ambroxol to minimize gastrointestinal side effects. Antibiotic therapy should be
combined with group makrolide if the long-term use of vitamin K as an anti-coagulant.
REFERENCES
1. AHFS drug information 2004 McEvoy GK, ed. Methotrexate. Bethesda, MD: American
Society of Health-System Pharmacists; 2003: 1082-9)
2. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A pathophysiologic Approach 7 th
3. PDPI, 2003 Pneuomonia Guidelines for Diagnosis and Management community in
Indonesia. Jakarta.
4. Joseph Loscalzo et al, 2010 Harrison's Pulmonary and Critical Care Medicine 17 th
Editions, The McGraw-Hill Companies, Inc., New York.
1279
5. Kasper L, Dennis., Et al, 2010, Harrison's Infectious Diseases, The McGraw-Hill
6. Koda-Kimble et al., 2009, Applied Therapeutics: The Clinical Use of Drug 9 th Edition,
Lippincott Williams & Wilkins, USA.
7. Lacy, FC, Armstrong LL, Goldman MP, Lance LLet al, 2010, Drug Information
Handbook, Lexi-Comp, the American Pharmacist Association.
8. MIMS 105th Annual Indonesian edition 2006/2007
1280
DRUG RELATED PROBLEMS IN ASCITES PATIENT
Sutriasi Umar1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Ascites is piling up of liquid serosa (similar to serum) cavity peritoneum. The
peritoneal cavity and abdominal cavity covers the pelvic area to surface under diaphragm,
not including the kidneys. This cavity is lined by a thin membrane called the peritoneum.5
Patient Mr. YL aged 48 years old, entered PGI Cikini Hospital on April 12, 2014 with was
diagnosed Ascites. Therapy treatment for treated were cefotaxime, aldactone, lasix, narfoz,
hepabalance, episan syr, rantin amp, 20% robumin, panadol and laktulax syr. Based on the
results of the practice of the clinics on wards K PGI Cikini Hospital then can be drawn the
conclusion that the existence of the DRPs (Drug Related Problems) in the form of the
interaction of several drugs that have no effect in significant were furosemid and
paracetamol, furosemid and spironolakton, sucralfat and paracetamol, paracetamol and
ranitidine, ranitidine and furosemid, ranitidine and sucralfat.4
Keywords : Ascites, cirrhosis and PGI Cikini Hospital.
INTRODUCTION
Ascites is piling up of liquid serosa (similar to serum) cavity peritoneum.5 The
peritoneal cavity and abdominal cavity covers the pelvic area to surface under diagfragma,
excluding kidney.5 This cavity is lined by a thin membrane called the peritoneum.5
The most common cause of the liver disease was developed ascites have advanced
or cirrhosis.1 The increase in portal blood pressure and a reduction in albumin (a protein
that was transported in the blood) may be environmentally responsible use in the formation
of pressure gradient and result in Ascites stomach, other factors contribute to a developed
ascites posible is containment of salt and water.1
Management developed ascites in patient with cirrhosis are typically involves the
use of sodium restriction of food and diuretic.9 For the patient it is advisable to reduce food
Ascites which many contain sodium should be approximately 2 grams daily.9 A single dose
of 100 milligrams daily spironolactone and 40 milligrams of furosemid is usually starting
1281
dose may be recommended.8 This can be increased gradually to acquire a proper response
on maximum doses of 400 milligrams of spironolactone and 160 milligrams of furosemid,
all patients can tolerate the increased doses without the side effects.8
CASE PRESENTATION
Mr. YL 48 years old, was entered the PGI Cikini hospital on April 23, 2014 with
major complaints of stomach bulge IE. The patient was complained of abdominal bulge
since ± 1 month SMRS, initially he was felt stomach swelling since patient ± 2 months
before entered in hospital, then stomach bulge that arise quickly and tightness when he was
tired of the road and do activities. The patient had been treated at the clinics but complaint
is not reduced. In addition the patient had a fever since CA. 1 week before entered in
hospital, fever was felt up and down, paracetamol has been drinking (+), nausea, vomiting,
disputed, not defecation was 2 days, a little since ± 2 days. Patient suffering from Hepatitis
C and had been operated on.
CLINICAL EVALUATION
The use of the drug lasix (furosemid) which is a powerful diuretic and cure the drug
aldactone (spironolactone) which is the drug potassium sparing diuretics, where the use of
both drugs were to treated fluid retention (edema) experienced by the patient. Drug Narfoz
(ondansetron) to prevent the occurrence of nausea and vomiting. Rantin injection
(ranitidine) to inhibit the production of stomach acid overload due to used of other drugs.
Episan (sucralfat) was used to coat the mucosa of the stomach of the patient. Cefotaxime
had given as sefalosforin antibiotic to inhibit the formation of bacterial cell wall. Panadol
(paracetamol) to lower fever patient. Robumin 20% to substitute for albumin in patient and
hypoalbuminemia due to lack of production of albumin. Hepabalance was given to
maintain the health of the patient liver function. Laktulax given to overcome constipation
and to avoid the occurrence of bleeding in patients due to port vein difficult chapters.
1282
DOSAGE AND DIRECTION2.7
Dosage and mode of use of the drugs to these patient were cefotaxime injection
used in iv 2 x 1 gr as antibacterial with a dose of common 2 times a day 1 GR. Lasix
(furosemid) used in injection iv 2 x 40 mg as a diuretic dose is common with loop 160 mg
for one week. Narfoz (ondansetron) was used for injection of 2 x 4 mg iv for nausea and
vomiting with common dosage of 4 mg twice a day. Aldactone (spironolacton) was used in
injection iv 2 x 100 mg potassium sparing diuretics as with common dose 100 mg/day to
400 mg/day dose for one week. Episan suspension (sucralfat) used orally 3 x 1 HR for
duodenal ulcer and peptic ulcers with a dose of common 2 gr 2 times daily or 1 gr 4 times a
day one hour before eating in the morning and at night before going to bed was given for 46 weeks or in a case that could be resistant to 12 weeks. Hepabalance used orally 2 x 1
tablet to maintain liver function with common dose of customarily 1-2 times daily. Rantin
amp (ranitidine) was used for injection iv 2 x 50 mg for duodenal ulcer and peptic ulcers
with a common dose 50 mg 3 times daily. Robumin 20% was used injection iv 100 cc to
weight with hypoalbuminemia, low plasma volume and udem that require limiting salt and
water as well as the addition of a plasma with volume of 100 ml of customary dose 20%
albumin/3l. Laktulax suspension was used orally 3 x 1 HR for the treatment of constipation
with the dose of prevalent 30-45 ml (20 gr/30 ml) 3-4 times/day. Panadol was used orally 1
x 500 mg for hot/cold-lowering doses commonly 0.5-1g every 4-6 hours up to a maximum
of 4 grams/day.
LABORATORY RESULTS
Results of laboratory examination day patient first obtained some abnormal results
include an increase in bilirubin total 5.2 mg/dl, bilirubin direk 1.6 mg/dl, bilirubin indirek
3.6 mg/dl, globulin 4.9 g/dl, SGOT 88 U/l, Gamma GT 82 U/l, blood glucose while 161
mg/dl, blood sedimentation rate 43 mm/h, reticulocyte 46 permil, monocytes 20%, and
albumin decrease in value of 1.4 g/dl, kolinesterase 3089, erythrocytes 4.11 10 ^ 3/: l,
hematocrit 36%, sodium (Na) blood 134 mEq/l, calcium (Ca) 7.9 mg/dl. Increase and
decrease the value of this laboratory had indicated the occurrence of damage to red blood
cells, infection acute chronical heart disease, presence of tissue damage in the liver, anemia,
1283
and the destruction or removal of excessive erythrocytes are offset by an increase in the
activity of the spinal cord.
Results of examination of urine and Parasitology of the second day the patient urine
clarity results obtained are somewhat murky, blood +, 3/200 cells/l, whereas: on the results
of examination of the sediment improved the value of erythrocytes, epithelial/LPB 2
71/LPB 130/LPB and bacteria, indicating the occurrence of infection, dehydration, blood in
the urine (hematuria), liver disease, or muscle damage of red blood cells in the body.
The sixth day of the laboratory examination results obtained by patient of abnormal
results include an increase in bilirubin total 4.1 mg/dl, bilirubin direk 1.6 mg/dl, bilirubin
indirek 2.5 mg/dl, globulin 4.0 g/dl, and a decrease in albumin 2.5 g/dl. Increase and
decrease the value of this laboratory was indicated the occurrence of damage to red blood
cells, infection acute, and tissue damage in the liver.
1.
Untreated Indication
There were indications without drugs, which patient experience weight loss as a
result of difficult to eat. Patient was recommended to provide additional therapy in the
form of supplements that may increase appetite such as curcuma or vitamin B complex
tablets and nutritional state of patient monitoring was done. From the results of
laboratory examination was known to patient experiencing anemia, he was
recommended to provide additional oral iron therapy.
2. Dosing Regimens
Drug dosage too low in rantin recipes (ranitidine) 2 x 50 mg daily, according to Dr.
Aine Burns (Renal Drug Handbook, 2009), was supposed to be 3 x 50 mg daily.
Episan (sucralfat) 3 x c1 daily, according to Dr. Aine Burns (Renal Drug Handbook,
2009), c1 should be 4 x daily. He was recommended to doctors to re-evaluate the used
of therapeutic doses of ranitidine and sucralfat.
3. Improper drug selection
Patient had given panadol 500 mg 1 x heat loss for patient, according to Dr. Charles
F Lacy (Drug Information Handbook, 2009) panadol can not be given for chronic liver
1284
disease because it can cause anti-hepatotoxic, but it can be replaced with the use of
sistenol (paracetamol + N-aceytilsistein) which was safer for patient with impaired
liver function.
4. Drug interactions 4
Drug interactions between furosemid and paracetamol, paracetamol can reduce the
effects of the deuretik loop (furosemid), where the paracetamol reduces the excretion
of prostaglandin in renal plasma and decrease renin activity. Furosemid and
spironolakton, furosemid may increase the levels of serum potassium and decrease
spironolacton. Sucralfat and paracetamol, sucralfat may decrease the effects of
paracetamol. So the distance a present time 2 hours after taking paracetamol.
Paracetamol and ranitidine, ranitidine can reduce the effects of paracetamol, so must
the time the distance as a present. Ranitidine and furosemid, ranitidine will reduce the
effect of furosemid. Sucralfat and ranitidine, ranitidine will reduce the effect of
sucralfat.
5. Human error
On the Medical Record, sometimes the nurses did not record a drug that has been
given to the patient so that it was advisable to nurse to always noted the drug was given
to patient. Conducted monitoring records medical record on nurses.
CONCLUSION
Based on the results of the practice in internist clinic at PGI Cikini Hospital can be
drawn the conclusion that the existence of the DRPs (Drug Related Problems) correlation
between drug therapy with the clinical condition of decreased appetite and anemia
(indication without drugs), inappropriate dosage regimens in the used of ranitidine and
sucralfat (drug dose too low), the use of paracetamol should be avoided in people with
chronic liver disease (inappropriate drug choices), and the existence of some drug
interactions that occur between furosemid and paracetamol, furosemid and spironolakton,
sucralfat and paracetamol, paracetamol and ranitidine, ranitidine and furosemid, ranitidine
and sucralfat, but this interactions have not effect significantly.
1285
REFERENCE
1. Akil A.M. 2009. In Textbook Of liver disease, first edition. Jakarta.
2. BPOM. 2008. National drug Informatorium Indonesia (IONI). Jakarta: Sagung Seto.
3. Dr. Aine Burns. 2009. The Renal Drug Handbook tree edition. New York: Oxford.
4. Bakter k. 2005. Stocley's Drug Interactions. The Pharmaceutical Press.
5. Corwin, E.J. 2009. Pocket Book Pathophysiology. Jakarta: EGC Cape.
6. Charles F Lacy. 2009. Drug Information Handbook seventin edition. The American
Apothecary Assiciation.
7. Moore KP, et al. 2006. The Guidlines of The Management of Ascites In Cirrhosis.
Report on The Consensus Conference of The International Ascites Club.
8. Runyon BA. 1994. Care of Patients With Ascites. N Engl J Med.
9. Suparyanto. 2011. The Textbook the science of liver disease, first edition. Jakarta.
1286
DRUG RELATED PROBLEMS (DRPs) ASSOCIATED WITH THE
TREATMENT FOR TUBERCULOSIS DISEASE IN PERSAHABATAN
JAKARTA HOSPITAL
Syahrul Tuba1 , Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Tuberculosis is a contagious infectious disease caused by Mycobacterium tuberculosis, an
aerobic bacilli resistant to acid, which is transmitted through the air (airborne)1.
Tuberculosis (TB) is another example of lower respiratory tract infection2. The disease is
caused by the microorganism Mycobacterium tuberculosis, which is usually transmitted by
inhalation spray saliva (droplet), from one individual to another and established
colonization in the bronchioles or alveoli, the bacteria also can enter into the body through
the gastrointestinal tract, through the ingestion of contaminated unpasteurized milk, or
sometimes through skin lesions2. The results of tuberculosis prevalence survey in 2004
showed that the prevalence rate of smear positive TB nationally 110/100,000 population 3.
Based on the above data TB remains a major public health problem in Indonesia3.
Case of Precentation: Patient Mrs. KR 28-year-old woman admitted to the ward pulmonary
disease. Patient was diagnosed with Pulmonary tuberculosis hemoptysis, bronchiectasis
infection and dyspepsia syndrome.
Clinical evaluation: Drug related problems (DRPs) that was found was the indication is not
handled (decreased appetite should be given multivitamins as appetite enhancer), a low
dose of Ranitidine and the need for administration of hepatoprotective as an additional
multivitamin to help maintain the patient's liver function.
Keywords: Tuberculosis, dyspeptic syndrome, Persahabatan Hospital
INTRODUCTION
Tuberculosis (TB) is an ancient disease, and evidence of TB dates back as far as
prehistoric times with evidence being found in pre-Columbian and early Egyptian remains4.
However, TB did not become a problem until the 17th and 18th centuries when crowded
living conditions of the industrial revolution contributed to its epidemic numbers in Europe
1287
and the United States4. Early physicians referred to TB as phthisis, derived from the Greek
term for wasting, because its clinical presentation consisted of weight loss, cough, fevers,
and hemoptysis4. Although its characteristics were well known, an etiologic agent was not
clearly defined until 1882 when Robert Koch isolated and cultured Mycobacterium
Tuberculosis and demonstrated its infectious nature4. With this knowledge, early treatment
in the mid-1800s to the early 1900s consisted of removing patients with TB from the
community and placing them in a sanatorium for bedrest and fresh air4. With the advent of
radiographic film, pulmonary cavitary lesions were found to be pivotal in the evolution of
the disease. Therapy then included procedures such as pneumoperitoneum, thoracoplasty,
and plombage to reduce the size of the cavitary lesion4. Some of these therapies may
continue to be used for severe and refractory cases4.
Tuberculosis is caused by M. Tuberculosis, an aerobic, non–spore-forming bacillus
that resists decolorization by acid alcohol after staining with basic fuchsin5. For this reason,
the organism is often referred to as an acid-resistant bacillus (ARB)5. It is also different
from other organisms in that it replicates slowly once every 24 hours instead of every 20 to
40 minutes as do some other organisms5. M. Tuberculosis thrives in environments where
the oxygen tension is relatively high, such as the apices of the lung, the renal parenchyma,
and the growing ends of bones5.
Area of Potential spread of Mycobacterium tuberculosis6.
a.
Respiratory isolation room
b.
Ambulatory and physiology waiting room.
c.
Toracs radiology space.
d.
Space bronchoscopy and sputum induction.
e.
Space nebulized phenthamydine.
f.
Area ventilation.
g.
day hospital
h.
Emergency room.
i.
Autopsy room.
j.
Laboratory microbiology.
Classification
1288
Classification of TB disease based on examination of the affected organ are divided into
two2:
a.
Pulmonary tuberculosis
Pulmonary tuberculosis is tuberculosis that attacks the tissue (parenchymal)
pulmonary, excluding the pleura (lining of the pulmonary) and the hilar glands.
b.
Extra-pulmonary tuberculosis
Tuberculosis that attacks the organs other than the pulmonary, such as the pleura, the
lining of the brain, the lining of the heart (pericardium), lymphatic gland, bone joints,
skin, intestine, kidney, urinary tract, genitals and others.
Extra-pulmonary TB is divided based on the severity of the disease, namely:
a.
Lightweight Extra Pulmonary TB
For instance tuberculosis of lymph glands, pleurisy ecsudativa unilateral, bone, bone
(except spine), joint and adrenal glands.
b.
Extra Pulmonary TB Weight
For instance meningitis, miliary, pericarditis, peritonitis, pleurisy eksudativa duplex, spinal
tuberculosis, intestinal tuberculosis, TB urinary tract and genitals.
CASE PRESENTATION
Patient Mrs. KR 28-year-old woman admitted to ward pulmonary disease. Patient
was hospitalized Persahabatan Hospital dated March 2, 2014 with complaints of patient feel
shortness of breath, or chest pain, patient often fever (seizures) and night sweats, no
appetite, and perceived weight loss, history of ulcer disease, and two days before entering
hospital patient cough sputum mixed with blood.
After the done some clinical intervention, especially laboratory tests of blood and urine, the
obtained results;
Examination
Hemoglobin
Leucocytes
Neutrophils
Eosinophils
Basophils
Hematocri
Results
25*
13.9*
72.2*
0.7*
2.0*
25*
Unit
g/dL
thousand/mm3
%
%
%
%
Reference value
13.0 - 16.0
5 – 10
50 - 70
2–4
0–1
40 - 48
1289
Platelets
Erythrocytes
Lymphocytes
Monocytes
Blood sedimentation rate
Creatinine
448*
2.98*
17.1*
10.6*
97*
0.7*
thousand/mm3
million/uL
µg/L
%
Mn
mg/dl
150 - 440
3.6 - 5.8
5 – 15
2–8
0 – 20
0.8 - 1.5
Based on the results of laboratory tests of blood, urine and complaints of the
patient's complaints, then was diagnosed with tuberculosis infection, infected bronciectasi,
and dyspepsia syndrome.
As for the drug therapy given to patient of Mrs. KR was 3 x 500 mg Paracetamol
began on 3 March to March 07, 2014 as an anti-analgesic and antipyretic effective in
reducing pain and fever the patient. Vitamin K 3 x 10 mg be given on March 6 and the
March 7th 2014, elections for the treatment of vitamin K is hipotrombinemia. Vitamin K
was used to stop bleeding. Patient complained of coughing up blood, so that doctors give
vitamin K to stop the bleeding. Vitamin C was 3 x 200 ml IV granted on 3 March to March
7th 2014, the using of vitamin C was for the patient endurance and also aims to repair or
regenerate damaged cells in the organs (pulmonary) patient's body. Ranitidine 2 x 50 ml
IV, granted on 3 March to March 7th, 2014. Selection of the proper functioning of
ranitidine has been for the treatment of dyspepsia patient often complained of nausea and
abdominal pain. Ceftazidime 1 g IV given on 4 March to March 7th 2014, the selection of
ceftazidime for gram-positive bacterial infections and gram negative bacteria in patients
who experienced Urinary Tract Infection (UTI). Ca gluconate 150 ml only granted on
March 3th, 2014, the use of Ca Gluconate aimed at handling hypocalcemia. NaCl 0.9% 500
cc granted on 3 March to March 7th, 2014, the use of 0.9% NaCl to maintain osmolarity
function and acid-base balance of electrolytes in the body. Inpepsa (sucralfate) 3 x 1 g
given on 3 March to March 6th 2014, elections Inpepsa (sucralfat) for short-term treatment
of acute pain that is moderate to severe. Rifampicin 1 x 450 mg was started on March 5,
2014, election of Rifampin for additional therapeutic anti-tuberculosis drugs in combination
with other anti-tuberculosis therapy for both early and advanced therapies. Isoniazid was
started on March 5, 2014, the use of Isoniazid therapy works for all forms of active
tuberculosis are caused by bacteria and combined with rifampin, pyrazinamid, ethambutol,
1290
and streptomycin as category II TB therapy. Ethambutol was started on March 5, 2014, The
use of anti-tuberculosis Ethambutol as active against mycobacteria, including
mycobacterium avium complex and combined with Rifampicin, pyrazinamid, isoniazid,
and streptomycin in the treatment of tuberculosis category II. Pyrazinamide 1 x 300 mg was
started on March 5, 2014, the initial treatment of active tuberculosis in adults and some
children when combined with other anti-tuberculosis drugs. Streptomycin 1 x 750 mg was
started on March 5, 2014, Streptomycin is used for patients with tuberculosis category II, so
take the injection of streptomycin to help TB therapy.
CLINICAL EVALUATION
Drug related problem 1
Patient failed to obtain the drug: Patient was experienced a decrease in appetite, but did not
get the drug to increase appetite. Curcuma could be an additional drug or multivitamin to
improve the patient's appetite and maintain the patient liver function.
Drug dose was too low: Ranitidine 2x50 mg a day, should 3x50 mg daily.
CONCLUSION
Based on the assessment of the drugs and the results of patient laboratory data, the
patient was diagnosed with tuberculosis infection, infected bronceiktasis, and dyspepsia
syndrome. Drug related problems that occur in patient of Ms. KS was a patient fails
receiving the drug and the patient complaints have decreased appetite but not given food
intake. Patient using the drug Ranitidine at a dose of 2 x 50 mg but based on book Renal
Drug Handbook should use a dose of 3 x 50 mg. Patient also failed to receive the drug as
hepatoprotective drug to protect or reduce the damage caused by the use of the progressive
elimination of drugs that primarily in the liver, especially tuberculosis antibiotic drugs.
REFERENCES
1. Asih, Niluh Gede Yasmin. 2003. Keperawatan Medikal Bedah : Klien dengan
Gangguan Sistem Pernafasan. Jakarta : EGC
2. Corwin, Elizabeth J. 2009. Patofisiologi : Buku Saku. Jakarta : EGC
1291
3. Departemen
Kesehatan
Republik
Indonesia.2008.
Pedomannasional:
penanggulangantuberkulosis. Cetakan ke-2.Jakarta: DepkesRI ;.hal.8-14.)
4. Michael B. Kays. 2009. Applied Therapeutics: The Clinical Use Of Drugs, 9th Edition.
Lippincott & Williams. USA.
5. Peloquin CA et al.1994. Infection caused by Mycobacterium Tuberculosis. Ann
Pharmacother ;28:72.
6. Palomino,et al.2007. Tuberculosis textbook ;rom basic science to patient care,1th ed.
Belgium.
7. Caroline Ashley and Aileen Currie. 2009. The Renal Drug Handbook Third Edition.
Radcliffe Publishing Ltd18 Marcham Road, Abingdon, Oxon
OX14
1AA.
United
Kingdom.
1292
TREATMENT ASSOCIATED WITH OF PATIENT CHRONIC HEART
FAILURE (CHF) DISEASE IN CIKINI JAKARTA HOSPITAL
Tetty Fitriany Purba1 , Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1Pharmacist Professional Program Student, Faculty of Pharmacy UTA'45 Jakarta
2Lecturer Pharmacy in Pharmacy Faculty University of 17 August 1945 Jakarta
(UTA’45 Jakarta)
ABSTRACT
Congestive heart failure (CHF) is a pathophysiological state of cardiac dysfunction so that
the heart is unable to pump blood to meet the metabolic needs of the network or its ability
only if accompanied by an abnormal elevation of the diastolic volume1. Naming congestive
heart failure which is often used in case of left-sided heart failure and right side1.
Congestive heart failure is the inability of the heart to pump adequate blood to meet the
networking needs for oxygen and nutrients2. Case Presentation : Patients host KT 71-yearold man admitted to the internal medicine ward K3 PGI Cikini Hospital in Central Jakarta.
Patients diagnosed with CHF (Chronic Heart Failure). Preclinical evaluation:
Hypoalbuminemia circumstances that are not addressed during treatment.
Keywords: CHF (Chronic Heart Failure), hypoalbuminemia, RS PGI Cikini.
INTRODUCTION
Congestive heart failure is a failure of pumping (in which cardiac output is insufficient
metabolic needs of the body), this may occur as a result of the end of heart problems, blood
vessel or the capacity of the oxygen carried in the blood that lead to the heart can not meet
the need of oxygen to the various organs3. Congestive heart failure (CHF) is a
pathophysiological state of cardiac dysfunction so that the heart is unable to pump blood to
meet the metabolic needs of the network or its ability only if accompanied by an abnormal
1293
elevation of the diastolic volume3. Naming congestive heart failure which is often used in
case of left-sided heart failure and right side1.
Congestive heart failure can be caused by 4 :
1. Abnormalities of the heart muscle
Heart failure often occurs in patients with abnormalities of the heart muscle, due to the
reduced cardiac contractility. Underlying condition causes muscle dysfunction include
coronary arteriosclerosis, arterial hypertension, and degenerative or inflammatory diseases.
2. Coronary atherosclerosis
Lead to myocardial dysfunction due to disruption of blood flow to the heart muscle.
Hypoxia and acidosis (due to accumulation of lactic acid). Myocardial infarction (death of
heart cells) usually precedes the occurrence of heart failure. Myocardial inflammation and
degenerative diseases, associated with heart failure due to conditions that directly damage
the fibers of the heart, causing kontrak tilitaas decreased.
3. Systemic or pulmonary hypertension (increased afterload)
Increase the workload of the heart, resulting of cardiac hypertrophy of muscle fibers.
4. peradangan dan penyakit myocardium degeneratif
5. Other heart disease.
Heart failure can occur as a result of actual heart disease, which is affects the heart directly.
The typical mechanisms include disruption of blooding flow that goes to the heart (mitral
valve semiluner), the inability of the heart to fill the blood (tamponade, the pericardium,
perikarditif constrictive, or stenosis AV), suddenly increase in load afteer.
6. Systemic factors
There are many large number of factors that play a role in the development and severity of
heart failure. The increase rate of metabolism (eg, fever, thyrotoxicosis), hypoxia and
anemia requires of cardiac output higher to approach the needed of systemic oxygen.
Hypoxia and anemia also can reduce oxygen supply to the heart. Metabolic and respiratory
acidosis or abnormalita electronic can decrease cardiac contractility.
Grade of heart failure according to the New York Heart associaion5.
Divided into 4 functional abnormalities:
1 Arising symptoms of shortness in heavy physical activity
1294
2 Arising symptoms of shortness in moderate physical activity
3 Embosing symptoms of shortness in light activity
4 Embosing symptoms of shortness in very light activity / rest.
Symptoms that appear according to the symptoms of left heart failure is followed by right
heart can the occurrence in the chest due to an increase oxygen demand. On physical
examination found signs - signs symptoms of congestive heart failure is usually a sound of
marching and noising due to regurgitation dominant mitral, Increased intravascular volume.
Congestive network of arteries and veins due to increased pressure and decreased cardiac
output. Manifestations of congestion can be different depend on which one happen
ventricular failure5,1.
PATHOPHYSIOLOGY 6
Abnormalities of intrinsic myocardial contract the typical ischemic heart failure,
interfere with the ability of effective ventricular emptying. Left ventricular contracts the
decrease stroke of bulk reducing and increase ventricular residual volume. With the
increase in EDV (end diastolic ventricular volume), there is also an increase in end diastolic
left ventricular pressure (LVEDP). The degree of improvement depends on the flexibility of
ventricular pressure. An increasing in LVEDP, there is also an increase in left atrial
pressure (LAP) for the atrials and ventricles during diastole related directly. The Increasing
LAP passes back into the vascular channels of the lungs, increasing the capillary pressure
and the pulmonary vein. If the hydrostatic pressure of the lung capillary channel exceeds
vascular oncotic pressure, there will be a transudation of fluid into the interstitial. If the
speed of the transudation of fluid exceeds the lymphatic drainage speed, there will be
interstitial edema. Further increase in pressure can result in fluid seeps into the alveoli and
pulmonary edema occurs.
Pulmonary artery pressure can be increased in response to a chronic increase in
pulmonary venous pressure. Pulmonary hypertension increases the resistance to right
ventricular ejection. A series of such event that occurs in the left heart, also happens to be
right heart, which is will happen evantually systemic congestive and edema7.
1295
The development of congestive systemic or pulmonary edema and may be
exacerbated by functional regurgitation of the tricuspid valves or mitralis alternate.
Functional regurgitation can be caused by dilatation of the valve annulus atrioventrikularis,
or changes in the orientation of the papillary muscle and chordae tendineae that occurs
secondary to dilation of space7.
INVESTIGATIONS8
1. Photos torax can reveal the presence of cardiac enlargement, edema or pleural effusion
which is confirms the diagnosis of CHF.
2. ECG may reveal the presence of tachycardia, hypertrophy and ischemic heart chambers
(if caused AMI), Echocardiogram.
3. Laboratory examination include : serum electrolytes revealed a sodium level low that
results from the excess blood hemodialysis water retention, K, Na, Cl, urea, blood sugar.
PRESENTATION OF CASE
KT is a 71-year-old man admitted to the internal medicine ward. Patients entered Cikini
Hospital on June 09, 2014, one week before entering the hospital tightness, heart
palpitations. Results of physical examination showed the patient's blood pressure 100/63
mm Hg, pulse 30 x / min, 37 ° C, respiration 20 x / min. The results of laboratory tests
before taking any medication on the 9th June 2014 erythrocyte sedimentation rate 83 mm /
h, hemoglobin 12.3 mg / dL, albumin 2.9 g / dl, globulin 4.2 g / dl, AST 36 U / L, alanine
aminotransferase 36 U / L , urea 79 mg / dl, creatinine 2.7 mg / dL, chloride 111 mmol / l,
calcium 7.9 mg / dl, magnesium 1.5 mg / dl. Patients diagnosed with chronic heart failure
after an investigation and the results showed mild diastolic dysfunction, and decreased
systolic function. As a drug therapy gave to patients is Lasix host KT 2x1 amp
(Furosemide) aims to edema disease of heart, liver, or kidney disorders. Peripheral edema
due to mechanical obstruction or venous insufficiency and hypertension. Rindopump
(Pantoprazole) 2x1 amp, aiming for gastric and duodenal ulcers, postoperative ulcers,
erosive esophagitis, reflux esophagitis. ISDN 1x5mg drug aimed at treating and preventing
acute attacks of angina pectoris. Placta (Clopidogrel) 1x75 mg aimed at prevention
1296
atherotrombosis events in patients suffering from myocardial infarction, stroke, or
peripheral arterial disease. Digoxin 1x1 / 2 tabs are used in congestive heart failure, atrial
fibrillation, atrial tachycardia proximal. 1x20 mg Simvastatin is used to reduce and lower
cholesterol levels. Miniaspi (Salicylic Acid Aseti) 1x80 mg aims to prevent the aggregation
of platelets in myocardial infarction and unstable angina, ischemic attack to prevent brain
cursory. Lactulac (lactulose) 4x1 C aims to overcome chronic constipation and portal
systemic encephalopathy. 1x5000 IU heparin for prophylaxis and therapy aimed at
tromboembolitik disorder.
EVALUATION OF CLINICAL
Patient had hypoalbuminemia but did not give drugs to deal with these indications.
Albumin is the binding of drug compounds in the blood, if the drug is bound weak / low
with albumin in the blood, it will cause a lot of free drug in the blood so that the effect of a
given drug is reduced or the drug may cause toxicity.
CONCLUSION
Based on observations and physical examination as well as the investigation of patients
diagnosed with CHF disease (Chronic Heart Failure). The use of drugs is used by the
patient in accordance with the indications but based on the value of the results of albumin
2.9 g / dl with normal values of 3.4-4.8 g / dl, the patient had hypoalbuminemia, but the
patient did not get the drug to increase albumin levels to normal levels.
REFERENCES
1. Mansjoer, Arif dkk, Kapita Selekta Kedokteran, Edisi Ketiga Jilid 1, Jakarta:
MediaAesculapios FKUI, 2001.
2. Smeltzer, Suzanne C, Brenda G bare, Buku Ajar Keperawatan Medikal Bedah Brunner
& Suddarth Edisi 8 Vol 2 alih bahasa H. Y. Kuncara, Andry Hartono, Monica Ester,
Yasmin asih, Jakarta : EGC, 2002.
3. Lewis T. 1993. Disease of The Heart. Macmillan. New York.
1297
4. Heni, Elly dan Anna. 2001. Buku Ajar Keperawatan Kardiovaskuler, Edisi Pertama
Jakarta:
Bidang Pendidikan dan Pelatihan Pusat Kesehatan Jantung dan Pembuluh
Darah
Nasional“Harapan Kita”.
5. Maas, Morhead, Jhonson dan Swanson.2004. Nursing Out Comes (NOC), United States
Of America: Mosby Elseveir Acadamic Press.
6. Mansjoer, Arif dkk,. 2001. Kapita Selekta Kedokteran, Edisi Ketiga Jilid 1, Jakarta:
Media Aesculapios FKUI.
7. Corwin Elizabeth J. 2009. Buku saku pathofisiologi. Edisis 3, alih bahasa Nike Budi
Subekti, Egi Komara Yuda, Jakarta: EGC
8. Smeltzer, Suzanne C, Brenda G bare,.2002. Buku Ajar Keperawatan Medikal Bedah
Brunner & Suddarth Edisi 8 Vol 2 alih bahasa H. Y. Kuncara, Andry Hartono, Monica
Ester, Yasmin asih, Jakarta : EGC.
9. Nanda International. 2009. Diagnosis Keperawatan: Defenisi dan klassifikasi, Jakarata:
EGC.
10. Hitzeroth. J. dkk. 2012. Heart Failure Society of South Africa (HeFSSA) perspective on
the European Society of Cardiology (ESC) 2012 chronic heart failure guideline. South
Africa.
1298
INAPROPRIATE DRUGS FOR PNEUMONIA + BRONCHIOLITIC
PATIENT AT PEDIATRIC WARD RSPAD HOSPITAL
Ummy Qalsum Ayu Andira1 , Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
Pharmacist Professional Program Student, Faculty of Pharmacy UTA'45 Jakarta 2Lecturer
Pharmacy in Pharmacy Faculty University of 17 August 1945 Jakarta (UTA’45 Jakarta)
ABSTRACT
Pneumonia is a pulmonary inflammation caused by microorganisms (bacteria,
viruses, fungi, parasites). Patient An.AB, age 2 months, enter the Gatot Soebroto Hospital
on March 17th, 2014 with was diagnosed of pneumonia with Bronkhiolitic. Therapy
treated during which Amoxicilin 200mg, Paracetamol syrup, Chloramphenicol 100mg,
Nebulizer (NaCl + Barotect + Atroven), Calmetasone 2mg, Nebulizer (NaCl + Ventolin +
Fulmicort). Based results of the clinical practice in children's disease Gatot Soebroto
Hospital, it can be conclusion that the presence of DRPs (Drug Related Problems) was not
appropriate drug selection where the selection of the antibiotic chloramphenicol were less
was effective and corticosteroid use in children less safe because side effects were too
severe that can lead to bone loss and inhibit the growth of children.
Keywords: Pediatrics, Pneumonia, Gatot Soebroto Hospital.
INTRODUCTION
Cause of death to baby and children result of ARI (Acute Respiratory Infection) is
the pneumonia12. ARI diseases, especially pneumonia is a major cause of morbidity and
mortality of baby and young children in developing countries. Pneumonia caused also four
million deaths in baby and young children in the world5.
The World every 20 seconds a child dies caused pneumonia (1 toddler/15sec) from
9 million in total to deaths7. In 2007 1.2 million people in the United States treated in
hospital with pneumonia and more than 52,000 people die result of this disease. Indonesia
occupy the 6th place with a number of cases as many as 6 million. The percentage of
pneumonia is 49.23% in 2010 years decline until 39.38% of the number of toddlers in
Indonesia7.
1299
In developing country like Indonesia disease like pneumonia still a public health
problem that is quite important7. The risk of transmission of each year in Indonesia was
considered quite high and varies between 1-3%, partially of people infected with
pneumonia usually accompanied by bronkhiolitik10.
Risk factors that correspond with the incident of pneumonia is divide into intrinsic
and extrinsic factors. Intrinsic factors like age, sex, nutritional status, body weight, low
birth, immunization status, breast feeding and vitamin. Extrinsic factors like the density of
housing, air pollution, type of housing, ventilation, smoke cigarettes, either maternal factors
of education, age, and mother's knowledge7.
In doing treatment one thing to note is the rational use of drugs because use a
irrational drugs can impact negatively on patient9.
CASE PRECENTATION
Patient AB, age 2 months entered Gatot Subroto Hospital on March 17th, 2014.
Patient come with shortness of breath complaint 1 day before entered in the hospital, cough,
fever, sputum can not get out. Patient also difficult breathing, breath sounds rochi. The
patient has decreased appetite, vomiting while drink breast feeding.
In patient does not have history this disease before, but the patient's parents say that
their children are allergic to cow's milk. Patient examinated a complete blood countand XRay.
CLINICAL EVALUATION
Used two combination of antibiotics namely Amoxicilin 200 mg and
Chloramphenicol 100 mg as therapy for pneumonia was given when the patient entered the
treatment room on March 17th, 20142. Calmetason 2 mg as an antihistamine because
allergic patient had given on the third days of treatment dated March 19th,
2014,
Paracetamol syrup as antipyretics was given on the fourth days of treatment on March 20 th,
2014 and for shortness of breath patient was given a nebulizer, nebulizer given on the
second days of treatment on March 18th, 2014 was nebulizer (NaCl + Barotec + Atroven)
and then replaced on the third days of treatment with a nebulizer (NaCl + Ventolin +
1300
Fulmicort) because the first nebulizer used not give effect and also a good used nebulizer
was the nebulizer group ß2 agonist salbutamol combination with corticosteroids
budesonide group. For Sputum that was difficult to exit treated with the inhaled vapor.
1. Amoxicillin and Chloramfenicol Inj
As a antibiotic for pneumonia, amoxicillin the dosage that given 3 x 200 mg, BWI usual
dose <20 kg 20-40mg/ kg. Chloramphenicol dose given 4 x100mg, usual dose of 50100mg/ kg/day.
2. Nebulizer (NaCl + Barotect + Atroven)
As nebulizer for shortness of breath, the dose given 4 times daily.
3. Paracetamol syrup
As antipiretik, the dose given 2 x 50 mg.
4. Calmertasone 2 mg
As antihistamine because the patient have allergies, the dose given 3 x 2 mg, usual dose
of 0.08 to 0.3 mg / kg / day.
5. Nebulizer (NaCl + Ventolin + fulmicort)
As nebulizer to over come the patient's shortness of breath, the dose given 4 times daily.
RESULTS OF LABORATORY
Results the investigation not normally.
1. Hemoglobin
10.7 g/dL (13 – 18 g/dL)
2. Hematokrit
32% (40 – 52 %)
3. Eritrosit
3.6 m/μL (4.3 – 6.0 m/μL)
4. Platelet
490000/μL (150.000 – 400.000/μL)
1301
1. The Election of medicine inappropriate
The election of medicine was not effective a election antibiotic of chloramfenikol,
because chloramphenicol does not the first therapy for pneumonia recomendation to change
azitromisin antibiotic form the faction antibiotic macrolic to offer for 4 days treatment
because firstly therapy for pneumonia is antibiotic the class penisilin to combination with
the antibiotic the class macrolic 2,11.
The medicine election do not peaceful is using corticosteroid for the child because
have the effect serious if used in long the time should be induce to broken bone and impede
to growth of child. Intervention of pharmacy was do not used corticostiroid more than two
weeks.
2. Human Error
In medicine list sometimes a nurse does not written to done a medicine gave to
medical patient until there suggestion for nurse to write anything to give the patient. It
doing in monitoring the nurse note at medicine list.
CONCLUSION
According to the result of clinical ward pediatric medicine in Gatot Soebroto
Hospital we can be able concluded that there was DRPs (Drug Related Problems) was not
congruent to election of medicine where a election antibiotic chloramfenicol not effective
and used corticosteroid to the child not calm because there effect very heavy was can make
the bone broken and growth the child be troubled.
REFERENCES
1. Arif, M. 2008. Kapita Selekta Kedokteran. Jilid 2. Edisi III, Arif (Eds). Jakarta :
Penerbit Media Aesculapius FK. UI
2. Azizi Hj Omar,Clinical Practice Guidelines on Pneumonia and RespiratoryTract
Infections in Children, Kuala Lumpur.
3. BNF, 2009 The essential resource for clinical use of medicines in children
4. BNF 61, 2011 British National Formulary 61 March 2011.
1302
5. Depkes RI, 2005, Keperawatan Balita, Departemen Kesehatan Indonesia, Jakarta.
6. JNC seven, 2003 National High Blood Pressure Education Program. The seventh
report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure.Arch Intern Med. 2003; N
7. Kartasasmita, C, 2010, Pneumonia Pembunuh Balita, Buletin Jendela Epidemiologi,
Vol. 3, hal. 22-28.
8. Kasper L, Dennis., et al, 2010, Harrison’s Infectious Diseases, The McGraw-Hill
9. Katzung, B.G., 2004. Farmakologi Dasar dan Klinik edisi 8. Universitas Air Langga :
Salemba Medika Jakarta.
10. Nurjazuli, 2011, Faktor Resiko Dominan Kejadian Pneumonia Balita, (online)
ejournals 1. undip.ac.id/index.pdf (diakses pada tanggal 17-10-2013)
11. PDPI, 2003 Konsensus Penatalaksanaan Pneumonia komuniti, 2003.
12. World Health Organization 2007, Dibalik angka Pneumonia pada balita dibawah lima
tahun, (online) who.int/Elena/titles/en/index6.html (diakses pada tanggal 22-12-2013).
1303
STUDY OF CHRONIC RENAL FAILURE DISEASE
IN THE WARD OF DISEASE IN PGI CIKINI HOSPITAL
Wardan Yunandar1 ,Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
ABSTRACT
Chronic Kidney Disease, or chronic renal failure is a process of pathological changes in the
kidney structure and function, so that going on a progressive decline in kidney function and
generally end up with kidney failed2. Patient ms. SP aged 51 years old, has went on the
ward of disease in PGI Cikini Hospital on June 24, 2014 with a diagnosis of Chronic
Kidney Disease on Hemodialisa. Therapy treatment for hospitalized there DRPs (Drug
Related Problems) in the form of drug interactions that Paracetamol and domperidon,
captopril and furosemid, furosemid and calcium chloride.
Case presentation: pasient ms. SP is 51 years old female treated in wards in the disease. The
patient was diagnosed with the disease CKD on HD.
Clinical Evaluation: basically, there are 3 interventions were found during studies of the
treatment of the patient, i.e. about Paracetamol and domperidon drug interactions, Kaptopril
and Furosemid and furosemid and calcium chloride.
Keywords: CKD on HD, internal medicine, PGI Cikini Hospital
INTRODUCTION
Disease chronic renal failure (GGK) is damage to the kidneys, > 3 moths be
abnormalities of kidney structure, can be reduced without any speed or filtration of the
glomerulus (LFG) that are characterized by abnormalities of the pathology and the presence
of kidney damage, alert can be either blood or urine laboratory abnormalities or
abnormalities in Radiology. LFG < 60 mL/min/1.73 m2 for > 3 months, may be
accompanied or without any damage kidney7.
The number of sufferers of chronic renal failure with hemodialisa therapy from
year to year more and increases very quickly, it is associated with an increase in the number
of acts of hemodialysisyear to year8. Based on the data service of dialysis data, according to
1304
Indonesia the number of dialysis activities indicated by one of the Department of health and
local government owned hospital has achieved a 125.441 action annualy1.
CASE PRESENTATION
SP is 51 years old female treated in wards in the disease. Patient entered in PGI
Cikini Hospital on June 24, 2014. Patient treated with complaints feel shortness of breath
since 3 days before entering the hospital, fever, cough, swollen in the leg, nausea/vomiting
and heartburn. Patient referred from the hospital Cipto Madura (RSCM) to the PGI Cikini
Hospital on June 24, 2014 for CKD on therapeutic action HD.
CLINICAL EVALUATION
The using of Catapras (Klonidin Hydrochloride) to overcome Hypertension;
migraine. Furosemide for treatment of edema associated with heart failure of coronary heart
disease, and given single or in combination with antihipertensi in the treatment of
hypertension. Bicnat (sodium bicarbonate) to metabolic acidosis, alkalinisasi ulcer
peptikum and urine. Calcium carbonate (CaCo3) is a supplement of calcium, phosphate
binder or substance (food) in kidney failure, according to the needs of the patient. Vitamin
B12 (Hidroksikobalamin) for pernicious anemia. Captopril for mild to moderate
hypertension and severe hypertension. Paracetamol for mild to moderate pain and fever.
Domperidon usage on nausea and vomiting. Omeprazol for gastric and duodenal. Ulsafat
(Sucralfate/Sukralfat) for peptic ulcers and duodenal ulcers. Ceftriaxon used for therapy of
septicemia, pneumonia, meningitis, infection of the bile duct, peritonitis, and urinary tract
infections. Cefixime for mild urinary tract infection.
Dosage and mode of use the drug in patient, i.e. on the first sign in patient given
the drug Catapras 0.15 mg (Klonidin Hydrochloride) 0.15 mg 2 times for orally for to
overcome Hypertension; migraine and given from the first day of the June24 2014 until six
days on June 29, 2014. Furosemide 40 mg given 1 time 40 mg for orally for treatment of
edema associated with heart failure of coronary heart disease, and given single or in
1305
combination with antihipertension in the treatment of hypertension and given from the first
day of the June24, 2014 until six days on June 29, 2014. Cps Bicnat 500 mg (sodium
bicarbonate) were given 3 times 1 cps orally to metabolic acidosis, alkalinisasi urine and
peptikum ulcer and was given the first day of the June 242014 until six days on June 29,
2014. Calcium carbonate (CaCo3) 500 mg given 3 times 500 mg for orally for calcium
supplements, or phosphate binder substance (food) in kidney failure, according to the needs
of the patient and given the first day of the June24 2014 until six days into June 29, 2014.
Vitamin B12 (Hidroksikobalamin) was given 1 times 1 tab for orally to pernicious anemia
and given from the first day of the June24th 2014 until six days into June 29, 2014.
Captopril 25 mg given 3 times 25 mg for peroral for mild to moderate hypertension and
severe hypertension and given from the first day of 24thJune 2014 until six days into June
29, 2014. Paracetamol tab given 1 time 1 tab for orally for mild to moderate pain and fever
and was given the first day of the 24th, the day three on 26 and day to five June 28th2014.
Domperidon given 3 times 10 mg for orally to cope with nausea and vomiting and was
given from the first day of June 24th2014 until six days into June 29, 2014. Omeprazol was
given 1 time 1 cps cps orally for gastric and duodenal and was given for five days on day
two-June 25, 2014 until the sixth days of the June 29, 2014. Ulsafat (Sucralfate/Sukralfat)
given 2 times 1 HR orally for peptic ulcers and duodenal ulcers and was given for five days
on day two-June 25, 2014 until days six of June 29, 2014. Ceftriaxon given 1 time 1 gram
was intramuskuler used for injection therapy of septicemia, pneumonia, meningitis,
infection of the bile duct, peritonitis, and urinary tract infections and given on the seventh
days on 30 June 2014 but patient experience shortness of breath after Ceftriaxon injection
so that doctors do not recommend using Ceftriaxon but replaced with Cefixime. On days
eight date July, 01th, 2014 and until today the tenth date July 03, 2014 patient given
Cefixime therapy 2 times 100 mg for a mild urinary tract infection.
CLINICAL LABORATORY EXAMINATION RESULTS
Blood glucose 11: 00 am
Results June
24, 2014
H 180
The value of
the reference
70 – 150
Mg/dl
Blood glucose Hours 16: 00
137
70 – 150
Mg/dl
Clinical Chemistry Examination
Unit
1306
Paracetamol and domperidon can increase the level of absorption of paracetamol so
need to distance of the useing1.
furosemid and calcium chloride calcium chloride levels lowers furosemid by increasing
kidney cleansing. Small or non-significant interaction4.
2. Adverse Drug Effects
Captopril and synergistic mechanism: nature of furosemid. Significant interaction. The
risk of acute hypotension, renal insufficiency and hypokalemia should be dimonitoring
to use
3. Drug Allergies
At the time of to be treated patientwith Ceftriaxon, patient was experiencing shortness
of breath.
CONCLUSION
Based on the results of the practice of the Internal Ward on the disease in clinics at
PGI Cikini Hospital then can be drawn the conclusion that the existence of the DRPs (Drug
Related Problems) in the form of drug interactions that Paracetamol and domperidon,
paracetamol absorption rate may increase, and calcium chloride and furosemid, the
furosemid lowers calcium levels in which chloride by increasing kidney cleansing, adverse
drug effects of granting along Captopril and furosemid through mechanism: synergistic
properties. Significant interaction might occur so that needs to be monitored. The risk of
acute hypotension, renal insufficiency hypokalemia is the effects of drug interactions
should be monitored and any drug allergies at a time when patients are given the therapy
Ceftriaxon patients experienced shortness of breath which also included one of the DRPs.
REFERENCES
1. Baxter, K. 2008. Stockley's Drug Interaction Eight Edition. London.
1307
2. Cecily Lyn Betz et al, 2009, pocket book Pediatrics Nursing, edsisi V, translated by Eny
Meiliya, EGC, Jakarta medical books.
3. RI Department Of Health. 2007. Diabetes Mellitus. Jakarta.
4. Medscape. Drug Interaction. 2014
5. Amir Sirait, Poltak Hutagalung, Nadeax Moxa.1997.100 years of the PGI cikini
hospital, with a touch of love. Jakarta.
6. Joint Formulary Commite. 2009. British National Formulary. London.
7. J Charlene Reeves. Medical Surgical Nursing. Jakarta. 2001
8. Sabri Mohammed. 2012. Corticosteroids. Jakarta.
9. Tjay Tan Hoan. 2007. Essential Medicines.. Elex Media Komputindo: Jakarta.
1308
STUDY IN DISEASES WARD TYPHOID FEVER
Yoan Heliana1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
(UTA’45 Jakarta)
2
e-mail: [email protected]
ABSTRACT
Typhoid Fever is a diseases of systematical infection have character acute cause of
Salmonella Typhi. Diseases marked by endless heat, sustain bacterial without involvement
of structure of endotel or of endocardial bacterium invasion and at the same time
multiplication into cell of fagosit mononuclear of liver, spleen, gland of limfe intestine and
peyer's of patch1. This Microorganisme many there are in dirt, human being faeces and
food or beverage which infection brought is fly. In fact especial source of this diseases is
dirty environment and unhealt2. Patient: Mr. HA, age: 36 year old, entered on Dr.
Mintohardjo Navy Hospital at 16 June 2014 with diagnose of typhoid. Patient gave
medication therapy during 4 day that is RL infus 500 ml, Ceftriaxone 1 gr, Ranitidin tablet
and injection, Ondancentron 8 mg, Sohobion tablet, Paracetamol 500 mg, Cyprofloxacin
500 mg, Domperidone tablet, Simvastatin 20 mg. Pursuant to result of clinic fiscal clerk
practice at diseases ward in Dr. Mintohardjo Navy Hospital hence can be pulled by
conclusion that there is him of Drug Related Problems (DRPS) in the form of existence of
reaction of allergy.
Keyword: Typhoid Fever, Diseases.
INTRODUCTION
Salmonella Typhi is like to other Salmonella is bacterium of gram negaif which have
flagela whit not capsule and not have anaerob sporafacultative. Having anti gensomatic (O)
which consist of oligosakarida, antigen flagelar (H) which consist of and protein of
envelope antigen (K) which consist of polysacarida3. Salmonella Typhi also can obtain get
factor plasmid of R related to resistensi to antibiotic multiple1.
Microorganisme Salmonella Typhi and Salmonella Paratyphi come into human being
body through beverage or food have infection. Some of annihilated microorganisme in
stomach with pH < 2, 7 some of geting away to come into intestine and there is multiply2.
When immunity respon of humoral mucosa (IgA) hence microorganisme will penetrate
1309
cells of epitel (especially cell M) and lamina propia. Microorganisme propia multiply and
fagosit by macrofag. Microorganisme earn and life in macrofag and is brought to plaque
peyerileum of distal later then to lymph gland3.
Fever symptom of typhoid frequently emerge after 1 until 3 week of invation start
from storey, is seriously. Classic symptom emerging start from high fever, lazy, headache,
diarrhea or constipation, Rose-Spot and chest of Hepatosplenomegali. Rose-Spot is a rash
rose colored of the size 1 mm - 5 mm, oftentimes met at abdomen area, thoraks, back and
extrime whites, but have never been reported to be found child1. This rash emerge on to 7 10 and stay during 2 - 3 day. Period of incubation typhoid fever on child among 5 - 40 day
with mean 10 - 14 day. symptom of clinical light do not need treatment, while symptom of
clinical heavy have to be taken care. If child have of high fever at evening until night time
and go down at morning. Many patient of typhoid resulted less dilution and food3.
CASE PRESENTATION
Patient: Mr. HA, age: 36 year old, entered on Dr. Mintohardjo Navy Hospital at 16
June 2014 with diagnosa of typhoid. Patient come with sign of ill stomach, queasy, puking,
ill chest left side to waist, confused, fever since last 3 day before entering to hospital.
Positive result of inspection in laboratory of imunoserologi S. Paratyphi A-H 1/320,
clinical of chemistry: Trigliserid 186 mg/dL, cholestrol 276 mg/dL, LDL cholestrol 183
mg/dL.
CLINICAL EVALUATION
Usage of RL to return electrolyte balance dehydrationing; Ranitidin tablet and
injection used for the hypersecretion of gastrointestinal (GI); Ondancentron used to
overcome queasy and puking; Ceftriaxone and Cyprofloxacin used to overcome infection
by Salmonella Typhi; Domperidone to overcome headache, queasy and vomiting;
Paracetamol used as by antipiretic; Sohobion used as multivitamin; Simvastatin used to
degrade rate of cholestrol, LDL and trigliserid.
DOSAGE AND USED
1310
At this case of therapy patient with RL 500 ml during 2 day (16 - 17); Ceftriaxone 2 x
1gr during 1 day (16); Ranitidin 2 x 1 ampl during 2 day (16 - 17); Ondancentron 3 x 8 mg
during 2 day (16 - 17); Sohobion 2 x 1 tablet during 4 day (16 - 19); Paracetamol 500 mg 3
x 1 tablet during 4 day (16 - 19); Cyprofloxacin 500 mg 2 x 1 tablet during 4 day (16 - 19);
Ranitidin 2 x 1 tablet during 2 day (18 - 19); Domperidone 3 x 1 tablet during 2 day (18 19); Simvastatin 20 mg 1 x 1 tablet during 2 day (18 - 19).
LABORATORY RESULT
Result of imunoserologi on 16/6/14 see of widal test result as positive S. Paratyphi
A-H 1/320 which the happening of infection by Salmonella Typhi; make-up of rate of
trigliserid 186 mg/dL ( 60-170 mg/dL), cholestrol 276 mg/dL (< 200 mg/dL), LDL
cholestrol 183 mg/dL (< 130 mg/dL) is existence of cholestrol.
LINE TREATMENT OF TYPHOID FEVER
First Line7
Faction antibiotic of chefalosporin represent especial choice for infection which because of
Salmonella Typhi.
Second Line6
Antipiretic
Third Line6
Queasy and vomiting, analgetic, vitamin.
DRUG RELATED PROBLEMS (DRPS)
Alergic Of Drug
Patient given ceftriaxone injection on 16/6/14 and happened allergy, hence
hereinafter patient not be given again ceftriaxone.
CONCLUSION
Pursuant to result of clinic fiscal clerk practice at diseases ward in Dr. Mintohardjo
Hospital Navy, hence can be pulled conclusion Drug Related Problems (DRPS) that
happened in the form of patient allergy to antibiotic of ceftriaxone and with correct
1311
handling hence Drug Related Problems (DRPS) can overcome better and patient of Mr.
HA get peaceful medication, rational and effective4.
REFERENCES
1. Sumarmo S, Poorwo Soedarmo, Herry Garna, Sri Rezeki S. Hadinegoro, Hindra Irawan
Satari. 2008. Buku Ajar Infeksi dan Pediatri Tropis. Jakarta: IDAI.
2. Ngastiyah. 2005. Perawatan Anak Sakit. Jakarta: EGC.
3. Soedarmo, Poorwo. 2010. Buku Ajar Infeksi dan Pediatri Tropis Kedua. Jakarta:
Ikatan Dokter Anak Indonesia FK UI.
4. Tatro, S. David. 2009. Drug Interaction Fact. Oklahuma: Wolters Kluwer
Health.,
Inc.
5. Harkness, R. 1989. Interaksi Obat. Bandung: Penerbit ITB.
6. Baxter, K. 2008. Stockley’s Drug Interaction. Eighth Edition. UK : Pharmaceutical
Press.
7. Joseph T. DiPiro. 1999. Pharmacotherapy A Pathophysiologic Approach. Sixth
Edition. United States of America : The McGraw-Hill Companies, Inc.
1312
DRUG RELATED PROBLEMS ASSOCIATED WITH TREATMENT
TO HEMORRHAGIC STROKE PATIENT IN PGI CIKINI HOSPITAL
Yuliana Amelia B1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
Jakarta)
E-mail : [email protected]
ABTSRACT
Stroke is a circulatory disorders in the brain led to death of brain tissue so cause someone
suffering from paralysis or death of while non-hemorrhagic stroke or ischemic stroke is a
blockage in the blood vessels. Non-hemorrhagic stroke is pathogenic mechanisms of
cerebral thrombosis and embolism is cerebral7. Mrs. EH, 55 years old, came to PGI Cikini
hospital on April 21, 2014, was diagnosed of non-hemorrhagic stroke. Clinical chemistry
shown patient has high blood sugar levels, that is diabetes mellitus. During hospitalized,
she has received lincocin, copidogrel, novorapid, sumagesic, semax, rantin, inpepsa,
amlodipine, lovenox, cefobactam, rocer, and cravit. Clinical evaluation, from of the
treatment found any DRP (Drug Related Problems) ie proper drug selection, untreated
indication and drug interactions.
Keywords: PGI Cikini Hospital, Non-Haemorrhagic Stroke, Ischemic Stroke
INTRODUCTION
Stroke is a circulatory disorders in the brain led to death of brain tissue so cause
someone suffering from paralysis or death of while non-hemorrhagic stroke or ischemic
stroke is a blockage in the blood vessels. Non-hemorrhagic stroke is pathogenic
mechanisms of cerebral thrombosis and embolism is cerebral7.
Diagnosis of non-hemorrhagic stroke can viewed by examination of urinalysis,
complete blood test, blood chemistry, serology, physical examination and other tests.
Treatment of non-hemorrhagic stroke based on the severity of the patient, usually using
antiplatelet drugs and neuroprotektif9.
1313
CASE PRESENTATION
Mrs. EH, 55 years old, came to
PGI Cikini hospital on 21st April, 2014, was
grievances right limb weakness since 4 hours before admission, and it’s so difficult to
swallows, drinking and eat. Patient has hypertension for 4 years. First time when patient
was came, she received lancolin, copidogrel, novorapid, sumagesic, and semax.
Hematology Test
Hematology Test
ESR
Hemoglobin
Leukocyte
Erythrocytes
Hematocrit
Reticulocyte
Leukocyte counts
Basophils
Eosinophils
Neutrophils stem
Neutrophils segment
Lymphocytes
Monocytes
Platelets
MCV
MCH
MCHC
Hemostatic
Freezing period
APTT
APTT Patient
APTT Control
Protombin Time (PT)
INR
Fibrinogen
21st April 2014
*33
14.0
*10,7
*4,73
40
12
Unit
mm/h
g/dL
10^3μL
10^3μL
%
Permil
Normal Range
0-10
13-16
5-10
4,5-5,5
40-48
5-15
%
%
%
%
%
%
10^3μL
fL
pg
g/dL
0-1
1-3
2-6
50-70
20-40
2-8
150-450
81-92
27-32
32-37
10-11
minute
10-16
32,4
30,6
sec
sec
26,4-37,5
1,0
*367
mg/dL
180,0-350,0
0
*4
*0
67
23
6
186
84
29,6
35,4
1314
Clinical Chemistry
Hematology Test
SGOT
SGPT
Urea
Creatinine
Blood sodium
Blood potasium
Calsium
Blood sugar during
21st April 2014
39
H 63
21
1,0
139
L 3,2
L 8,3
H 287
Unit
U/L
U/L
mg/dL
mg/dL
mEq/L
mEq/L
mEq/L
mg/dL
Normal Range
0-50
0-50
10-50
0,6-1,1
135-147
3,5-5,0
8,8-10,0
70-150
CLINICAL EVALUATION
Lancolin (citicoline) used for neuroprotective to increased blood flow and oxygen to
the brain on cerebrovascular disorders, clopidogrel as antiplatelet function to inhibited clot
formation in blood vessels, novorapid used to lower blood sugar levels, sumagesic to
reduce pain, semax used as a neuroprotective , rantin used to gastric acid irritation, inpepsa
to coat the gastric mucosa, amlodipine as antihypertensive, lovenox as anticoagulant,
cefobactam is cefoperazon and sulbactam combination is used for upper respiratory tract
infection or down, rocer used to treated nausea and vomiting, and cravit for chronic
bronchitis , pneunomonia, skin infections.4
Patient was diabetes mellitus controlled by diet and oral hypoglycemic drugs, require
insulin therapy in the acute phase of stroke. And then patients getting insulin during the
acute phase of stroke.8
Used of hypertension in acute stroke based on Stroke 2011 association guidelines by
neurologist Indonesia. The decreased high blood pressure in acute stroke is not
recommended, because of the possibility to exacerbate neurological output. In some patient,
the blood pressure will go down by itself within the first 24 hours after stroke onset. Stroke
guideline in 2011 recommending decreasing the blood pressure in acute stroke must be
careful, ie :6
 In patients with acute ischemic stroke, lowered blood pressure by about 15%
(systolic and diastolic) in the 24 hours after onset if the systolic blood pressure> 220
mmHg or diastolic blood pressure> 120 mmHg. In acute ischemic stroke patient
1315
given thrombolytic therapy (rtPA), lowered systolic blood pressure to <185 mmHg
and diastolic blood pressure <110 mmHg. Antihypertensive drugs used are
labetalol, Nitropruside, Nikardipin or intravenous diltiazem
 In patients with acute intracerebral hemorrhage stroke, if the systolic blood
pressure> 200 mm Hg or mean arterial pressure (MAP)>150 mmHg, blood pressure
is lowered by using a continuous intravenous antihypertensive drugs by blood
pressure monitoring every 5 minutes.
Dipiro 2006, hypertension in stroke drug of first choice is ACE-inhibitor group. But
the ACE-inhibitor drugs is less than helpful for geriatric patient because will be
hypotension, especially in patients with hypovolemic and sodium deficiency, older people,
and in conjunction by use of diuretic drugs, and better for geriatric patient given drug class
calcium channel blockers (CCB)e.g. amlodipine.5
In reviews the Clopidogrel versus Aspirin study in Patients at Risk of Ischemic
Events (CAPRIE), clopidogrel and aspirin in stroke patients showed that clopidogrel is
more effective than aspirin in reducing the risk of ischemic stroke, myocardial infract, and
death of. When combined with aspirin, clopidogrel become the gold standard in the
prevention of sub acute stent thrombosis (SAT) and reduce the incidence of adverse
cardiovascular patient.1 However the effect of clopidogrel in patients is varied. Some
another proof also recommends use of anti-platelet aggregation in ischemic stroke, but has
not been significant differences in the drug combination.
DRUG RELATED PROBLEMS (DRPS)
a. Untreated Indication
Patient complained of declining sight, but did not followed up
b. Improper Drug Selection
Use of levofloxacin is not so precise because are not significant leukocytes. Giving
antibiotics is not based antibiotic resistance literature, beside the length of time
antibiotics is not proper just 2 days.
c. Drug Interactions :
1) Acetaminophen (Sumagesic) + Enoxaparin (Lovenox)
1316
Acetaminophen increase effect of enoxaparin with unknown mechanism. Small or no
significant interaction.
2) Enoxaparin (Lovenox) + Clopidogrel
Enoxaparin, clopidogrel. Potential to dangerous interactions. Be careful when using
the drugs. Increased risk of bleeding
3) Levofloxacin + Insulin aspart (Novorapid)
Levofloxacin enhances the effects of insulin aspart by pharmacodynamics
synergism. Giving Quinolone antibiotics can cause hyper - or hypoglycemia.
4) Omeprazole + Clopidogrel
Omeprazole decreases effects of clopidogrel by affecting hepatic enzyme CYP2C19
metabolism. High serious or life-threatening interaction. Contraindicated unless
benefits outweigh risks and no alternatives available. Drugs that inhibit CYP2C19
may reduce Clopidogrel efficacy. Inhibition of platelet aggregation by clopidogrel is
entirely due to an active metabolite. Clopidogrel is metabolized to this active
metabolite in part by CYP2C19.
CONCLUSION
Found any DRP in the treatment of Mrs. EH, such as Lovenox (enoxaparin) is an
anticoagulant and copidogrel (antiplatelet) both have the same function so could cause
bleeding. Selection of antihypertensive drugs with DM and the first chosen therapy class of
antihypertensive drug is an ACE-inhibitor, for example captopril because it can increased
insulin sensitivity, renal protective effect and reduce cardiovascular events but in this case
used amlodipine because patient suffered from ischemic stroke too, and if given captopril
will worsen the condition, side effect of captopril is coughing can cause a breakdown of the
blood vessels. Patient also complained of decreasing sight, caused by to high blood glucose
so capillaries in the eye rupture.2
SUGGESTIONS
a. Always do monitoring to drug interactions.
b. Give the interval to taking medicine
1317
c. Always control blood pressure and sugar levels
d. Diet
REFERENCES
1.
Adiwijaya JA. Effect and Resistance in Acute Coronary Syndrome. Medical Journal of
Indonesia Medika 5th edition; Jakarta.
2.
American Diabetes Association, 2004. Diagnosis and classification of diabetes
mellitus. Diabetes Care. America
3.
POM RI, 2008. Indonesian National Drug Information. POM; Jakarta.
4.
BNF 61, 2011. Britsh National Formulary 61 March Handbook, Mc Graw Hill
Company.
5.
Dipiro, Joseph. , 2006. Pharmacotherapy Handbook sixth edition, Mc Graw Hill
Company.
6.
Guidelines Stroke, 2011, Association Of Stroke Neurologist Indonesian Doctors;
Jakarta
7.
Hudak & Gallo. , 1996. Critical Nursing: A Holistic Approach Volume II. EGC:
Jakarta
8.
Kashyap SR, Levin SR. The subacute srtoke patient: glucose management. In: Cohen
SN, editors. Management of ischemic stroke. McGraw-Hill. New York; 2000
9.
Mansjoer, Arif., Et al. , 1999. Capita Selecta Medicine. Faculty of Medicine, UI:
Media Aescullapius
10. Sukandar Elin Yulinah, et al., 2009. ISO Pharmacotherapy. ISFI; Jakarta
1318
TREATMENT MEDICINE TO PATIENT ACUTE LOW BACK
PAIN,DISPEPSIA AND POST INFECTION BUILDING OF ORIF AT
PGI CIKINI HOSPITAL
Adinda Riskia Indriani Putri1 , Aprilita Rina Yanti Eff2 and Diana Laila R2
1
Student of Pharmacist Program, Faculty of Pharmacy UTA'45Jakarta
2
Lecturer of Faculty of Pharmacy UTA'45Jakarta
ABSTRACT
Low back Pain was a the pain on the back between bottom corner of rib bone to arounded
tail bone. The pain also can be spread to other areas such as upper back and hip . Dispepsia
is a pain block or indication clinical (syndrom) uncomfortable or the pain that could be feel
arrounded abdomen part upper within other squawk such as feeling warm on the chest and
stomach,regurgitas,puffy,stomach felt fill, early satiety, saltpeter, anorexia, odious, throw
up, and spend a lot of gas from mouth. infection in the joint could be divided two kind of,
acute infection caused by bacteria and chronic infection caused by tuberculosis bacteria.
Cronical infection could be indicated with swelling of the joints, severe pain and
acute,fever and weakness. The women patient is 60 years old has story about post orif
lumbal disease some years ago,the patient feeling the pain in front her abdomen and waist
(the pain was spreading). The patient has been diagnosed Acute Low Back Pain,dispepsia
and post infection building of orif. From the result of laboratorium inspection the patient
has been got abnormalitas condition on value of erythrocyte sedimentation rate it is 84
mm/hours (0-20 mm/hours), reticulocyte is 16 permill(5-15 permill), leukosyte is 17.9 µl
(5.0 – 10.0 µL), MCV is 77 fl (81-92 fl), and MCH is 25.8 fg (27.0 – 32.0 fg). The patient
treated with torasic (ketorolac tromethamine) 1x 30 mg. ranitidin injeksi 2 x 1 amp, inpepsa
(sukralfat 500 mg) 3 x 1 tablespoon, ultracet (tramadol 37.5 mg and acetaminophen 325
mg) 3 x 1, remopain (ketorolac tromethamine 10 mg) 2 amp/24 hours, feldene gel
(piroxicam), profenid (ketoprofen) and amitriptiline 1 x 12.5 mg. From the medicine
treatment was be used by patient founded DRP(Drug Related Problem) that is using
medicine haven’t effective and drug interaction.
Keyword : Low Back Pain, Dispepsia, Infeksi Post Pemasangan ORIF, RS PGI Cikini
PRELIMINARY
Low back pain (LBP) is a pain in the back between the bottom corner of the costal
(rib) to the lumbosacral (around the tail bone). Pain can also spread to other areas such as
1319
the upper back and groin (Rakel, 2002). LBP or lower back pain is a musculoskeletal
disorder that is caused by poor body activity (Maher, Salmond & Pellino, 2002)..
Clasification
Acute Low Back Pain
Acute Low Back pain is characterized by pain that strikes suddenly and just a short span of
time, between a few days to a few weeks. The pain can be lost or recovered. Acute Low
Back Pain can be caused by traumatic injury such as a car accident or fall, the pain can
disappear a moment later. These events can damage tissues in addition, can also injure the
muscles, ligaments and tendons. Until now, the initial management of acute low back pain
focused on the break and using analgesics (Judith, 2011).
Chronic Low Back Pain
The pain on the Chronic Low Back can be spread more than 3 months. This pain can be
repeatedly or reoccuring. This fase has onset more dangerous and would be cure at long
time usually. Chronic Low Back Pain may occure due to osteoarthritis, rheumatoidarthritis,
degeneration process discus intervertebralis and tumor (Judith, 2011).
PRESENTATION OF CASE
The women patient was 60 years old who has desease of Post ORIF Lumbal for
years ago, patient complained of pain in the front of the abdomen and waist (radiating
pain). Patients diagnosed with Acute Low Back Pain, dyspepsia and infection mounting
post ORIF.
EVALUATION CLINIC
The patient has clinical chemistry examination and experience abnormal conditions
on the value of erythrocyte sedimentation rate (ESR) is 84 mm / h (0-20 mm / h), which is
16 permill reticulocytes (5-15 permill), leukocytes ie 17.9 mL (5.0 - 10.0 mL), the MCV is
77 fl (81-92 fl) and MCH is 25.8 fg (27.0 - 32.0 fg). Patients also underwent radiography
Sacred Dolphin looks Orif impression that the L4, L5 and Sacrum, mild spondylitis
dicuridai L1-L2 and lumbar Spondyarthrosis. The patient got therapy which began on day
8 treatment .
1320
DOSAGE AND USAGE
Patient gets therapy triject drug (cefriaxone sodium injection) with dosage 1 x 1g
that used to infection treatment is ‘caused by Negative gram bacteria. Torasic (ketorolac
tromethamine) at a dose of 1 x 30 mg is used for short-term treatment of acute moderate to
severe pain after surgery. Ranitidine injection at a dose of 2 x 1 amp used for peptic ulcers
and ulcer patients intestine 12 fingers. Inpepsa (sucralfate 500 mg) at a dose of 3 x 1
Tablespoon used short-term treatment of duodenal ulcer in patients. Ultracet (tramadol 37.5
mg and acetaminophen 325 mg) at a dose of 3 x 1 is used for short term treatment of acute
moderate to severe pain. Remopain (ketorolac tromethamine 10 mg) at a dose of 2 amps /
24 hours are used for short term treatment of pain. Gel Feldene (piroxicam) with 2 x daily
usage that is used for patients osteoartitritis, rheumatoid spondylitis anklos,
muskuloskeletol disorders in patients with acute and acute gout. Profenid (ketoprofen) with
the use of 2 x daily is used for trauma, swelling and aches and pains after treumatik.
Amitriptiline with a dose of 1 x 12.5 mg is used as an adjuvant (to induce sedation)
DISCUSSION
Based on the results of laboratory tests on the value of erythrocyte sedimentation
rate (ESR) is 84 mm / h (0-20 mm / h), and the value of leukocytes is 17.9 mL (5.0 - 10.0
mL) inferred Post Installation patients had infections that patients treated with ORIF Triject
(Cefriaxone sodium injection).
In this case the patient was given torasic (ketorolac tromethamine), ultracet
(tramadol 37.5 mg and acetaminophen 325 mg), remopain (ketorolac Tromethamine 10
mg), gel Feldene (piroxicam), profenid (ketoprofen) to treat pain. Offering of ranitidine and
inpepsa (sucralfate) in patients aims to overcoming the adverse effects of NSAID drugs
(keterolac tromethamine, tramadol and acetaminophen) and the provision of amitriptiline
used to cause sedation in patients.
Of a given drug therapy found some DRP (Drug Related Problem) that excessive
drug therapy and are not effective to treat pain patients is torasic (ketorolac tromethamine),
ultracet (tramadol 37.5 mg and acetaminophen 325 mg), remopain (ketorolac tromethamine
1321
10 mg), gel Feldene (piroxicam) and Profenid (ketoprofen). Offering the therapy includes
offering polyfarmacy.
DRP (Drug Related Problem) other interaction that occurs between Amitriptiline
with sucralfate, which sucralfate may cause signs of Amitriptiline absorption reduction and
interactions between Tramadol (Ultacet) with Amitriptiline, where the use of tramadol with
amitriptiline simultaneously can potentially CNS depressants (nervous system center)
(Baxter, 2008).
Drug Ineffective
In case this happens to excessive drug therapy and are not effective to treat pain patients is
torasic (ketorolac tromethamine), ultracet (tramadol 37.5 mg and acetaminophen 325 mg),
remopain (ketorolac tromethamine 10 mg), gel Feldene (piroxicam) and Profenid
(ketoprofen). Offering the therapy includes offering polyfarmacy.
Drug Interactions
Amitriptiline with sucralfate, which sucralfate may cause signs of Amitriptiline absorption
reduction. (Baxter, 2008)
Tramadol (Ultacet) with Amitriptiline, where the use of tramadol with amitriptiline
simultaneously can potentially CNS depressants (central nervous system) (Baxter, 2008).
CONCLUSION
Based on observations in the case of a patient can be concluded that occur DRP
(drug related problems) that excessive drug therapy and are not effective (including the
granting of polypharmacy) and drug interaction occurs.
REFERENCES
1. Baxter, K. (ed). 2008. “Stockley’s Drug Interaction”. Eight Edition. Pharmaceutical
Press. London and Chicago.
2. Cailliet Rene M.D. (1981). Low Back Pain Syndrome, Edisi ke 3, F.A Davis Company,
Philadelphia.
1322
3. Departemen Farmakologi dan Terapeutik. “Farmakologi dan Terapi”. 2011. Edisi 5.
Badan Penerbit FKUI. Jakarta.
4. Depkes RI. 2008. “Informatorium Obat Nasional Indonesia”. Dirjrn Pengawasan Obat
5. Judith A. Kaufmann, Low Back Pain : Diagnosis and Management in Primary care.
Dalam Lippncott’s Primary Care Practice, Vol 3. Number 4. July 2000,Philadelphia :
Lippincott William & William Inc.
6. Sandra M. Nettina, 2000, Taking Care Of Your Lower Back and Neck Pain, Dalam
Lippncott’s Primary Care Practice, Vol 3. Number 4. July 2000,Philadelphia :
Lippincott William & William Inc.
7. Toward Optimized Practice, Low Back Pain. 2009. Toward Optimized Practice (TOP)
Program.
1323
DRUG RELATED PROBLEM AMONG RIGHT EMPYEMA
PULMUNARY, TUBERCULOSIS WITH THE TYPE 2 DIABETES
MELLITUS IN GATOT SUBROTO HOSPITAL
Andi Fajaruddin(1), Aprilita Rinayanti Eff(2)and Diana Laila Ramatillah(2)
1
2
[email protected]
ABSTRACT
Empyema pulmonary is the one of common diseases and frequently encountered on the
fourth floor of the treatment room lungs of Gatot Subroto Army Hospital. Empyema is a
condition where in the pleural cavity contained pus (pus) resulting from bacterial acute
infection, the result traumatic of outside or complications of lung uncontrolled disease
other. When pus collects in the pleural space then an increase in pressure in the lungs so
that breathing becomes difficult and painful. Empyema is usually a complication of lung
infection (pneumonia) or pouch bag localized pus (abscess) in the lung. Mr. SW 54 years
old was admitted on the fourth floor of pulmonary care. Patient was diagnosed with
empyema in the right lung and a positive TB infected with type II diabetes. Patient was
treated with ceftriaxon, rifampicin, isoniazid, ethambutol, pyrazinamid, ponstan
(mefenamic acid), Novorapid (short-acting insulin), Levemir (long acting insulin), OBH
syr, ranitidine, furosemide, aldacton (spironolacton), valsartan, bisoprolol. In this case is
found DRP (Drug Related Problem) that are patient was given with two different
antibiotics in therapeutic regimens that ceftriaxon and pyrazinamide, but based on the
results of the laboratory examination, increasing leukocytes caused by tuberculosis
bacteria, so the handling of the TB infection is enough to give one kind of antibiotics
pyrazinamide, in this case to reduce the resistance factor that occurs in patient.
Keywords: Drug Related Problems, Empyema pulmonary, Tuberculosis, DM type II and
Gatoto Subroto Hospital
1324
1. INTRODUCTION
Empyema pulmonary is the one of common diseases and frequently encountered on
the fourth floor of the treatment pulmonary room, Gatot Subroto Army Hospital. Empyema
is a state where in the pleural cavity contained pus (pus) resulting from bacterial acute of
infection, traumatic result of complications due to external or other lung uncontrolled
diseases.1
When the pus accumulated in the pleural space, that an increase in pressure on the
lungs that breathing becomes difficult and feels the painful. Empyema is usually a
complication of pulmonary infection (pneumonia) or the localized pockets pouch of pus
(abscess) in the lung.2
Due to pleural invasion of piogenik results,it will be acute inflammation has occurred
followed by the formation of serous exudate. polimorphonucleus cell number (a) both the
living and dead, and the increasing levels of the protein, then the liquids becomes turbid
and viscous. The presence deposits of fibrin will form pockets which is pus localize these.
When the thoracic wall and out through the skin, it is called nessensiatis empyema. The
stadium is still calledacute empyema who eventually will become chronic.3
As for signs and symptoms of empyema in general are fever, night sweats, pain,
pleural dispnea, anorexia, and weight loss, chest auscultation, found percussion, breath
sounds decreased chest, found decreased fremitus.3
Patient, Mr. SW 54 yearsold diagnosed with empyema of the right lung. Patient
entered the Gatot Subroto Army Hospital on 13 may 2014, at 15:20 pm. At the time of
admission the patient complained of shortness of breath, chest tightness right, fatigue,
decreased appetite, and hyponatremia. patient has a past medical history of pulmonary
tuberculosis and that type 2 DM and CAD (Coronary Artery Disease). Clinical laboratory
results showed an increase in the value of Fasting Blood Sugar (GDP) of 150 mg / dL, and
Blood Sugar 2 hours (GD2jam) is 309 mg / dL, results of microbiological examination
positive patients TB infected.
1325
3. CLINIC EVALUATION
In this case, patient was treated with Ceftriaxon for treatment of an infection that
characterized by an increase in the value of leukocytes. Rifampicin, Isoniazid, Ethambutol,
and Pyrazinamid to overcome bacterial infection with Mycobacterium tuberculosis, ponstan
(mefenamic acid) to reduce pain at the puncture marks at the time of examination TTNA
(Transthoracal Needle Aspiration) is taking tissue specimens using a fine needle to
penetrate the chest wall, Novorapid given to addressing hyperglycemia in patients with
diabetes mellitus (short-acting insulin), Levemir given to addressing and control of
hyperglycemia in patients with diabetes mellitus (long acting insulin), OBH syr to
expectorants (thinning phlegm) cough disorders, ranitidine injection to stimulate the
inhibition of gastric acid secretion and pepsin, furosemide used in the treatment of
pulmonary edema due to left ventricular heart failure, aldacton (spironolacton) to cope with
congestive heart failure, valsartan to address heart failure and hypertension, bisoprolol to
cope with chronic heart failure, hypertension and angina.
4. THERAPEUTIC REGIMENS 5
During the 7 days admission patient was given
injection ceftriaxon 1x2 g
administered for 6 days, ranitidine injection administered for 7 days 2x1, 3x1 OBH
teaspoon syrup given on day 3 to day 7, Novorafid 3x10 units given on day 3 to day 7,
Levemir 1x10 units given on day 3 to day 7, ponstan (mefenamic acid) 3x1 administered on
day 3 to day 7, 2x1 furosemide administered on day 4 to day 6, aldacton (spironolacton)
2x1 administered on day 4 to 6, 1x1 valsartan given on days 4 to 6, 1x1 bisoprolol given on
days 4 to 6, 1x1 rifampicin administered on day 3 to day 7, 1x1 isoniazid given on day 3 to
day 7, ethambutol 1x1 given on day 3 to day 7, 1x1 pyrazinamid given on day 3 to day 7.
5. RESULT OF LABORATORY EXAMINATION 6
Result of clinical laboratory tests showed that were elevated levels of Fasting Plasma
Glucose/ FPG (150 mg / dL), and plasma glucose 2 h PP ( 309 mg/dL), and showed
decreasing in the value of MCV (69 fl), sodium (124 mmol /L), and chloride (46 mmol / L).
While the results showed an increase in leukocytes test hematology ie 13,700 / uL, platelets
1326
432,000 / uL. And the results of microbiological examination showed positive patients
infected with TB.
6. DRUG RELATED PROBLEM 7
6.1 Drug-induced Disease 7
Rifampicin is used antituberculosis orally drugs. Concurrent use of rifampin with
isoniazid can cause hepatotoxicity that occurred in the metabolic process in the liver.
Patient
should
be
supplemented
with
vitamin
B
6.
Pharmacist Interventions: should be added with vitamin B 6, vitamin B 6 which serves
as a peripheral neuropathy that can prevent the occurrence of hepatotoxicity.
Patient was treated with two different antibiotics in therapeutic regimens that
ceftriaxon and pyrazinamide, but based on the results of the laboratory examination of
the increase in leukocytes caused by tuberculosis bacteria, so the handling of the TB
infection is enough to give one kind of antibiotics pyrazinamide, in this case to reduce
the resistance factor that occurs in patient.
7. CONCLUSION
In this case is found DRP (Drug Related Problem) that are patient was given with two
different antibiotics in therapeutic regimens that ceftriaxon and pyrazinamide, but based on
the results of the laboratory examination, increasing leukocytes caused by tuberculosis
bacteria, so the handling of the TB infection is enough to give one kind of antibiotics
pyrazinamide, in this case to reduce the resistance factor that occurs in patient
8. REFERENCE:
1. PDPI, 2003. Empyema Community Guidelines for Diagnosis and Management in
Indonesia. Jakarta
2. Somantri Irman.2009. Nursing the Client with Respiratory System Disorders. Jakarta:
Salemba Medika s
1327
3. Muttaqin, Arif. , 2008. Clients with Disorders Nursing Exhalation System. Jakarta:
Salemba Medika.
4. MOH. , 2008. Indonesian National Medicine Information. Director General of Food and
Drug Administration. Jakarta.
5. D.Hepler Charles and Richard Segal. , 2003. Preventing Medication Errors and
inproving Drug Therapy Outcomes. LLC.Boca Raton CRC Press. Florida.
6. Sutedjo, AY. , 2007. Disease Handbook Knowing Through the results of laboratory
tests. Amara Books. Yogyakarta
7. Baxter, K. 2008. Stockley's Drug Interaction. Eight Edition. Pharmaceutical Press,
London and sChicago.
1328
TREATMENT FOR CONGESTIVE HEART FAILURE (CHF) IN PGI
CIKINI HOSPITAL JAKARTA
Andi Risnawaty(1), Aprilita Rina Yanti Eff(2) and Diana Laila Ramatillah(2)
1
2
[email protected]
ABSTRACT
Congestive heart failure (CHF) is a condition in which the heart's function as a pump is
inadequate to deliver oxygen rich blood to the body. Congestive heart failure can be caused
by, diseases that weaken the heart muscle, diseases that cause stiffening of the heart
muscles, or diseases that increase oxygen demand by the body tissue beyond the capability
of the heart to deliver adequate oxygen-rich blood.
Patient Mr. M aged 61 years old, entered the hospital PGI Cikini Hospital on March 4,
2014. He has diagnosed of CHF (Congestive Heart Failure) and COPD (chronic obstructive
pulmonary disease). Patient was treated with: Aspilet, Isosorbite dinitrate, sodium
bicarbonate, Lasix, Levofloxacin, Omeprazole, Allopurinol, Ventolin Inhalation and
Bisolvon. Based on the results of the clinical practice in a hospital ward K (internist) PGI
Cikini Hospital it can be concluded that the presence of DRPs (Drug Related Problems) .
The DRPs are the patient did not require medication but was given the drug and existence
of drug interactions (Allopurinol and Aspilet, Lasix and Allopurinol, Lasix and Aspilet,
Bicnat and Aspilet).
Keywords: Congestive Heart Failure (CHF), PGI Cikini Hospital, Disease
1.INTRODUCTION
Heart failure develops when the heart, via an abnormality of cardiac function
(detectable or not), fails to pump blood at a rate commensurate with the requirements of the
metabolizing tissues or is able to do so only with an elevated diastolic filling
pressure. Congestive heart failure is the inability of the heart to pump blood around the
body. The risk of congestive heart failure will be increased in the elderly due to a decrease
1329
in ventricular function due to congestive heart. Heart failure can become chronic if
accompanied by diseases such as hypertension, valvular heart disease, cardiomyopathy, and
others. Congestive heart failure can also be a condition of developing acute and sudden in
myocardial infarction. There were some induced of the disease is congestive heart failure,
myocardial infarction, systemic hypertension, infection and inflammation of the
myocardium disease, emotional stress, arrhythmia, pulmonary embolism.(3)
(4)
Currently congestive heart failure is the cardiovascular disease whose incidence and
prevalence continues to increase. The risk of death from heart failure ranged between 510% per year in mild heart failure will increase to 30-40% in severe heart failure. In
addition, heart failure was a disease that most often require repeated treatment at the
hospital (readmission) despite outpatient treatment has been administered optimally.(6)
This paper will be evaluated the treatment of congestive heart failure (CHF) in
patient that hospitalized at PGI Cikini Hospital.
2.METHODOLOGY
The case studies was conducted to the patient on K-Unit based on the length of
patients treated. The evaluation was done based on the data of drug use, include drug name,
dosage and mode of administration and rationalization of the using of the drug (the right
dose, the right indication, the right patient, the right of use) with see Drug Related
Problems of drug use based on the literature.
3.CASE PRESENTATION
Patient male, aged 61 years old entered PGI Cikini Hospital on March 4, 2014.
Patient present with spasms, pain during a week. The patient previously had a history of
congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The
patient did not have allergies to medication or disease that used previously because of
heredity.
Patient was treated with Aspilet, Isosorbite dinitrate, sodium bicarbonate, Lasix,
Levofloxacin, Omeprazole, Allopurinol, Ventolin Inhalation and Bisolvon.
1330
4. LABORATORY RESULTS AND DISCUSSION
On hematological examination results on 04 March 2014, had showed abnormal
values in blood sedimentation rate was 39 mm / h (0-20 mm / h), the increased in the
number of erythrocytes was 4.17 10 ^ 3μL (4.00 to 4.5 10 ^ 3μL), reticulocyte values was
19/mil (5 - 15/mil), the neutrophils values was 76% (2-6%), the value of which monocytes
was 164% (2 -8%).
Clinical chemistry examination on 04 March 2014, had showed that the value of
abnormal globulin 64 g / dl (1.3 to 3.7 g / dL), SGOT 64 U / L (0-50 U / L), alanine
aminotransferase (SGPT) 73 U / L (0-50 U / L), SGOT and SGPT increased indicates a
disturbance in the heart. Urea examination had showed abnormal values were 63 mg / dl
(10-50 mg / dL), creatinine value of 2.1 mg / dl (0.6 to 1.1 mg / dL) increased urea and
creatinine values indicate decreased kidney function already and indicates renal disease and
uric acid 11.0 mg / dl (3.0 to 7.0 mg / dL).
Examination of blood pressure in patient of Tn. M who indicates a value that varies.
On the first day of entrered into PGI Cikini hospital, the patient's blood pressure was only
100/80 mmHg (08.00), On days 2-3 showed relatively normal blood pressure of 120/80
mmHg, but on day increased range 5-10 160/110 mmHg.
Patient as long as treated at PGI Cikini Hospital, patient was received 9 kinds of
drugs. Aspilet as antiplatelet was given to dilute and accelerate blood circulation, and
reduced the risk of myocardial infarction in unstable stenocardia. ISDN was used for the
treatment and prevention of angina pectoris in ischemic heart failure disease. Bicnat and
Lasix was given to metabolic acidosis and edema respectively. Levofloxacin was used for
acute exacerbations of chronic bronchitis, because patient was diagnosed with COPD while
Omeprazole was used for the treatment of gastric ulcer and duodenal ulcer. Allopurinol was
used for gout arthritis. Inhaled Ventolin was used to relief spasms attack (asthma). Bisolvon
used for relief of cough and mucus in the bronchi.(2)
5. DRUG RELATED PROBLEMS
5.1. Drug interactions
1331
Giving Allopurinol the same time with Aspilet can cause decreasing effectiveness
of Allopurinol, because it increases uric acid levels in plasma. Lasix and Allopurinol can
cause hypoglycemia effect. Lasix and Aspilet which may increase the toxicity of
salicylate.(1)
5.2. Failed to receive medication
In this case there were no failures in the administration of drugs or in other words
the administration of drugs were given to patient already as recommended by your doctor.
6.CONCLUSION
Based on the results of the clinical practice in a hospital ward K (internist) PGI
Cikini Hospital it can be concluded that the presence of DRPs (Drug Related Problems) .
The DRPs are the patient did not require medication but was given the drug and existence
of drug interactions (Allopurinol and Aspilet, Lasix and Allopurinol, Lasix and Aspilet,
Bicnat and Aspilet).(1)
REFERENCES
1. Anonymous. ,2005. Stocley's Drug Interactions. The Pharmaceutical Press
2. BPOM. ,2008. Indonesian National Medicine Information (IONI). Jakarta: Sagung Seto
3. Bertram G.Katzung, 2012. Basis and Clinical Pharmacology, 10th edition. EGC
Medical Book
4. Drs. Priyanto, Apt. M.Biomed, 2008. Pharmacotherapy and Medical Terminology.
Institute for Studies and Consultations pharmacological.
5. Saragi, Sahat, 2012. For the Use of Drugs Concept Equipped with Pharmaceutical
Care, Drug Counseling Theory, Theory Drinking Drug Compliance, Publishers
Rosemata Publisher, Jakarta
6. Sudoyo A, et al. , 2006. Textbook of Medicine: Faculty of medicine. Jakarta
1332
EVALUATION OF TREATMENT ANGINA PECTORIS DISEASE AT
GATOT SOEBROTO ARMY HOSPITAL
Andi Walinono1, Aprilita Rina Yanti Eff 2 and Diana Laila Ramatillah2
1
2
ABSTRACT
Ischemic clinically defined a situation where there is lack of balance between the supply of
oxygen to the oxygen demand of the heart. The amount of oxygen the heart needs is
determined by the heart rate6. Left ventricular wall tension (which owns function of blood
pressure is affected by adrenoceptor activity, Ca2+ channels, etc.6. Patient Mrs S, aged 74
years, entered Gatot Soebroto Army Hospital on December 17, May 2014 with angina
pectoris diagnosis. Patient was treated with herbersser, amoxillin,mefenamic acid,
gentamicin, ciprofloxacin. Based on the results of clinical work practice in military
medicine wards at Gatot Soebroto Army Hospital it can be concluded that there was no
DRP (drug related problems) and treatment was given to patient has appropriate
Keywords: Angina pectoris and Gatot Soebroto Army Hospital
1. INTRODUCTION
Angina pectoris is a clinical syndrome which occurs typical chest pain, which feels
like pressure or weight on the chest, often radiating to the left arm. The chest pain usually
occurs at the time of doing the activity and immediately lost when resting. Angina pectoris
is a clinical syndrome that occurs from myocardial ischemia. Condition in which the
myocardial oxygen demand can not be met by the supply of oxygen in blood.usuallly this
was due to the occurrence of spasm (tension) in the coronary arteries. Coronary artery
disease (coronary artery disease) is a major cause of angina associated with atherosclerosis
in the arteries of the heart. atherosclerosis is a common cause of stenosis (narrowing of
blood vessels) in the coronary artery that is referred to as angina pectoris6.
1333
In angina, the chest pain like pressure usually heavy objects, such as clamped, or feels hot,
sometimes just a bad feeling in the chest. Chest pain in angina pectoris usually occurs
during activity, such as brisk walking, hurry, climb the road, or up the stairs. The chest pain
will soon disappear when patients stop the activity.In patients suffering from severe angina
pectoris, chest pain that can occur at minimal activity such as bathing, eating satiety, and
emotions. Angina pectoris attacks may occur at rest or at night6.
Patient Mrs. S admitted to hospital with complaints almost fainting and chest pain on
the left there, feels like flying, (BAK, BAB). Patient come to plan the installation of PPM
(permanent pecmeker). Patient had a history of hypertension. The general condition of the
patient at the time of hospital admission were blood pressure 125/89 mm Hg, pulse
70/minute, respiratory rate 18 / min, temperature 36 ° C.
Patient was treated with herberser for overcome hypertension and arrhythmias prior to
installation of TPM (temporertpecmeker) and PPM (permanent pace meker), amoxilin was
given at the time of installation of the TPM, and mafenamicat acid was given at the time of
installation of the TPM and PPM. After few days using TPM patient was continue
instalation of PPM and was given the antibiotic gentamicin and ciprofloxacin treatment
injection for 5 days.
4.
DOSE AND USING OF DRUG,2,3
Regimen
Drugs
Dose
1x1 200 CD Herbersser
3x1
Amoxillin
Indication
Treatment of
angina pectoris,
angina pectoris
prophylaxis Parian,
asensial mild to
moderate
hypertension.
Urinary tract
infections, otitis
Cara
pemakaian
PO
PO
Usual Dose
100-200 mg
1x1 daily
PO : 250 mg
every 8 hours
1334
3x1
Asammefena
mat
2x1
Gentamicin
2x1
Ciprofloxacin
media, also for
ofilaksissinositis
endocarditis.
Mild to moderate
pain and
dysmenorrhea
associated
conditions and
menorrhagia.
Septicemia and
sepsis in neunatus,
meningitis and
other CNS
infections.
Infection of grampositive and gramnegative, surgical
prophylaxis in the
upper
gastrointestinal
tract.
PO
IV
IV
PO : 500 mg
3x 1 daily
After eating
better, but not
more than 7
days.
IV : 2-5
mg/kg BB
daily
PO : 200-400
mg 2x1 daily
5. RESULTS OF CLINICAL LABORATORY
Type of examination
Hemoglobin
Hematocrit
Erythrocytes
Leukocyte
Platelets
MCV
MCH
MCHC
Normal Value
12-16 g/dL
37-47 %
4.3-6 juta/μL
4800-10.800 / μL
150.000-400.000/μL
80-96 fL
27-32 pg
32-36 g/dl
18/5
13,2
39
* 4,1
* 4700
198000
95
32
34
6. CONCLUSION
Based on the results of clinical work practice in military medicine wards at Gatot
Soebroto Army Hospital it can be concluded
that there was no DRP (drug related
problems) and treatment was given to patient has appropriate
1335
REFERENCES
1.
2.
3.
4.
BNF.2009 The essential resource for clinical use of medicines in children
BNF 61.2011,British National Formulary 61 March 2011
David S. Tatro, 2003 A to Z Drug Facts Facts and Comparisons 2003
Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A Pathophysiologic Approach 7th
5. IDAI,2006
Konsensus
Penatalaksanaan
Kejang
Demam,
Unit
KerjaKoordinasiNeurologi, IDAI 2006
6. JNC seven, 2003 National High Blood Pressure Education Program. The seventh
report of the Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure.Arch Intern Med. 2003;N o . 0 3 - 5 2 3 3
7. Tatro DS.2004Drug Interaction Facts. Facts and Comparisons, St. Louis.
1336
DRUG RELATED PROBLEMS ON TYPE II DIABETES MELLITUS DISEASE
TREATMENT IN MINTOHARDJO HOSPITAL
Surianti1, Aprilita Rina Yanti2 and Diana Laila2
1
2
[email protected]
ABSTRACT
Type II diabetes mellitus is a chronic disease that occure when the pancreas produces
enough insulin but the body can not effectively using the insulin that is produced. This
could result from the habit of unhealthy eating patterns. When patients with type II diabetes
mellitus who have insulin resistance so that blood sugar will rise, it will result in the
occurrence of complications.
Patient, Mrs S, aged 57 years old entered RSAL Mintohardjo on April 18, 2014, with a
diagnosis of type 2 diabetes. Patient was treated with metformin, amlodipine, Aspilet
(aspirin), Neurodex, Diaversa (glimepiride), Bufenol (paracetamol), Ranitidine tab,
Ranitidine ampule and Infusion RL.
Based on the result of the clinic secretariat in Mintoharjo Hospital, it could be concluded
that there was presence of DRP (Drug Related Problems) and the interaction between
metformin and ranitidine (Ranitidine inhibit metformin metabolism and increasing
hypoglycemia effect of metformin) (David , 2012).
Keywords:
1.
Drug
Related
Problems,
type
II
diabetes,
Mintohardjo
Hospital
INTRODUCTION
Indonesian Health development is directed to solving health problems to achieve a
healthy life for every resident in order to realize optimal health status. Health problems can
be influenced by lifestyle, diet, work environment, exercise and stress. Lifestyle changes,
especially in big cities, led to the increasing prevalence of degenerative diseases, such as
heart disease, hypertension, hyperlipidemia, diabetes mellitus (DM) and others (Waspadji,
2009).
Diabetes mellitus is a chronic disease characterized by high blood sugar levels and
metabolic disorders in general, which in its way if not properly controlled will lead to
various complications of both acute and chronic. Abnormalities basis of this disease is
1337
deficiency of insulin hormone produced by the pancreas, which is deficient in quantity and
or work (Isniati, 2003). The number of sufferers worldwide number of people around the
world, namely 1998 ± 150 million, ie 2000 ± 175.4 million estimated in 2010 that is ± 279
million (Murwani, 2007).
Based Riskesdas 2007, prevalence of DM in Indonesia based on the diagnosis by
health workers was 0.7%, while the prevalence of DM (D / G) at 1.1%. These data suggest
the diagnosis of DM coverage by health workers reached 63.6%, higher than the coverage
of asthma and heart disease. National prevalence of diabetes mellitus disease was 1.1%
(based on diagnoses and symptoms of health professionals).
According to the Management of Diabetes Mellitus Consensus in Indonesia
counseling and meal planning is the main pillar of the management of diabetes. Therefore,
meal planning and explanation to patients with DM should receive the most attention
(Waspadji, 2009).
The main goal of therapy is to achieve DM good metabolic control in order to
prevent long-term complications. But unfortunately, the quality of data in Indonesia about
the treatment of patients with type 2 diabetes are still not sufficient. Clinical treatment
guidelines are used as a reference in selecting among various drug therapies available to
treat type 2 diabetes in order to provide appropriate treatment decisions in specific
circumstances. However, the facts on the ground indicate there are many mismatches
selection of treatment with clinical treatment guidelines for various obstacles (Perkini,
2011).
2.
CASE PRESENTATION
Patient Mrs S age 57 year old was diagnosed diabetes mellitus. Patient has had
symptoms of headache since 1 day before entering the hospital, felt intermittent pain, pain
is felt in the entire head, especially the front and rear, patients also feel weak, nauseated but
not vomiting. The left abdomen feels hot and painful. No chest pain. The patient also
complained of pain in the arm until the legs feel numb and tingling and felt heavy when
driven. Patients treated with the drug ranitidine injection of 2 times 1 ampoule for 4 days,
Ringer lactate infusion of 20 drops per minute for 3 days, metformin 500 mg 3 times for 5
1338
days, diaversa (glimepiride) 2 mg 1 time for 1 day, amlodipine 5 mg 1 time for 3 days,
neurodex 2 times 1 tablet for 2 days, ranitidine 150 mg tablet 2 times for 1 day, bufenol
(paracetamol) 1 tablet 2 times for 1 day.
3. DISCUSSION
In this case patient had a history of diabetes mellitus. Patient treated with infusion of
Ringer's lactate as a liquid electrolyte and ranitidine injection is an antihistamine H2
receptor blocker (AH2). H2 receptor excitation will stimulate gastric acid secretion
(BPOM, 2008). In H2 receptor inhibits ranitidine work fast, specific and reversible through
reduction and hydrogen ion concentration of gastric fluid. Metformin is an oral antidiabetic
drug that lowers blood sugar in diabetics the pancreas is still able to produce insulin.
Metformin works by inhibiting gluconeogenesis and increases glucose utilization in the
tissue (Mycek, 2003). Amlodipine is a calcium antagonist of the dihydropyridine class that
inhibits the influx (influx) of calcium ions through the membrane into the vascular smooth
muscle and cardiac muscle contraction thereby affecting vascular smooth muscle and
cardiac muscle is used to treat hypertension. Amlodipine inhibits the influx of calcium ions
selectively, where most of the cells have an effect on vascular smooth muscle than cardiac
muscle cells (ISFI, 2011). Aspilet (aspirin) as antiplatelet aggregation can inhibit thrombus
especially often found in the arterial system (Mycek, 2003). Neurodex is a neurotrophic
vitamin B1 contains (thiamin), B6 (pyridoxine), B12 (cobalamin), vitamin B1 (thiamine) as
a coenzyme in the decarboxylation of alpha-keto acids and plays a role in carbohydrate
metabolism. Vitamin B6 (pyridoxine) in the body turn into pyridoxal phosphate and
phosphate piridoksamin that can aid in the metabolism of proteins and amino acids.
Vitamin B12 (cobalamin) plays a role in the synthesis of nucleic acids and the effect on cell
maturation and maintains the integrity of the neural network (BPOM, 2008). Bufenol
(paracetamol) as an antipyretic (fever-reducing). In addition, peripheral analgesic
paracetamol classified so that paracetamol can be used as a pain reliever. Mechanism of
action of these drugs can inhibit prostaglandins (pain mediators) in the brain but little
activity as an inhibitor of prostaglandin peripheral (Neil, 2005). Ranitidine tablets is a
histamine H2-receptor antagonist that works by blocking histamine in a competitive labor
1339
on H2 receptors and reduces gastric acid secretion, is indicated for the treatment of peptic
ulcers (Mycek, 2008). Diaversa (glimepiride) is a drug to lower blood glucose is given
orally, is included in group sulfunilurea, is indicated for patients with noninsulinDependent (Type II) diabetes mellitus (NIDDM) whose hyperglycemia can not be
controlled with diet and exercise its own, used as Investigations in diet and exercise to
lower blood sugar (Ikawati, 2006). The use of a combination of drugs known as
sulfonylureas and metformin is diaversa (glimepiride) to tackle diabetes in patients who
GDS (sewaktunya blood glucose) can not be adequately controlled with the maximum dose
every day by antidiabetic glimepiride or metformin-containing single (Baxter, 2008). The
results of examination of blood glucose in patients with abnormal values are 349 mg / dl
(normal 80-125 mg / dl). Both sulfonylurea drugs can be used together with dietary
restrictions and exercise program planned, so that diabetes can be well controlled.
Treatment with additional medication begins with low doses, depending on the blood sugar
levels which can further be increased gradually up to a maximum dose per day (Khatzung,
2007). In the therapeutic treatment of these patients are DRP (Drug Related Problems) and
the interaction between metformin and ranitidine are H2 antagonists inhibit metabolism in
the liver sulfunilurea, shingga likely increase the effects of hypoglycemia (David, 2012).
4. CONCLUSION
Based on the result of the clinic secretariat in Mintoharjo Hospital, it could be
concluded that there was presence of DRP (Drug Related Problems) and the interaction
between metformin and ranitidine (Ranitidine inhibit metformin metabolism and increasing
hypoglycemia effect of metformin) (David , 2012).
5.
REFERENCES.
1. Badan POM RI, 2008. Information Obat Nasional Indonesia, Jakarta.
2. Baxter, K. 2008. Stockley’s Drug Interaction. Eight edition. UK: Pharmaceutical Press.
3. David s. Tatro. 2012. Drug Interaction Facts. Pharmaceutical Press.USA
4. Elin, Yulinah, 2011. Iso Farmakoterapi 2. Penerbit: Ikatan Apoteker Indonesia, Jakarta
1340
5. Ikawati, Zullies, 2006, Pengantar Farmakologi Molekuler, Gadjah Mada University
Press, Yokyakarta
6. Isniati, 2003, Hubungan Tingkat Pengetahuan Penderita Diabetes Militus Dengan
Keterkendalian Gula Darah Di Poliklinik Rs Perjan Dr. M. Djamil Padang Tahun.
Jurnal Kesehatan Masyarakat, September 2007, I (2).
7. Katzung, Bertram. G. 2007. Farmakologi Dasar dan Klinik. Jakarta: Salemba Medika.
8. Mycek, mary J. dkk. 2003. Farmakologi Ulasan Bergambar edisi 2, Jakarta: Widya
Medika
9. Murwani, Arita dan Afifin Sholeha, 2007. Pengaruh Konseling Keluarga Terhadap
Perbaikan Peran Keluarga Dalam Pengelolaan Anggota Keluarga Dengan Dm Di
Wilayah Kerja Puskesmas Kokap I Kulon Progo 2007. Jurnal Kesehatan Surya Medika
Yogyakarta. Ilmu Keperawatan Stikes Surya Global Yogyakarta.
10. Neil, M. J. 2005. At A Glance Farmakologi Medis Edisi Kelima. Jakarta: EMS
11. Perkini. 2011. Konsensus Pengendalian dan Pencegahan Diabetes Mellitus Tipe2 di
Indonesia 2011. PB PERKENI. Jakarta.
12. Waspadji, S. (2007). Diabetes Melitus: Mekanisme dasar dan pengelolaannya yang
rasional. Dalam Penatalaksanaan Diabetes Mellitus terpadu. Jakarta.: Balai Penerbit
FKUI.
1341
TREATMENT PATIENT EVALUATION OBSTRUCTIVE JAUNDICE
IN PGI CIKINI HOSPITAL
Arif Setiawan (1), Aprilita Rinayanti Eff(2)and Diana Laila Ramatillah(2)
1
2
ABSTRACT
Obstructive Jaundice is a condition where the blockage of the flow of bile from the liver.
Jaundice (jaundice) is defined as the yellowing of skin and sclera color due to the
accumulation of the pigment bilirubin in the blood and tissues. Bilirubin levels will reach
35-40 mmol / L before jaundice cause clinical manifestations. When the blood bilirubin
level exceeds 2mg% increase then jaundice will be visible. It can happen to an increase in
indirect bilirubin (unconjugated) or direct (conjugated). Jaundice obstructive jaundice that
is caused by obstruction of bilirubin secretion in normal circumstances should be channeled
to the gastrointestinal tract. Male patient aged 30 years old, admitted to hospital with
complaints of itching all over the body, eyes yellow. Had a history of hepatitis A in 2011.
Based on the results of laboratory tests were known there was an increase in total bilirubin
level that is equal to 13.7 mg / dL. Ultrasound examination of patient has fatty liver known.
Patient on therapy with ceftriaxone injection 1g, 1g inj cefoperazon, hepabalance, inpepsa
syr, CTM, urdahex tab, estazor tab. In this case found a DRP (Drug Related Problem) in the
form of drug interaction (ceftriaxone and cefoperazon, inpepsa and urdahex, hepabalance
and urdahex, CTM and hepabalance).
Keywords: obstructive jaundice, indirect or direct bilirubin, PGI Cikini Hospital
INTRODUCTION
Obstructive Jaundiceis a condition where there is a block age of bile flow from the
liver. Jaundice (jaundice) is de fine das they ellowing of skin and sclera colordue to the
accumulation of the pigment bilirubin in the blood and tissues. Bilirubin levels should
reach 35-40 mmol/L before jaundice cause clinical manifestations. When the blood
bilirubin level exceeds 2mg% increase it will be visible jaundice bilirubin increase in
1342
indirect (unconjugated) or direct (conjugated) (Rusepno Hasan, et al, 2007). Jaundiceis a
condition where tissue eyello wish due to deposition of bilirubin that occurs when blood
bilirubin level sreached 2mg/dL. Obstructive jaundice it self is jaundice caused by
obstruction of bilirubin secretion in normal circum stances should bechanneled to the
gastrointestinaltract. As a result of these obstac les occure gurgitation of bilirubin into the
blood stream so that there was jaundice (Sudoyo A, etal. 2006).
In the absence of obstructive jaundice occurring components of bile in the small in
testine and reserves that caused the spillin the systemic circulation. Feces usually become
spaledue toa lack of bilirubin reaching the small intestine, the absence of biles alt scan
cause mal absorption, resulting in vitamin deficiency. (Prodjosudjadi, Wiguno. 2006).
ETIOLOGY
Bile block age can occurdue to abnormalities in the wall of the channel such as the
presence of tumor so rnarrowing due to trauma. The conditions that can cause this block
age also include most of tenis the state of biliary atresia is the failure of formation of
bilirubin bile ducts so jetting out to disturbed bowel. The failure of the current formation in
fetalgrow this also an influence of various factors among pregnant women is excessive
anxiety and the use of certain drugs during pregnancy. Other conditions that can cause
obstructive jaundice is koledokalcysts (Choledochal Cyst) and spontan eous perforation of
the extrahepaticbile duct. (Sudoyo A, etal. 2006)
MANAGEMENT
Management of obstructive jaundice is by surgically removing the cause of the
obstruction. Performed exploratory surgery to diagnose whether the obstruction caused by
gall bladder stones or tumors. If caused by carcinoma (usually at the head of the pancreas),
the surgeon may make a bypass from the gallbladder to the jejunum (Sudoyo A, et al.
2006). The general objective of the management of jaundice is to prevent indirect bilirubin
levels in the blood reached levels that allow for neurotoksikositas.
CASE PRESENTATION
1343
30-years old male patient has complained of itching of the skin around the ± 1 week before
entering the hospital PGI Cikini, yellow eyes since 3 weeks before entering the hospital.
History of right upper abdominal pain 1 month before admission. Patient was diagnosed by
a physician with obstructive jaundice.
CLINICAL EVALUATION
In the case of patient treated for 10 days from the date of 5-14 March 2014 using 1g inj
ceftriaxone, cefoperazone injection 1g, hepabalance, inpepsa syr, CTM, urdahex tab, and
estazor tab.
LABORATORY EXAMINATION RESULTS
On hematological examination results increased erythrocyte sedimentation rate is 19
mm / h (0-10 mm / h), ie a decrease in erythrocyte 3μL 3.93 10 ^ (10 ^ 3μL 4.5-5.5), high
reticulocyte values are 17/mil (5-15 mile), low neutrophil rod that is 0% (2-6%), low
platelet 3μL ie 120 10 ^ (10 ^ 3μL 150-450).
Clinical chemistry examination, showed abnormal low albumin 3.0 g / dl (3.4 to 4.8
g / dl), high value globulin 3.9 g / dl (1.3 to 3.7 g / dl ), high ALP 298 U / L (30-120 U / L),
a high value of GGT is 59 U / L (0-30 U / L), high SGOT is 46 U / L (0-35 U / L), alanine
aminotransferase values as high as 76 U / L (0-35 U / L). High blood calcium 8.5 mEq / L
(8.8 to 10.3 mEq / L), the value of direct bilirubin 11.8 mg / dL (0.1-0.2 mg / dL), indirect
bilirubin value of 2, 1 mg / dL (0.8-1.0 mg / dL) and total bilirubin 13.7 mg / dL (0.1-1.0
mg / dL).
The results of the examination were known elevated levels of SGPT (Serum
Glutamic Pyruvic transaminase) and SGPT (Serum Glutamic Oxaloacetic transaminase)
which is a parameter to determine the health of the liver due to viral or bacterial infection.
The presence of AST levels at 46 U / L and SGPT are high at 76 U / L of the patient
indicates that the patient was suffering from obstructive jaundice. Check laboratory results
also showed bilirubin levels reached 13.7 mg / dL. Whereas the normal maximum level of
1.0 mg / dL. Increased bilirubin cause reddish urine like strong tea and yellowish eyes and
skin obstructive jaundice causes of the disease. During the treated patient were given drugs
1344
for injection 1g ceftriaxone for treatment of infection of the lower respiratory tract, and
cefoperazone injection 1g for the treatment of respiratory tract infections because the top
and bottom, hepabalance to help maintain healthy liver function, inpepsa syr duodenal ulcer
as a treatment of chronic gastritis and gastric , CTM for the treatment of urticaria, urdahex
tab used for cholestatic hepatitis, and estazor tabs are used as hepatic cirrhosis.
1.
Dose subterapetik
On day 2 of 5-7 patient were given antibiotics that ceftriaxone and cefoperazone.
Both of these drugs is aclass that has abroad spectrum cephalosporin effective against
microorganisms and gram-positive and gram-negative. Treated patient given the drug for
injection 1g ceftriaxone for treatment of infection of the lower respiratory tract, and
cefoperazone injection 1g for the treatment because of respiratory trac tinfections the top
and bottom.
2.
Drug interactions
a) Ceftriaxone and cefoperazone
Interactions occur when administered concurrently because it can cause nephrotoxic,
should be given one of the drug alone.
b) Inpepsa and urdahex
Inpepsa can inhibit the absorption of urdahex in the stomach.
c) Hepabalance and urdahex
Hepabalance can improve the work of urdahex.
d) CTM and hepabalance
CTM can reduce the effects of hepabalance work.
ADVICE
1. Disease In patient with obstructive jaundice should beno dose adjustment. Dosage
adjustments may include dose reduction, extending the time of drug administration or a
combination of both.
2. Monitor bilirubin levels during treatment.
1345
3. Non-pharmacological therapy: low-fat diet, quitting smoking and doing regular physical
activity.
CONCLUSION
Based on the results of the examination of patient was found a DRP that is the
subtherapeutic dose and drug interactions.
REFERENCES
1. Anonymous. , 2005. Stocley's Drug Interactions. The pharmaceutical Press
2. Bertram G.Katzung, 2012. Basis and Clinical Pharmacology, 10th edition. EGC Medical
Book
3. Prodjosudjadi, Wiguno. 2006. Ilmu Medicine Volume 2 Issue 4. Jakarta: Department of
Medicine Faculty of Medicine, University of Indonesia.
4. Rusepno Hassan, et al. , 2007. Books Lecture Pediatrics Faculty of medicine Volume 2.
Infomedika, Jakarta.
5. Saragi, Sahat, 2012, for the Use of Drugs Concept Equipped with Pharmaceutical Care,
Drug Counseling Theory, Theory Drinking Drug Compliance, Publishers Rosemata
Publisher, Jakarta.
6. Sudoyo A, et al. , 2006. Dalam.Jakarta Textbook of Medicine: Faculty of medicine.
1346
EVALUATION OF TREATMENT SEIZURES, CEREBRAL
TOXOPLASMOSIS, ORAL CANDIDIASIS, HEMIPARESE DEXTRA,
SUSPECTED OF PULMONARY TUBERCULOSIS, PULMONARY
PNEUMONIA, HYPOKALEMIA, HYPONATREMIA AND PATIENTS
ON HIV / AIDS IN FLOOR GENERAL MAINTENANCE IV ARMY
HOSPITAL EDUCATION GATOT SUBROTO
JAKARTA
Muhammad Arrivad Iriansyah1, Diana Laila Ramatillah2, Aprilita Rinayanti Eff2
1
2
(UTA’45 Jakarta)
ABSTRACT
HIV infection is defined as an individual with HIV infection according to clinical phase
(including Phase 4 is known as AIDS) were confirmed by laboratory criteria of each
country. Mrs.Y patients age 44 years. On 24 April 2014 came to the Gatot Subroto Army
Hospital. Patients present with seizures only on the right side of the body, the right hand
often stiff, tingling, nausea, vomiting accompanied by fever. Patients with AIDS are phase
IV. In 2011 the patient had a seizure and get treatment, the patient stopped consuming
medicines after feeling recovered. Disconnect antiretroviral drugs for 7 months. Patients
diagnosed by a doctor suffering from seizures, Hemiperase Dextra, and cerebral
toxoplasmosis. In the course of treatment of patients experiencing nosocomial infections
and re-diagnosed as Suspect Pulmonary Tuberculosis, Pneumonia Pulmonary patients also
experienced, and occurs Hypokalemia and hyponatremia, based on the doctor's examination
and laboratory values were obtained. 18 patients given the drug type Ceftriaxone,
Omeprazole, Dexamethasone, Pirhymethamine, Clindamicyn, Neurobion 5000,
Metronidazole, Cotrimoksazole, Curcuma, Candistatin drip, Coditam, Micamine, Rantin,
KSR, Methycol, Fluconazole, Albumin and Paracetamol. Of the Drug Related Problem
(DRP) is required additional medication with antibiotics right combination, therapy
received by the patient is not a first-line therapy in the standard treatment of Cerebral
toxoplasmosis and Oral candidiasis in AIDS patients in which immunoglobulin G
1347
antibodies CD4 + count <100uL³, use of metronidazole and dexamethasone, metronidazole
and sulfametaksazol, sulfametakzasol and fluconazole, as well as fluconazole and
trimethoprim simultaneously can cause significant interactions.
Key Word: HIV/AIDS, RSPAD Gatot Soebroto.
INTRODUCTION
HIV infection is defined as an individual with HIV infection according to clinical phase
(including Phase 4 is known as AIDS) were confirmed by laboratory criteria of each
country(7).
HIV infection occurs through three main ways: sexual, parenteral, and perinatal. Sex,
either anal or vaginal, is the most common mode. The possibility of transmission through
anal intercourse 0.1 to 3% and 0.1-0.2% contact vaginal sex. In general, the risk increases
with the severity of sexual partners. Individuals who are at high risk in heterosexual
relationships is a person with ulcerative sexually transmitted diseases, many sexual
partners, sexual partners of parenteral drug users(7).
The use of contaminated needles by injecting other drug users is a major cause of
transmission is parenteral and final end of the quarter the number of reported AIDS cases in
the United States. Health workers have a small risk of contracting HIV as a result of his
work, most of the transmission from needles(7).
Perinatal or vertical transmission of infection, the major cause (> 90% 0 in children
with HIV infection. Risk of mother-child transmission of approximately 25% occurred in
the case of not breastfeeding or ARV therapy. Providing breast milk (breast milk) can also
transmit HIV(6).
Clinical manifestations of primary infection varies, but patients often experience
symptoms or mononucleosis-like illness such as fever, pharyngitis, and adenopathy. (glands
especially lymph gland disorder). Symptoms may disappear after a year of two weeks(7).
The possibility of the development of AIDS associated with RNA virus loads, in a
study, developing speed in the 5 years was 8%, 26%, 49%, and 62% for a copy of the virus
/ mL or <4530, <4531 becomes 13020, 13021, 36270 and be > 36 270 copies of virus(7).
1348
AIDS indicator includes some but not all of the clinical phase 4 as pneumocystis
pneumonia, oesophageal candidiasis, cryptococcal meningitis, cerebral toxoplasmosis,
unexplained washting or malnutrition. Defined according to the WHO Integrated
Management of Childhood Illness Guidelines: Oral thrush is a small plaque on the soft
white-beige normal mucosa/red that can be cleaned (pseudomembranous), or red spots on
the tongue, palate or edges are generally soft and sore mouth. Severe pneumonia cough or
difficulty breathing in children with chest interested, or common dangerous sign. Latheragi
or unconscious, can not drink milk or suck, vomiting or a history of seizures during the last
illness. Severe sepsis: Fever or low body temperature in infants with signs of severity such
as rapid breathing or chest interested, the crown stands, lethargi, sweating movement, do
not drink or breastfeed, convulsions, and stiff neck(7).
METHODOLOGY
The survey was conducted on a 44-year-old female patient in the general care floor IV
Gatot Subroto Army Hospital, based on the length of time the treatment, expected retrieval
time for 36 (thirty six) days to obtain profiles that may represent a therapeutic treatment
that the patient executed. Evaluation studies conducted on the use of patient medication
include drug name, dose and route of administration. It is also rational (proper dosage,
proper indications, the right patient, the right way of life) of treatment of patients with a
look at whether there is interaction or the potential side effects that occur from the use of
drugs based on the literature.
PERCENTATION OF CLINICAL
Patients aged 44 years Mrs Y. On 24 April 2014 came to the Gatot Subroto Army
Hospital. Patients present with seizures on the right side of the body, the right hand often
stiff, tingling, nausea, vomiting accompanied by fever. The patient is known HIV/AIDS
phase 4 In 2011 the patient had a seizure and get treatment, the patient stopped consuming
medicines after feeling recovered. ARV drug withdrawal 7 months. Patients diagnosed by a
doctor suffering from Seizures, Hemiperase Dextra, and Cerebral Toxoplasmosis, Suspect
Pulmonary Tuberculosis, Pneumonia Lung, Hypokalemia, and Hyponatremia
1349
EVALUATION CLINIC
Patient Getting Omeprazole therapy to cope with peptic ulcers and duodenal ulcers,
associated with NSAIDs, gastric lesions and dudenum, H. pylori eradication regimens in
peptic ulcer and reflux esophagitis(1). Ceftriaxon for treatment of bacterial infections of
gram-positive and gram-negative(1). Dexamethason to relieve the symptoms of the disease,
improve the appetite, provide a healthy feeling and can improve the prognosis of serious
diseases(1). Pyrimethanime as antiparasitik for the therapeutic treatment of toxoplasmosis(2).
Clindamisin for therapeutic treatment of staphylococcal infections, and infections of the
mouth caused by Candida albicans(1). Neurobion 5000 as an adjunctive therapy for vitamin
deficiency(1). Metronidazole in the treatment of protozoal infections and anaerobic
infections(1). Cotrimoxazole is a combination of trimethoprim and sulfa metaksazol with a
ratio of 1:5 for the therapeutic treatment of toxoplasmosis(3). Candistatin for therapeutic
treatment of fungal infections of oral and perioral(1)(3). Fluconazole 1x1 (iv) for the
treatment of Candida albicans infections(1)(3). Paracetamol as an antipyretic to treat pain and
reduce fever(1)(3). Mycamine cup (in RL 100 ml) for the acute treatment of candidiasis (5).
Methycol 3x1 tablet (po) as additional vitamins for liver dysfunction(5). Curcuma for the
treatment of liver dysfunction(5). Potassium 1x1 tablet (po) for the therapeutic treatment of
potassium deficiency(1)(5). Albumin (iv) for the emergency treatment of shock, and
conditions that require immediate return of blood formula(5). Coditam 1x1 tablet (po)
equivalent to 30 mg of Codeine to relieve severe pain(5). Rantin for omeprazole replacement
therapies(5).
RESULTS AND DISCUSSION
Based on the results of laboratory tests on the first day of acquired immunological
abnormal results. The number of CD4 count 4 cell/uL (410-1590 cells/uL), Anti-HIV
(Rapid I) Reactive (non-reactive) and HBsAg (Rapid) non-reactive (non-reactive). Based
on the results of laboratory tests of hematology on April 28, 2014, obtained results under
normal abnormal amount of hemoglobin is 11.2 g/dL (12-16 g/dL), hematocrit 34% (3747%) and erythrocytes 4.1 million/uL (4.3 to 60 million/mL). Value of clinical chemistry
1350
laboratory results above normal AST is 73 U/L (<35 U/L), alanine aminotransferase 105
U/L (<40 U/L), globulin 3.6 g/dL (2.5-3.5 g/dL). Cl 108 mmol/L (95-105 mmol/L).
Based on the results of laboratory tests of hematology on 6th May 2014, obtained
results are abnormal. That is the normal hematocrit below 35% (37-47%), erythrocyte
sedimentation rate Advanced (LED) which is as high as 61 mm/h (0-20 mm/h). In the
clinical chemistry laboratory tests abnormal results obtained above normal AST value is
153 U/ L (<35 U / L), and alanine aminotransferase 105 U / L (<40 U / L), leukocytes
11,700 uL (4800-10800 mL), Value Businofil below normal differential count is 0% (13%), Trunk 1% (2-6%), segment 86% (50-70%), lymphocytes 9% (20-40%), MCV 79fL
(80 to 96 fL).
Based on clinical chemistry laboratory results On May 14, 2014, obtained results are
abnormal. Sodium below normal value is 130 mmol/L (135-147 mmol/L), potassium 5.8
mmol/L (3.5-5 mmol/L), total bilirubin 16.7 mg/mL (<1.5 mg/mL), Fospatase Alkaline
(ALP) 1486 U/L (42-98 U/L), AST 280 U/L (<35 U/L), AST 431 U/L (<40 U/L), Ɣ- GT
1778 U/L (5-36 U/L), albumin 3.3 g/dL (3.5-5.0 g/dL).
Based on the results of laboratory tests of hematology at the date of May 27, 2014, the
results were abnormal. Normal hemoglobin values below 4.5 g/dL (12-16 g/dL), hematocrit
12% (37-47%), erythrocytes 1.5 million/mL (4.3 to 60 million/mL), leukocytes 28,000 uL
(4800-10800 mL), counts MCHC 37 g/dL (32-36 g/dL). Clinical chemistry laboratory
results obtained results under normal, abnormal sodium is 127 mmol/L (135-147 mmol/L).
Based on the results of laboratory tests of hematology at the date of May 28, 2014, the
results were abnormal. Normal hemoglobin values below 8.0 g/dL (12-16 g/dL), hematocrit
23% (37-47%), erythrocytes 2.8 million/mL (4.3 to 60 million/mL), leukocytes 23 280 uL
(4800-10800 mL), Platelets 18,200 uL (150000-400000 mL), Value Businofil below
normal counts were 0% (1-3%), segment 76% (50-70%), monocytes 1% (2-8 %), MCV 80
fL (80-96 fL), RDW 17.10% (from 11.5 to 14.5%). Clinical chemistry laboratory results
obtained abnormal results. Total bilirubin value of 27.37 mg/mL (<1.5 mg/mL), Fospatase
Alkaline (ALP) 785 U/L (42-98 U/L), AST 162 U/L (<35 U/L), ALT 133 U/L (<40 U/L),
total protein 4.3 g/dL (6 to 8.5 g/dL) Albumin 2.4 g/dL (3.5-5.0 g/dL) , globulin 1.9 g/dL
(2.5-3.5 g/dL).
1351
Based on the results of laboratory tests for the microbiological examination of sputum
smear-type material on the 9th, 12th, 13th, and May 14 obtained negative results.
Patients treated with omeprazole 2x40 mg (iv) to treat nausea and vomiting was given
for 19 days (April 24-May 14). Ceftriaxon 2x2 grams (iv) for the treatment of bacterial
infections of gram-positive and gram-negative given for 19 days (April 24-May 14) then
treatment is given again on May 27, during treatment (27 to 30 May). Dexamethason (iv).
100 mg 2 ampoules. (first time) then 4x5 mg (iv) a day to relieve the symptoms of the
disease, improve the appetite, provide a healthy feeling and can improve the prognosis of
serious illness(1) was given for 19 days (April 24-May 14) and then the dose was lowered to
2x5 mg (po) (on 8-14 May) until the end of therapy dismissed. Pyrimethanime 8 tabs. 25
mg (first time) is given in the emergency department before entering the treatment room,
then 3x25 mg (po) daily as anti-parasitic for therapeutic treatment of toxoplasmosis,
treatment was given for 36 days (April 24-May 30). Clindamisin 4x600 mg (po) for the
therapeutic treatment of staphylococcal infections, and infections of the mouth caused by
Candida albicans is given for 20 days (April 25-May 14). Neurobion 5000 1x1 as an
adjunctive therapy for vitamin deficiency is given for 16 days (April 29-May 14). 3x500
mg metronidazole (iv) as a therapy protozoal infections and anaerobic infections for 12
days (2 to 14 May). Curcuma 3x1 (po) as a therapeutic treatment of impaired liver function
is given during treatment (7 to 30 May). Cotrimoxazole 1x960 mg tablets (po) a
combination of trimethoprim and sulfa metaksazol with a ratio of 1:5 for toxoplasmosis
treatment therapy is given during treatment (7 to 30 May). Candistatin drop 4x1 (po) for the
therapeutic treatment of oral and perioral fungal infections, given for treatment (7 to 30
May). Rantin 2x1 (iv) in lieu of the use of Omeprazole to reduce nausea and vomiting, was
given for 8 days (May 15 to 23). Fluconazole 1x1 (iv) additional therapy for the treatment
of Candida albicans infection (19 to 30 May).
On May 25-26 patients receiving treatment with 4x500 mg paracetamol for fever then
replaced with 3x1 Sistenol (po) is given when (if) the patient's fever (May 28). Mycamine
cup (in RL 100 ml) for the acute treatment of candidiasis was given for 6 days (May 15 to
21). Methycol 3x1 tablet (po) as additional vitamins to impaired liver function, given
1352
during treatment (15-30 May). Potassium Tablets (po) for the therapeutic treatment of
potassium deficiency.
In the therapeutic treatment of Mrs. Y, is found the DRP (Drug Related Problem) that
required additional medication with antibiotics right combination(3), treatment received by
the patient is not a first-line therapy to standard treatment of Cerebral toxoplasmosis in
which immunoglobulin G antibodies CD4 + count <100 μL³ and oral candidiasis in AIDS
patients (3) and drug interactions (5).
Concomitant use of metronidazole and dexamethasone. Metronidazole will increase the
effects of dexamethasone and affect CYP3A4 enzyme metabolism in liver/intestine.
Significant interactions required close monitoring(4). The use of metronidazole and
sulfamethoxazole
Mechanism:
decreased
metabolism.
Significant
interaction(4).
Concomitant use of sulfamethoxazole and fluconazole, increase QTc interval (QT interval
is a measure of the time between the beginning of the Q wave and the end of the T wave in
the heart of the electrical cycle. QT interval represents electrical depolarization and
repolarization of the ventricles. Prolonged QT interval is a potential marker for ventricular
tachyarrhythmias such as torsades de pointes and risk factors for sudden death)(8).
Interaction potential as a dangerous, use with caution and close monitoring is required(4).
Concomitant use of fluconazole and trimethoprim increase QTc interval, as a potential
dangerous interaction, use with caution and close monitoring is required(4).
CONCLUSION
Of the DRP is required additional medication with antibiotics right combination,
therapy received by the patient is not first-line therapy in the standard treatment of
toxoplasmosis and oral candidiasis in AIDS patients in which immunoglobulin G
antibodies CD4 + count <100uL³, and drug interactions, namely between metronidazole
and dexamethasone, metronidazole and sulfametaksazol, sulfametakzasol and fluconazole,
as well as fluconazole and trimethoprim(4).
1353
SUGGESTION
1. It is recommended to do a test toxo, because the use of the therapy requires regular
monitoring of laboratory results.
2. Need additional treatment with appropriate antibiotics. Standard first-line treatment for
the treatment of toxoplasmosis in which immunoglobulin G antibodies CD4 + count
<100uL³ namely Trimethoprim and sulfamethoxazole 1 tablet orally (cotrimoxazole)
with 2 power (active substance) 480 mg once daily(3)(6). Therapy for acute infection in
adult AIDS patients is pyrimethamine 200 mg orally once a day then 50-75 mg / day in
combination with sulfadiazine 1-1.5 g orally 4 times a day and leucovorin 10-20 mg
orally once daily for 4-6 weeks(3). The first choice for the treatment of oral candidiasis
in AIDS patients is Fluconazole 100 mg orally for 7-14 days (AI) or 500,000 units of
oral nystatin swish (~ 5 mL) 4 times daily for 7-14 days (BII) (3).
3. It should be monitoring the results of routine CD4+ immunoserologi laboratorium(1).
4. Need setting the time interval between the administration of metronidazole and
dexamethasone, metronidazole and sulfametaksazol, sulfametakzasol and fluconazole,
pyrimethamine and sulfametaksazol and fluconazole and trimethoprim(4).
REFERENCES
1. Badan Pengawas Obat dan Makanan Republik Indonesia. 2008, Informatorium Obat
Nasional Indonesia 2008. KOPERPOM, dan CV Sagung Seto: Jakarta.
2. Chandra, G. 2013. Toxoplasma gondii : Aspek Biologi, Epidemiologi, Diagnosis, dan
Penatalaksanaannya. Aventis Pharma: Indonesia.
3. Dipiro, J.T., R.L Talbert, G.C. Yee, B.G. Wells, and L. M. Posey. 2005,
Pharmacotherapy : A Pathophysiologic Approach, 7th Edition. Mc. Graw-Hill
Companiec Inc Wahington, D.C.: United State Of America. Section 16: Infection
Diseases. Page: 2065-2084.
4. http://www.medscape.com
5. Kasim, F. 2008. ISO: Informasi Spesialite Obat Indonesia, Volume 4. Penerbit ISFI:
Jakarta.
1354
6. Schwinghammer, T. L., Koehler., J. M. 2009, Pharmacotherapy Casebook : A Patient
Focused Approach, 7th Edition. Mc. Graw-Hill Companiec Inc Wahington, D.C.:
United State Of America.
7. Sukandar, E. Y., Andrajati, R., Sigit, J. I., Adnyana, I. K., Setiadi, A. P., and
Kusnandar. 2011. ISO Farmakoterapi Volume 2. Penerbit Ikatan Apoteker Indonesia:
Jakarta.
8. Wikipedia Indonesia http://en.wikipedia.org/wiki/QT_interval
1355
CASE STUDY IN HOSPITAL K OF DISEASE
NON HEMORRHAGIC STROKE (SNH) POST. HEAD TRAUMA
Muhammad Ashar Muslimin, Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
ABSTRACT
Non Hemorrhagic Stroke (SNH) Post. Head trauma is the death of brain tissue due to
inadequate blood supply. Head trauma due to a conflict so that the head and the lining of
the brain injury that causes bleeding3. Mr. patients. DH, aged 44 years, entered the hospital.
PGI Cikini on February 12, 2014 with a diagnosis of stroke Non-Haemorrhagic (SNH)
Post. Head trauma, falling down iron in the head, over the wound in the head, blurred
vision, constipation (difficult BAB), and headache were heavy but the patient does not
experience fainting and vomiting. During the treatment the patients treated with
Ceftazidime, Vit K, Transamin, Torasic, Lancolin, Lactulac and mefenamic acid. Based on
the results of their clinical practice in a hospital ward K. PGI Cikini it can be concluded that
that the presence of DRP (Medicine Related Problem) form of the drugs interaction
(ceftazidime and ketorolac; ketorolac and Vit k; transamin and Vit K; torasic and
transamin;
mefenamic
acid
and
Vit
K;
Ceftazidimeandmefenamicacid).
Keywords: Non-Hemorrhagic Stroke (SNH) Post. Head Trauma, Medicine and
Cikini
RS.PGI
INTRODUCTION
Medication plays an important role in health care. Treatment and prevention of
various diseases cannot be separated from the act of medicine therapy or pharmacotherapy.
Wide selection of currently available medicines, requiring careful consideration in choosing
a medicine for a disease. No less important, the medicine should always be used correctly
in order to provide optimal clinical benefit. Too many types of medicines available were
also able to provide its own problems in practice, especially regarding how to choose and
use the medicine properly and safely .Using improper medication, ineffective, unsafe and
uneconomical or more popular, the term does not rational, has now become its own
1356
problem in health care, both in developed countries as well as developing countries. This
problem is encountered in health care units, for example in hospitals, health centers, private
practice, and society. Improper use of medicines which might occur if the risk is not
balanced with the benefits of giving a medicine action1.
Rational medicine use in health care in Indonesia is still a problem. The use of
polypharmacy in which a patient's average get 3, 5 medicines, more than 50% receive 4 or
more for each piece of the recipe, excessive use of antibiotics (43%), short consultation
time that is on average only 3 minutes and not presence of patient compliance in taking
medication is a common pattern that occurs in irrational medicine use in Indonesia with the
increasing complexity of the medicines currently used mainly in the treatment, and the
development of polypharmacy, the possibility of getting big interaction2.
Non Hemorrhagic Stroke (SNH) Post. Head trauma is the death of brain tissue due
to inadequate blood supply caused by trauma to the head due to the conflict so that the
injury suffered head injuries and brain membranes. Marked by severe headaches and due to
bloody3. This is due to pathological bleeding from a tear that occurs in the walls of vessels
or cerebral circulation by partial occlusion or the entire lumen of the blood vessel with the
influence of temporary or permanent. It can cause death, due to impaired blood circulation
and inadequate blood supply and also leads to focal or global brain function impaired4.
To select the appropriate medicine to the patient or commonly mentioned to as medicine-P
starts from determining the group of medicines that are effective, and then choose one or
more medicines - medicines that are most appropriate to the patient. To select medicine-P
must be based on scientific considerations, including consideration of effectiveness, safety,
suitability, practicality, and cost. It also must consider the aspects of the kinetics and
dynamics of medicine5.
CASE PRESENTATION
Mr. patients. DH, age 44 RS.PGI Cikini entered on February 12th , 2014, patient
came with complaints falling down iron head, wound in the head, blurred view of the
patient, the patient also have constipation (difficult BAB) and a heavy headache but
patients do not experience fainting and vomiting.
1357
CLINICAL EVALUATION1
In the case of patients treated with ceftazidime, where ceftazidime which is used for
infections due to head trauma. The use of ant platelet ie Vit K (menadione HCl) and
transamin (ketorolac tromethamine) as an antiplatelet medicine used to prevent the
occurrence of hemorrhage (bleeding) in which there is bleeding in these patients due to the
collision of iron in the head area., But using both medicines may decrease and increase of
effects or levels of one of the medicines, which decrease the antiplatelet effects of
transamin, while the antiplatelet effects of Vit K increases. Giving lancolin (sitikolin) is
used for acute conditions in the loss of consciousness due to head trauma. In addition,
patients were also treated with Torasic (tranexamic acid) is an analgesic or anti-pain both
short-term symptomatic therapy, medium and severe acute pain. Also used other anti-pain
that mefenamic acid, as well as giving lactulac (lactulose) syrup used for constipation
(difficulty to take a bowl).
DOSE AND INDICATION8
In the case of patients treated with a dose of 1 g of ceftazidime with 3 x 1 given by
injection daily, Vit K (menadione HCl) 10 mg / 1 ml 2 x 1 day with the use of the injection,
Transamin (tranexamic acid) dose of 100 mg / 5ml 3 x 1 day with the use of the injection,
Torasic (ketorolac tromethamine) at a dose of 30 mg / ml 2 x 1 daily injection use, Lancolin
(sitikolin) at a dose of 500 mg 1 x 1 daily administered orally, mefenamic acid at a dose of
500 mg 3 x 1 day with oral usage, and Lactulac syrup (lactulose) at a dose of 30 ml of 1 x 1
cc a day taken orally.
RESULT OF THE LABORATORY7
Results of laboratory tests on the patient Mr. DH which showed abnormalities in hematocrit
is 37% (normal value: 40-48%), 12,700 thousand leukocytes / mm3 (normal value: 5-10
thousand / mm 3), Ca 8.5 Mg / dl (normal value: 8.8 - 10.3 Mg / dl).
1358
DRP 1: Required additional medicine
By looking at the condition of the patient does not need the addition of a medicine
or condition in which patients have to add another medicine, because of the treatment given
are in accordance with his therapy.
DRP 2: Drug interaction1,6
Ceftazidime with torasic (ketorolac tromethamine) can increase the effect or torasic
levels. Vit K (menadione HCl) when administered concurrently with torasic may increase
the effects or levels of Vit K. Provision of antiplatelet transamin (tranexamat acid) with
other antiplatelet that Vit C can cause effects or decreased while the effect transamin levels
or levels of Vit K will increase. Torasic and transamin can cause bleeding effects (bleeding)
longer. Mefenamic Acid and Vitamin K may enhance the effects or levels of Vitamin K.
And Ceftazidime and mefenamic acid may increase the effect or concentration of
mefenamic acid, but it is not too dangerous.
DRP 3: Failure in receiving the drugs
In this case, there are no failures in the administration of medicines or in other
words the administration of medicines given to patients already as recommended by
yourdoctor.
DRP 4: Ineffectiveness of the drugs
In this case, there are no administration of medicines that are not effective or in
other words the administration of medicines that are not in accordance with the indication.
DRP 5: Non-compliance
In the case of non-compliance affects also the DRP, but the treatment is done, the
patient can adhere to and follow the recommended treatment has been determined, so no
problems arise.
DRP 6: Other
In the book list is sometimes nurses did not write medicine that is given to the
patient or the dose given. So it is advisable to nurses to always take note of what has been
given to the patient, but in this case, this is not the case. But still perform monitoring nurse
notes on the list of medications.
1359
CONCLUSION
Based on the results of their clinical practice in case study in hospital k of disease, it
can be concluded that the presence of DRP (Medicine Related Problem) form of the
medicine interaction (Ceftazidime and ketorolac; ketorolac and Vit k; transamin and Vit K;
torasic and transamin; Mefenamid acid and Vit K; Ceftazidime and Mefenamid acid).
REFERENCES
1 BPOM. 2008 Indonesian National Medicine Information (IONI). Jakarta: Sagung Seto
2 Syamsuddin, Dr. M. Biomed, Apt. Medicine Interactions 2011. Basic Concepts and
Clinical. Jakarta: University of Indonesia Press
3 Mansjoer, A, et al. 2007 Capita Selecta Medicine second volume. Jakarta: Faculty of
medicine Aesculapius Media
4. Harsono,. 2003 Capita Selekta Neurulogi Second Edition, Yogyakarta: Gadjah Mada
University Press
5. Priyanto, Drs. M. Biomed, Apt. 2009, Pharmacotherapy and Medical Terminology.
Jakarta: Leskonfi
6. Anonymous, 2005, Stocley's Medicine Interactions. The Pharmaceutical Press
7 Sutedjo, AY. 2007 Pocket Book About Disease Through Laboratory examination results.
London: Amara Books
8 Burns, Dr. Aine. Renal Medicine Handbook 2009 third edition. New York: Oxford
1360
DRUG RELATED PROBLEM ASSOCIATED IN TREATMENT OF
HNP (HERNIATED NUCLEUS PULPOSUS) DISEASE IN
MINTOHARDJO NAVY HOSPITAL
Astinapati Sampe Bua1, Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
[email protected]
ABSTRACT
Herniated nucleus pulposus is prolapse of an intervertebral disc through a tear in the
surrounding annulus fibroses where the annulus fibroses along pulpous nucleus protruding
into the spinal canal. HNP is the degeneration process of the intervertebral discs, therefore
more common in geriatric patients (Rybock, 1993). Mr. A, 44 years old, came to
Mintohardjo Navy Hospital on April 27th, 2014, was diagnosed of pain in the waist and
spread to right leg. Before the incident patient was practicing karate and kick with the right
leg. Laboratory tests and vital signs showed normal values. During hospitaziled, patients
has received ketorolac therapy RL drip 20 drops per minute, ranitidine injection of 2 x 1
ampoule, 3x1 diazepam injection ampoules, tramadol tablet 2 x 50 mg, amitriptyline 3 x
12.5 mg tablets, 2 x 50mg sodium diclofenac, and allopurinol 1 x 100mg to reduced the
pain, 1x 30 mg gemfibrozil to reduced triglycerides. Based on the result of the clinic
secretariat at Mintohardjo Navy Hospital, it could be concluded that there was DRP (Drug
Related Problems) such as: tramadol and amitriptyline need monitoring because it can
increased the serotonin in the brain, and CNS depressants happened when giving diazepam
and tramadol and amitriptyline.
Keywords : DRPs, HNP, Mintohardjo Navy Hospital
1.INTRODUCTION
Herniated nucleus pulposus is prolapse of an intervertebral disk through a tear in the
surrounding annulus fibroses. Herniated nucleus pulposus is a condition which part or the
entire soft, gelatinous central portion of an intervertebral disk is through a weakened part of
the disk, resulting in back pain and nerve root irritation (Nettina & Mills, 2006).
1361
Back pain is a common complaint found in the life and is one of the reasons to visit a
doctor. Back pain is often causing of activity restrictions in the population of age less than
45 years old (Sufitni, 2009).
Patients often complain of lumbar HNP are getting the pain during activities like
sitting for long, bending, raised a heavy object, also when the coughing, sneezing and
straining. This is commonly caused by a transient increase in intrathecal pressure along
durometer (Rybock, 1993)
2.CASE PRESENTATION
Mr. A, 44 years old, came to Mintohardjo Navy Hospital on April 27th, 2014, was
diagnosed of pain in the waist and spread to right leg. Before the incident patient was
practiced karate and kick with the right leg and waist. Pain will increased if sneeze or
cough even he could not walk. Laboratory tests and vital signs shown normal values.
In the case of patient was treated with 30 mg ketorolac RL drip 20 drops per minute,
tramadol tablets 50mg X 2 and
2 x 50mg of sodium diclofenac
to reduced pain,
Ranitidine injection of 2 x 25mg to treated gastric irritation, diazepam injection 2 x 2mg for
tranquilizers, amytriptilin 3x12 tablets, 5mg, as an anti-depressant, gemfibrozil 1x30mg, to
decreased triglyceride levels, allopurinol 1x100mg for the treatment of gout (Elin Yulinah,
2011)
Laboratory tests were performed 2 times that were on the 27th showed normal values,
while on December 28, an increase in triglycerides 207 (normal value <170).
4. DISCUSSION
In this case, patient first time treated with ketorolac drip RL, ranitidine injection,
diazepam injection, and tramadol tablets. After the action is taken, patient was moved to
Selayar care room. On the second day added amitriptyline. On the third day, RL drip
ketorolac and ranitidine was discontinued and replaced with diclofenac sodium,
discontinued caused by reduced perceived pain. On the fourth day patient can go home and
1362
patient received oral medication tramadol 2 x 1, 2 x 1 diclofenac sodium, gemfibrozil 1 x 1
and allopurinol 1 x 1.
Based on the result of the clinic secretariat at Mintohardjo Navy Hospital, it could be
concluded that there was DRP (Drug Related Problems) such as use of tramadol can cause
respiratory depression, because patient also had a history of asthma, so the use of tramadol
should be careful.
Other DRPs (Drug Related Problem) is the use of diazepam and tramadol and
amitriptyline can cause potentiation of CNS depressant effects. The effect is excessive
sedation or respiratory depression effects can even lead to death.
It can be seen during patient treated at the hospital, patient feels weakness, and
excessive sleepiness, and perception is weakeness.
5.CONCLUSION
Based on the result of observation during hospitalized on Selayar roomcare at
Mintohardjo Navy Hospital it can be concluded that occurred the DRP (Drug Related
Problem), that are drug interaction between tramadol and amytriptilin. Giving both of
them can increased serotonin in the brain and potentiation of CNS depressants effect when
giving of diazepam, tramadol, and amytriptilin together
6.REFERENCES
1. Elin Yulinah, 2011, ISO Pharmacotherapy 2, Publisher: Ikatan Apoteker Indonesia,
Jakarta
2. Drug Interaction, www.medscape.com, access 10/06/2014
3. Sufitni. 2009. The diagnosis of neurological topics. edition 2. Jakarta : EGC
4. Rybock JD, Low Back Pain And Lumbar Disc Herniation, in: current therapy in
neurologic disease ed.4, Mosby – year book inc, 1993.
5. Badan POM RI, 2008, Indonesian National Drug Information, Jakarta.
6. BNF 61, 2011, Britsh National Formulary 61 march
7. Diporo, Joseph T, 2006, pharmacotherapy Handbook Six Edition, Mc Graw Hill
Company.
1363
8. UK Renal pharmacy Group, 2009, Renal Drug Handbook third edition, Radcliffe
publishing oxford, New York.
1364
DRUG RELATED PROBLEM ASSOCIATED IN TREATMENT
CHRONIC KIDNEY FAILURE DISEASE
Ayu Ashari1, Aprilita Rinayanti Eff2 and Diana Laila R2
1
2
[email protected]
ABSTRACT
According to the National Kidney Foundation (NKF) Kidney Disease Outcomes Quality
Initiative guidelines update in 2002, the definition of chronic kidney disease (CRF) is
kidney damage over 3 months, in the form of structural abnormalities of the kidneys, can or
without decreased glomerular filtration rate (GFR), which is characterized by abnormal
pathology, and the presence of markers of kidney damage, can be abnormalities such as
blood or urine laboratory or radiological abnormalities in glomerular filtration rate less than
60 mL/menit/1,73m2 for more than 3 months can be with or without kidney damage. (1).
Patient Mr. As, aged 57 years, entered Mintohardjo Naval Hospital on 22 April 2014, with
the diagnosis of chronic kidney failure. During the treatment the patient was treated with
CaCO3, Sodium Bicarbonate, folic acid, amlodipine, Ondasentron Amp, Valsartan,
Mefenamic Acid, Allopurinol and perform hemodialysis.Based on the results of their
clinical practice on the third floor of a screen treatment in RSAL Mintohardjo it can be
concluded that the presence of DRP, That the correlation between drug therapy with
disease, the selection of appropriate drugs and significant drug interactions.(5)
Keywords: Chronic Kidney failure, and RSAL. Dr. Mintohardjo.
1.
INTRODUCTION
Kidney is a vital organ that plays a very important in maintaining the stability of the
environment in the body. The kidneys regulate the body's fluid balance and electrolyte and
acid-base in a way that is through the kidneys filter blood, selective reabsorption of water,
electrolytes and non-electrolytes, as well as urinary excrete the excess. The primary
function of kidney is to maintain the volume and composition of the extra-cellular fluid
within normal limits. The composition and volume of extracellular fluid is controlled by
glomerular filtration, tubular reabsorption and secretion. 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
1365
minute). Over 90% of blood enters the kidneys are in the cortex, while the rest flowed into
the medulla. (7)
Chronic kidney diseaseis a progressive loss of kidney function, which occurs
months to years, which is characterized by structural changes gradually with normal renal
interstitial fibrosis. CKD is categorized based on the level of kidney function,Glomerular
filtration rate/GFRinto stage 1 to stage 5, with an increase in the number indicates an
increase in the degree of severity of the disease was defined as a decrease in GFR
In
developed
countries,
cronic
non-communicable
diseasesparticularly
cardiovascular disease, hypertension, diabetes mellitus, and chronic kidney disease, has
replaced communicable diseasesas a major public health problem.
The development and progress of CKD can not be predicted, in patient with CKD
stage 1 or 2 are generally no symptoms and metabolic disorders commonly experienced by
patient with CKD stages 3 to 5, namely anemia, secondary hyperparathyroidism,
cardiovascular disorders, malnutrition and fluid abnormalities and electrolyte which is a
sign of impaired kidney function. Uremic symptoms (fatigue, weakness, shortness of breath
/ wheezing, mental disorders, vomiting, bleeding nausea and anorexia) generally does not
appear on stage 1 and 2, there was minimal at stage 3 and 4, and occurs in patients with
stage 5 CKD is also commonly experienced itchy skin.(6)
2.
CASE PRESENTATION
Patient Mr. As, aged 57 years entered RSAL Mintohardjo on April 22, 2014. Patient
present with symptoms of dizziness, nausea, vomiting, felt claustrophobic the first time
after a long run, weakness, body aches, decreased appetite since 1 month before admission,
weight loss ± 5 kg in a month, 3 bowel movements once a day, and complained of
difficulty sleeping. The patient had a history of hypertension and kidney disease. Patient
entrance with a diagnosis of CKD stage V or end stage renal disease who routinely have to
perform hemodialysis. Patient was treated with CaCO3, Sodium Bicarbonate, Folic Acid,
Ondasentron amp, valsartan, amlodipine, Mefenamic Acid and Allopurinol.
1366
3.
CLINIC EVALUATION
From the results of the examination of patient obtained some abnormal results are
an increase in urea levels so that patient experience nausea and treated with ondasentron.
hiperposfatemia can inhibit the absorption of calcium levels that need to be treated with
calcium carbonate, uric acid so should be treated with allopurinol, administration of sodium
bicarbonate to control metabolic acidosis, a decrease in hemoglobin in patient with
hematocrit indicates anemia thus treated with folic acid and packed cells red. Test results
showed an increase in blood pressure, so it is treated with a combination of
antihypertensive drugs namely amlodipine (CCB group) and valsartan (ARB group), in
patient with CKD who have gastritis, appetite will be reduced so that treated with ranitidine
4.
1.
The Correlation Drug Therapy and Disease
Laboratory findings showed increased triglycerides and decreased HDL values so
patients should be treated with drugs antihiperlipidemithat gemfibrozil. (6)
2.
Selection of Appropriate Drugs
The use of drugs is not recommended mefenamic acid in patient with CKD (4)
3.
Drug Interaction
Drug interactions significant interactions occurring between:
a.
Calcium carbonate dan allopurinol, calcium carbonate decreases levels of
allopurinol by inhibition of GI absorption. Applies only to oral form of both
agents. Significant interaction possible, monitor closely. Separate by 2 hours.
b.
Sodium bikarbonate dan allopurinol, sodium bicarbonate decreases levels of
allopurinol by inhibition of GI absorption. Applies only to oral form of both
agents. Significant interaction possible, monitor closely. Separate by 2 hours.
c.
Calcium carbonate dan amlodipine, calcium carbonate decreases effects of
amlodipine by pharmacodynamic antagonism. Significant interaction possible,
monitor closely.
d.
Valsartan dan asam mefenamat,valsartan,mefenamic acid. Either increases toxcity
of the other by Other. Significant interaction possible, monitor closely. Comment:
1367
May result in renal function deterioration, particularly in elderly or volume
depleted individuals. (5)
5.
CONCLUSION
Based on the results of clinical practice on the third floor of a screen treatment
RSAL Mintohardjo it can be concluded that the presence of DRP (Drug Related Problem),
there are a clinical condition in which there is no untreated, the selection of drugs that are
less effective to the patient so that the use of mefenamic acid is not recommended for use in
patient with CKD, a significant interaction occurred between CaCO3 and allopurinol,
where CaCO3 lowering effects of absorption and absorption so that the use of both drugs
should be given about one or two hours. Bicnat and allopurinol where bicnat lowering
effect of allopurinol absorption and should be given about one or two hours of use of the
two drugs. CaCO3 and amlodipine where CaCO3 decrease in the pharmacodynamic effects
of the antagonism that its use must be monitored. Valsartan and mefenamic acid where
mefenamic acid which lowers the pharmacodynamic effects of valsartan in antagonism and
should be monitored for potentially harmful interactions. (5)
6.
REFERENCES
1. Alam, syamsir dan Hadibroto iwan, 2007. Gagal Ginjal, Gramedia pustaka utama;
jakarta
2. Baradero, Marry dkk, 2008. Klien Gangguan Ginjal, Penerbit buku kedokteran EGC;
jakarta
4. BNF 61, 2011. Britsh National Formulary. Pharmaceutical Press: London
5. Baxter, karen, 2008. Stockley’s Drug Interaction. Pharmaceutical Press: London
7. Elin Yulinah, 2011, ISO Farmakoterapi 2, Penerbit: Ikatan Apoteker Indonesia, Jakart.
8. Sukandar, Enday. 2006. Gagal Ginjal dan Panduan Terapi Dialisis. Pusat
Informasi
Ilmiah Bagian Ilmu Penyakit Dalam FK.UNPAD. Bandung
1368
9. UK Renal Pharmacy Group. 2009.Renal Drug Handbook Third Edition, Radcliffe
publishing Oxford. New York
1369
DRUG RELATED PROBLEMS ON URINE RETENTION DISEASE IN
PGI CIKINI HOSPITAL
Ashar1, Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
[email protected]
ABSTRACT
Urinary retention is a state of the buildup of urine in the bladder and does not have the
ability to empty it completely. Patient, Mr. SS aged 73 years old, entered PGI Cikini
Hospital on March 9 th 2014. Patient was diagnosed urinary retention. Patient was treated
with Ceftriaxone injection, Kalnex injection, Vit K injection, Torasic injection, Urocholin,
Paracetamol, Levofloxacin, and Neurobion. Based on the results of the clinical practice in a
hospital ward K PGI Cikini it can be concluded that the presence of DRPs (Drug Related
Problems) , there are form of the drugs were not necessary and drug interactionbetweenis
Ketorolac and Vitamin K.
Keyword: Urine retention and RS PGI Cikini
I.INTRODUCTION
Urinary retention is a state of the buildup of urine in the bladder and does not have
the ability to empty it completely. Urinary retention is the difficulty of micturition due to
failure of fesikaurinaria urine.(6)
Causes of urinary retention, among others, diabetes, enlarged prostate gland, urethral
abnormalities (tumor, infection, calculus), trauma, childbirth or neurological disorders
(stroke, spinal cord injury, multiple sclerosis and Parkinson's). Some medications can cause
urinary retention either by inhibiting bladder contractions or increased resistance of the
bladder.(6)
In this paper profiles will be evaluated in the treatment of patient with urinary retention PGI
Cikini Hospital.
2.METHODOLOGY
The case studies was conducted to the patient on Cardiac unit based on the length
of patients treated. The evaluation was done based on the data of drug use, include drug
name, dosage and mode of administration and rationalization of the using of the drug (the
1370
right dose, the right indication, the right patient, the right of use) with see Drug Related
Problems of drug use based on the literature.
3.CASE PRESENTATION
Patient Mr. SS, aged 73 years old, entered PGI Cikini Hospital on March 9th, 2014.
Patient present with urination is not smooth, no past medical history.
Patient was treated with Ceftriaxone injection, Kalnex injection, Vit K injection, Torasic
injection, Urocholin, Paracetamol, Levofloxacin, and Neurobion.
4.RESULTS AND DISCUSSION
In clinical chemistry test results on the eighth day showed increased blood glucose
value was 155 mg / dl (70 -80 mg / dl), and on the ninth day showed a relatively normal
blood glucose was 112 mg / dl (70-150).
Hematological examination on the ninth day showed the value of an abnormal blood
sedimentation rate of 70 mm / h (0-20 mm / h), which was leukocyte count 13.6 10 ^ 3μL
(5.0 to 10.0), red cell count was 4, 26 10 ^ 3μL (4.00 to 4.5 10 ^ 3μL), and neutrophils
segment was 81% (50-70%).
Examination of blood pressure in patient with Mr. SS on the first day to the tenth
showed relatively normal blood pressure 120/80 mmHg.
As long as patient treated at PGI Cikini Hospital, patient was received 8 types of
drugs. The used of drug therapy, Ceftriaxone administered to patient for the treatment of
urinary tract infections. Kalnex used for abnormal bleeding. Vitamin K was used for blood
clotting. Torasic (Ketorolac) was given to patient for short-term symptomatic treatment,
and to moderate acute pain - severe. Urocholin (Betanecol) was used to treat patients with
urinary retention, and in people with neurogenic bladder. Paracetamol was used to relieve
pain. Levofloxacin was used for acute exacerbations of chronic bronchitis, and urinary tract
infections. Neurobion was used to for the treatment of deficiency of vitamin B1, B6, B12,
convalescence after illness.(2) (4)
1371
5.DRUG RELATED PROBLEMS
1. Medication is not needed
- Kalnex (tranexamic acid) and vitamin K need not be given because no bleeding
- Need not be given Paracetamol for pain relief, because the treatment has been given
torasic (Ketorolac).(1)
2. Drug Interaction
Ketorolac and Vitamin C will enhance the effect of ketorolac as an anti-pain
medication.(1)
6.CONCLUSION
Based on the clinical practice in the pital ward K PGI Cikini Hospital it can be concluded
that there was a DRP (Drug Related Problem), the presence of drugs that do not need to
be given as well as drug interactions that occur Torasic (Ketorolac) and Vitamin C will
enhance the effect of ketorolac as anti-pain medication.(5)
7.REFERENCES
1. Anonymous. , 2005. Stocley's Drug Interactions. The Pharmaceutical Press
2. BPOM. , 2008. Indonesian National Medicine Information (ioni). Jakarta: Sagung
Seto
3. Bertram G.Katzung, 2012. Basis and Clinical Pharmacology, 10th edition. EGC
Medical Book
4. Drs. Priyanto, Apt. M.Biomed, 2008. Pharmacotherapy and Medical Terminology.
Institute for Studies and Consultations pharmacological.
5. Saragi, Sahat, 2012, for the Use of Drugs Concept Equipped with Pharmaceutical
Care, Drug Counseling Theory, Theory Drinking Drug Compliance, Publishers
Rosemata Publisher, Jakarta
6. Sudoyo A, et al. , 2006. Textbook of Medicine: Faculty of medicine. Jakarta
1372
DRUG RELATED PROBLEMS WITH THE TREATMENT FOR
DIABETES MELLITUS (TYPE II DM) IN PERSAHABATAN
HOSPITAL
Cana Rapika1, Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
ABSTRACT
Diabetes mellitus is a metabolic disorder characterized by hyperglycemia-related
abnormality of metabolism of carbohydrates, fats and proteins caused by decreased insulin
secretion or insulin sensitivity decrease or both chronic microvascular complications and
cause, makrovaskuler, and neuropathy. Ny Patients. 42 year old Unah, sign Friendship
Centre General Hospital (was) may 17, 2014 at at 07 with a diagnosis of hypoglycemia,
unconsciousness and DM type II. A patient comes in with complaints of loss of
consciousness, unable to speak and lip look oblique. During the treatment of Friendship
was given i.e. diet 1500 ckal, Dextrose 10% 500cc, Captopril, Clonidine, Amlodipin, KSR,
Ceftriakson, Azitromicin, Simvastatin, Lantus (insulin glargine) and Novoravid. Based on
the results of monitoring the use of the drug for patients cared for it can be concluded that
the existence of DRP namely drug called simvastatin, amlodipin and between Captopril and
potassium chloride, a failure in receiving patients drugs at check list of nursing, indication
without drugs.
Keywords: Diabetes mellitus type 2 disease and was in a friendship.
I.
INTRODUCTION
Diabetes mellitus is a chronic disease or metabolic disorder characterized by high
blood sugar levels accompanied with disturbance of carbohydrate metabolism, lipid and
protein as a result infusiensi insulin function. Criteria for diagnosis of diabetes mellitus is
more than fasting glucose levels 126 mg/dl or 2 hours after eating over 200 mg/dl or
HbA1c more than 8%. If glucose levels two hours after eating more than 400 mg/dl but less
than 200 mg/dl glucose tolerance was weak (Elin, 2011).
Diabetes mellitus Type I usually has a skinny body and develop into diabetes
Ketoacidosis (DKA) because the very lack of insulin production accompanied by an
1373
increase in the hormone glukogon. A number of 20-40% of patients experienced a few days
after experiencing DKA, poliuria, polydipsia, polifagia, and lose the weight of the body.
Diabetes mellitus type II occurs in 90% of all cases of diabetes and are usually marked with
resisitensi insulin and insulin deficiency relative. Insulin resistance is characterized by an
increase in lipolysis and production of free fatty acids, increased production and decreased
hepatic glucose uptake of glucose in muscle skelet. Beta cell dysfunction resulting in
disorders of the blood glucose control. DM type 2 is caused because the lifestyle of excess
calories like diabetics, lack of exercise, and obesity compared to genetic influences.
Obesity or overweight is one of the major factors pradisposisi. In contrast to Diabetes
mellitus type 1 in Diabetes mellitus type 2 patients, particularly those who are in the early
stages, generally can be detected quite a number of insulin in the blood, as well as glucose
levels high. The early Diabetes mellitus type 2 not patofisiologis due to the lack of insulin,
but because the target cells to insulin without fail or respond to insulin normally.
Diabetes caused by other factors (1-2% of all cases of diabetes) including endocrine
disorders (akromegali, cushing's syndrome), diabetes mellitus gestational (DMG), the
exocrine pancreas disease (pancreatitis), and because (glucocorticoids, pentamidin, niacin,
and alpha-interferon). Impaired fasting glucose and impaired glucose tolerance occur in
patients with plasma glucose levels are higher than normal but not included in Diabetes
mellitus. This disorder is a risk factor for developing cardiovascular disease, Diabetes
mellitus and became associated with the syndrome of insulin resistance. Kardovaskular
complications of diabetic nephropathy, neuropathy, and makrovaskular complications such
as coronary heart disease, vascular disease, and stoke the peripheral. Function of insulin
insufficiency can be caused by insulin deficiency or disorder by the beta cells of the
pancreas, a gland or Langerhans is caused by the lack of responsiveness of body cells to
insulin (WHO, 1999).
Patients with diabetes mellitus type 2 is often asymptomatic, the emergence of
complications can indicate that a patient has suffered over many years Diabetes mellitus,
generally appears neuropathi. The diagnosis is generally detected poliuria, nokturia, and
polydipsia and weight loss significantly rare (Elin, 2011).
1374
Patient, Mrs U, aged 42 years old, entered the hospital on May 17, 2014 at at 07.
Patient complaints of loss of consciousness, unable to speak and lip look oblique, another
complaint like a little cough, nausea and vomiting Before entered Persahabatan hospital,
she already has a history of asthma, heart disease and DM since 5 years ago, however
patient did not remember treatment that has given earlier. After coming in Persahabatan
hospital, patient was diagnosed diabetes mellitus type 2 and experienced hypoglycemia.
In this case, patient was treated with combination therapy Captopril, Amlodipin
and Clonidine for controlling high blood pressure (BP:180/100), also was given KSR for
overcome hypokalemia, because results of laboratory showed that potassium plasma under
normal i.e. 3.39 mmol/L. Antibiotic azitromicin and ceftriakson for treatment respiratory
tract infection, patient got this therapy because patient experience infections, a slight cough
and result of laboratory test showed increasing in lecosit and netrofit, simvastatin was
used for manage of hyperkolesterolemia, lantus (long-acting insulin) and novoravid (shortacting/regular insulin) for the treatment of Diabetes Mellitus .
4. DOSAGE AND USING OF DRUGS
In this case of patient was given diet Therapy with 1500 ckal (calories), Dextrose
10% use 500cc per 8 hours for intravenous, Captopril 25 mg orally daily, Amlodipin 5 mg
od and can be increased until a maximum dose of 10 mg, Clonidine 0,15 mg tid, 600 mg
tid, Ceftriakson injection 1 gr bid, Azitromicin 500 mg od 20 mg of Simvastatin 1 a day
orally, 10 units of Lantus therapy for use in injection dose 1 customarily 10 IU once a day,
Novoravid 3x8 unit dosage is often 0.5 to 1 iu/kg/day, the results of the last patient of the
GDS 183 mg/dl (IONI, 2008).
5. LABORATORY RESULTS
From the results of laboratory examination, it looks there is abnormality on laboratory
results presented in Table1
1375
Table 1. laboratory results
1. Hematology
Results
Unit
Normal values
Routine blood
Lekosit
Netrofit
Lymphocytes
Eosiofil
Hemoglobin
Hematokrit
12,86
85,2
11,4
0,2
11,8
33
thousand / mm3
%
%
%
g/dl
%
5-10
50-70
25-40
2-4
12,0-16,0
35-47
MCV
76,7
Fl
80-100
557
thousand / mm3
150-440
183
Mg/dl
<180
Potassium (K)
Chloride (Cl)
3,39
101,1
Mmol/L
Mmol/L
3,5-5,5
98-109
Total Protein
4,8
g/dl
6-8
Ureum
45
Mg/dl
20-40
Albumin
Triglycerides
2,2
375
g/dl
Mg/dl
3,4-5
<150
Kolesterol total
309
Mg/dl
Kolesterol LDL
183,0
Mg/dl
< 200 is desirable, 200239 is
borderline high, > 240
high
< 100 is optimal, 100129 nears the optimal,
130 to 159 high limit,
high, 160-189 > 190
very high
Trombosit
2. Clinical Chemistry
GDS
Electrolyte
6. DRUG RELATED PROBLEM
Based on lab results and medication therapy patients were drug related problems
(DRP) such as:
1. Patient failed to receive medication
On 18th may dan 19 2014 patient failed to receive therapy captopril (3x1), amlodipine
(3x1), clonidine (3x1), KSR (2x1), the nurse just gave the drug usage i.e. 18.00 (1x1). In
order to do a check list on a regular basis on the record nurses routinely every day
1376
according to the use of drug usage rules rendered more medicine physician and
completeness note.
2. Administration of Drug without indication
Based on the results of blood sugar levels, patient should have a diabetes therapy on
18 May 2014, but lantus was given the new Lantus on 19 May and on novorapid on 20
May
Follow-up directly to the patient room, she experienced a slight cough the patient
should be given cough medicine.
3. Treatment less appropriate
For the treatment of diabetes, patients was treated with Lantus at the first time. Lantus
(long-acting insulin) was given od and continued with Novorapid (short-acting insulin).
Based on guidelines for DM therapy, insulin therapy begins with a short-acting and then
continued with a long-acting therapy.
4. Drugs Interactions
a. Amlodipin and simvastatin
Amlodipin increase levels of simvastatin, but their interaction is beneficial because
it increases effect of simvastatin in the treatment of cholesterol. Based on laboratory results
showed that LDL cholesterol was very high (183,0 Mg/dL, <100), therefore amlodipin
gives benefit effect for simvastatin in normalize level of cholesterol.
b. Captopril and Potassium Chloride (KSR)
Captopril can increase plasma levels of potassium chloride (KSR) by lowering the
subsequent process of elimination led to hiperkalemia. KSR profitable because of the
patient's potassium low lab results i.e. 3.39 Mmol/L (3.5-5.5 Mmol/L) the patient
experiencing hypoglycemia. Interactions that occur in two types of these drugs provide
positive benefits for the patient, but the monitoring needs to be done on the levels of
potassium and do follow up patients are there effects caused during therapy is given.
5. Miscellaneous
a) List of records on the use of drugs is sometimes a nurse did not record a drug that has
been given to the patient for that recommended that nurse to always check the list of
1377
what has been given. Monitoring is done on the record books list the nurse
administering the drug.
b) The patient's laboratory results of the obtained indications such as high i.e. ureum 45
g/dl (20-40 Mg/dl), i.e. 375 high triglycerides Mg/dl (375 Mg/dl), creatinin 1.3 Mg/dl
(0.8-1.5 Mg/dl), albumin is low, i.e. 2.2 g/dl (3.4-5), and from the lab results showed
that the patient had complications of DM in the kidneys, kolseterol, hepar,
hyperlipidemia. Control of laboratory results and follow up patients regularly to better
know the conditions of the patient experience in directly, preferably given other
therapies which can control the results of the laboratory.
c) Side effects of clonidine is kidney damage. Result of laboratory examination showed
that level uruem very high and and patient had complications in renal. Therefore,
selection of hypertensive drug should be notice .
d) Side effect using of Lantus is hypoglycemia, whereas patient diagnosed with loss of
consciousness and hypoglycemia, the initial dose should be reduced by about 20% to
avoid the effects of hypoglycemia.
6. CONCLUSION
Based on the results of the practice of the Clerk's Ward on the disease Diabetes mellitus
type 2 it can be concluded existence of a DRP form, there were Patient failed to receive
medication, administration of Drug without indication, Treatment less appropriate and
drug interaction.
7. REFERENCES
1) Anonymous, 2007. Diabetes mellitus, http://Diabetes_mellitus. Retrieved on December
21, 2007.
2) BPOM, 2008. The national drugs information (IONI). Jakarta: Sagung Seto
3) Dr. Aine Burns. 2009. the Renal Drug Handbook third edition. New York: Oxford
4) Department of health RI, 2005. Pharmaceutical Care for diabetes mellitus, Jakarta.
5) Elin Yulinah, 2011. ISO Farmakoterapi 2. Publisher: Indonesia, Jakarta Pharmacists
Association Gleadle, j. 2007. At A Glance The Anamnesis. Jakarta: Eason.
1378
DRUG RELATED PROBLEM ASSOCIATED WITH TREATMENT
FOR NASOPHARYNX CANCER PATIENT IN PGI CIKINI
HOSPITAL
Nur Chasanah1, Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
[email protected]
ABSTRACT
Nasopharynx cancer is a malignancy of mucosal epithelial layer nasopharynx
(Christanti, 2011). Nasopharyngeal cancer is a disease caused by unhealthy lifestyle.
Etiology of nasopharynx cancer caused by various factors. The risk factors them are
environmental, genetic, lifestyle and occupation (Melani, 2009). Female 36 years old, came
to hospital was diagnosed cannot swallow since one month, had no history of allergies,
there is a lump in the neck right / left. Patient had been doing the biopsy, suffered vomiting
and diarrhea. Patient had a history of asthma. Patient was diagnosed with nasopharynx
cancer. Patient's blood pressure during treatment is stable. On hematological examination
for the five measurements on different days shown abnormalities on several parameters, ie
leukocytes, hemoglobin, platelets and hematocrit. Based on examination clinical chemistry
measurements three times on separate days is abnormal, ie the parameters of potassium
levels. She has received Meropenem Inj, Ondansetron injection, calcium gluconas,
Omeprazole, Rimstar, KCl, Ketesse (Dexketoprofentrometamol), Panadol (Paracetamol),
Ceftazidim, Co-amoxiclav, New Diatab (Attalpulgit), KSR, and Octalbin. Based on the
result of the clinic secretariat at the ward of K in PGI Cikini Hospital, it could be concluded
that there was DRPs (Drug Related Problems) such as untreated indication. Patients get
Rimstar (TB Drugs) but not suffering Tuberculosis indicated, so it is necessary to evaluate
sputum examination. Overuse of antibiotics can increased the side effects and lead to
resistance.
Keywords : Nasopharynx cancer, DRP
1379
I.INTRODUCTION
Nasopharynx cancer is a malignancy of mucosal epithelial layer nasopharynx
(Christanti, 2011). Nasopharyngeal cancer is a disease caused by unhealthy lifestyle.
Etiology of nasopharynx cancer caused by various factors. The risk factors them are
environmental, genetic, lifestyle and occupation (Melani, 2009).
Symptoms and signs Nasopharyngeal cancer are not specific, often misdiagnosed or
treatment by doctors in the advanced stages of the condition, so treatment becomes more
complicated. Besides surgery, chemotherapy is also need, so that the cost of more
expensive and sometimes unsatisfying treatment outcomes. Nasopharynx cancer treatment
need discipline (Melani, 2009).
2.METHODOLOGY
The case studies was conducted to the patient on K-Unit based on the length of patients
treated. The evaluation was done based on the data of drug use, include drug name, dosage
and mode of administration and rationalization of the use of the drug (the right dose, the
right indication, the right patient, the right of use) with see Drug Related Problems of drug
use based on the literature.
3.CASE PRESENTATION
Female 36 years old, came to hospital was diagnosed cannot swallow since one
month, had no history of allergies, there is a lump in the neck right / left. Patient had been
doing the biopsy, suffered vomiting and diarrhea. Patient had a history of asthma. Patient
was diagnosed with nasopharynx cancer. Patient's blood pressure during treatment is stable.
Hematological examination for five measurements on different days shown a decreased
hemoglobin = ie 8.7; 10.2; 10.6; 9.9; 10 (g / dL), that indicate the presence of cancer and
could be causing of antibiotics, decreased leukocytes 2.9; 3.2; 3, 2; 3.2 (103/mL) caused by
infection and use of antibiotics, decreased hematocrit 26; 30; 30; 29; 30 (%), which
indicates the presence of anemia and cancer, a decrease in platelets below 100,000 ie 29;
62; 94; 101; 134 (103/mL), indicates the barriers of blood clotting and can lead to bleeding.
On hematological examination in 3 times in the different measurements abnormal value is
1380
decreasing erythrocytes 3.55; 3.93; 3.96 (106/mL), a decrease Eosinophil 0 (%) caused by
stress and shock, a decrease in MCV 72; 74; 76 (fl), and indicate the presence of radiationinduced anemia, a decrease of 24.5 MCH; 25.2; 25.3 (pg) showed the presence of anemia,
increase in monocytes 10; 13; 11 (%), indicate the presence of cancer and infection. Then
based on the results of hematological examinations for two different times on the day
measurements showed abnormalities ie decrease Lymphocytes 11% and 5%, indicate the
presence of cancer and anemia. In the first day of treatment decreased reticulocyte (2 mile)
that can be caused anemic and radiation therapy, that remains ongoing destruction
erythrocytes but erythrocyte production stops. But on day 6 treatment increased
reticulocytes (17 mile) indicate the presence of anemia and because of the condition of
post-hemorrhage (Sutedjo, 2008).
Based on examination clinical chemistry measurements on 3 different days, ie showed
an abnormal decrease in the levels of Potassium (K) 3.1 mEq / L; 2.3 mEq / L; 3.1 mEq / L,
indicating the occurrence of hypokalemia, and decreased 2 and 2.8 Albumin (g / dL) at 2
times measurement on different days can cause of edema, because of the presence of
inflammation in the body . Then at once measurements different days, the levels of Sodium
(Na) is seen to rise (hypernatremia) ie 156 mEq / L. Hypernatremia can occur because of
patients dehydration, vomiting, diarrhea, high Na intake, and use of antibiotics. A level of
Calcium (Ca) is decreasing (hypocalcaemia), hypocalcaemia occurred because of
gastrointestinal malabsorption, Ca intake deficiency, hypothyroidism, and infections
(Sutedjo, 2008).
Meropenem is used for infections. Omeprazole & Ondansetron is used to treated nausea
and vomiting. Calcium gluconas used to tread bleeding because there is a history of
Epitasis. KCl and KSR used for therapeutic treatment of hypokalemia. Ketesse
(Dexketoprofentrometamol) and Panadol (paracetamol) are used to treated pain and fever.
Ceftazidim and Co-amoxiclav used to infection. Octalbin used to raise albumin, because the
patients had Hipoalbumin. New Diatab (Attalpugit) is used to treated diarrhea (Saragi,
2012).
1381
4.1.DRP (Drug Related Problem) I
Untreated indication. Patient was diagnosed with nasopharynx cancer, but she doesn’t
treated with anticancer drugs
4.2.DRP (Drug Related Problem) II
Failure to received medication. Patient had diarrhea and had a drug prescribed by a
doctor but the nurse did not give.
4.3.DRP (Drug Related Problem) III
Drug use without indication. Patient is not indicated of Tuberculosis, but she is
receiving drug therapy to tuberculosis that is Rimstar.
4.4.DRP (Drug Related Problem) IV
Improper drug selection (Meropenem, Ceftazidim, Co-amoxiclav) can increase side
effects and lead to resistance.
4.5.DRP (Drug Related Problem) V
a. Drug Interaction between Rimstar with Omeprazole
Rimstar will increase the effect of Omeprazole by changing drug metabolism.
b. Drug Interaction between Rimstar with Ondansetron
Rimstar will increase the effect of Ondansentron by changing the metabolism of the
drug.
c. Drug Interaction between calcium gluconate with Rimstar
Rimstar lower levels of calcium gluconate to reduce drug absorption from the stomach
and intestines into the body when taken by mouth.
d. Drug Interaction between Omeprazole with Ondansetron
Omeprazole will reduce the effect of Ondansetron by changing the metabolism of the
drug.
e. Drug Interaction between paracetamol with Rimstar
-
Rimstar decrease effects of paracetamol by speed up drug metabolism
-
Rimstar increase the toxicity of paracetamol by an unknown mechanism.
-
Rimstar will increase the effect of Paracetamol by changing drug metabolism.
1382
5.CONCLUSION
Based on the result of the clinic secretariat at the ward of K in PGI Cikini Hospital,
it could be concluded that there was DRPs (Drug Related Problems) such as untreated
indication. Patients get Rimstar (TB Drugs) but not suffering from Tuberculosis indicated,
so it is necessary to evaluate sputum examination. Overuse of antibiotics can increased the
side effects and lead to resistance.
6. REFERENCES
1. Adeyemi BF, Adekunie LV, Kolude BM, et al, 2008, Head and Neck Cancer A
Clinicopthological Study in a Tertiary Care Center, Journal oh the National Medical
Association.
2. Bhurgri Y, Bhurgri A, Usman A, et al, 2006, Epidemiological Review of Head and
Neck Cancers in Karachi, Asian Pasific J Cancer Prev. 7
3. Christanti, 2011, Nasopharyngeal Cancer. Textbook of Medical Sciences Ear Nose
Throat Head & Neck. Sixth edition, FK UI Publisher: Jakarta
4. Hepler, C.D., Strand, L.M., 1990, Opportunities and responsibilities in pharmaceutical
care. Am J Hosp Pharm
5. http://www.diahome.org/en-US/News-and-Publications/Publications-andResearch/DIJ.aspx
6. http://online.epocrates.com/nonframe
7. Melani, 2009, Characteristics of NPC patients who are hospitalized in the Hospital
Medan dr.Pirngadi 2007, Thesis, FKM USU
8. Saragi, Sahat, 2012, Guide of Drug Use with Pharmaceutical Care Concept, Drug
Counseling Theory, Theory Drinking Drug Compliance, Publishers, Rosemata
Publisher, Jakarta
9. Sutedjo, AY, 2008, Pocketbook, Disease From Laboratory Results, Yogyakarta
10. www.healthline.com/druginteractions
11. www.rxlist.com/drug-interaction-checker
1383
HAS NOT TREATED WITH ARV YET ON GATOT SUBROTO ARMY
HOSPITAL
1
Christina Mahdalena , Aprilita Rina Yanti Eff2 and Diana Laila R2
1
2
[email protected]
ABSTRACT
HIV (Human Immunodeficiency Virus) is the virus that weakens the immune system
and eventually causes AIDS. AIDS (Acquired immunodeficiency syndrome) is a group of
medical conditions that indicate immune weakness, frequent infections tangible follow-up
(opportunistic infections) and cancer, which until now could not be cured 1. Oportunisik
infection (OI) may occur due to the decline in immunity in patients with HIV / AIDS.
Generally death in people with HIV / AIDS (PLWHA) is caused by an opportunistic
infection that needs to be known and diobat IO. Antiretroviral therapy when there are still
active IO, because basically opportunistic infection (OI) should be treated or mitigated
before, except Micobacterium avium complex(MAC), where antiretroviral therapy is a
better option, especially if a specific therapy for MAC not available. Other circumstances
which may be improved when starting antiretroviral therapy (ART) is candidiasis and
riptosporidiosis2. Patient. Mr LA aged 62 years, entered into IGD Gatot Subroto Army
Hospital on April 28, 2014 with bucalis abscesses diagnose. Past medical history of HIV
and antiretroviral therapy yet. Therapy treatment for the treated cefpirome injection,
ketorolac injection, meropenem injection, ranitidine injection, intravenous levofloxacin,
paracetamol tablets, paracetamol infusion, tablets cotrimoxazol, nystatin drop, fluimucyl
200 mg sachets, syrup OBH, diatab new tablet, Pulmicort inhalation, vitamin B6 tablets ,
INH tablets 400 mg, rifampicin 450 mg tablet, tablet pyrazinamid 1000 mg, ethambutol
100 mg tablets, ventolin nebulizer, omeprazole 20 mg tablets, infusion mycamin, vitazym
tablets, injection ondansentron 8 mg and 200 mg tablets curcuma. Based on the results of
their clinical practice, found the presence of DRPs (Drug Related Problems) form of
inaccuracy choose drugs, ROTD (Drug Reactions are Not Desired), treatment too long,
there is no indication of drugs, drug interactions. Improper dosage regimen in the use of
tablets and nystatin cotrimoxazol drop too low a dose of the drug. The interaction of several
drugs that rifampicin and isoniazid; rifampicin and paracetamol; omeprazole and
paracetamol; isoniazid and paracetamol; isoniazid and ethambutol.
Keywords: Drug Related Problems (DRPs), HIV, ARVs, Army Hospital
1384
I. INTRODUCTION
Along with the rapid development of world science, pharmacy has now not only
oriented to drugs or products derived from (drug-oriented) but also evolved with the
pharmacy service-oriented paradigm in a patient (patient-oriented). Pharmacy services
were originally only focused on pengelolaaan medicine has evolved as a commodity
orientation to patient care(pharmaceutical care).
The orientation of the patient's pharmacy is responsible for the therapeutic effect
and safety of a drug in order to achieve the optimum effect. Provide pharmacy services in
plenary with attention to patient safety factors, among others, in the process of
pharmaceutical management, monitoring and evaluating the success of therapy, providing
education and counseling as well as work closely with patients and other health
professionals are efforts that can be undertaken to improve the quality of life patients.
HIV can damage the immune system so the body can no longer repel infection. This
leads to reduced immunity acquired syndrome (Acquired Immune Deficiency Syndrome AIDS). An important feature of HIV infection is that it usually takes a long period after
initial infection during which the person showing very little or even no symptoms of this
disease. HIV usually develop through several stages. HIV is not as infectious hepatitis B
virus (HBV) or hepatitis C (HCV) but spread in the same way with HBV. HIV infection
can occur through the transfer of blood from an infected person or through a liquid /
material other body which occurs during sexual intercourse either anal or vaginal, cuts from
sharp objects (including needles) and needles were used jointly in drug use. Spread may
also occur from an infected mother to her baby during pregnancy, childbirth or
breastfeeding.
HIV is usually not transmitted through non-sexual relationship, the contact with
people. However the virus can be transferred through infected material such as blood or
fluid / other body materials in direct contact with open skin or mucous membranes of eyes,
nose or mouth. The use of shared toothbrushes and razors may increase the risk of
transmission. In the workplace, generally occurs through the transmission of infection
through needles and other contaminated sharp objects, or through the mucous membrane
contact (such as body fluid splashes to the mouth, nose, eyes or non-intact skin). Although
1385
HIV can survive in the fluid / material body outside the body, but the virus is more
susceptible than the hepatitis viruses and can not survive for long outside the body.
The role of clinical pharmacy have an impact on patient treatment outcomes, both in
terms of humanistic (quality of life, satisfaction), the clinic (better control of chronic
disease), and the economic (reduction of healthcare costs). Clinical pharmacy services
considered effective in improving the quality of health services, especially by monitoring
prescription and medication side effects. Role of clinical pharmacy in hospitals are
expected to provide pharmacy services to patients and ensure that the treatment given to
each individual patient's ARV treatment is rational.
2.CASE PRESENTATION
Patient. LA age of 30 years old, entered the emergency room (ER) Gatot Subroto
Army Hospital on April 28, 2014 Patients present with swelling of the lips and right
cheek. Swelling felt since 3 days ago before admission (history of ulcers 1 month ago), and
boils broke, then right cheek became swollen and there is pain in the right cheek, toothache
denied, the patient complained of nausea but no vomiting, no fever, but the patient
complained of cough with phlegm 2 days before hospital admission. Previous history of the
patient is not treated HIV and ARV (Antiretroviral). History of allergies and no family
history of the disease. At the time of admission given ketorolac injection, to reduce or
eliminate the patient complained of pain. Infusion therapy NaCl 3% per 24 hours in these
patients to cope with hyponatremia (123 mmol / L *). Drug therapy given early entry is
ceftriaxon 2 g per 24 hours, ranitidine 50 mg per 12 hours and ketorolac 30 mg per 8 hours.
During treatment, the patient's complaints and symptoms of clinical worsening. The
patient complained of diarrhea without heartburn, persistent fever with a temperature of 3840 0 C, cough, tightness, fatigue, candidiasis of mouth and sores occur on the arms and
body. Dated May 6, 2014 patients with a blood culture examination results yield sensitive
antibiotic is amikacin, ciprofloxacin, cefpirome, netilmycin, and fosfomycin. Based on
consideration of the results of laboratory, clinical and culture ceftriaxon antibiotic therapy
(leukocytes 12010μ / l *) is replaced with cefpirom 1 g per 12 hours (14 May). However,
antibiotic therapy cefpirome for 12 days led to decreased patient leukocytes (leukocyte
1386
2160μ / l *), and persistent fever. So the replacement of antibiotics done again on the basis
of clinical experience worsening symptoms than before. Combination antibiotic therapy
and intravenous levofloxacin injection meropenem began on May 24, 2014 after the skin
test. During the use of combination therapy patients had improvement of laboratory
values. Mr. LA patients had opportunistic infections this can be seen from the monitoring
of patients based on the results of laboratory tests, and indicate supporting reference value
outside
the
normal
range,
including
opportunistic
infections
oral
candidiasis,
PCP(Pneumocystis jiroveci Pneumoniaa), active pulmonary TB.
Opportunistic infections and other HIV-related illnesses that need treatment
alleviated before starting ARV therapy. Type of tuberculosis opportunistic infections,
according to national guidelines and clinical management of HIV infection in adults
antiretroviral drug recommended is given at least 2 weeks after patients receive treatment
for opportunistic infections. Mr.. LA using OAT treatment (Anti-Tuberculosis Drugs) after
a diagnosis of active pulmonary TB, doctors prescribe OAT on the 18th of May 2013 given
by the physician handling for IO oral candidiasis is nystatin therapy drop, while the
opportunistic infections are given tablets cotimoxazol PCP.
When you sign in LA tn care bucalis abscess diagnosed, but not HIV antiretrovirals,
dyspepsia, difficult intake, hyponatremia. During treatment of patients experienced clinical
deterioration, the patient died with a diagnosis of chronic diarrhea, category 1 with
pulmonary
TB
smear
positive,
severe
Coagulation (DIC non-overt) and Multiple
sepsis
Organ
with Disseminated
Dysfunction
Intravascular
Syndrome (MODS),
sepsis Hospital Acquired Pneumonia (HAP) Late-onset sepsis with respiratory failure
type 1, Community Aquired Pneumonia (CAP) deterioration, suspec varicella, candidiasis
oral, buccal selulutis repair no edema, decrease pain, normocytic anemia, normokromil,
increased transaminase enzymes suspected drug-induced liver injury (DILI), hipertemia,
resti infection, hipoalbuminemi, hypokalemia, loss of consciousness with the diagnosis of
intracranial infection.
1387
The use of injection cefpirome 1 g given per 12 hours is used to treat
infections. Injeksis meropenem 1 g per 8 hours and intravenous levofloxacin 750 mg / 24
hours to treat sepsis.Rantin (Ranitidine) 50 mg / 2 mL per injection given 12 hours a day is
used to treat nausea and side effects due to the use of analgesic drugs and
antibiotics. Paracetamol tablets 500 mg per 8 hour day is used to reduce fever, if the body
temperature> 38 0 C was treated with the IV preparation. Omeprazole tablet 20 mg per 24
hours is used to overcome the gastric ulcer and duodenal ulcer. Tablet rifampicin 450
mg, isoniazid 300 mg, pyrazinamide and ethambutol 1000 mg 1000 mg tablets given per 24
hours is used as an anti-tuberculosis, tabletvitamin B6 10 mg tablet given 3 times a day is
used to prevent peripheral neuritis. Ambroxol 30 mg tablets given 3 times a day is used as
secretolytic. Fluimucil (Acetylcysteine) sachets of 200 mg administered per 8 hours is used
as therapy viscous mucus hypersecretion. Nystatin drop 1 cc / 6 hours, mycamin injection
to overcome candidiasis. cotrimoxazole prophylaxis is used to address the primary and
secondary prevention of chronic diarrhea after treatment of PCP. New diatab to overcome
diarrhea, curcuma 200 mg / 8 h as hepatoproktektor, ketorolac injection 30 mg per 8 hours
is used to reduce pain, Combivent inhalation or nebulizer ventolin used to treat shortness of
breath.3
4. LABORATORY DATA
Results of a general examination (when entering treatment) tn consciousness. LA is
composmentis with general state (KU) weak (looks sick) and installed Infusion 0.9% 20
TPM (drops per minute), respiratory rate / Respiration Rate (RR) 18 x / minute, pulse
/ heart rate (HR) 70 x / minute, blood pressure (BP) 120/80 mmHg, body temperature
36 0 C, and the pupillary light reaction in the right eye (+) and left (-), O 2 saturation 98%,
pain scale 5, BAK / CHAPTER patients normal / normal.
Hematology laboratory results at the time of entry treatment Hb 11.5 g / DL * (1318 g / dL), hematocrit 32% * (40-52%), erythrocytes 3.7 million / mL * (4.3-6.0 million /
ml), 12010 leukocytes / mL * (4800-10800 / ml), platelets 142000 / mL * (150000-400000
/
ml), mean
corpuscular
volume (MCV)
87
Fl
(80-96
fL), mean
corpuscular
1388
hemoglobin (MCH)
31
pg
(
pg
27-32), mean
corpuscular
hemoglobin
concentration (MCH C) 36 g / Dl (32-36 g / Dl). Clinical chemistry examination on
admission showed SGOT (AST) 22 U / L (<35 U / L), alanine aminotransferase (ALT) 20U
/ L (<40 U / L), total protein 6.2 g / dL (6-8.5 g / Dl), albumin 3.2 g / dL (3.5-5.0 g / Dl),
globulin 3.0 g / Dl (2.5-3.5 g / dL), total cholesterol 3.7 mg / Dl (<200 mg / dL),
triglycerides 91mg / dl * (<160 mg / Dl).
Examination results hematology, clinical chemistry and blood gas analysis on May
26, hemoglobin 9.0 g / dL, hematocrit of 27% *, erythrocytes 3.2 million / uL *, 2440
leukocytes / uL *, platelets 55,000 / uL *. Basophils count type 0% (0-1%), eosinophils 1%
(1-3%), trunk 3% (2-6%), segment 68% (50-70%), lymphocytes 21% (20-40% ),
monocytes 7% (2-8%), MCV 86 fL (80-96 fL), MCH 28 pg (pg 27-32), MCHC 33 g / dl
(32-36 g / Dl), red cell distribution ( RDW) 15:50% (11.5-14.5%), SGOT (AST) 138 U / L
* (<35 U / L), alanine aminotransferase (ALT) 89 U / L * (<40 U / L), sodium (Na) 134 *
mmol / L (135-147 mmol / L), potassium (K) 3.7 mmol / L (3.5-5.0 mmol / L), chloride
(Cl) 105 mmol / L (95-105 mmol / L), urea 39 mg / Dl (20-50 mg / Dl), kreatinin1.2 mg /
Dl (0.5-1.5 mg / Dl). Examination of the blood gas analysis was conducted on May 26,
2014 is 7,527 mmHg ph * (7:37 to 7:45 mmHg), PCO2 18.3 mmHg * (33-44 mmHg), pO2
48.8 mmHg * (71-104 mmHg), bicarbonate (HCO 3) 15.3 mmol / L * (22-29 mmol / L),
base excess -4.5 mmol / L * ((-2) - 3 mmol / L), O 2 saturation of 89.4% * (94-98%).
Hematological examination results on May 27, 2014, namely hemoglobin 9.6 g /
dL, hematocrit 27%, erythrocytes 3.2 million / uL *, 5700 leukocytes / uL *, 97000
platelets / uL *.Calculate Type MCV 85 fL, MCH 30 pg, MCHC 35 g / dl. Clinical
chemistry examinations were carried out on those who carried albumin 2.5 g / dl (3.5-5.0 g
/ dl), sodium (Na) 135 mmol / L *, potassium (K) 3.3 mmol / L, chloride (Cl) 105 mmol / L
, urea 21 mg / Dl, kreatinin1.0 mg / Dl.
Hematology and coagulation test results conducted on May 28, 2014 obtained ddimer 15570 ng / ml * (<550 ng / ml). Hemostatic coagulation physiology examination
including examination time protrombine time (PT) 10.9 seconds control is obtained, the
patient PT that was obtained exceeds the reference value of 13.0 sec * (9.3-11.8
seconds). Activated partial thromboplastin time control (aPTT) 29 .6 seconds in patients
1389
with normal values of 53.8 seconds * 31-47 seconds, fibrinogen 301 mg / dl (136-384 mg /
dl). Examination of the blood gas analysis was conducted on May 28, 2014 is 7,470 ph
mmHg, PCO2 25.3 mmHg, 51.7 mmHg pO2, bicarbonate (HCO 3) 18.6 mmol / L *, base
excess -3.8 mmol / L *, O 2 saturation 89.1 %.
Hematological examination results on May 29, 2014, namely hemoglobin 10.6 g /
dL, hematocrit of 30% *, erythrocytes 3.5 million / uL *, 7400 leukocytes / uL, platelet
71000 / uL *.Calculate the mean corpuscular volume type (MCV) 85 fL, mean corpuscular
hemoglobin (MCH) 30 pg, mean corpuscular hemoglobin concentration (MCH C) 35 g /
dl. Clinical chemistry examinations were conducted on May 29, 2014 showed albumin 2.5
g / dl * (3.5-5.0 g / dl), sodium (Na) 135 mmol / L, potassium (K) 3.3 mmol / L *, chloride
(Cl) 105 mmol / L, urea 21 mg / Dl, kreatinin1.0 mg / Dl. Examination of the blood gas
analysis was conducted on May 29, 2014 is 7,470 ph mmHg, PCO2 18.3 25.3 mmHg, 51.7
mmHg pO2, bicarbonate (HCO 3) 18.6 mmol / L, base excess -3.8 mmol / L, 89.1%
O 2 saturation.
Examination conducted Imunoserologi is HBsAg (Rapid) is non reactive, AntiHCV (non-reactive) non reactive, Anti-HIV (Rapid I) (non-reactive) reactive with SD
reagents, reagent oncoprobe, intex reagents, CD4 (410-1590 cell / Ul) 23 cells /
ul. Procalcitonin results obtained 51.95, while the reference value for procalcitonin was
<0.5 ng / mL normal value / possibility of local infection. If 0.5-2 ng / mL possibility of
sepsis, should be interpreted in conjunction with the patient history are advised to do a reexamination (6-24 hours). While> 2NG / mL high risk of sepsis (systemic infection)
examination conducted by the method of procalcitonin ELFA (Enzyme Linked fluorecent
Assay).
In the results of the diagnostic workup including chest photo on date 28-04-2014
when entering treatment showed the heart (cor) and large normal form, the lungs appear in
the filtratein the second fibro hilum. Sinus and good diaphragm. KP impression (lung
disorders) active duplex. Dated May 13, 2014 and a chest x-ray examination showed the
heart was not enlarged, CTR (Cardio-Throracic Ratio) <50%, normal aorta, both hillus not
enlarged, pulmonary bronchovaskuler corakan well, looks infiltrates in both lungs
increases, Sinus costofrenikus and diaphragms both. Impression than the previous photo,
1390
infiltrates in both lungs increases. Examination of sputum cultures resistant type. The date
of the examination conducted on May 7, 2014 with blood type materials using BACTEC
media. The preparation does not appear to be any direct gram germs. On culture results do
not seem the growth of germs. Resistance test was not performed.
5.DRUG RELATED PROBLEMS (DRPs)
1.
Drug interactions
a. Levofloxacin and ketorolac
Significant interactions to be monitored closely because of the potential for
dangerous interactions. Use with caution and monitor closely as possible the risk
of Central Nervous System (CNS) stimulation / seizures as a result of the transfer
mechanism Gamma Aminobutyric Acid (GABA) receptor in the brain, so that the gift is
given at different times. 4
b. Rifampicin and Isoniazid
Interactions that are serious. Rifampicin increases toxicity of isoniazid by
increasing metabolism. Possible interactions of serious or life-threatening so it needs to
be monitored closely. Use an alternative if available. Rifampin increases the
metabolism of isoniazid for hepatotoxic metabolite. The use of rifampicin given 1 hour
before eating while Isoniazid was given 2 hours after meals to reduce (minimize) or
prevent the interaction of this drug occurs. 4
c. Paracetamol and Isoniazid (INH)
Significant interaction (monitor closely). Isoniazid will increase levels or
effects of acetaminophen by CYP2E1 metabolism affect liver enzymes. Significant
interaction possible, monitor closely. Giving given time interval. 4
2.
Corellation between drug treatment and disease
The indication of therapy but not be seen from the results of laboratory tests of
potassium 27/5 Mr. LA less than the normal of 3.3 mmol / L * value referral hospital
potassium 3.5-5.0 mmol / l. Patients previously treated with KSR but after potassium
values had returned to normal use of the drug stopped. However, after the patients stopped
therapy KSR decreased potassium (Hypokalemia). Suggested therapy KSR per 8 hours to
1391
resume the monitoring of serum potassium, glucosa, chloride, pH, urine output and heart
monitor.
There are indications but not prescribed. According to national guidelines in 2011
patients with HIV co infection with HIV and TB should start antiretroviral therapy
immediately after OAT therapy can be tolerated and steady state (2-8 weeks after the
initiation of OAT or pemngobatan opportunistic infections) 2. Mr. LA patients starting
therapy OAT on 20 May 2014 so that the patient can not be treated with antiretroviral drugs
because the patient's condition has not stabilized and treatment of opportunistic infections
has been running for a few days.
The existence of patients suffering from ROTD (Drug Reactions are Not Desired)
According to Ministry of Health guidelines one TB drug side effects patients experienced
jaundice in addition to the use of such drugs patients also get the paracetamol antipyretic
therapy has side effects hepatotoksis. According to these guidelines when a patient has
jaundice, the treatment should be discontinued until the oats jaundice disappeared and
therapeutic treatment can be restarted from the beginning. Treatment of TB, rifampicin,
isoniazid and pyrazinamide may increase the risk of hepatotoxic 2.
The use of paracetamol is used as an analgesic and antipyretic used in almost all TB
patients infected with Human Immunodeficiency Virus. Almost all patients with HIV /
AIDS have a fever as a result of infection of various types of bacteria, viruses, fungi and
parasites. Other causes of fever are common on the appearance of PLWHA (People Living
with HIV-AIDS) is an allergic reaction to medication, infections, and skin cancer called
Kaposi's sarcoma (KS). 5 Paracetamol can also increase the risk of hepatotoxic so that
additional therapy is given to patients curcuma 200 mg tablets per 8 hours to maintain liver
function. Therapy occurrence of nausea and vomiting in patients suspected to be caused due
to side effects of drugs that are in use patients.
3.Inaccuracy choose drugs
Patient Mr. LA is a new case of pulmonary tuberculosis. according to guidelines that
should be used, namely OAT OAT category 1 which begins with an intensive phase, in
such patients beginning treatment patients receive appropriate therapy, namely OAT
intensive phase of category 1 but after six days (May 20 to 26) to get OAT therapy liver
1392
function test results showed an increase in serum transaminases AST is increased 3-4 times
normal levels. Mr.. LA is getting OAT therapy in the intensive phase of category 1 patient
laboratory data showed serum levels of aspartate amino transaminase (AST) and alanine
amino transferase (ALT) were each increased by 3-4 times of normal levels (<35 U / L) is
of 27 U / L (May 19) to 138 U / L (May 26) for AST and of <23 U / L (19 May) to 89 U / L
for ALT. so should the use of OAT category 1 discontinued and replaced with OAT
Streptomycin and Ethambutol, but treatment with OAT category 1 remain granted.
Patient experiencing drug-induced hepatitis is characterized by elevated levels of
serum transaminases in this case the AST levels increased almost 4 times than normal, then
the selected OAT guide with Ethambutol Streptomycin. Selection of Streptomycin and
Ethambutol for patients with drug-induced hepatitis is based because the second is not
hepatotoxic drugs like pirazimmid, isoniazid, and rifampin which is the main component of
the OAT intensive phase of category 1. 6 Provision OAT category 1 in patients with
elevated serum transaminases may cause more severe liver damage caused by a
combination of drugs that are in category 1, namely OAT pyrazinamide, isoniasid, and
rifampin have hepatotoxic effects. Liver damage can be caused by direct toxicity of the
drug or its metabolites or as an idiosyncratic response in people who have a specific gene
that influence it. 7
4.Dosage regimens
In patients with AIDS because of decreased immune system , infection agent will
easily invade and disrupt the symbiosis between the normal flora of the body that causes
the normal flora will change to the pathogen. 8 Antibiotics are the main treatment options
for infectious diseases. Co-trimoxazole is a combination of two antibiotics namely
trimetoprime (TMT) and sulfamethoxazole (SMZ) is used for many bacterial infections and
some infections caused by fungi, including several opportunistic infection in people living
with HIV 9. One of the most common opportunistic infection in people living with HIV
is pneumocystis pneumonia (PCP) which affects the lungs. Without treatment, more than
85% of people with HIV / AIDS will eventually develop PCP. Pneumocystis pneumonia
(PCP) became one of the leading killer of people living with HIV. Pneumocystis
1393
pneumonia (PCP) is caused by a fungus that is present in almost every person's body. A
healthy immune system keeps it under control. However, PCP causes illness in adults and
children with weakened immune systems, the fungus Pneumocystis almost always affects
the lungs, causing pneumonia (lung inflammation) 10.
According to national guidelines kemenkes clinical management of HIV infection
and
antiretroviral
therapy
in
2011.
Providing
cotrimoxazole
as
primary
prophylaxis. Indication when available examinations CD cell count, all patients were given
cotrimoxazole given to patients with CD4 counts <200 cells / mm 3 at a dose of 960 mg /
day dose. At the beginning of treatment entered Mr. LA cotrimoxazol therapy given 1 x
960 mg are in accordance with the indications of KDP (Preventive Medicine
cotrimoxazole). 2 However,
during
the
treatment
the
patient
showed
clinical
deterioration. Patients get IO with PCP (Pneumocystis jiroveci pneumonia) with a clinical
display congested cough, shortness of breath fever.
According kemenkes cotrimoxazole treatment of choice in 2011 (TMT SMZ 15 mg
+ 75 mg / kg / day) in 4 divided doses or cotrimoxazole 480 mg, 2 tablets 4 times daily for
body weight <40 kg and 3 BB tablet-4x daily for> 40 kg for 21 days. The provision of
cotrimoxazole for this patient based on the patient's weight with the clinical symptoms of
the above should be the provision of improved therapies for the treatment of these patients,
but given the 960 mg dosage per 24 hours is equal to the initial dose in (intermediate
culture results) so that the expected effect of the drug has not been achieved due to dose is
too low. During treatment it is recommended to drink (at least 1.5 liters a day) to prevent
crystalluria due to the use of cotrimoxazole. In the long-term use of blood tests should be
performed periodically
Candidiasis is a common opportunistic fungal infections in patients with HIV /
AIDS. In AIDS patients causes a decrease in the number of CD4 immunological
mechanisms to fight infection candida, candida species where this is normal flora in
humans, especially in the gastrointestinal tract and urogenital tract, and skin. According to
the management of HIV therapy with oral candidiasis therapy is recommended tablets
nystatin 100,000 IU of inhaled every 4 hours for 7 days or Nystatin suspension 3-5 cc
gargled 3 times a day for 7 days. 2 In the treatment of patients tn LA 1cc nystatin therapy
1394
(100,000 units / ml) 6 hours per dose given is too low and way of life of the patient is not in
the mouth so that drug therapy is not optimal.
The presence of drug pennggunaan too long according to the BNF 58 2008 dose in
adults and children over 16 years, 10 mg orally every 4-6 hours (older every 6-8 hours) is
needed;maximum 40 mg daily; max. duration of treatment of 7 days. While adults and
children over 16 years, by intramuscular injection or intravenous injection for at least 15
seconds, initially 10 mg, then 10-30 mg every 4-6 hours as needed (up to every 2 hours
during the early postoperative period); max. 90 mg per day (elderly and patients weighing
less than 50 kg maximum of 60 mg per day.); maximum duration of treatment 2 days (note:
when converting from parenteral to oral dose on day converting a combined total should
not exceed 90 mg (60 mg in the elderly and patients weighing less than 50 kg, which
should not be more than 40 mg). Ketorolac is used for the short-term (≤ 5 days)
management of moderately severe acute pain that requires analgesia at the opioid level; not
indicated for minor or chronic painful conditions. Provision of intra-venous (IV) 30 mg as a
single dose or 30 mg / 6hr; not exceed 120 mg / day. IM 60 mg as a single dose or 30 mg /
6hr; not exceed 120 mg / day. Per oral (po) 20 mg once after intravenous (IV) therapy
or intra muscular (IM), the 10 mg / 4-6 hours; not exceed 40 mg / day. always start with
parenteral therapy; oral is indicated only as continuation of IV / IM dose, if necessary.
Duration of therapy should not exceed 5 days. dose exceeded the maximum dose or the
label will not give better success but will increase the risk of serious side effects. Decrease
daily dose in patients> 65 years, <50 kg, or with a high enough serum creatinine 3.
Patient complain of pain according to Mr. LA NRS (Numeric Rating Scala) received
a score of 3-5 (moderate) drugs used for pain with 3 scale is adjuvant therapy may be used
alone or in combination with non opiad. The use of ketorolac according to the BNF (British
National Formulary) 58 (im not allowed more than 2 days, A to Z (maximum of 10 days
orally), and Medscape (≤ 5 days) in these patients begins early use of ketorolac in the
hospital to cope complained of pain to the patient out of treatment. ketorolac therapy in
patients with pain on a scale of 3-5 (moderate) according to the selection of appropriate
pain management has continued to cure and overcome pain and is recommended for
relaxation therapy remain to be done according to the journal. 11th Clinical studies show
1395
single dose ketorolac has greater efficacy than morphine, pethidine (meperidine) and
pentazocine moderate to severe postoperative pain, with some evidence of side-effect
profile is more favorable than morphine or pethidine. ketorolac In a single dose study also
compared with aspirin , paracetamol (acetaminophen) and some anti-inflammatory nonsteroidal others. mechanism of action of ketorolac inhibits prostaglandin synthesis by
blocking the action of cyclooxygenase isoenzymes 1 (COX-1) and cyclooxygenase 2 (COX2). So that needs to be monitored to prevent or reduce the side effects of gastric bleeding
levels (Serum Glutamic Pyruvic Transaminase)-SGOT SGPT (Serum Glutamic oxaloacetic
transaminase), serum creatinine levels. 12th
Replacement cefpirome with a combination of meropenem and levofloxacin
antibiotics due to the deteriorating condition of the patient based on laboratory data and
clinical gejal fever patients. Patients with sepsis after administration of this antibiotic
combination of laboratory results improved so that the selection of the combination therapy
is the right choice. It can be seen from the increase in leukocytes and platelets examination
results are an improvement on the 21, 26, 27 and May 29 respectively are 2160μ / l *,
2440μ / l *, 5700μ / l, and 7400μ / l, although the results of the examination culture showed
sensitive antibiotics is (amikacin, ciprofloxacin, cefirom, netilmycin, fosfomycin). On
examination of the antibiotic meropenem culture because culture is not performed
laboratory reagents depleted. Monitoring leukocytes, culture and clinical symptoms in order
to avoid the development of drug resistance, the drug should be used only on bacterial
infections proven or strongly suspected.
6.CONCLUSION
Based on the results of their clinical practice in Internal Medicine Ward Gatot
Subroto Army Hospital, it can be concluded that the presence of Drug Related Problems
(MTO) in the form of a correlation between drug therapy with clinical indications of the
condition but are not prescribed in the diagnosis of HIV but have not received antiretroviral
therapy for patients experiencing worsening. Improper dosage regimen in the use of
nystatin and cotrimoxazole drop too low a dose of the drug. The interaction of several drugs
that Levofloxacin infusion and Ketorolac injection; rifampicin and isoniazid ; paracetamol
1396
and isoniazid . Inaccuracy of drug selection on TB drug use after patients undergoing
therapy for 6 days OAT patients have elevated AST and ALT of OAT Drug category 1
streptomycin and ethambutol will be but the patient still receives treatment in a category 1
patient underwent Multiple Organ Failure.
7. SUGGESTIONS
Poly pharmacy is very likely to occur in patients with HIV infection
accompanied. The role of pharmacists is very large in Drug Related Problem Identification
(MTO), Recommendation completion / MTO prevention (intervention), provision of drug
information, and monitoring results of the intervention, especially in intensive care patients,
patients who received more than 5 kinds of drugs and patients who experienced a decline in
function organs, especially the liver and kidneys, laboratory test results of patients who
reached a critical value, as well as patients who have a narrow therapeutic index and
potentially fatal ROTD.
The need for better management of appropriate antibiotic therapy (according to
guidelines) in order to achieve the goals of therapy and duration of antibiotic use needs to
be monitored in order to avoid resistance role of the pharmacist is in need unruk monitor
the rational treatment of patients with HIV / AIDS
8.REFERENCES
1. International
Labour
(2005). PedomanBersama
Organization
ILO
/
and
WHO
the
on
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, July 18, 2014.
2. Ministry of Health (2012). Guidelines for the Clinical Management of HIV Infection
National and Antiretroviral Therapy in the Adult and Youth .Jakarta: Ministry of Health.
3. http://reference.medscape.com/drug-interactionchecker
4. http://www.mims.com/indonesia
5. Shulman et al. Basic Biological and Clinical Diseases Infections, IV Edition University
of Gadjah Mada, Yogyakarta, 1994.
1397
6. Ministry of Health. National Guidelines for Tuberculosis Control. Ministry of Health of
the Republic of Indonesia, Jakarta. In 2008.
7. Prihatni D, Ida P, Idaningroem S, Coriejati R. Hepatotoxicity Effect Against
Tuberculosis Anti levels of alanine aminotransferase and aspartate aminotransferase
Serum Pulmonary Tuberculosis Patients. Laboratory of Clinical Pathology, Faculty of
Medicine, University of Padjadjaran / RS. Hasan Sadikin, Bandung, 2005.
8. Hasibuan, Poppy Z. Anjelisa Effectiveness Monitoring Gentamicin Therapy of Multiple
Dose Bolus Intra Venus Against Infection In Chronic Obstructive Pulmonary
Disease. University of North Sumatra, Medan, 2008.
9. Anonymous a. PCP (Pneumocystis pneumonia) .Yayasan graphics, Jakarta, 2009.
10.Anonymous b. Cotrimoxazole. NAM Foundation, Jakarta, 2009.
11. http://link.springer.com/ January 1990, Volume 39, Issue 1 , pp 86-109
1398
DRUG RELATED PROBLEM IN THERAPY CHRONIC KIDNEY
DISEASE (CKD) IN INTERNAL MEDICINE WARD Dr.
Desi Irma Rinding1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
According to the National Kidney Foundation Kidney Disease Outcome Quality intiative
(NKF KDOQI), the definition of chronic kidney disease (CKD) is kidney damage over 3
months, as definied by structural abnormalities of the kidney, with or without decreased
glomerular filtration rate (GFR), manifest by either pathological abnormalities, and markers
of kidney damage, including abnormalities in the composition of the blood or urine, or
abnormalities in imaging test (Hogg, 2002). Patient Mrs. EN, 49 years old, admitted to the
Dr. Mintohardjo Navy Hospital on 16 April 2014 with a diagnosis of CKD (Chronic
Kidney Disease). Therapy for the treatment during hospitaliziation is Nefrosteril (amino
acids 7%), furosemide injection, amlodipine, valsartan, Bicnat, Folic Acid, Prorenal, New
Diatab (Activated attapulgite), Imodium (loperamide HCl) and dextromethorphan. Based
on the clinical practice results in third class internal medicine ward of the Dr. Mintohardjo
Navy Hospital, it can be concluded that was found DRP (Drug Related Problem) such as
significant drug interaction between valsartan and furosemide which valsartan increases
and furosemide decreases serum potassium. The interaction between furosemide and folic
acid which furosemide decreases levels of folic acid by increasing renal clearance.
Keywords: Drug related problem (DRP), Chronic Kidney Disease (CKD), Dr. Mintohardjo
Navy Hospital
1.
INTRODUCTION
Chronic kidney disease (CKD) is a condition of kidney damage over 3 months, as
definied by structural abnormalities of the kidney, with or without decreased glomerular
filtration rate (GFR), manifest by either pathological abnormalities, and markers of kidney
damage, including abnormalities in the composition of the blood or urine, or abnormalities
1399
in imaging test. GFR glomerular filtration rate less than 60 mL/menit/1, 73 m2 for more
than 3 months, with or without kidney damage (Hogg, 2002).
End stage renal failure is a condition in which patients have decreased renal function,
as measured by creatinine clearance not more than 15 ml/min. End stage renal failure
patients, regardless of the etiology of disease, requires special treatment, called renal
replacement theraphy or treatment. Renal replacement therapy consists of hemodialysis,
peritoneal dialysis and kidney transplantation. Among any replacement therapy above, the
common replacement therapy was widely practiced in Indonesia is Hemodialysis (HD)
(Kresnawan, 2005).
According to data collected by the Indonesi Renal Registry (IRR), patients with end
stage renal failure who underwent the hemodialysis in Indonesia starting from 2007 to 2009
is 1885,1936,4707,5184,6951, and 91615. Data from several research centers that spread
through Indonesia reported that the cause of the end stage renal failure that underwent
dialysis was glomerulonephritis (36,4%), kidney obstruction and infection (24,4%),
diabetic kidney disease (19,9%), hypertension (9,1%), and other reasons (5,2%)
(Prodjosudjadi, 2009). According to the data from the United States Renal Data System
(USRDS), in 2009, end stage renal failure is commin and the prevalence is about 10-13%.
In the United States, the number reached 25 million people and in Indonesia is estimated
about 12,5% or 18 million peoples (Suharjono, 2009).
2.
CASE PRESENTATION
Mrs. EN, 49 years old admitted to the Dr. Mintohardjo Navy Hospital on April 16
2014. Patient come to hospital with swelling in both feet. Swollen feet present since 1-3
weeks. Swelling would gone down after she rest and come back after she do more
activites. Patient also felt nauseous on an empty stomach and watery bowel movements
immediately after eating meal. The patient also complained dry cough. In addition the
patient also has history of diabetes mellitus, hypertension, ulcers, and cardiovascular
disease. Patient allergic to amoxicillin. In 2009 the patient had experienced the same thing.
1400
3.
CLINICAL EVALUATION
In this case, the patient was treated with Nephrosteril (amino acids 7%) as the
supply of amino acids in severe impairment of renal function and dialysis. Injection Lasix
(furosemide) for diuretic therapy and edema in which the patient complained of swelling in
both feet. Amlodipine and valsartan was administered as antihypertensive to decrease blood
pressure which the patient had blood pressure 180/80 mmHg. Folic acid used for adjuvant
therapy in patients with chronic renal failure. It as a cofactor in erythropoietin production
that stimulate the hemoglobin production and prevent anemia and improve the condition
of the skin which
change in blackish discoloration due to hemodialysis.
Sodium
bicarbonate is administered to correct metabolic acidosis. Prorenal for the treatment of
chronic renal insufficiency. New diatab (Activated attapulgite) and Imodium (loperamide
HCl) for the treatment of diarrhea. Dextromethorphan to relieve dry cough in which patient
complain of dry cough since the first day of hospitalization (BPOM, 2008).
4.
DOSAGE AND USING THE DRUGS
During eight days of treatment in Dr. Mintohardjo Navy Hospital, patient Mrs. EN
take 9 kinds of medication. Dosage and use drug therapy that was took by Mrs. EN
include Nefrosteril (amino acids 7%) 14 TPM was administered subcutaneously as a
supply of amino acids in severe impa irment of renal function and dialysis. Injection Lasix
(furosemide) was administered intravenously 2 times 1 ampoule for the treatment of
diuretic and edema in which the patient complained of swelling in both feet. The Usual
Initial Dosage of lasix is 20-40 mg given IV / IM as single dose. Amlodipine 5 mg daily
and then was increased 10 mg daily administered orally and valsartan 80 mg daily
administered orally as antihypertensive. Amlodipine works as a potent vasodilator and
release of reflex sympathetic. Valsartan is a potent nonpeptida tetrazol derivative. Its ability
to lower blood pressure, it may used as an antihypertensive therapy. In addition, valsartan
can also be used to repair kidney demage (Saydam, 2007). Folic acid 5 mg 3 times daily
with usual dose 5-10 mg daily administered orally for adjuvant therapy in patients with
chronic kidney disease. It as a cofactor
in erythropoietin production that stimulate the
hemoglobin production and prevent anemia and improve the condition of the skin which
1401
change in blackish discoloration due to hemodialysis. Sodium bicarbonate 1 tablet 3 times
daily with usual dose of 4.8 mg daily given to treat metabolic acidosis. Prorenal (DL-3methyl-2-oxo-valeric acid 67 mg, 4-methyl-2-oxo-valeric acid 101 mg, 2-oxo-3-phenylpropionic acid 68 mg, 3-methyl-2-oxo -butyric acid 86 mg, DL-2-hydroxy-4-methylthiobutyric acid 59 mg, L-lysine Monoacetate 105 mg, 53 mg L-threonine, L-tryptophan 23
mg, 38 mg L-histidine, L-tyrosine 30 mg) 3 times daily 1 tablet administered orally for the
treatment of chronic renal insufficiency with the usual dose of 4-8 tablets 3 times daily
maximum 50 tablets. New diatab (Activated attapulgite) 1 tablet daily given as
symptomatic therapy for non-specific diarrhea with new diatab usual dose 6 tablets daily.
Imodium (loperamide HCl) 1 tablet daily
administered orally administered for the
treatment of acute and chronic diarrhea with Imodium usual dose of 8 tablets daily.
Dextromethorphan 15 mg 3 times daily with the usual dose of 8 tablets daily (BPOM,
2008).
5.
LABORATORY TEST RESULT
The Results of laboratory tests Mrs. EN on April 15, 2014 revealed an increase in
cholesterol levels of 205 mg% (> 200 mg%). The existence of cholesterol in the blood
vessels at high levels will cause precipitated crystals/slab that will narrow or clog blood
vessels. Creatinine levels at 3 times test on December 15, 17 and 21 April 2014 is higher
than normal levels is 8.0 U/L, 7.5 U/L, and 5.1 U/L (0.9 to 1.4 U/L). Elevated serum
creatinine indicate decreased kidney function and skeletal muscle contraction period. The
results of urea test twice on 17 and 21 April 2014 is higher than normal is 144 U/L and 129
U/L (17-43 U/L). Increased urea indicate a decrease in the volume of blood to the kidneys
and increased protein catabolism. Creatinine clearance test results on 18 April 2014
revealed creatinine clearance lower than normal levels is 1.62 ml/min (75-125 ml/min).A
Low creatinine clearance levels in the blood indicate a moderate to severe renal
impairment. Results of hemoglobin test twice on 17 and 19 April 2014 which is lower than
the normal levels 6.2 g% and 8.0 g% (12-16 g%). A low hemoglobin count stimulates the
secretion of erythropoietin. Decreased secretion of erythropoietin as an important factor in
stimulating the production of red blood cells by the bone marrow lead to reduced product of
1402
hemoglobin and anemia resulting in increased oxygen by hemoglobin (oxyhemoglobin) is
reduced. The results of the examination of erythrocytes in 2 times inspection on 17 and 19
April 2014 is lower than normal, namely 2.16 and 2.97 103μL 103μL (103μL 3.5 to 5.4).
Low erythrocytes in the blood due to the decrease in blood erythropoietin because
eritopoetin can not be produced due to impaired renal function. Hematocrit test results at 2
times the inspection on 17 and 19 April 2014 is lower than normal, namely 18% and 26%
(38-46%). Decreased hematocrit indicates hemorrhage (Sutedjo, 2008).
6.
DISCUSSION
Patient Mrs. EN admitted to the Dr. Mintohardjo Navy Hospital on April 16, 2014.
Patient present with swelling in both feet. Based on the results of laboratory tests, patient
Mrs. EN had chronic kidney disease. Patient was diagnosed with chronic kidney disease is
based on the complaints of patients include swelling in the feet, back pain, nausea, and
dizziness. Based on vital signs examination such as blood pressure 180/80 mmHg and the
results of laboratory tests include kidney function, hematology, and chemistry clinics such
as urea levels 144 u/l and the patient's creatinine 8.0 u/l higher than normal levels. Elevated
serum creatinine indicate decreased kidney function and decreased muscle mass. Elevated
creatinine levels was found in acute or chronic renal failure. Test results also showed
creatinine clearance lower than normal levels is 1.62 mL / min (75-125 ml / min) indicate a
moderate to severe renal impairment (Sutedjo, 2008). In addition peripheral blood test
revealed hemoglobin, hematocrit, and erythrocyte lower than normal levels which causes
anemia, in which anemia is almost always found in patients with chronic renal failure.
Anemia in chronic kidney disease is mainly caused by a deficiency of erythropoietin
(Suwitra, 2009).
7.
DRUG RELATED PROBLEMS
1. Failure to receive medication
The patient complained of dry cough since the first day of hospitalization but the
doctor had just prescribed dextromethorphan on seventh and eighth day
2. Untreated Indication
1403
The patient complained of vomiting dan back pain but doctor did not prescribed
medication.
Interaction between furosemide and valsartan, valsartan increases and furosemide
decreases serum potassium. In addition there is also interaction between furosemide
and folic acid, furosemide decreases levels of folic acid by increasing renal clearance.
8.
CONCLUSION
Based on the clinical practice result in class III internal medicine wards Sangeang
Island Dr. Mintohardjo Navy Hospital can be concluded that was found DRP (Drug
Related Problem) in, it can be concluded that was found DRP (Drug Related Problem)
such as significant drug interaction between valsartan and furosemide which valsartan
increases and furosemide decreases serum potassium. The interaction between furosemide
and folic acid which furosemide decreases levels of folic acid by increasing renal clearance.
9.
REFERENCES
1.
Baradero M, SPC, MN, Dayrit M, Siswadi Y, 2009. Klien Gangguan Ginjal :
Penerbit Buku Kedokteran EGC. Jakarta.
2.
BPOM, 2008. Informatorium Obat Indonesia (IONI). Jakarta : Sagung Seto.
3.
Sutedjo, A.Y, 2007. Buku sakti mengenali penyakit melalui pemeriksaan
laboratorium,. Jakarta
4.
BNF staff. 2011, British National Formulary 61, Pharmaceutical Press, London,
UK, p. 346.
5.
Drug Interaction Checker, 2014, Medscape Reference Drug, Diseases &
Procedures, Retrieved June 21, 2014, http://reference.medscape.com/druginteractionchecker.
6.
Hogg, J.R, 2002. Kidney Disease Outcomes Quality Iniatiative of The National
Kidney Foundation. Clinical Practice Guidelines for Chronic Kidney Disease:
Evaluation, Classification, and Stratification.
1404
7.
Kresnawan,Triyani. 2005. Penatalaksanaan Diet Pada Penyakit Ginjal Kronis,
Pertemuan Ilmiah Nasional II AsDi, Bandung.
8.
M. Saydam and S. Takka, 2007. Bioavailability. File: Valsartan," Journal of
Pharmacological Science, vol. 32, pp. 185-196, 2007.
9.
Prodjosudjadi, Wiguno, Suhardjono., 2009. End-Stage Renal Disease In Indonesia
: Treatment velopment. Ethnicity & Disease, Volume 19.
10. Suhardjono, 2009. Penyakit Ginjal Kronik adalah suatu wabah baru (global
epidemic) di seluruh dunia. Annual Meeting Perhimpunan Nefrologi Indonesia. 19.
11. Suwitra K., Penyakit Ginjal Kronik. Dalam: Sudoyo AW et al, eds. “Buku Ajar
Ilmu Penyakit Dalam”, Jilid I . Edisi Keempat. Jakarta: Pusat Penerbitan Ilmu
Penyakit Dalam FKUI; 2007. h.570-573h
12. Suwitra K., Penyakit ginjal kronik. In: Sudoyo AW, Setiyohadi B, Alwi I, K SM,
Setiati S, editors: Buku ajar ilmu penyakit dalam. 5nd ed. Jakarta: Interna
Publishing; 2009.p.1035-40.
13. USRDS, 2011. Chapter Twelve : International Comparisons. Retrieved June 21,
2014 http://www.usrds.org/2011/view/v2_12.asp.
1405
ON ACUTE GASTROENTERITIS DISEASE IN MINTOHARDJO
HOSPITAL
Dewi Sri Utami 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Acute Gastroenteritis or acute diarrhea is the symptoms of the frequency of defecate and
the dilution in which the frequency is more than 3 times in a day and the quantities is more
than 200 – 250 gram. This term to be a reference that the inflammatory process in the
gastric and intestines, it caused of the bacteria, virus or pathogen parasite (Syaiful, 1996).
Mrs. M. W. Widyartiyanyi, 74 years old came to Mintohardjo Navy Hospital on February,
14th 2014. Results of laboratory test shows the protein abnormalities is 5.5 (Normal values
W: 6.6 – 8.8 g/dL), globulins 1.1 (Normal values W: 6.6 – 8.8 g/dL), Erythrocyte
sedimentation rate 28 (Normal values W < 20 mm), Eosinophil (Normal values % W: 2 –
4), was diagnosed gastroenteritis. During hospitalized, patient received RL intravenous 20
drop per minute, Ceftriaxon injection 2 x 1 gram, Ranitidine injection 3 x 1 ampoule,
Ondasentron 3 x 1 ampoule during 4 days, New Diatabs 3 x 2 tablet during 5 days and
Mefenamic Acid 3 x 500mg on the fourth and fifth day. The medicines was given to
reduced dizziness caused by gastric problems, headache and nausea. Based on the result of
the clinic secretariat at the ward of K in PGI Cikini Hospital, it could be concluded that
there was DRPs (Drug Related Problems) is improper drug selection.
Keyword : Gastroenteritis, MIntohardjo Navy Hospital.
I.INTRODUCTION
Acute gastroenteritis is non – specific condition of pathologic in gastrointestinal
tract. (Diskin, 2009). Acute gastroenteritis is a kind of diarrhea with frequency of defecate
and the dilution is more than 3 times each day and the quantities is more than 200 – 250
gram (Syaiful, 1996). Diarrhea also mean defecate with the quantity of feces is more than
usual, with liquid feces or semi liquid (semi solid) can also be accompanied by increased
frequency (Arif, 1999). Infectious agent can cause acute gastroenteritis. This agent causes
1406
diarrhea mucous invasion, enterotoxin production and or cytotoxic production (Diskin,
2009). Acute diarrhea also can cause because of intoxication, allergic, reaction of
medicines, and psychological factor (Zein, 2004).
2.CASE PRESENTATION
Mrs. M. W. Widyartiyanti, 74 years old came to Mintohardjo Navy Hospital on
February, 14th 2014. She got diarrhea with yellow and slimy dregs. The frequency of
diarrhea 20 times each day. Vomiting 3 – 10 times since in the morning. Patient’s has
hypertension and seafood allergic history. Medical laboratory check result shows the
protein abnormalities is 5.5 (Normal values W: 6.6 – 8.8 g/dL), globulins 1.1 (Normal
values W: 6.6 – 8.8 g/dL), Erythrocyte sedimentation rate 28 (Normal values W < 20 mm),
Eosinophil (Normal values % W: 2 – 4).
In these case the patient was treated with RL intravenous 20 drop per minute to
keep the balance of body fluids, Ceftriaxone injection 2 x 1 gram to treated infections
caused by gram positive or negative bacteria, Ranitidine injection 2 x 1 ampoule to prevent
gastric irritation (ulcer), Ondansetron injection 3 x 1 ampoule to treated the nausea and
vomit during 4 days, New Diatabs 3 x 2 tablet during 5 days to the diarrhea, Mefenamic
Acid 3 x 500 mg on 4th and 5th day to reduce the dizziness (Yulinah, 2011).
4.DISCUSSION
Patient was diarrhea with yellow and slimy dregs and happens 20 times each day.
Vomiting 3 – 10 times since morning. On first day, patient was treated with RL
intravenous, Ceftriaxone injection 2 x 1 g, Ranitidine injection 2 x 1 ampoule,
Ondansentron 3 x 1 ampoule, New Diatabs 3 x 2 tablets and Mefenamic Acid 3 x 1 tablet.
The medicines was given to decreased the dizziness because of gastric problem, headache
and nausea. Second day, patient was treated by New Diatabs to stop the diarrhea. At fifth
day RL, Ceftriaxone, Ranitidine, and Ondansentron has been stopped.
1407
Based on laboratory test showed abnormalities in total protein is 5.5 (Normal values
W: 6.6 – 8.8 g/dL), globulins 1.1 (Normal values W: 6.6 – 8.8 g/dL), Erythrocyte
sedimentation rate 28 (Normal values W < 20 mm), Eosinophil (Normal values % W: 2 –
4) , then patient should be given enough protein intake and get parenteral nutrition
(Luckmans, 1996), abnormalities seen an increased in erythrocyte sedimentation rate which
result 28 mm while the normality is < 20 mm, it’s sign there is gastrointestinal tract
infection, then patient was given Ceftriaxone injection. The result of uric acid test shows
that out of index normality, 8.2 mg/dL, so patient recommended the low purine and
pyrimidine diet and control blood pressure too because patient had a history of
hypertension (Setyohadi, 2007).
5.CONCLUSION
Based on the result of clinical at “Pulau Perawatan Selayar” 3rd floor of Mintohardjo
Navy Hospital it could be concluded that there was drug related problem such as improper
drug selection. If Mefenamic acid is used to continuously it can increased gastric acid
(IONI, 2008).
6.REFERENCES
1.
DuPont, Herbert L. 1997. Guidelines on Acute Infectious Diarrhea in Adults. In: The
American Journal of Gastroenterology. The American College of Gastroenterology.
2.
Farthing, M. 2008. World Gastroenterology Organization Practice Guideline: Acute
Diarrhea.World Gastroenterology Organization
3. Badan POM RI, 2008. Indonesian National Drug Information, Jakarta.
4.
Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A Pathophysiologic Approach 7th
5.
UK Renal Pharmacy Group, 2009, Renal Drug Handbook Third Edition, Radcliffe
publishing Oxford. New York.
1408
CASE STUDY OF DISEASE IN PGI CIKINI HOSPITAL JAKARTA
MASSIVE ASCITES
Endah Permata Sari(1), Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
Ascites is the accumulation of fluid (usually serous fluid which is a pale yellow and clear
fluid) in the abdominal cavity (peritoneal). Abdominal cavity is located below the chest
cavity. Ascites fluid commonly found in patients such as heart disease, cancer, congestive
heart failure, and kidney failure. Massive ascites is Ascites the highest degree or difficult
to cure because of massive ascites prognosis is poor, with a survival rate of less than 1 year
50% (Grace, 2006). Patient Ms. YY, age 45 years old, entered the hospital PGI Cikini on
March 8, 2014 was diagnosed massive ascites. Patient had treated with Intrix (ceftriaxone),
Lasix (furosemide), Aldacton (spironolactone), Ca gluconate, Robumin (albumin), Vitamin
K, Paracetamol, Tramal (tramadol), Cernevit, Albuminar (albumin), Rimstar (rifampicin).
Based on the results of clinical practice in a hospital ward K PGI Cikini it can be concluded
that the presence of DRP (Drug Related Problem) in the form of unnecessary drug therapy,
need additional drug therapy, drugs are not effective, the dose is too low, and drug
interactions (furosemide and paracetamol, paracetamol and rifampicin, as well as
ceftriaxone and ca gluconate).
Keywords: Massive Ascites, Disease and PGI Cikini Hospital
INTRODUCTION
Ascites is derived from the Greek language meaning Askos bag or purse. Ascites is
the accumulation of fluid in the abdominal cavity patoligis. 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, nephrosis etc (Fredman, 2010 ; Isselbacher, 1999).
Classification of ascites is divided into 2 following as :
1409
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
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 intraabdominal 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 α-fetoprotein for hepatoma, CA 125 for ovarian cancer).
Management
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.
1410
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 Ms. YY, aged 45 years old entered PGI Cikini Hospital on March 8, 2014.
Patient present with abdominal swelling 3 months before entering the hospital. Patient felt
enlarged stomach progressive.
CLINIC EVALUATION
Results of the laboratory toward, on hematological examination showed the value of
blood sedimentation rate (BSR) is high, 70 mm/h (0 to 20 mm/h), the increase in the value
of globulin is 4.9 g/dL (1.3 to 3.7 g/dL), eosinophils 4% (1-3%) and monocytes 11% (2 to
8%), decreased hemoglobin, the hemoglobin value of 10.0 g/dL (12.0 to 14.0 g/dL), MCV
71 fl (81 to 92 fl), MCH 23.0 pg (27.0 to 32.0 pg), neutrophil 0% (2 to 6%) and hematocrit
31% (37-43%).
Examination of liver function showed that the value of direct bilirubin was 0.3
mg/dL (0.1 to 0.2 mg/dL), and decreased albumin 2.8 g/dL (3.4 to 4.8 g/dL). Result of
electrolytic parameter showed that impaired calcium (Ca) that was 7.7 mg/dL (8.8 to 10.0
mg/dL), magnesium (Mg) 1.7 mg/dL (1.8 to 3.0 mg/dL), cholinesterase (CHE) 6023 U/L
(7000 to 19000 U/L). The third day of examination ascites fluid and ascites fluid obtained
yellowish. The fifth day of immunological examination include CEA (Carcinoma
Embriome Antigen) 125 which indicates that an increase was 280.8 U/mL above the normal
value (0 to 35 U/mL) (Sutedjo, 2007).
In this case, patient treated with Intrix (ceftriaxone), intrix was used for abdominal
infections, Lasix (furosemide) was used as a diuretic drug used to treat edema in patients.
Aldacton (spironolactone) was used as a diuretic drug. The use of Ca. gluconate to calcium
deficiency because of the patient's laboratory data calcium levels below the normal value.
The albumin was used to normalize the levels of albumin in the body that below normal.
Where albumin was one of the caused of edema. Vitamin K was given to prevent bleeding,
1411
Rimstar (rifampicin) was used for tuberculosis infection whereas laboratory report does not
indicate that the positive TB patient (Anderson, 2002).
DOSAGE OF DRUGS
In the case of patient has treated with Intrix (ceftriaxone) at the dose of 2 x 1 g,
Lasix (furosemide) at the dose of 1 x 1 ampoule daily, Aldacton (spironolactone) at the
dose of 2 x 100 mg a day, Ca gluconate at the dose of 2 x 1 ampoule injection, Robumin
with the dose of 1 x 100 cc a day, use of Vitamin K with the dose of 2 x 1 ampoule daily,
with the dose of 1 x Paracetamol 500 mg daily, Tramal (tramadol) is used in post-op biopsy
laparotomy with 2 x 100 mg dose, Cernevit a multivitamin that does not decrease the
immune system, and Rimstar (rifampicin) was used for the treatment of TB infection
(Anderson, 2002; Anonim, 2009).
DISCUSSION
In hematological parameters result in the first day, showed the value blood
sedimentation rate (BSR) was high, 70 mm/h (0 to 20 mm/h), an increase in globulin 4.9
g/dL (1.3 to 3.7 g/dL) with has increased blood sedimentation rate (BSR) usually occurs as
a result of increased levels of globulin and fibrinogen as local and systemic acute infection,
eosinophils 4% (1 to 3%) and monocytes 11% (2 to 8%) showed viral infection occurs.
Decreased hemoglobin was 10.0 g/dL (12.0 to 14.0 g/dL), MCV 71 fl (81 to 92 fl), MCH
23.0 pg (27.0 to 32.0 pg) contained in anemia and cancer, neutrophil 0% (2 to 6%) present
in viral infections, and hematocrit 31% (37 to 43%) in which a decreased in hematocrit
occurred in patient who have anemia, malnutrition, and liver cirrhosis.
On examinations of liver function showed has increased in the value of direct
bilirubin was 0.3 mg/dL (0.1 to 0.2 mg/dL), direct bilirubin which was usually caused by
intrahepatic or extrahepatic obstructive jaundice due to cell damage or stone and
impairment albumin 2.8 g/dL (3.4 to 4.8 g/dL) which resulted in a decrease in albumin
discharge leading to vascular tissues, causing edema. Diseases that cause hipoalbumineria
include malnutrition and liver cirrhosis. While on electrolytic parameter, impaired calcium
(Ca) that is 7.7 mg/dL (8.8 to 10.0 mg/dL), magnesium (Mg) 1.7 mg/dL (1.8 to 3.0 mg/dL),
1412
cholinesterase (CHE) 6023 U/L (7000 to 19000 U/L) where the impairment of Ca, Mg and
cholinesterase (CHE) contained in malabsorption, liver cirrhosis and infection (Sutedja,
2007).
On the third day of the examination and the ascites fluid obtained yellowish ascites
fluid which, according to Grace (2006:41) if the yellowish ascites fluid indicates that
patients with liver cirrhosis. The fifth day of immunological examination includes CA
(Cancer Antigen) 125 which indicates that an increase is 280.8 U/mL above the normal
value (0 to 35 U/mL). It is one of the markers of cancer but the results can not yet be able to
detect early whether a person has cancer. Because according to data that > 20% of women
suffering from ovarian cancer results CA (Cancer Antigen) 125 normal (Anonim, 2014).
Patient as long as has treated at PGI Cikini Hospital, she has received 11 types of
drugs. On the second day until day 7 in five patient had given treatment including drug
types Intrix (ceftriaxone) at the dose of 2 x 1 gram daily, which intrix used for abdominal
infections, the use of Lasix (furosemide) dose was 1 x 1 ampule daily use as a diuretic drug
used to cope with edema in patient. The use Aldacton (spironolactone) that the dose of 2 x
100 mg daily was used as a diuretic drug furosemide and spironolactone combination
where the most effective way to reduce the buildup of fluid in the abdomen and prevent
hypokalemia due to furosemide (Fredman, 2010; Mathew, 2008 & Moore KP, 2006).
The used of Ca gluconate at the dose of 2 x 1 ampoule injection used for calcium
deficiency because of the patient's laboratory data calcium levels below the normal value.
Albumin was used to normalize the levels of albumin in the body is below normal. Because
the drug binds to the protein and albumin is the main protein in plasma, if albumin not
normalized levels when patients were given other drugs will many free drug in the blood
that would cause toxicity. Where most of the drugs administered in therapeutic binds to
proteins in the plasma. In addition, the condition was one of the causes of
hypoalbuminaemia edema. The use of albumin only on day two to day four. Vitamin K
with the dose of 2 x 1 ampoule daily with the use of injections given to prevent bleeding if
patients with cirrhosis of the liver where the risk of bleeding was definitely there and the
use of vitamin K plays a role in blood clotting. On the second day without any complaints
of pain or fever patient had given paracetamol therapy because of the used of the drug was
1413
highly susceptible to patient with hepatic impairment has occurred while the patient's liver
damage.
On day 7, the patient was treated again with some drugs such as Tramal (tramadol)
at the dose of 2 x 100 mg taken orally was used as an analgesic because at that time the
patient did post-op biopsy laparotomy and the patient complained of pain, Cernevit used as
a multivitamin . On the 8th day until the last day, the patients received therapy Albuminar
(albumin) because albumin levels are still below the normal value. On day 9 Rimstar given
therapy (rifampicin) were used for infection but did not found that laboratory tests showed
that the positive TB patient (Anderson, 2002; Anonim, 2009).
DRUG RELATED PROBLEM (Cipolle, 2004)
1. DRP 1 : Unnecessary Drug Therapy
In this case the patient should not be given the drug as paracetamol. Paracetamol
was a drug used as an analgesic-antipyretic that has side effects may damage the heart
while the patient was experiencing liver failure. So it can aggravate the condition of the
liver of the patient. In addition, the use of rimstar (rifampicin) appears to be less precise
because there are no laboratory tests also showed that patients who test positive for TB.
2. DRP 2 : Need Additional Drug Therapy
By looking at the condition of the patient needs additional drug therapy in which
the patient views of laboratory data for 10 days treatment Hb values are still below the
normal value so that the patient needs to be given treatments such as folic acid, EPO
(erythropoietin), iron salts to treat anemia that occurs in these patients.
3. DRP 3 : Drugs are not Effective
In these cases, drug treatment was only given furosemide injection 10mg/ml in
preparation so as to cope with ascites slightly less effect because the initial doses of
furosemide for ascites was 40 mg (Mathew, 2008 & Moore KP, 2006).
4. DRP 4 : Dose is too low
The combination of furosemide and spironolactone most effective way to reduce
the buildup of fluid in the abdomen. Where the initial dose was given 40 mg of
furosemide and spironolactone 100 mg. The furosemide therapy was only given 10
1414
mg/ml in injection preparations. If there was no weight loss or increase in urinary
sodium excretion after two or three days then second dose of drug should be increased.
The dose of spironolactone may be increased to 400 mg daily and furosemide increased
to 160 mg daily (Fredman, 2010; Mathew, 2008 & Moore KP, 2006).
5. DRP 5 : Drug Interaction
Furosemide-Paracetamol, paracetamol may decrease the effects of loop diuretics
(furosemide). Where paracetamol decrease in renal prostaglandin excretion and
decrease plasma renin activity. Paracetamol-rifampicin, therapeutic effectiveness of
acetaminophen as an analgesic/antipyretic may be decreased slightly by rifampicin.
Rifampicin may increase the toxicity of acetaminophen. Ceftriaxone-Ca gluconate,
increase particulate fluid in the lungs and kidneys. Should be spaced 48 hours of usage.
Therefore, to avoid drug interactions that happen then should be spaced interval of 2
hours for the next drug (Anonim, 2005).
CONCLUSION
1. Based on clinical practice in internal medicine in Ward K PGI Cikini Hospital it can be
concluded that the patient suffered from massive ascites due to cirrhosis of the liver and
tuberculosis infections occur based on laboratory results were performed. In addition
there was DRPs (Drug Related Problems) for therapeutic treatment which found the
presence of DRPs (Drug Related Problems) includes unnecessary drug therapy, need
additional drug therapy, drugs were not effective, the dose is too low, and drug
interactions.
2. Total cost of treatment was for 10 days Rp. 9.045.266
REFERENCES
1. Anderson, Philip, et.al. 2002. Handbook of Clinical Drug Data 10rdEdition. United
States of America : The McGraw-Hill Companies
2. Anonim. 2014. CA125. http://en.wikipedia.org/wiki/CA-125
3. Anonim. 2009. British National Formulary 57. London : BMJ Group and RPS
Publishing.
1415
4. Anonim. 2005. Stocley’s Drug Interactions. The Pharmaceutical Press
5. Cipolle, Robert J, et al. 2004. Pharmaceutical Care Practice Second Edition. USA: The
Mc.Graw-Hill Companies Inc.
6. Fredman, L. Scott. 2010. Clinical Hepatology : Principles and Practice of
Hepatobiliary Disease Volume 1. London : Springer.
7. Grace P, Borley N. 2006. At a Glance Ilmu Bedah, Edisi ketiga. Jakarta : Erlangga. Hlm
40-41
8. Isselbacher, J Kurt. 1999. Harrison Prinsip-prinsip Ilmu Penyakit Dalam / editor edisi
bahasa Inggris, Kurt J. Isselbacher [et al] ; editor edisi bahasa Indonesia, Ahmad H.
Asdie Ed. 13. Jakarta : EGC.
9. Mathew, K. George, Aggarwal Praveen. 2008. Medicine : Prep Manual For
Undergraduates 3rd Edition. New Delhi : Elsevier
10. Sutedjo, Ay, 2007. Buku Saku Mengenal Penyakit Melalui Hasil Pemeriksaan
Laboratorium. Jakarta : Birata Karya Aksara
11. Moore KP, dkk. 2006. Guidelines of The Management of Ascites In Cirrhosis. Report
on The Concensus Conference of The International Ascites Club
1416
DRUG RELATED PROBLEMS ON NON-HEMORRHAGIC STROKE
AND DIABETES MELLITUS DISEASE TREATMENT IN
MINTOHARDJO HOSPITAL
Endang Rahayu 1, Aprilita Rina Yanti2 and Diana Laila Ramatillah2
1
2
Lecturer of Faculty of Pharmacy UTA'45Jakarta (1343700062)
[email protected]
ABSTRACT
Stroke is clinical manifestation, of quick cerebral function disorder both focal and
global, for more than 24 hours or ends with death, without any other causes found than
vascular disorder. Mostly Non-hemorrhagic stroke caused by ektracranial embolism or
intracranial thrombosis (Sutrisno, 2007). Diabetes mellitus (DM) is chronic hyperglycemia
state accompanied by a variety of metabolic abnormality due to hormonal disorders, which
causing a variety of chronic complications to the eye, kidney, nerve and blood vessel,
accompanied with lesion in the basement membrane in electron microscopy examination
(Mansjoer 2009). Patient of Mr. LT, 55 years old entered to RSAL Mintohardjo on February
17, 2014. Laboratory test showed abnormality of 291 mg% fasting blood glucose, 436
mg/dl triglyceride, 233 mg/dl cholesterol, and 152 mg/dl LDL cholesterol. During
treatment the patient received intravenous RL fluid therapy, neulin injection, injection
ketorolac, mefenamic acid, amitriptyline, gabapentin, simvastatin, citicolin, clopidrogel,
gemfibrosil, cilostazol, neulin ps, ascardia, actrapid, Lantus, Metformin. Drugs were given
to address complaints suffered by patient such as half body numbness, pains, half body
limp, hypercholesterolemia, hypertriglyceridemia and hyperglycemia. In this case found
DRP (Drug Related Problem) The patient failed in talking drugs. Improper drugs selection.
Unwanted drugs reaction. Drugs interactions with drugs, and there were drugs duplication.
Keywords: Non-hemorrhagic stroke, diabetes mellitus. RSAL Mintohardjo.
I. INTRODUCTION
Non Hemorrhagic Stroke
Non-hemorrhagic stroke (SNH) is clinical syndrome that initially arise suddenly,
rapid progression of focal or global neurological deficit lasting for 24 hours or more or
causing death directly caused by non-straumatik brain blood circulation disorder. Stroke
attacks all ages, including children, but most of the cases found in people over 40 years old,
1417
the older someone age, the greater the risk of suffering stroke, this disease for all gender,
but stroke more affects men than women, and in terms of skin color, colored people more
likely to have stroke than white (Sutrisno, 2007).
By pathological abnormality, stroke can be divided into:
1.
Hemorrhagic stroke
a. Intra-cerebral hemorrhage
b. Extra cerebral hemorrhage (sub-arachnoid)
2.
Non-hemorrhagic Stroke
a. cerebral thrombosis
Thrombotic stroke is stroke that is caused by blockage on brain’s blood vessels
lumen, because thrombus get thicken so that blood flow is not smooth.
b. cerebral embolism
Ischemic infarction can be caused by emboli that arise from ateromatus lesion located
in the more distal vessels.
The main symptoms of non-hemorrhagic stroke is sudden neurological deficit, it occur
when resting, consciousness does not decrease unless the embolics is large in
hypercoagulable state (Muttaqin 2008).
Diabetes Mellitus
Diabetes mellitus (DM) is chronic hyperglycemia state accompanied by a variety of
metabolic abnormality due to hormonal disorder, which causes a variety of chronic
complications in the eye, kidney, nerve, and blood vessels, with lesions in the basement
membrane in electron microscopy examination, diagnosis of diabetes mellitus begins with
typical symptoms such as polyphagia, polyuria, polydipsia, limp, and severe weight loss,
other possible symptoms complained by patient are tingling, itching, blurred eyes, and
impotence in men, and pruritus vulva in women, complaints and typical symptoms plus
blood glucose test results > 200 mg/dl or fasting blood glucose > 126 mg/dl is sufficient to
establish the diagnosis of diabetes mellitus, when blood glucose test results dubious, TTGO
checking also necessary to confirm the diagnosis of diabetes mellitus (Mansjoer 2009).
DM Etiological classification of American Diabetes Association (1997) as per
1418
recommendation of the Indonesian Endocrinology Society (Perkeni) are:
1.
Diabetes mellitus type 1 (β cell destruction, usually leading to absolute insulin
deficiency): autoimmune and idiopathic.
2.
Diabetes mellitus type 2, in diabetes mellitus type 2 the insulin level is normal, even
more, but the number of insulin receptors located on the cell surface is reduced.
2.
Another type of Diabetes, genetic defects on beta cell function, genetic defects on
insulin works, exocrine pancreas disease, endocrinopathy, due to chemical drugs,
infection, rare immunological causes, other genetic syndromes associated with DM.
3.
Gestational Diabetes Mellitus (GDM)
2.CASE PRESENTATION
Patient of Mr. LT, 55 years old entered to Emergency of RSAL Mintohardjo on
February 17, 2014, with main complaint of numbness in the right hand half body, pain and
limp in half body, past-disease history diabetes mellitus was not controlled, insomnia, there
was fall history of in 2013. Laboratory test results showed abnormal fasting blood glucose
291 mg% (70-115 mg%), triglycerides 436 mg/dl (<170 mg/dl), cholesterol 233 mg/dl
(<200 mg/dl). LDL cholesterol 152 mg/dl (<130 mg/dl). AST 55 U/L (<35 U/L). SGPT 52
U/L (<31 U/L). hemoglobin 16.8 g/dl (12-16 g/dl), and blood glucose 388 mg%. (<200
mg%). Head CT scan: lacunark infarction, Thorax photo: artery atherosclerosis, bilateral
chronic mastoiditis susp, abnormality not appear. The patient's blood pressure on 2nd day
from 120/80 mmHg increased to 140/90 mmHg on 3rd day until 7th day.
3.CLINIC EVALUATION
In this case the patient was treated with intravenous ringer lactate 20 drops per
minute aims to restore the body fluids balance. 2x500 mg Neulin injection was indicated to
improve cerebral blood flow. 30 mg/kolf Ketorolac injection was indicated for the shortterm procedure of moderate to severe acute pain (non-narcotic analgesic). 3x500 mg
mefenamic acid
was
indicated for analgesic. 25 mg 3x½ tablets Amitriptyline was
indicated for sedation. 2x100 mg Gabapentin was indicated to relieve pain. 2x500 mg
tablets Citicolin was indicated for consciousness disorders followed by cerebral injury,
1419
infarct selebral. 1x20 mg Simvastatin was indicated for hypercholesterolemia treatment.
1x75 mg Clopidrogel was indicated to reduce further atherothrombotic accompanying
myocardial infarction, stroke or peripheral vascular disease, non-st segment elevation acute
coronary syndrome with asetosal use together. 3x300 mg Gemfibrozil was indicated for
hypercholesterolemia treatment, preventing the risk of coronary heart disease,
hypertriglyceridemia treatment, dyslipidemia treatment. 2x100 mg Pletaal was indicated for
antiplatelet drugs. 2X1 Neulin PS (choline citrate, cytidine) was indicated to preserve poststroke health. 1x50 mg Glucobay (acarbose) and 1x100 mg eclid (acarbose) was indicated
for adjunctive therapy with diet for patient with diabetes mellitus. 1x80 mg Ascardia was
indicated for antiplatelet therapy. 3x16 units Actrapid (HM insulin recombinant with origin
DNA) and 1x10 unit Lantus (insulin glargine) was indicated for diabetes mellitus who
required insulin therapy. 3x500 mg metformin indication for diabetes patient treatment
(ISFI, 2014).
4.DISCUSSION
Patient entered with main complaint of numbness in the right hand half body, pain
and limp in half body. On the first day of admission to hospital the patient was treated with
RL infusion, neulin injection, injection ketolorac, mefenamic acid, amitriptyline,
gabapentin. After examination and then the patient was transferred to the Pulau numpor
treatment room and treated with infusion RL, 2x500 mg neulin injection, 30 mg/kolf
ketolorac injection, 3x500 mg mefenamic acid, 25 mg 3x½ tablets amitriptyline, 2x100 mg
gabapentin, 20 mgx1 simvastatin, from the foregoing drugs taking has to do with patient
complaints, the drugs given aim to reduce numbness in half body, pain and limp in half
body. On 2nd day, and all three patients were prescribed with the same drugs. But on the
third day there was the addition of 1x50 mg glucobay and 1x100 mg eclid because the
patient's blood glucose was not normal, 5th day with infusions RL, neulin injection, and
injection ketolorac were stopped because of patient’s complaints has been reduced, and
there were addition of 2x500 mg citicolin, 1x75 mg clopidrogel and 3x300 mg gemfibrosil
until 6th day, to reduce atherothrombotic, hypercholesterolemia and hypertriglyceridemia,
whereas pletaal made only on 7th and 8th day, to antiplatelet, 2x1 Neulin ps, 1x80 mg
1420
ascardia, 3x16 units actrapid, 1x10 units Lantus, 3x500 mg metformin was given on 8th
day. Changes in medication prosedure often occurs due to pharmacokinetics and
pharmacodynamics factors related with age increase of a person (IONI 2008).
Based on laboratory test results on the first day showed abnormality in blood
glucose and blood glucose during fasting, which indicates the patient had hyperglycemia
condition. Hyperglycemia condition in this patient must be addressed using short-acting
insulin antidiabetic (actrapid) drugs and metformin. Patient also suffered triglyceride,
cholesterol, and LDL cholesterol increase, which indicates patient had hypertriglyceridemia
and hypercholesterolemia. The selection of drugs for cholesterol and triglycerides were less
precise, gemfibrosil combination with simvastatin then gemfibrosil will inhibit the
metabolism of simvastatin, resulting in an increase in plasma levels in simvastatin causing
rhabdomyolysis. Geriatric patient has higher rhabdomyolysis risk, should patient who had
hypertriglyceridemia and hypercholesterolemia with gemfibrosil only. SGOT increased.
SGPT, and hemoglobin, can occur to patient with non-hemorrhagic stroke because there
was blockage of blood clots in the blood vessels in the brain or artery leading to the brain.
On 3rd to 7th day an increase in blood pressure due to side effects of the amitriptyline
(IONI 2008)
Ketolorac drugs and mefenamic acid should be given separate within 2 hours due to
pharmacodynamic interaction between ketorolac and mefenamic acid, and ketorolac
mefenamic acid the both improves anticoagulation and increase in serum potassium, so it is
necessary to check the electrolyte (potassium) and hemostasis (PT/APTT), significant
interaction between simvastatin and amitriptyline is simvastatin increases the amitriptyline
effect so need close monitoring, there was drugs duplication of glucobay and eclid
prescription they are acarbose class, it is necessary to conduct counseling to patient to
follow healthy lifestyle and medication adherence.
5.CONCLUSION
Based on clinical secretariat practice results in Pulau Numpor treatment room of RSAL
Mintohardjo we may conclude there was existence of DRP (Drug Related Problem). Patient
failed in taking drugs. Improper drugs selection. Unwanted drugs reactions. Drugs
1421
interactions with drugs, and there was drugs duplication.
6.REFERENCES
1.
Allah A, Kuswara FF, A,Wuysang, Overview on brain blood circulation disorders in
neurology selected topics of sixth printing editing by Harsono.Gadjah Mada
University press,Yogyakarta .2007.
2.
Arif Mansjoer et al,2009, Medical selected topics,Volume 1 third edition of Media
Aesculapius.
3.
http://reference.medscape.com/drug-interactionchecker
4.
Sutrisno,Alfred Stroke ? You Must Know Before You Get.Jakarta.PT.Gramedia
Pustaka Utama,2007.
5.
Arif
Muttaqin,Asuhan
Keperawatan
Klien
dengan
Gangguan
Sistem
Persarafan.Jakarta:Salemba Medika.2008.
6.
UK Renal Pharmacy Group, 2009, Renal Drug Handbook Third Edition, Radcliffe
7.
Indonesian Pharmacist Society,2013-2014,ISO Indonesia Volume 48 ,Jakarta:PT ISFI.
8.
Natinal Agency of Drug and Food Control,2008.Informatorium of Indonesian
National Drug,Jakarta.
1422
FOR STROKE HEMORRHAGIC PATIENT IN MINTOHARDJO
HOSPITAL
Erviyani Batmar1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Stroke hemorrhage is caused blood vessel in the brain ruptures and blood out of the blood
vessels. Subarakhnoid bleeding can occur from heavy injuries or a broken or defective
intracranial aneurisme arteriovena. Intraserebral bleeding occurs when blood vessels are
damaged in the brain leads to formation of parenkim hematomasubdural most injuries occur
due to weight. (Nurdjaman, 2011). Patient Mr. Dn, aged 73 years old, entered RSAL
Mintohardjo on april 26th, 2014 with was diagnosed of stroke hemoregik. Patient was
treated with tyarit (amiodaron), simarc (warfarin), digoxin, aldacton, candesartan, inj,
ondansentron ranitidine inj, lasix inj, transamin, inj chiticoline. Based on the results of the
practice of the clinic on the maintenance of selayar RSAL Mintohardjo 3th floor then it can
be drawn the conclusion that the existence of the DRP (Drug Related Problem) in the form
of election of remedies were not appropriate, such as simarc, the interactions that occur
between transamin and simarc which will increase the occurrence of trombolisis aldacton
and simarc, where aldacton could reduced the effects of simarc (warfarin), and interactions
in farmacodinamic between the Digoxin and ranitidine inj, lasix (furosemid) and digoxin so
its used should be in monitoring.
Key words: Drug Related Problem, Stroke Hemorrhage, Mintohardjo Hospital
INTRODUCTION
A Stroke is a brain functional disorder and acute global focal plane, more than 24
hours, comes from blood flow disorder of the brain. Stroke was not caused by circulatory
disorders of the brain at a glance, brain tumor, stroke or trauma due to secondary infection
caused by focal cerebral vascular occlusion which caused the decline in the supply of
oxygen and glucose to the brain suffered inner green. The appearance of signs and
symptoms of focal or global on stroke caused by decreased blood flow to the brain. There is
1423
no evidence of pharmacological strategies for the treatment of bleeding intraserebral.
Medical guidelines for regulating blood pressure, increased intracranial pressure, and other
medical complications in acute sufferers in neurointensive care unit should run.
(Setyopranoto, 2004)
Stroke (serebrovaskuler disease) is the death of brain tissue (cerebral infarction)
happens due to decreased blood flow and oxygen to the brain. They can be in the form of
Ischemic Stroke or hemorrhage on ischemic stroke, brain has stopped because
atherochlerosis or blood clots that have been clogging the blood vessels. On stroke
hemoregik, the blood vessels rupture so inhibiting normal blood flow and blood seeping
into an area in the brain and ruin it. (Yulinah E, 2011)
CASE PRESENTATION
Patient Mr. Dn aged 73 years old in RSAL Mintohardjo on April 26, 2014. A
patient comes in with complaints of vomiting twice, while watching TV with funny all of a
sudden the sound oblique pelo lips, tingling right hand 1 hour before entered hospital while
first worship. Patient have a history of stroke in 2012.
CLINICAL EVALUATION
Results of laboratory Patient Mr. Dn on april 26, 2014 on blood chemistry
examination showed abnormal PH 7,491 so experienced hipoventilasi, SBE (Standard Base
Excess) 6.3 the excess strong base in blood, bicarbonat, 29,7 HCO3 excess potassium 3.0
hiperkalemia
DOSAGE AND INDICATION
Dosage and mode of used of the drugs in these patient that ringer lactate 20 tpm
given by subcutaneous to prevent dehydration and lactate ringer customarily doses
according to the patient's condition, tyarit 1 times 1 (amiodaron) was given oraly to
overcome heart arrhythmias and initial dose tyarit customarily dose 5 mg/kg body weight
for 20 minutes to 2 hours, simarc (warfarin) given oraly for the prevention of venous
thrombosis and a dose of common simarc early dose of 5 to 10 mg/day for 2 Today,
1424
digoxin was given 1 1 time orally to address congestive heart failure common with doses of
digoxin tab 1 to 3 days. Aldacton (spirinolacton) 25 mg 1 time given to overcome high
blood pressure patient with doses of common aldacton adult beginning 25 mg/day later
raised to 100 mg/day in a single dose or divided, Candesartan 4 mg 1 time given orally to
overcome high pressure in patient with initial dose of 4 mg candesartan customarily 1
times/day can be increased up to 1 time/day, Injection Ranitidine 2 times 1 ampules given
intra venous gastric irritation to overcome 150 mg twice/day (morning and night) or 300
mg of 1 time/day, Lasix injection (furosemid) 2 times 1 ampules given intra venous edema
and heart for a dose of lasix was often the initial 20-40 mg single dose, IV/IM ondansentron
injection 3 times 4 mg ampules intra venous given to overcome nausea common with doses
8 mg in early ondansentron inj IV, transamin injection 500 mg 3 times given intravenously
for abnormal bleeding that occurs in patient with a dose of common transamin 250-500
mg/day in a 1 to 3 doses, citicoline injection 500 mg 2 times given intravenously to
overcome the degenerative nerve and common dosage citicolin 100-500 mg to infuse the
drip IV or IV injection 1 to 2 times/day (IONI,2008)
1. Election of remedies are not appropriate
Selection of inappropriate drugs, namely the use of simarc (warfarin), simarc will
aggravate bleeding if used as a therapy treatment on stroke hemoragik, antiplatelet
therapy should be used for its treatment.
2. Drug interaction
Interaction transamin and simarc which will increase the occurrence of trombolisis,
aldacton and simarc, where aldacton can reduce the effects of simarc. And the
interaction of Digoxin injection ranitidine and lasix, digoxin, and so its use should be in
monitoring. (BNF, 2011)
CONCLUSION
Based on the results of the practice of the of clinics on Selayar Island room 3th floor
treatment RSAL Mintohardjo can be conclused that the existence of DRP (Drug Related
1425
Problem) in the form of election of remedies was not appropriated where the granting of
simarc on the therapeutic used of stroke will hemoragik, interactions and transamin simarc
which will increase the occurrence of trombolisis, aldacton and simarc, where aldacton can
decrease the effect simarc. And interactions in farmakodinamik between the Digoxin and
ranitidine injection, lasix and digoxin so its use should be in monitoring. (BNF, 2011)
REFERENCES
1. Yulinah E, 2011, ISO Farmakoterapi 2, Penerbit: Ikatan Apoteker Indonesia,
Jakarta
4. Dipiro, Joseph T., et. al., 2008, Pharmacotherapy: A Pathophysiologic Approach.7th
5. Setyopranoto,ismail, 2004.”Gejala dan Penatalaksanaan stroke”.Fakultas Kedokteran
Universitas Gadjah Mada: Yogyakarta
6. Tjay, Tan HoandanRahardjaKirana, 2007, Obat-obatPetingEdisi VI, Jakarta
7. UK Renal Pharmacy Group, 2009, Renal Drug Handbook Third Edition, Radcliffe
1426
FOR DIABETES MELLITUS KETOACIDOSIS PATIENT IN GATOT
SOEBROTO ARMY HOSPITAL
Fadli Akbar1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
According to the American Diabetes Association (ADA) in 2010, diabetes mellitus is a group of
metabolic diseases with characteristics hyperglycemia that occurs due to abnormal insulin secretion,
insulin action, or both. Patient Ms. YS, aged 66 years old, entered Gatot Soebroto Army Hospital on
May 16, 2014 with has diagnosed of diabetic ketoacidosis and vertigo. Therapy was the treatment
for insulin treated novorapid (short-acting) insulin Levemir (long-acting), RL (Ringer lactate), 0.9%
NaCl, mertigo (betahistin mesilate), ondansentron, ranitidine, sucralfate, ramipril, betaserc
(betahistin dihydrochloride), and paracetamol. Based on the results of their clinical practice in
General Nursing floor ward at Gatot Soebroto Army Hospital IV it can be concluded that the
presence of DRPs (Drug Related Problems) a dosage regimen that Levemir dose (long-acting) that
ws used too low at only 10 units / day. Levemir usual dose is 20 units / day. Levemir dose is too
low causing hyperglycemia control inaccurate. This was evident from the results of the laboratory
examination on the fourth day and the fifth day because of a patient's blood sugar remains high
(while blood glucose 176 mg / dL and fasting blood glucose of 240 mg / dL). The usual dose 1-2
times daily Levemir 0.2-1 iu / kg / day (IONI, 2008).
Keywords : Diabetic ketoacidosis, vertigo and Gatot Soebroto Army Hospital
I.INTRODUCTION
According to the American Diabetes Association (ADA) in 2010, diabetes mellitus is a
group of metabolic diseases with karasteristik hyperglycemia that occurs due to abnormal
insulin secretion, insulin action, or both (ADA, 2010). Ketoacidosis is an acute
complication of diabetes that is characterized by elevated blood glucose levels are high and
can vary from 300 to 800 mg / dl (16.6 to 44.4 mmol / L), accompanied by the presence of
signs and symptoms of plasma ketone acidosis and positive. The main cause of diabetic
1427
ketoacidosis is insulin administered or administered with a reduced dose, sickness or
infection, the first manifestation of the disease undiagnosed and untreated (Smeltzer, 2002).
The classic symptoms of diabetes mellitus was characterized by plasma glucose as 200
mg / dL (11.1 mmol / L). Plasma glucose while an examination for a moment on one day
without regard to time of last meal, fasting plasma glucose 126 mg / dL (7.0 mmol / L),
fasting meant patient did not receive additional calories at least 8 hours, 2-hour plasma
glucose level in oral glucose tolerance (Oral glucose Tolerance test) 200 mg / dL (11.1
mmol / L), TTGO (Oral glucose Tolerance test) conducted by WHO standards, using a
glucose load equivalent to 75 g of glucose anhidrus dissolved in water (Tan, 2012).
The main goal of therapy is to achieve DM good metabolic control in order to prevent
long-term complications. But unfortunately, the quality of data in Indonesia about the
treatment of patients with type 2 diabetes are still not sufficient (PB Perkeni, 2011).
2.CASE PRESENTATION
Patient Ms. YS, aged 66 years old, entered Gatot Soebroto Army Hospital on May 16,
2014 at 18:00 in General Nursing IV floor. Patient was treated with primary complaints
were nausea, vomiting and dizziness spinning 1 day before entering the hospital. Complaint
of patient was felt throughout the day so that there is no appetite. Bowel movements
normal, complaints of dizziness sometimes accompanied by ringing in the ears spin and
epigastric.
The patient previously had been treated in the emergency room (ER) since this
morning with complaints of dizziness such as spinning, nausea, vomiting, vomiting of less
than 3 times, there was a decrease in appetite, shortness of normal, abnormal chest pain,
abnormal heart, pain in the gut. The patient had a history of diabetes since last 20 years,
taking medication metformin and nitrogliserit (gliserit trinitrate) but before complaints arise
only taking metformin alone. Patient diligently to control the disease, patient had
experienced the same thing, the results of the CT scan are backing neck constriction of
blood vessels. In addition the patient had a history of heart since 2 years ago.
1428
Novorapid was using of insulin (short-acting) and insulin Levemir (long-acting) to
cope with diabetes mellitus. RL (Ringer's lactate), 0.9% NaCl, mertigo (betahistin mesilate)
for dizzines vertigo and balance disorders associated with blood circulation that occurs on
or Meniere's disease, Meniere's syndrome and peripheral vertigo, betaserc (betahistin
dihydrochloride) to overcome vertigo, tinnitus and hearing loss, ondansentron for the
prevention of nausea and vomiting, ranitidine and sucralfate for duodenal and gastric
ulcers, ramipril for hypertension, and paracetamol for pain and fever.
4.DOSAGE AND METHODE OF USAGE
Dosage and how to use the drug in patient was the first day of therapy treatment given
RL (Ringer's lactate) 20 drops / min from the first day to the fifth day by intravenous
administration to restore electrolyte balance in dehydration and common dosage RL
(Ringer's lactate) in accordance the condition of the patient, 0.9% NaCl given 30 drops /
min from the first day to the fifth days by intravenous administration to restore electrolyte
balance in dehydration and NaCl usual dose of 2.5 mL / kg / hour or 60 drops/70 kg / min
or 180 mL or adjusted patient's condition, novorapid (short-acting) administered 3 times 6
iu of the first day to the fifth day subcutaneously for type I diabetes mellitus type II and
individual dose novorapid usual dose (0.5-1 iu / kg / day) immediately before a meal or
immediately after a meal if necessary as required, ondansetron 4 mg given 3 times
intravenously for the prevention of nausea and vomiting and dose levels were prevalent
ondansentron 4 mg/2mL (injection) 4-8 mg every 12 hours. Ranitidine administered 2 times
50 mg intravenously for gastric and duodenal ulcers and ranitidine usual dose of 50 mg
every 6-8 hours (injection), sucralfate had given 3 times in 1 tablespoon orally for gastric
and duodenal ulcers and chronic gastritis and usual dose sucralfate 2 g 2 times daily or 1 g
4 times a day 1 hour before meals and at bedtime (suspension 500 mg / mL). Betaserc
(betahistin dihydrochloride) given 2 mg orally 4 times the first day and on the third day for
vertigo, tinnitus and hearing loss tied with Meniere's disease and betaserc usual dose
starting dose of 16 mg 3 times a day as well as adult dose 24-28 mg / day in 3 divided doses
(adjusted to patient response). On the third day of paracetamol tablets given 3 times orally
1429
for 1 basis and atipiretik analgesic (mild to moderate pain and pyrexia) and the usual dose
of paracetamol initial dose of 250-500 mg every 4-6 hours as needed. On the fourth day and
the fifth day of therapy given Levemir (long-acting) 1 times 10 iu subcutaneously for
diabetes mellitus and prevalent Levemir dose individualized dose (day 1-2 times 0.2-1 iu /
kg / day), ramipril 1 times 2.5 mg administered orally for mild to moderate hypertension
and ramipril usual starting dose of 1 tablet low dose of 1.25, 2.5 mg and 5 mg 1-2 times
daily for 2-7 days, ondansentron 4 mg given 3 times it orally for the prevention of nausea
and vomiting and dose levels were prevalent oral ondansentron initial dose of 4 mg or up to
8 mg / day, 2 times 1 ranitidine administered orally for gastric and duodenal ulcers and
ranitidine dosage usual starting dose of 150-300 mg 2 week 4-8 times a day (oral),
sucralfate 3 tablespoons 2-3 times given orally for gastric and duodenal ulcers and chronic
gastritis and usual dose sucralfate 2 g 2 times daily or 1 g 4 times a day 1 hour before meals
or before sleep and packing suspension 500 mg / mL. Mertigo (betahistin mesilate) 3 times
1 administered orally for vertigo, tinnitus and hearing loss tied with Meniere's disease and
mertigo usual dose starting dose of 16 mg 3 times a day as well as adult dose 24-28 mg /
day in 3 divided doses (adjusted with response of patients) (IONI, 2008).
5.CLINICAL LABORATORY STUDIES
The results of clinical laboratory tests on the first day showed abnormal values in blood
glucose levels while that is 326 mg / dL, MCV 79 fL deficient hemoglobin in erythrocytes,
pCO2 31.0 mmHg shortage of carbonic acid and acetone positive, the second day while
blood glucose level decreased to 261 mg / dL and acetone negative, on the third day rise
again while blood glucose to 280 mg / dL, on the fourth day while blood glucose decreased
to 176 mg / dL and acetone positive, 11-hour blood glucose is 283 mg / dL and acetone
negative , on the fifth days of fasting blood glucose of 240 mg / dL and 2-hours blood
glucose PP is 250 mg / dL to experience hyperglycemia. Examination HbA1C 8.6%
undergo structural changes due to high blood glucose.
1430
6.DRUG RELATED PROBLEMS
Dose Regimen
Dosage Levemir (long-acting) was used too low at only 10 units / day. Levemir usual
dose is 20 units / day. Levemir dose is too low causing hyperglycemia control inaccurate.
This was evident from the results of the laboratory examination on the fourth days and the
fifth day because of a patient's blood sugar remains high (while blood glucose 176 mg / dL
and fasting blood glucose of 240 mg / dL). The usual dose 1-2 times daily Levemir 0.2-1 iu
/ kg / day (IONI, 2008)
7.CONCLUSION
Based on the results of their clinical practice in General Nursing floor ward at Gatot
Subroto Army Hospital IV it can be concluded that the presence of DRPs (Drug Related
Problems) a dosage regimen that Levemir dose (long-acting) that was used too low at only
10 units / day. Levemir usual dose 20 units / day. Levemir dose was too low causing
hyperglycemia control inaccurate. This was evident from the results of the laboratory
examination on the fourth days and the fifth days because of a patient's blood sugar remains
high (while blood glucose 176 mg / dL and fasting blood glucose of 240 mg / dL). The
usual dose 1-2 times daily Levemir 0.2-1 iu / kg / day (IONI, 2008).
8. REFERENCES
1. American Diabetes Association., A Handbook for prescribers. ADA Edisi 2010
2. Badan POM RI, 2008. Information Obat Nasional Indonesia, Jakarta.
4. Nathan, Buse, Davidson, et al. 2209. Medical Management of Hyperglycemia in Thype
2 diabetes,: a Consensus Algorithm for Initiation and Adjustment of Therapi. Diabetes
Care 32, 193-203.
5. PERKENI. 2011. Konsensus Pengendalian dan Pencegahan Diabetes Mellitus Tipe2
di Indonesia 2011. PB PERKENI. Jakarta.
1431
6. Smeltzer. S, 2002. Buku Ajar Keperawatan Medikal Bedah. Jakarta : Buku Kedokteran
EGC.
7. 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 maret
2013.
1432
TREATMENT EVALUATION ON PATIENTS WITH IHD (ISCHEMIC
HEART DISEASE) AT ARMY HOSPITAL “GATOT SOEBROTO”
Faradillah Albaar1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
email: [email protected]
ABSTRACT
Ischemic Heart Disease (IHD), or known as myocardial ischemia, is a disease that reduced
blood and oxygen supply of the heart muscle, usually due to coronary artery disease
(atherosclerosis
of
the
coronary
arteries).
Many
studies
have shown that ischemic heart disease affects people from any gender and race, often
occurs before a person reach age 20 due to number risk of factors. Mr. Ed, Patient aged 43
years diagnosed with IHD (Ischemic Heart Disease), complained shortness of breath 2 days
after hospitalization, shortness felt since ± 1 month ago with light activity. For the
treatment of Ischemic Heart Disease patients get 9 types of drugs. Captopril, ISDN
(Isoniazid dinitrate), Clopidogrel, Bisoprolol, KSR, Furosemide, Aldactone, Simvastatin
and Neurobion. In Mr. Ed medication profiles, found a Drug Related Problem (DRP) such
as drugs interaction and un given medicine due to the lack of data from Laboratories. Use
of simvastatin with clopidogrel and Captopril with Furosemide.
Keywords: IHD (Ischemic Heart Disease), Drug Related Problem (DRP)
INTRODUCTION
Ischemic heart disease is a condition that causes imbalance between myocardial
oxygen supply and demand.
The most common cause of myocardial ischemia is atherosclerosis (Price, 1994).
The existence of atherosclerosis narrowing
the lumen of epicardial coronary
arteries that reduced oxygen myocardial supply (Price, 1994).
Myocardial ischemia can also occur due to increased myocardial oxygen demand is
not normal as in ventricular hypertrophy or aortic stenosis (Isselbacher, 2000).
1433
If the transient ischemic events associated with angina pectoris, if prolonged, it can
lead to myocardial necrosis and scar formation with or without clinical features of
myocardial infarction (Isselbacher, 2000).
IHD risk increases due to aging, smoking, hypercholesterolemia (high cholesterol),
diabetes, and hypertension, is more common in men and those who have close relatives
with ischemic heart disease (Smeltzer, 2002).
The most common cause of ischemic heart is reduced inflow of blood to the heart
muscle caused by a thrombus mindless blockage in the coronary artery atherosclerotic
disease in areas near (Smeltzer, 2002).
Ischemic heart occurs due to cardiac oxygen demand exceeds the ability
arterikoronaria to supply blood and oxygen due to atherosclerosis. If the oxygen demand of
the heart are not met the maximum filtering, it will increase coronary blood flow through
vasodilation and increased blood flow average (Smeltzer, 2002).
Atherosclerotic coronary arteries experience a state of "Hypoxia" and the shift from
aerobic to anaerobic, the accumulation of lactic acid and a decrease in intracellular pH and
cause the typical pain (Smeltzer, 2002).
METHODOLOGY
Performed based on patients duration of stay in the Cardiac Care Depo , expected
from 6 (six) days of retrieval will obtain profiles that may represent patients therapeutic
treatment. Evaluation studied the use of patient drugs include the drug name, dosage and
way of taking the medicine. Rationality (proper dosage, and indications, right patient, as
well as the right way of taking it) of the patients treatment whether there is interaction or
potential side effects that may occur from using the drugs based on the literature.
RESULTS AND DISCUSSION
Mr. Ed, entered hospital on May 18, complained shortness of breath 2 days after
hospitalization, shortness felt since ± 1 month ago with light activity. Treatment on New
Patient given on May 19 based on the results from Hematology and Clinical Chemistry
Laboratory. Patient already had edema in both legs at the time of admission. Captopril,
1434
ISDN (Isoniazid dinitrate), KSR, Bisoprolol, Clopidogrel, Furosemide, Aldactone,
Simvastatin and Neurobion was given to the patient.
Patient Mr.ED was given Bisoprolol (β-blockers) which is cardio selective, in
Ischemic Heart Disease it's benefits are increasing the patient oxygen supply to the heart
muscle and decrease myocardial oxygen demand (Davey, 2005).
Blood pressure of the patient since hospitalize till leave showing normal results
120/80 mmHg. On May 19, after taking the medicine, edema in both legs of patients began
to improve. And terminated KSR on May 21. Clinical chemistry examination of patients
shows increasing in SGPT and decreasing of SGOT. In this stage of result, there is not
required of therapy.
1. Interactions between drugs.
Furosemide given together with captopril would reduce the effect of furosemide. In
its management If Captopril given together with furosemide, patient weight and fluid status
should be monitored
Giving clopidogrel in conjunction with simvastatin can inhibit the effects of
clopidogrel, and should be aware of rhabdomyolysis side effects cause by Simvastatin.
Therefore, patient's cholesterol levels should be monitored.
2. No drug should be given without a complete laboratory results.
Patients was given simvastatin without laboratory results that shown abnormal
cholesterol level. Cholesterol is one of Ischemic Heart Disease cause of, simvastatin given
maybe based on doctor temporary assessment with Tn. Ed Ischemic Heart Disease, while
patient not doing laboratory tests for cholesterol level. In order to know the exact cause of
IHD It's necessary to know patient disease history as well as additional examination of
cholesterol, blood sugar, and hypertension
1435
CONCLUSION:
1. In this case the therapy selection of IHD (Ischemic Heart Disease) has been quite
optimal and it is the best IHD (Ischemic Heart Disease) choice of therapy
2. DRP (Drug Therapy Problem) found
in Mr. ED treatment, which is
interaction
between drugs and prescription without complete laboratory check.
SUGGESTION:
For drugs use that could cause DRP, it is suggest that the usage is monitored, in
order to avoid unwanted effects.
Patients are advise to perform a complete laboratory examination in order to ensure
that patients have Ischemic Heart Disease.
REFERENCES
1. Carpenito, Linda Juall. 2000. Diagnosa Keperawatan edisi 8. Jakarta: EGC
2. Doengoes, Marlyn. 1989. Nursing Care Plans second edition. Philadelphia: FA Davis
Company 2000.
3. Davey, Patrick. 2005. At a Galance Medicine. Penerbit Erlangga. Jakarta.
4. Long, Barbara C. 1989. Perawatan Medikal Bedah. Bandung: Ikatan Alumni
Pendidikan & Keperawatan Padjajaran Bandung.
5. Price, Sylvia Anderson. 1994. Patofisiologi: konsep klinis proses-proses penyakit edsi
4. Jakarta: EGC
6. Rencana Asuhan Keperawatan: Pedoman untuk Perencanaan dan Pendokumentasian
Perawatan Pasien. Jakarta: EGC
7. Smeltzer, Suzanne C dan Brenda G Bare. 2002. Buku Ajar Keperawatan Medikal
Bedah edisi 8 vol. 1. Jakarta: EGC.
1436
FOR TUBERCULOSIS (TB) PATIENT IN PERSAHABATAN
HOSPITAL JAKARTA
Fatimah Kadir, 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Tuberculosis (TB) is a disease caused by infection of Mycobacterium Tuberculosis that is
capable of infecting a latent nor progressive. Cough, fever, sweating, hemoptysis and
weight loss are common symptoms of pulmonary TB (Government, 2013). Patient Mr. R.
patient 33 years old, it was in Persahabatan Hospital April 5, 2014 with was diagnosed of
pulmonary TB Acid-Resistand Baccili (Positively) the lesions break up drug cases in the
area of OAT category II, cor pulmonale suspec (allegedly ventikel enlargement right),
Nosocomial Pneumonia and sepsis. Therapy treatment treated with oxygen, NaCl 0.9%,
aminofluid, meropenem, gentamicin, combivent inhalation, ambroxol, OAT 4FDC,
streptomycin, ranitidine injection, and N-Acetyl cysteine. Based on the results of the
practice of the Treat Ward on pulmonary disease clinic at the Persahabatan Hospital was
then be drawn the conclusion that the existence of the DRP (Drug Related Problem) in the
form of shared use of gentamicin and streptomycin can increase the side effects of drugs.
This can cause damage to the kidneys or nerves. Meropenem and gentamicin may cause
nephrotoksicity. Antituberculosis drugs use can cause hepatotoxic. Drug dose too low on
the use of ranitidine, drug dose too high on the patient use of gentamicin and failure in
receiving the drug.
Keywords: Pulmonary TB, Soka, RSUP Persahabatan
INTRODUCTION
Tuberculosis (TB) is a disease caused by infection of Mycobacterium Tuberculosis
that is capable of infecting a latent nor progressive. Cough, fever, sweating, hemoptysis and
weight loss are common symptoms of pulmonary TB (Government, 2013).
Generally the Mycobacterium tuberculosis strike in pulmonary and a small
percentage of other organs of the body. It had a special nature of the germ, which is
1437
resistant to acid on coloring, it was used for identification of phlegm microscopically. So it
was referred to as the acid-resistant bacilli (ARB).
The source of transmission of TB sufferers are positive at the time of the ARB
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 several
hours. People can become infected if droplets were inhaled into the respiratory tract. Based
on spot organ which invaded by germs. Tuberculosis Pulmonary Tuberculosis and
differentiated into Extrapulmonary tuberculosis.
Pulmonary Tuberculosis is tuberculosis that attacks the tissues of lung parenkim, not
including pleural (lung membranes). Based on the results of the examination of the sputum
of pulmonary TB, divided in:
1. Pulmonary tuberculosis ARB positive
-
At least 2 of the 3 specimens of sputum ARB positive results.
-
1 result of sputum ARB positive specimens and chest x-rays showed a picture of
active tuberculosis.
2. Pulmonary Tuberculosis ARB negative
Examination of specimens of sputum ARB result 3 negative and chest x-rays showed a
picture of the active tuberkulosa.
Pulmonary ARB negative TB positive divided based on x-rays the severity of the
ailment, which is a form of heavy and light. Heavy forms when the chest x-rays showed
a picture image of lung damage and general state of the patient is bad
Extra pulmonary tuberculosis is tuberculosis attacking the organs other than the
lungs, such as pleural membranes, the membranes of the brain, the heart (the pericardium),
lymph glands, bones, joints, skin, intestines, kidneys, urinary tract, genitals, and others
(Muchid, 2005)
CASE PRESENTATION
Patient Mr. Rh, aged 33 years old of was signed Persahabatan Hospital on April 5,
2014. A patient comes in with complaints of cough ± 1 month before entering the hospital,
many of the greenish yellow sputum, shortness of lost weight arising, dropping 20 pounds
1438
in 1 month, nausea. On April 14, 2014 until May 3, 2014 Patient treated in the Fatmawati
hospital because the complaint longtime cough and tightness. Patient was diagnosed with
Pulmonary TB positive Acid Resistant Bacilli, Cor Pulmonale (enlargement of the alleged
right-ventikel). The patient was then repatriated because conditions improved.
In 2011 the patient medical treatment at health centers because the old cough and
was diagnosed with tuberculosis, treated with OAT for 2 months and stopped by the patient
because of perceived conditions have been improved.
CLINICAL EVALUATION
The results of laboratory examination of Mr. Rh on May 5, 2014 suggests
Teratology studies on leukocyte values is 22,29 thousandmm3 (5-10 thousandmm3),
netrofil 81,8 (50-70), lymphocytes 6.2 (25-40), monocytes 10.5 (2-8), eosinophils 1.8 (2-4).
Teratology studies on the results of this inspection showed that patient experience
infections. Teratology studies on the value of PO2 29,8 mmHg (35-45 mmHg), O2
saturation 51,7 (96-97) so that the patient was experiencing shortness of breath.
Sputum examination results TN. Rh on May 6, 2014 results ARB I (negative), dated
May 7, 2014 ARB II (1 positive), and ARB III (1 positive). On the results of this inspection
showed that patient was experiencing pulmonary TB ARB positive.
DOSAGE AND METHOD
Dosage and mode of using of the drug in patient was to take oxygen to overcome
patients’ shortness of breath, NaCl 0.9% and aminofluid given by subcutan to prevent
dehydration, common dosage of NaCl and aminofluid according to the patient's condition.
Ambroxol 3 times 50 mg given in orally to cope with cough productive, with the common
dose ambroxol 2 to 3 times 45 mg/15 ml. Ranitidine 50 mg 2 times given intravenously to
overcome stomach irritation, patient with dose of 50 mg ranitidine customarily every 6 to 8
hours, Rimstar 4FDC (Rifampisin 150 mg, INH 75 mg, Pirazinamid 400 mg, Etambutol
275 mg) 1 tablet 3 times daily given in oral for the treatment of Tuberculosis, with a dose
of common Rimstar 4FDC weight 30 to 37 kg 2 tablet/day. Streptomycin 1 time 750 mg
given intravenously for the treatment of tuberculosis patient, with a dose of 750 mg a day
1439
customarily streptomycin 3 times/week. Combivent inhalation 4 to 6 times/day given by
inhalation to address patient’s shortness of breath, with a dose of combivent inhalation
customarily a day 4 times 2 spray, to a maximum of 12 times a day. Meropenem injection 3
times 1 gram intravenously given for the treatment of sepsis, with a dose of meropenem
1000 mg every 8 hours. 240 mg gentamicin 1 time given intravenously for the treatment of
sepsis, a common dose of gentamicin 2-5 mg/kg/day in the divided doses every 8 hours. Nacetylcystein 3 times 200 mg oral per given as mukolitik and antioxidants, with common
N-acetylcystein dose 200 mg, 2 to 3 times a day orally.
1. Drug dose too low
Drug dose low at recipe ranitidine 2 times 50 mg a day, according to Aine (2009), was
supposed to be 3 times 50 mg a day. It was recommended to doctors to re-evaluate the
use of therapeutic doses of ranitidine, doses or raise ranitidine to 3 times 50 mg. Do
check the list periodically nurses notes.
2. Drug dose too high
Drug dose high on prescription gentamicin 1 times 240 mg a day. According to Elin
(2011) dose of gentamicin 2-5 mg/kg/day in the divided doses every 8 hours. It was
recommended to doctors to re-evaluate the use of therapeutic doses of gentamicin.
3. Failed to receive medication
Patient failed to receive drugs that were not received injection ranitidine 18.00 on 6-52014, at 18.00 on 7-5-2014, and 06.00 on 8-5-2014 and doesn't accept ambroksol 18.00
on 7-6-2014. Ask the nurse and nurse's records list check performed periodically.
a. Use of anti-tuberculosis drugs may cause hepatotoxic, so it is advisable to ask the
patient to observe related perceived symptoms (nausea, vomiting, Dizzy head),
SGPT, SGOT and monitoring of patient.
b. Gentamicin and streptomycin can increase the side effects of drugs. This can cause
damage to the kidneys or nerves. So it is advisable to separate the second usage of
the drugs haul.
1440
c. Gentamicin and meropenem may cause nefrotoksisitas. So it is advisable to separate
the usage range
CONCLUSION
Based on the results of the practice of the Treat Ward on pulmonary disease clinic at
the Persahabatan Hospital was then be drawn the conclusion that the existence of the DRP
(Drug Related Problem) in the form of interaction between gentamicin and streptomycin
which both can increase the side effects of the drug, gentamicin and meropenem may cause
nefrotoksisitas, anti-hepatotoxic too low on the use of ranitidine, drug dose too high on use
of gentamicin, and failure in patient receiving the drug.
REFERENCES
2. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxfor
3. Elin Yulinah, 2011, ISO Farmakoterapi 2, Penerbit: Ikatan Apoteker Indonesia, Jakarta
Gleadle, J. 2007. At A Glance Anamnesis. Jakarta : Erlangga.
5. Tjay, Tan Hoan dan Rahardja Kirana, 2007, Obat-obat Penting Edisi VI, Jakarta.
6. Muchid A, 2005. Pharmaceutical Care Untuk Penyakit Tuberkulosis, Jakarta.
7. Government, A. 2013, The Australian Immunisation Handbook 10 th edition 2013.
http://www.immunise.health.gov. accessed data on Juny 15, 2013.
1441
EVALUATION OF DRUG RELATED PROBLEMS (DRPs)
ASSOCIATED WITH THE TREATMENT FOR PULMONARY
TUBERCULOSIS WITH HYPOALBUMINEMIA AND CIRRHOSIS IN
GATOT SUBROTO HOSPITAL
Pebrianti1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
Tuberculosis (TB), a multi systemic disease with myriad presentations and manifestations, is the
most common cause of infectious disease–related mortality worldwide. The disease is becoming
more Infection with Mycobacteriu tuberculosis results most commonly through exposure of the
lungs or mucous membranes to infected aerosols. Droplets in these aerosols are 1-5 μm in
diameter; in a person with active pulmonary TB, a single cough can generate 3000 infective
droplets, with as few as 10 bacilli needed to initiate infection (1). Patient, Mr. MY, 21 year old,
entered Gatot Subroto Hospital on May 13, 2014 has diagnosed with pulmonary tuberculosis and
cirrhosis of the liver accompanied hypoalbumin. During 11 days of treatment patient was treated
with ceftriaxone, fluimucyl sach, ventolin, hepamerz, HP Pro, curcuma, vip albumin, rifampicin,
INH, pyrazinamide, ethambutol, lasix (metformin), aspar K and ponstan. Based on the results of
their clinical practice in pulmonary disease ward at Gatot Subroto Hospital, it can be concluded
that there was found DRP (Drug Related Problem). The DRP is a clinical condition is not
treated, the selected drug is not effective, Adverse Drug Reaction (ADE), drug interactions and
administration of drug that is contraindicated with the patient condition.
Keywords: Drug Related Problem, pulmonary tuberculosis, Hypoalbuminemia, Cirrhosis, and
Gatot Subroto Hospital
1. INTRODUCTION
Tuberculosis (TB), a multisystemic disease with myriad presentations and
manifestations, is the most common cause of infectious disease–related mortality
worldwide. Although TB rates are decreasing in any country, the disease is becoming
more common in many parts of the world. In addition, the prevalence of drug-resistant
1442
TB is increasing worldwide. Infection with M tuberculosis results most commonly
through exposure of the lungs or mucous membranes to infected aerosols. Droplets in
these aerosols are 1-5 μm in diameter; in a person with active pulmonary TB, a single
cough can generate 3000 infective droplets, with as few as 10 bacilli needed to initiate
infection. When inhaled, droplet nuclei are deposited within the terminal airspaces of the
lung. The organisms grow for 2-12 weeks, until they reach 1000-10,000 in number,
which is sufficient to elicit a cellular immune response that can be detected by a reaction
to the tuberculin skin test (2).
Tuberculosis (TB) is an important public health problem in the world. In 1992 the
World Health Organization (WHO) has declared tuberculosis as a "Global Emergency".
WHO report of 2004 stated that there were 8.8 million new cases of tuberculosis in
2002, 3.9 million were sputum smear (Acid Bacillus) is positive. A third of the world
population has been infected with tuberculosis germs and according to the WHO
Regional largest number of TB cases occur in Southeast Asia, namely 33% of all TB
cases in the world, but when viewed from a population of 182 there are cases per
100,000 people. In Africa almost 2 times larger than southeast Asia that is 350 per
100,000 population1.
An estimated number of TB deaths is 8000 every day and 2-3 million per year.
WHO report in 2004 stated that the largest number of TB deaths are in southeast Asia
that is 625,000 people or mortaliti numbers by 39 people per 100,000 population. The
mortality rate was highest in Africa at 83 per 100,000 population, the prevalence of HIV
is quite high resulting in rapid increase in TB cases arise. Indonesia still ranks third in
the world for the number of TB cases after India and China. Each year there are 250,000
new cases of TB and 140,000 deaths due to TB. In Indonesia, tuberculosis is the number
one killer among infectious diseases and is the third cause of death after heart disease
and acute respiratory illness in all the ages1. Tuberculosis (TB) remains the principal
cause of death from a curable infectious disease. Indonesia is estimated to have the third
highest case load worldwide, but TB prevalence has not been measured for 25 years (3).
1443
Patient, aged 21 year old, entered Gatot Subroto Army Hospital on May 13, 2014.
Patient was diagnosed pulmonary tuberculosis accompanied hypoalbumin. Patient had
complaints with shortness of breath more than 2 weeks, swelling of both lower limbs since
last 5 days before admission, nausea, dizziness, stomach feels fullness and weight loss.
Results of laboratory tests showed acid fast bacily positive, increasing in leukocytes and
decreasing in albumin values patient with a history of liver cirrhosis.
Patient was treated with Rifampicin, Ethambutol, Isoniazid, Pyrazinamid as antituberculosis drug therapy, Ceftriaxone useful for respiratory tract infections that e
characterized by increasing leukocytes value, patient was given albumin because he suffered
hypoalbunimemia, fluimucyl as mucolytic and antioksidan, ventolin for management asthma
associated with airway obstruction, curcuma as hepaprotector and improve appetite, aspar K
for potassium supplements and electrolyte balance, hp pro to maintain heart health and blood
circulation, hepamerz for treating hyperammonemia due to liver cirrhosis, lasix as diuretic
beneficial for management ascites.
4.DOSAGE AND METHOD
During the eleven days hospitalized patient was treated with 14 kinds of drugs. that
were rifampicin, ethambutol, isoniazid, pyrazinamide was given on the first day but then
stopped for a week due increasing in SGOT and SGPT. Patient also was given Ceftriaxone
injection (1x2 g daily for seven days) ventolin (bid) if necessary for 8 days, hepamerz (tid)
for 10 days, curcuma (tid), albumin vip (bid) for 11 days, Lasix (bid) for 8 days, aspar K
(bid) for 7 days and ponstan / mefenemic acid (tid) for 2 days.
5. RESULTS OF LABORATORY TESTS
Hematological examination on May 13, 2014 showed decreasing in hemoglobin value
(12.2 g / dL (13-18 g / dL), hematocrit (37%), albumin (2.7 g / dL). Increasing leukocytes
1444
(13730/μL), SGOT (130 μ / L) and SGPT (67 μ / L). Hematological examination on 19 May
2014 showed decreasing in hemoglobin value (11.3 g / dL), hematocrit (38%), ie MCH
(25pg), MCHC (30g / dL), albumin (3.4 g / dL ), potassium (2.8 mmol / L). Increasing
leukocytes value (15.300/μL) and increasing SGOT value (43 μ / L).
6.DISCUSSION
Patient, aged 21 year old, entered Gatot Subroto Army Hospital on 13 May 2014.
Patient was diagnosed pulmonary tuberculosis accompanied hypoalbumin. Patient had
complaints with shortness of breath more than 2 weeks, swelling of both lower limbs since
last 5 days before admission, nausea, dizziness, stomach feels fullness and weight loss.
Results of laboratory tests showed acid fast bacily positive, increasing in leukocytes and
decreasing in albumin values patient with a history of liver cirrhosis.
Based on hematological examination indicates the patient experienced tuberculosis,
anemia, hypoalbuminemia, got infection and liver disorders. For management of tuberculosis
was treated with Rifampicin, Ethambutol, Isoniazid and Pyrazinamid. ceftriaxone injection,
ventolin, hepamerz, curcuma, vip albumin, lasix, aspar K and ponstan. The using of
rifampicin, ethambutol, isoniazid, pyrazinamid as anti-tuberculosis drug therapy, ceftriaxone
for respiratory tract infections, vip albumin to increase levels of albumin in the body,
fluimucyl as mucolytics and antioxidants, to overcome ventolin asthma-related airway
obstruction, curcuma as hepaprotector and improve appetite, aspar K as a potassium
supplements and electrolyte balance, Hp pro to maintain heart health and blood circulation,
hepamerz for overcome hyperammonemia due to liver cirrhosis, liver ascites lasix as diuretic
and mafnemic acid as pain killer.
1. Patient experienced disease but didn’t get treatment
Patient requiring therapeutic iron and folic acid because based on the results of laboratory
examinations, the patient suffered anemia. Patient required the addition of vitamin B6 to
reduce effect of tuberculosis drug.
2. The drug was selected less effective
1445
Patients was given pyrazinamide while patient suffering liver cirrhosis. According PDPI
(2006) patients with abnormal liver function should not be given pyrazinamide
3. Adverse Drug Reaction (ADR)
The using Tuberculosis drugs create a new disease, patient experienced DIH (Drug
Induced Hepatitis) due to tuberculosis drugs
4. Drug interaction with laboratory data is clinically meaning full
The using of tuberculosis drugs caused abnormalities of liver function which marked
increasing in SGOT-SGPT .
5. Giving drug was contraindicated with patient condition
The using of tuberculosis drug contraindicated for patients with liver cirrhosis, because
tubercolosis drug is hepatotoxic.
8. CONCLUSION
Based on the results of their clinical practice in pulmonary disease ward at Gatot Subroto
Hospital it can be concluded that founda DRP (Drug Related Problem), those are Patient
experienced disease but didn’t get treatment, the drug was selected less effective, adverse drug
reaction (ADR), drug interactions with laboratory data, and giving drug was contraindicated
with patient condition.
9. REFERENCES
1.
PDPI, 200 6. Guidelines for Diagnosis and Treatment Tuberculosis in Indonesia. Jakarta,
pp. 1-11.
2.
Priyanto, 2008. Pharmacology and Terminology Medical. Institute studies and Consultation
Pharmacology. Jakarta
3.
Soemantri,S., Senewe, P.F., D. H. Tjandrarini., et al. 2007. Three-Fold Reduction In The
Prevalence Of Tuberculosis over 25 years in Indonesia. International Journal Tuberc Lung
Disease, 11(4):398–404
4.
Sutedjo, AY.2008. Knowing Disease Through Examination Result Laboratory. Amara
books. Yogyakarta
5.
MIMS.2012. Instructions Consultation Edition II. Medidata Indonesia
1446
6.
Department Gatot Subroto Army Hospital Lung Subroto, 2008. Standards Service Medical.
Jakarta
7.
MOH, 2008. Information is Drug Indonesian National. Jakarta
8.
DHB, Canterbury.2003. Drug Information Serviceat Christ church Hospital. New Y ork.
9.
Kasper L, Dennis., Et al, 2010, Harrison's Infectious Diseases, The McGraw-Hill
Companies, Inc. New York.
1447
FOR DYSPEPSIA PATIENT IN MINTOHARDJO HOSPITAL
Fras Korompis 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Dyspepsia is a medical condition characterized by pain or discomfort in the upper
abdomen or chest that usually occurs after eating. Dyspepsia is caused by irregular eating
patterns, effects of drugs, also food and beverage that irritate the stomach. In this case,
female patient, 48 years old, came to the ICU with symptoms of pain in the pit of the
stomach, vomiting since 2 weeks before entering the hospital. The patient also had fever,
cough, flu, and a sour taste in the throat and acid out of the mouth. Patient is a smoker and
often eats late. The patient also had hypertension. There are several DRP in this case,
patient had cough since the first day of admission, but Sanadryl DMP given on the third
day, the use of antiemetics Ondancentron and Amlodipine are not appropriate indications,
also the duplication of medication (Ranitidine).
Keyword: Dyspepsia, Drug Related Problem, RSAL Dr. Mintohardjo
1. INTRODUCTION
Dyspepsia is a medical condition characterized by pain or discomfort in the upper
abdomen or chest that usually occurs after eating. Gastroesophageal reflux disease is one of
the most common causes of dyspepsia. Other major causes include eating too much, eating
too fast and ignore the process of mastication and digestion through the salivary glands of
the right foods, the effects of drugs - drugs that irritate the stomach, as well as food and
beverages that can irritate the stomach (spicy, soft, oily, acidic, etc). Dyspepsia occurs
when the muscles of the organs of the digestive tract or the nerves that control the organs
are not functioning properly (Djojoningrat and Dharmika, 2009).
Dyspepsia is a chronic disease that usually lasts for years, even a lifetime (Harahap,
2007).
1448
Hypertension is blood pressure that is excessive and almost constant in the arteries.
The pressure generated by the force when the heart pumps blood. Hypertension is
associated with a rise in diastolic pressure, systolic pressure, or both continuously (Dewi,
2010).
Cough is not a disease but a clinical sign or symptom that is most often found in the
lung and airway disease. Cough is one of the ways the body to clear the airways of mucus
and foreign objects or materials that enter. Coughing serves as the body's immune or
protection against foreign objects, but can also be a symptom of a disease (Rab and
Tabrani, 2010).
Female patient, 48 years old, came to the ICU with symptoms of pain in the pit of
the stomach, vomiting since 2 weeks before entering the hospital. Patients previously drank
lemon juice to cure the cough and then she felt pain in the pit of the stomach, vomiting of
blood without pulp, fever, cough, flu. Before admission, she had received medication from
a doctor to resolve the symptomps, but the symptoms was not accompanied by reduced
pain in the pit of the stomach and a sour taste in the throat and acid out of the mouth.
Patient is a smoker and often eats late. The patient also had hypertension and cough.
3.
CLINICAL EVALUATION
In this case, patient was treated with infusion of Ringer's lactate (RL) indicated for
the treatment of electrolytes and minerals. Acran Injection (Ranitidine) and Ranitidine
tablets indicated to reduce gastric acid secretion in patients with dyspepsia, peptic ulcers,
and intestinal ulcers and reduce the symptoms of excess stomach acid. Ondancentron
Injection indicated for the prevention of nausea and vomiting due to chemotherapy,
radiotherapy, and surgery. Episan syrup (Sucralfate) indicated to protect the gastric mucosa
in patients with peptic ulcers and intestinal ulcers. Amlodipine treatment of hypertension
indicated as peripheral arterial vasodilator which can lower blood pressure. Sanadryl DMP
(Dextromethorphan) is an antitussive which is indicated to treat dry cough.
1449
4.
DOSAGE AND RUTE OF ADMINISTRATION
Ringer's lactate infusion 40 drops per minute, Acran 50mg twice daily IV injection,
Ondancentron 4mg 3 times daily IV injection, Episan syrup 100mL 1 tablespoon 2 times
daily orally, Amlodipine 15mg once daily orally, Sanadryl DMP syrup 1 tablespoons 3
times daily orally, Ranitidine 150mg tablets twice daily orally.
5. LABORATORY VALUE
Results of laboratory tests are normal and only had increasing in SGOT level
36 (normal value SGOT women: <31). Examination of vital signs showed an increase in
blood pressure on the first day is 140/100 mmHg.
6. DISCUSSION
6.1.Drug Related Problem 1 (Failure to Receive Medicine)
Patient had cough since admission. During treatment in hospital, the doctor just
gave Ranitidine treat dyspepsia and Amlodipine to treat hypertension. Sanadryl DMP
(Dextromethorphan) has given on the third day during treatment. This makes the patient
still has a cough during the treatment until she going home on the third day. Patients
experienced coughing due to her smoking habits that need to do laboratory tests and
spirometry tests to determine the cause of the patient's cough.
Pharmacist Intervention: adviced the doctor to give Sanadryl DMP since the first
day of admission to treat the cough. Patients are advised to stop smoking and conduct
laboratory tests to determine the exact cause of the cough her experienced.
6.2.Drug Related Problem 2 (Therapeutic Duplication)
Patient received two drugs of H2 antagonists’s class, Acran injection (Ranitidine)
and Ranitidine tablets for treating dyspepsia. Duplication of this medicine may result in
increased side effects. Acran injection doses given daily is 2 x 50mg tablets and ranitidine
doses given daily is 2 x 150 mg, so that patients get 400 mg ranitidine daily. Maximum
dose of ranitidine with IV bolus is not more than 400mg daily. IV is given only if the
patient’s condition does not allow for taking tablets.
1450
Pharmacist Intervention: adviced the doctors to stop either one of these drugs and
monitor the patient's condition. Replaced ranitidine injection with ranitidine tablets if
dyspeptic symptoms experienced by patients has been reduced or lost. Advising the patient
to eat on time and avoiding foods and drinks that can trigger an acid secretion.
6.3.Drug Related Problem 3 (Improper Drug Selection)
Patient received Amlodipine 5 mg to treat hypertension. The use of amlodipine in
this case is not appropriate for patients with uncomplicated hypertension. According to JNC
8 hypertension guidelines, thiazide diuretics are the first-line therapy to treat hypertension
without complication.
Pharmacist Intervention: adviced the doctor to replace amlodipine with
hydrochlorothiazide (HCT) to treat hypertension.
6.4.Drug Related Problem 4 (Improper Drug Selection)
Patient got ondancentron to cure her nausea. The use of antiemetics ondancentron
not appropriate in this case because it’s indication is for the prevention of nausea and
vomiting after surgery and chemotherapy.
Pharmacist Intervention: adviced the doctor to replace ondancentron with other
antiemetic such as domperidone.
7. CONCLUSIONS
In this case, there are 4 Drug Related Problem (DRP), Failure to Receive Medicine,
Therapeutic Duplication of H2 Antagonist class, and Improper Drug Selection of
Amlodipine and Ondancentron. Laboratory tests and spirometry test is very important to
know the causes of cough, so the treatment can be more precise and optimal. Giving advice
to a patient to stop smoking and eating on time is very important to patients and prevent the
disease relapse.
8.
REFERENCES
1. America Medical Association. 2014. Joint National Committe (JNC) 8 , 2014 EvidenceBased Guidline for the Management High Blood Preassure in Adults. America:
American Medical Association.
1451
2. Dewi. 2010. Hipertensi dan Komplikasi. Jakarta: EGC.
3. Djojoningrat, Dharmika. 2009. Pendekatan Klinis Penyakit Gastrointestinal. Buku
Ajar: Ilmu Penyakit Dalam. Edisi 5. Jakarta: Balai Penerbit FK UI.
4. Harahap Y. 2007. Karakteristik Penderita Dispepsia Rawat Inap di RS Martha Friska
Medan Tahun 2007. Skripsi. Medan: Fakultas Kesehatan Masyarakat Universitas
Sumatera Utara.
5. Hepler CD, Segal R. 2003.
Preventing Medication Errors and Improving Drug
Therapy Outcomes Through System Management. Boca Raton, FL: CRC Press
6. Rab, Tabrani. 2010. Ilmu Penyakit Paru. Jakarta: Trans Info Media.
1452
DRUG RELATED PROBLEM IN CORONARY ARTERY DISEASE
TREATMENT AMONG PATIENTS IN PGI CIKINI HOSPITAL
Frans Marguna1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRAK
Coronary artery disease is coronary artery pathological condition characterized by
abnormal accumulation of lipids or fatty material and fibrous tissue in the blood vessels
walls resulting in changes in the structure and function of arteries and reduced blood flow
to the heart (Brunner and Suddarth, 2002).
The patient is a 58-year-old male was treated at the K ward PGI Cikini hospital. Patient
diagnosed with coronary artery disease with symptoms such as swollen legs when sitting
for long periods, fatigue, anxiety, patient had no shortness of breath, no cough and no chest
pain.
Patient treated with Noperten, Clopidogrel, Allopurinol, Estazor, Omeprazole and Heparin.
In this case the presence of Drug Related Problems found that omeprazole taken with
clopidogrel can reduce the effect of clopidogrel (Eric et al, 2011) and the use of allopurinol
with Angiotensin Converting Enzyme inhibitors (ACE) which can increase hypersensitivity
reactions such as Stevens-Johnson syndrome, the risk of hematological reactions such as
leucopenia and some allergic reactions (Baxter, 2008)
Keywords: Coronary Artery Disease, PGI Cikini hospital
1.
INTRODUCTION
The main cause of coronary artery disease is atherosclerosis. Atherosclerosis is the
hardening of the artery walls. Atherosclerosis characterized by the accumulation of fat,
cholesterol, intima layer of arteries. This heap is called atheroma or plaque. Atherosclerosis
begins when cholesterol, fat accumulate in the arterial intima. Stockpiles will lead to
disruption of nutrient absorption endothelial cells that make up the inner lining of blood
vessels and block blood flow because this pile protruding into the lumen of blood vessels.
Endothelial cells of blood vessels affected will have become necrotic and scar tissue.
1453
Furthermore, a narrow lumen and increase blood flow could be hampered. In the lumen is
narrowed and rough walled, will tend to the formation of blood clots (Rokhaeni, 2011).
2.
CLINICAL PRESENTATION
The patient is a 58-year-old male who was treated in K ward PGI Cikini hospital.
Patient diagnosed with coronary artery disease. Patient was starting hospitalized on the 10th
of January, 2014 with complain of swollen legs when sitting for long periods, fatigue,
anxiety, patient had no shortness of breath, no cough and no chest pain. Clinical chemistry
test laboratory results show an increase in the value of erythrocyte sedimentation rate is 11
mm / hour, which is 16 per mil increase in reticulocytes, which is 4% increase in
eosinophils, a decrease in neutrophils rod that is 1%, 11% decrease in monocytes, an
increase in globulin is 4 g / dL, an increase in uric acid is 8 mg / dL, a decrease in calcium
that is 8.2 mEq / L, an increase in fasting blood sugar is 118 mg / dl and a decrease in urine
specific gravity is 1.010 g / ml. Drug therapy given to patients include Noperten
(Lisinopril) to treat hypertension and congestive heart failure, Clopidogrel to reduce the
incidence of myocardial infarction in the thrombolytic recently occurred, Allopurinol used
for hyperuricemia, Estazor (ursodeoxycholic acid) for X-ray translucent gallstones in
diameter ≤ 20 mm, patients with a high risk if patients who refuse surgery or gallbladder
surgery, elderly patients and patients with idiosyncratic reaction to general anesthesia and
patients who refused surgical intervention, Omeprazole is used for the treatment of peptic
ulcers, Heparin as an anticoagulant (Tjay, 2007 ).
3.
CLINICAL EVALUATION
Omeprazole taken with Clopidogrel can reduces the effect of clopidogrel through the
mechanism of inhibition the CYP2C19 enzyme that responsible for the metabolism of
clopidogrel to its active form.
Intervention pharmacists: It is recommended to use omeprazole and clopidogrel spaced
approximately 2 hours or substitute omeprazole with ranitidine (Anonymous, 2014).
1454
Allopurinol taken with Angiotensin Converting Enzyme inhibitors can increase the risk of
hypersensitivity reactions such as Stevens-Johnson, the risk of hematological reactions such
as leucopenia and some allergic reactions. Hypersensitivity reactions are rare and the
mechanism of this interaction is not established.
Pharmacist Interventions: Monitoring closely the signs of skin hypersensitivity or
decreased white blood cells characterized by sore throat, fever, etc., especially if the patient
had renal problem, strongly recommended monitoring every 2 weeks after starting therapy.
(Baxter, 2008)
4.
CONCLUSION
It should be noted the presence of several Drug Related Problem that is:
1.
Use of omeprazole to reduce the effect of clopidogrel by inhibiting enzymes that play a
role in the metabolism of CYP2C19 Clopidogrel, so its use should be spaced
approximately 2 hours or replace omeprazole with ranitidine.
2.
Use of Allopurinol with Angiotensin Converting Enzyme inhibitors can increase
hypersensitivity reactions such as Stevens-Johnson risk, the risk of hematological
reactions such as leucopenia and some allergic reactions, so it needs close monitoring
for signs of hypersensitivity of the skin or a decrease in white blood cells which can be
characterized by sore throat, fever, etc.
REFERENCES
1. Anonymous. 2014. Clopidogrel Dosis Ganda, Memperbaiki Efek Antiplatelet Akibat
Penggunaan PPI. http: // pio.uad.ac.id/archives/773 on July 10th 2014.
2. Baxter, K. 2008. Stockley’s Drug Interaction. Eight Edition. Pharmaceutical Press,
London and Chicago
3. ISO Indonesia Volume 47. 2012-2013. Jakarta: Ikatan Apoteker Indonesia.
4. Rokhaeni, H., Purnamasari, E & Anna, U.R. 2001. Buku Ajar Keperawatan
Kardiovaskuler ed 1. Jakarta : Bidang Pendidikan dan Pelatihan Pusat Kesehatan
Jantung dan Pembuluh Darah Nasional “ Harapan Kita”.
1455
5. Saragi, sahat. 2012. Panduan Penggunaan Obat Dilengkapi dengan Konsep
Pharmaceutical Care, Teori Konseling obat, Teori Kepatuhan minum obat. Rosemata
Publisher. Jakarta.
6. Sudoyo. W. Aru,et,al. 2006. Buku Ajar Ilmu Penyakit Dalam. Jakarta. FKUI.
7. Suyono, Slamet. 2001. Buku Ajar Ilmu Penyakit Dalam vol 2 ed 3. Jakarta: FK UI
Publisher.
8. Tjay, T.H. 2007. Obat-Obat Penting. PT. Elex Media Komputindo, Jakarta.
1456
ANEMIA GRAVIS, HYPOKALEMIA, HEMATOSKEZIA DISEASE
Gini Krislina 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
Abstract
The definition of anemia is a decrease in hemoglobin concentration in the blood resulting in
perfusion of O2 to tissues. Called gravis which means weight and hemoglobin values below
7 g / dl and require additional generally through transfusion. Anemia is reduced to below
the normal value of red blood cells, hemoglobin quality and volume of packed red blood
cells (hematocrit) per 100 ml of blood (Price, 2006: 256). Hypokalemia is a level where
low levels of potassium in the blood. Potassium become important substances in the body
that must be met. Hematoskezia is fresh blood that comes out through the anus / rectum.
Source perdarahaan generally come from the anus, rectum, or colon left side (sigmoid or
colon descendens), tetapijuga derived from the small intestine or upper gastrointestinal
(SCBA) when the ongoing massive bleeding (blood volume so most did not get contact
with the stomach acid) and rapid intestinal transit time. Patients 27 years old. Mr. HP
entered persahabatan hospital since July 14, 2014 with a diagnosis of anemia is gravis. The
therapy treatment for hospitalized RL 500 cc / 12 hours, until the PRC transfusion Hb ≥ 10
g / dl stages 3 bag / day, transamin 3x500 g IV, 3x10 g IV vitamin K, KSR 3x600 mg PO,
soft diet 1700 kcal / day, laxadine 3x15 cc PO. Based on the results of their clinical practice
in persahabatan hospital cempaka ward, it can be concluded that the presence of DRP
(Drug Related Problem) form no indication without drug therapy.
Keywords: Anemia gravis, hypokalemia, hematoskezia in the department of Persahabatan
INTRODUCTION
The definition of anemia is a decrease in hemoglobin concentration in the blood
resulting in perfusion of O2 to tissues. Called gravis which means weight and hemoglobin
values below 7 g / dl and require additional generally through transfusion. Anemia is
reduced to below the normal value of red blood cells, hemoglobin quality and volume of
packed red blood cells (hematocrit) per 100 ml of blood (Price, 2006: 256).
The etiology of anemia is the most common cause of deficiency of nutrients
required for the synthesis of red blood cells, such as iron, vitamin B12 and folic acid. The
1457
rest is the result of a variety of conditions such as hemorrhage, genetic abnormalities,
chronic disease, drug toxicity, and so on.
Pathophysiology of anemia reflects a failure of the bone marrow or excessive loss
of red blood cells or both. Bone marrow failure may occur due to nutritional deficiencies,
toxic exposure, or tumor inuasi mostly due to unknown causes. Red blood cells can be lost
through bleeding or hemolysis (destruction) in the latter case, the problem may be due to
the effects of red blood cells that are not in accordance with normal red blood cell survival
or due to some factors outside the red blood cells which causes the destruction of red blood
cells. Red blood cell lysis (dissolution), especially in the system or in the phagocytic
reticuloendothelial system, especially in the liver and spleen. As a byproduct of this process
bilirubin is formed in phagocytes will enter the blood stream. Any increase in red blood cell
destruction (hemolysis) immediately reflected by increasing plasma bilirubin (normal
concentration of 1 mg / dl or less levels of 1.5 mg / dl result in jaundice in the sclera.
PERCENTAGE CASE
Mr. HP 27 years old entered persahabatan hospital since July 14, 2014, the patient
came with complaints of dizziness, body felt weak since 1 week, nausea, vomiting,
palpitations, and bloody bowel movements.
EVALUATION CLINIC
Mr. HP laboratory result on the date of July 14, 2014 showed abnormalities in
neutrophil value is 86.9 thousand / mm 3 (50-70 thousand / mm 3), lymphocytes 7.2
thousand / mm 3 (25-40 thousand / mm 3), eosinophils 0.2 thousand / mm 3 (2-4 thousand /
mm 3), erythrocytes 2.13 million / mm3. Hemoglobin 3.4 g / dl (13,0g / dl-18.0 g / dl),
hematocrit 12% (40-52%). Abnormalities on the results of this investigation indicate that
the patients had anemia due to red blood cell count or hemoglobin (the oxygen-carrying
protein) in red blood cells are below normal. Test results on the electrolyte potassium 3.3
mmol / L (3.5-5.0 mmol / L), this abnormality indicates a low value or potassium in the
blood is called hypokalemia.
1458
Mr. HP laboratory result on the date of July 15, 2014 shows the changes in value of
73.4 thousand neutrophils / mm 3 (50-70 thousand / mm 3), lymphocytes 17.4 thousand /
mm 3 (25-40 thousand / mm 3), eosinophils 0.3 thousand / mm 3 (2-4 thousand / mm 3),
erythrocytes 0.3 million / mm3. Hemoglobin 4.4 g / dl (13,0g / dl-18.0 g / dl), hematocrit
16% (40-52%). Test results on the electrolyte potassium 3.5 mmol / L (3.5-5.0 mmol / L)
had shown normal values after treatment with potassium KSR
Dosage and how to use the drug in these patients is the RL given intravenously for
dehydration, RL usual dose given according to the patient's condition, transamin given in
intravenous form for local fibrinolysis, KSR to cope with a shortage of potassium for oral
administration 2-4g dose (approximately 25-50 mmol) per day while for intravenous 3 x 1
day. Ceftriaxon used for the treatment of infections of gram-positive and gram-negative.
Doses used for intravenous 1 g / day in a single dose, in severe infections 2-4 g / day dose.
Doses over 1g given in two or more places, Vitamin K is used for deficiency of vitamin K,
an adult dose of 10-40 mg per day. Laxadine given for constipation, adult dose of 15-30 ml
once daily before bed. (IONA, 2008)
1 There is no indication of drug
Earlier in the cross-check to the doctor if need be added folic acid. Because folic acid is
needed to stimulate the formation of red blood cells.
2 Others
In the book list nursing nurses sometimes do not record the medication that is administered
to the patient. So it is advisable to nurses to always take note of what has been given to the
patient. Do monitoring nurse notes on the book list nursing.
1459
CONCLUSION
Based on the results of their clinical practice on the wards in the department of
Friendship lung disease, it can be concluded that the presence of DRP (Drug Related
Problem) which is the indication of the disease without medication
REFERENCES
1.
FDA. 2008 Indonesian National Medicine Information (ioni). Jakarta: Sagung Seto.
2.
Mansjoer 2, 2000, the Capita Selecta Medicine: London: Aesculapius media.
3.
Elin Yulinah 2011, ISO Pharmacotherapy 2, Publisher: Pharmacist Association of
Indonesia, Jakarta Gleadle, J. 2007 At A Glance History. New York: McGraw.
4.
David Tatro, 2006 Drug Interaction FactTM, America: Fact & Comparisons
5.
Acton, Sharon Enis & Fugate, Terry (1993) Pediatric Care Plans, Addisowesley Co.
Philadelpia.
6.
Department of Health, Director General P2PL, 2009, Guidelines for Infection Disease
Control Persnapasan Acute, Jakarta.
7.
A. Price Sylva, Pathophysiology Clinical Concepts Disease Processes, EGC, vol 2,
issue 4, Jakarta, 1995, p 645-707
1460
DRUG RELATED PROBLEM TREATMENT OF PNEUMONIA IN
PATIENTS TREATED IN THE LUNG GATOT SOEBROTO ARMY
HOSPITAL
Habrianti Pertiwi Elwi1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Pneumonia is infection in the bronchial and alveolar end that can be caused by
various pathogens such as bacteria, fungi, viruses and parasites. Pneumonia is a cause of
death in young children and infants as well as being the most common cause of disease.
Pneumonia can occur throughout the year and can hit all ages. Became very severe clinical
manifestations in patients with the very young, the elderly and in patients with critical
conditions. Patients Mrs H, aged 28 years, entered Gatot Subroto Army Hospital on May
15, 2014 with a diagnosis of sepsis bronchopneumonia. Therapy for the treatment at
hospitalized was Meropenem injection, Levofloxacin injection, methyl prednisolone
injection, Omeprazole injection, oral expectoran Ventolin, Hidonac (N-acetylcysteine)
injection, Ventolin Nebulizer, Vitamin C injection, injection Neurobion 5000, Flukonazole,
and nystatin drop. Based on the results of their clinical practice in the treatment of lung at
Gatot Subroto Army Hospital then found a DRP (Drug Related Problem) a correlation
between drug therapy with disease and lack of proper drug selection.
Keywords: pneumonia and Gatot Subroto Army Hospital.
I.INTRODUCTION
Pneumonia is inflammation of the lung parenchyma, distal to the terminal
bronchioles which includes respiratory bronchioles, alveoli, and cause consolidation of lung
tissue and cause local disruption of gas exchange
1.
Bronchopneumonia used fatherly
describe pneumonia that has a mottled pattern of spread, organized in one or more localized
areas within the bronchi and extends into the adjacent pulmonary parenchyma around it. In
bronchopneumonia occurred consolidation stained area
2.
The origins of pneumonia are at
the damage caused by the influx of particles in the lower respiratory tract attacker. The
driveway is a frequent inhalation of small particles, but the aspiration of particles greater
1461
infection of the oropharynx are spread from distant focus of infection or spread directly
from surrounding tissues used as an entrance by agents that cause pneumonia. These
particles can cause lung damage because they contain ingredients that can cause infection,
it can spread through the air (water borne) when infectious agents are still active, and stay
active while suspended in the air and then go into the network, where the particles can lead
to infection. The combination of these conditions may help explain why pneumonia is less
common and why some locations are more at risk than other locations 3.
2.CASE STUDY
Patients Ny. H admitted to hospital with complaints of shortness of breath since less
than 1 hour prior to hospital admission. Shortness of breath more damning to talk tough,
patients sleep with 1 pillow. The patient complained of cough since about 2 weeks before
entering the hospital. Cough with phlegm, sputum can not get out, nausea, vomiting after
eating, heartburn and body felt weak. The patient had a history of brain tumor disease after
being diagnosed two months ago. The general condition of the patient at the time of
hospital admission were blood pressure 110/80 mm Hg, pulse 100 beats / min, temperature
36.9 ° C, RR 30 breaths / min.
Management of therapy for Ny. H preferred to tackle pneumonia. Meropenem was
given for infection gram positive and gram negative, aerobic and anaerobic. Additionally
meropenem administered to patients because of sepsis. Levofloxacin was given for
infection due to microorganisms sensitive as CAP (community acquired pneumonia).
Methyl prednisolone as an anti-inflammatory and allergic disorders: cerebral edema
associated with malignancy. Omeperazole given for stomach and duodenal ulcers
associated with NSAID, lesions of gastric and duodenal, H. pylori eradication regimens in
peptic ulcer, reflux esophagitis, Zollinger Ellison syndrome. Giving Hidonac (Nacetylcysteine) on pneumonia serves as a mucolytic to cope with excessive phlegm cough
suffered by the patient.
1462
Other therapies given to these patients Fluimucyl therapy, a thick mucus
hypersecretion therapy and thickness of the respiratory tract that serves to dilute the
phlegm. Ventolin is used to overcome the shortness of breath that works as a receptor
agonist with a beta II activation of multiple receptor beta I. On day six patients was treated
and given flukonazole nystatin drop as patients experiencing fungal infections around the
mouth, where flukonazole and serves as an anti-fungal nystatin for treatment and
prevention of intestinal candidiasis or oral. Administration of vitamin C and a multivitamin
Neurobion 5000.
4.DOSAGE AND METHOD OF USE
Dose
prescription
Drug Name
Indication
How to use
Prevalent
Dosage
Chronic lower
respiratory tract
infection: 2 g
every 8 hours
Meropenem
injection
Infection of grampositive and gramnegative
1 x 750 mg
Levofloxacin
injection
Infections due to
sensitive
microorganisms such
as the CAP
((community acquired
pneumonia)
3 x 3, 125
g.
Methyl
prednisolone
injection
As an antiinflammatory
1 x 40 mg
Omeprazole
To overcome the
adverse effects of
Methyl Prednisolone
Injection
Oral: 20 mg 1 x
daily for 4 weeks
IV: 40 mg 1 x
day
1 x 400 mg
Vitamin C
Multivitamins
Injection
Adult: 200 mg
usual dosage 300 mg.
3x1g
Injection
Injection
Injection
Oral: 250 mg 500 mg 1 x day
Pneumonia: 500
mg 1/2 times
daily for 7-14
days.
IV: 500 mg 1/2 x
daily
Oral: Common
2-40 mg / day
IV: the
beginning of 10500 mg
1463
1x1
ampoule
Neurobion 5000
Multivitamins
Injection
3x1
Ventolin syrup
expectoran
Expectoran syrup
Oral
8 cc in 100
cc of NaCl
(finished in
3 hours)
Hidonac (Nacetylcysteine)
mukolitik
Injection
3x1
Ventolin
nebulizer
Overcoming shortness Nebulizer
1 x 400 mg
Flukonazole
Treatment of
candidiasis
3 x 1 cc
3x1
Oral
Adult: 500 mg
usual dosage.
Adult:
respiratory
disorders
prevalent dose of
10-20 ml.
Adult: 150 mg /
kg bolus in 60
minutes.
Hidonac solution
that has been
dissolved, adult
50 ml, 200 ml
children.
Adults: 1
nebulize / x
provision can be
given 4 x 1 a day
if necessary.
Adult:
Candisiasis:
kriptokokol
meningitis =
initially 400 mg,
200 mg daily for
26 days.
Nystatin drop
Treatment candidiatis
Drop
Adults: The
usual dose of 4 x
1 1-6 ml
Fluimucyl
viscous mucus
hypersecretion
therapy and thickness
of the respiratory
tract.
Oral
Adults: The
usual adult dose
of 200 mg.
1464
5.LABORATORY EXAMINATION RESULTS
Value
Examination
normal
15/5
Hemaglobin
Date
16/5
17/5
18/5
19/5
12-16 (g / dl)
13.4
11.9
12.8
37-47%
39
36
38
erythrocytes
4.3-6 million / mL
5.1
4.6
4.9
leukocyte
4800-10800 / mL
24800 *
14400 *
17900 *
Platelet
150.000-400.000/μL
417000 * 394000
457000
*
MCV
-
77
78
77
mch
-
26
26
26
MCHC
-
34
33
34
3.5 to 5.0 g / dl
4.4
4.1
20-50 mg / dl
45
37
23
0.5 to 1.5 mg / dl
0.8
0.7
0.5
<140 mg / dl
168
122
128
123
115
Sodium (Na)
135-147 mmol / L
134
134
145
144
143
Potassium (K)
3.5 to 5.0 mmol / L
3.5
4.0
4.2
4.7
4.4
95 -105 mmol / L
108 *
108 *
104
103
103
pH
7:37 to 7:45
7.625 *
7628 *
7746
PCO 2
33-44 mmHg
33.8
37.2
33.6
pO 2
71-104 mmHg
124.9 *
100.4
191.9 *
hematocrit
Albumin
urea
creatinine
Glucose during
Clorida (Cl)
1465
Bicarbonate (HCO3) 22-29 mmol / l
Bases excess (BE)
O2 saturation
D-dimer
35.5 *
39.3 *
46.6 *
(-2) - 3 mmol / l
14.2
17.4
25.9
94-98%
99.4
98.8
99.9 *
0-300 ng / ml
770 *
Procalcitionin
<0.5 ng / ml normal
0.5
PT
-
12.1
APTT
-
34.4
Calcium
-
9.8
10
Magnesium
-
1.63
2:06
Lactate
-
1:40
SGOT
-
15
SGPT
-
13
6.DRUG RELATED PROBLEM
1. The correlation between drug therapy with disease
In these cases found no indications of drugs, where patients experience nausea and
vomiting but not get treatment for nausea and vomiting experienced by patients. It is
recommended as an anti-emetic for nausea and vomiting experienced by patients
should be given metoclopramide who have mild side effects.
2. Selection of drugs
In this case reveal any improper drug selection is antibiotics meropenem. To use of
antibiotics meropenem without culture and sensitivity test may lead to increased
resistance. Meropenem for treatment should be done in advance so that the test cultures
of bacteria causing the infection can be known with certainty. The election found that
1466
excess anti-fungal medication that is flukonazole and nystatin. Anti-fungus therapy is
quite one kind of therapy .
7.CONCLUSION
Based on the results of their clinical practice on Lung Treatment Room at Gatot
Subroto Army Hospital it can be deduced that the presence of DRP (Drug Related
Problem) a correlation between drug therapy with a disease in which patients experience
nausea and vomiting but not given drug treatment for nausea and vomit, the selection of
antibiotic therapy is less precise meropenem in the treatment of pneumonia due to the use
of antibiotics meropenem should do culture and sensitivity testing as well as the use of
quite a wide antifungal one kind of therapy .
8.REFERENCES
1. Syamsuddin, 2009. Pharmacotherapy Textbook Cardiovascular and Renal. Jakarta:
Salemba Medika, Hal. 113
2. Smeltzer, Suzanne C. 2000 . Textbook of Medical Surgical Nursing, Volume I, Jakarta:
EGC, Hal. 121
3. Zul Dahlan., 2000 Internal Medicine. Second edition, New York: Hall Publishers,
Faculty of medicine, Hal. 83
4. Anomia 2006. MIMS Indonesia Guidance and Consultation, 6th edition 2006/2007.
Jakarta: PT. Master information, CMP Medica license.
5. National authorities. , 2008. Indonesian National Medicine Information (ioni). Jakarta:
Sagung Seto.
6. ISFI 2009 - 2010. ISO (Indonesian Spesialise Indonesian drug), Vol.44, New York:
Association Scholar Pharmaceutical Indonesia.
1467
FOR UPPER RESPIRATORY INFECTIONS AND DIABETES
MELITUS TYPE II PATIENT IN MINTOHARDJO JAKARTA
HOSPITAL
Hernianti1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
DM (Diabetes Mellitus) is metabolic disorder marked by hyperglicemia relating to
teratology metabolism of carbohydrates, fat and protein caused by decreased secretion of
insulin or decrease of sensitivity insulin or both, and cause chronic microvasculer and
macrovasculer complication, and neurophaty. criteria diagnosis of diabetes mellitus is
glucose levels of fasting ≥ 126 mg/Dl, on 2 hours after eating ≥ 200 mg/dL or HbA1c ≥
8%. If glucose levels 2 hours after eating > 140 mg/dL but smaller than 200 mg/dL
expressed glucose tolerance weak (Yulinah, 2011).
Upper Respiratory Infections is a disease that attacks in toddlers happened to respiratory
and most is a viral infection or bacterial. Patients will have a fever, cough, rheum or
combination of the symptoms (Nasution, 2008).
Patient Ms.TI, aged 54 years old, was entered Mintohardjo Hospital on April 16 2014 with
was diagnosed Upper Respiratory Infections and Diabetes Mellitus Type II. Patient was
treated with novorapid, lantus, ceftriaxon, betahistin, cefixime, domperidon, paracetamol
and ranitidin.
Based on the practice of clinic on the I Mintoharjo Hospital it can be concluded that the
presence of DRPs (Drug Related Problems), that are drug interaction between metformin
and ranitidin and duplication of a drug that is granting an antibiotic ceftriaxon with
cefixime.
Keywords : Drug Related Problem, Upper Respiratory Infections And Diabetes Melitus,
Mintohardjo Hospital
INTRODUCTION
Diabetes mellitus defined as a disease or disorder of metabolism chronic with multi
aetiology characterized by high glucose levels accompanied with impaired metabolism of
carbohydrates, lipid and protein insufficiency function as a result of insulin by cell of the
pancreas, betas of langerhans glands or causes by less responsif against insulin. Any
1468
degenerative diseases which may arise due to patterns and life style that can interfere with
health of a person is diabetes mellitus
Diabetes Mellitus is a metabolic chronic disease characterized by hyperglicemia
caused by absolute deficiency of insulin productin or the occurrence of resistance at a
receptor insulin. The symptoms of Diabetes Mellitus namely glucosaria, 3P (polyuria,
polydipsia, polyfagia), weight loss, a wound that are difficult to recover, a sense of
tingling/immune, languid, weak, and cetoasidosis (Yulinah, 2011).
Upper Respiratory Infections of the respiratory tract acute, the term in includes three
elements namely the infection, channel respiratory and acute. By understanding as follows:
1.
Infection is the entry germs or micro-organisms into human body breed of causing
symptoms of disease
2.
Respiratory is an organ of the nose to the alveoli internal organs such as sinus-sinus
the cavity of the middle ear and the pleura. Upper Respiratory Infections in
anatomical includes the Upper Respiratory tract
3.
An acute infection is an infection that lasts 14 days is taken to indicate the process of
acute. Although several diseases that can be classed in Upper Respiratory Infections,
this process takes place more than 14 days (Nasution,2008)
CASE PRESENTATION
Patient Ms.Ti, aged 54 years old, entered Mintoharjo Hospital on April 16, 2014.
The patient came with compliants cough fever, an ulrcer wamble a sour taste that
propagates through the gullet, often urination, quick thirsty and a few days defecate slimy.
CLINICAL EVALUATION
Laboratory result showed abnormality in the value of glucose 2hpp and HDL
Cholesterol.
Patient was given novorapid and Lantus to lower her glucose level. Novorapid is an
insulin work quickly (short acting), this insulin lowering glucose level in five minutes after
used, paek time is about 1 hour and inactve within 3 hours. injected just before eating or
after supper. While insulin Lantus work long (long acting), begin work six hours and
1469
provides work insulin light intensity in 24 hours. This insulin can control sustainably and
only need once injection in a day.
Ringer lactate 20 tpm given subcutaneously to prevent dehydration and dosage customarily
ringer lactate in accordance with the condition of patient, insulin novorapid 3x16 unit given
subtaneously with the diabetes mellitus, insulin Lantus 1x14 unit given subcutaneosly to
overcome glucose levels in the blood (DM), betahistin 3x1 given in per oral to overcome
vertigo and headache ceftriaxon 2x1 gram given in IV to overcome, infection of the
respiratory tract cefixime 2x100 mg given in per oral to overcome, infection of the
respiratory tract domperidon 3x1 given in per oral to overcome nausea and vomiting,
metformin 3x500 mg given orally to cope with the diabetes mellitus glucobay 2x50 mg
given in per oral to cope with diabetes mellitus, Ranitidin 2x1 given in per oral to
overcome, irritation of the stomach paracetamol 3x1 given in per oral to cove the pain. To
overcome glucose levels patients on the first day given, ginev novorapid 3x16 units and
Lantus 1x14 units. After declining glucose level of patients given only Novorapid 1x16
units and Lantus 1x14 units.
1. The correlation between drug therapy and disease
Therapeutic treatment in patients Mrs. Ti, drug were given medical in accordance with
the indications
2. Selection of appropriate drug
Selecting of drug is not conforming when patient get antibiotic same time without
supported by workup laboratory
3. Regimen doses and conferring is secure and schedule granting doses maximize the
effect of therapy, compliance with minimal side effects, interaction medicine, and
regimen that complex.
4. duplication drug
There are duplication of a drug that is ceftriaxon with cefixime. Both this medicine is
group of cephalosporin that have broad spectrum and effective against microorganisms
1470
of gram-positive and gram-negative. But for the treatment of acute respiratory tract
infection effective use is cefixime.
5. Allergic and intoleran
Patient experiencing no intoleran against allergies or one (or chemicals related to
treatment)
6. Adverse effect
No symptoms/induced medical problems
7. Drug interaction
The
interaction
that
happens
is
in
significant
metformin
with
ranitidin
pharmacokinetic, where metformin will heighten the effect of ranitidin, must be
monitored.
CONCLUSION
Based on the practice of clinician on the island of care selayar the floor III Mintoharjo
Hospital can be concluded that the presence of DRPs (Drug Related Problems) is
happening with the interaction between metformin, ranitidin in pharmacokinetic, where
metformin that will increase the effect ranitidin on the basis of the cation drug competition
for clearance to the kidney tubules so that its use should be in monitoring and there are
duplication of a drug that is granting an antibiotic ceftriaxon with cefixime.
REFERENCES
2. Elin Yulinah, 2011, “ISO Farmakoterapi 2” Penerbit: Ikatan Apoteker Indonesia,
Jakarta
3. Direktorat Bina Kefarmasian. 2005. “Pharmaceutical Care untuk Penyakit Infeksi
Pernafasan”. Jakarta : DEPKES
4. Mabsjoer, A, dkk. (2011).” Kapita Selekta Kedokteran (Ed.III)”. Jakarta : Media
Aezcolaius
5. Nasution, M.2008. “Infeksi Laring Faring (Faringitis Akut)”. Medan : USU
1471
PLEURAL EFFUSION TUBERCULOSIS PATIENT IN PGI CIKINI
HOSPITAL
Hevi Viliani 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Pleura Efusion is acumulation of liquid which excessing in pleura hollow,as the
liquid arrounded a lung. Liquid in within amount excess could be breathing trouble definly
streching the lung for a inhalation process. Pleuritis Tuberculosis was formed a
Tuberculosis disease within manifistetion accumulate of liquid in lung hollow,exactly
between external layer and internal layer of lung. (Alsagaff,2002). Women patient has old
19 years who has been cared at Bangsal K PGI Cikini Hospital. The patient has been
diagnosis got Efusion Pleura Tubercolasis disease. From the result inquiry Hematologi
Labotarium patient to be involved abnormalitas at LED it 92 mm/hours,hemoglobin 9,4
g/dL (12-14, hematrokit 29%(37-42). From the result Clinic Chemistry, the patient was
getting abnormalitas in albumin 2,7 g/dL (3,4-4,8), SGOT 81 U/L,SGPT 105 U/L. The
patient has been getting therapy within cefotaxime for 3 days,omeprazole injection 2X1
ampl/day, lycoxy 1x1 tab/day, panadol 3x1 tab/day k/p, hepamax 2x1 cps/day, OBH x1
per/tblspn, amikasin 2x500 mg/hr, rifampisin 1x300 mg/day, INH 2x100 mg/day,
etambutol 3x250 mg/day, pyrazinamide 3x250 mg/day. From the treatment therapy was be
used by patient founded DRP as : need medicine but it hasn’t given , need Drug Induce
Hepatotocsic and occured ADR within medicine interaction for user tuberculosis
medicines.
Key words : Efusi Pleura Tuberculosis, PGI Cikini Hospital.
1.
INTODUCTION
Efusion Pleura Tuberkulosis frequently can be find at Develop Country include at
Indonesia, eventhough diagnosis difficult building definitly. Efusion Pleura as appeared
since of a disease , due to it should be wanted the ‘cause of it. Efusion Pleura was a
accumulation of liquid was more in pleura hollow, the liquid arrounded a lung and in
1472
Liquid in within a amount excess could be breathing trouble definly streching the lung for a
inhalation process. Pleuritis Tuberculosis was formed a Tuberculosis disease within
manifistetion accumulate of liquid in lung hollow,exactly between external layer and
internal layer of lung. The clinic drawing and radiologic betweem transudat and eksudat in
fact between efusion pleura tuberkulosis and non tuberkulosis both of almost couldn’t be
different . Since the laboratorium inqury be more urgently (Alsagaff,2002).
2.
CASE PRESENTATION
Women patient has old 19 years who has been cared at Bangsal K PGI Cikini
Hospital.
The patient has been diagnosed and the result she got Efusion Pleura
Tuberculosis. She has been already at PGI Cikini Hospital on February 24th 2014. The
patient has been fever since 3 days ago, asthmatic, disgusting, appetite be less and febris.
The patient has been getting therapy within cefotaxime for 3 days,omeprazole injection
2X1 ampl/day, lycoxy 1x1 tab/day, panadol 3x1 tab/day k/p, hepamax 2x1 cps/day, OBH
x1 per/tblspn, amikasin 2x500 mg/hr, rifampisin 1x300 mg/day, INH 2x100 mg/day,
etambutol 3x250 mg/day, pyrazinamide 3x250 mg/day.
3.
CLINICAL EVALUATION
The patient get ashmatic then did pufsi pleura, emerge liquid which yellow-green
color about 825 cc. Medicine therapy that given to patient included cefotaxime to treat
heavy infection which caused by patogens that it sensitive to cefotaxime, hindrance proton
pump (omeprazole) to treat flank sore, Lycoxy (multivitamine) is used to keep stamina of
body, Panadol (Paracetamol) is used to reduce fever. OBH is used be a ekspektoran (thinner
of mucus) in annoyance of a cough, Hepamax (supplement) is used to keep the healthy of
function liver, rifampisin, INH, Etambutol, Amicasin and Pyrazinamide is used be a
medicine combination to therapy Tuberculosis. RL infus is used to return the balance of
electrolit in dehydration condition.
1473
4.
LABORATORIUM PARAMETER
The result inspection clinic chemical showed a abnormalitas at SGOT is 81 U/L (0-
35), SPGT is 105 U/L (0-35) which it pointing occured hepatitis acute, albumin is 2.7 g/dL
(3.4-4.8) has been indication infection.
While in hematologi inspection showed a
abnormalitas at rate blood stoop it is 9 mm/hours (0-20) has been indication infection,
hemoglobin is 9.4 g/dL (12-14) has been indication less a oxsigen in the blood it make
ashmatic and anemia, hematokrit is 29% (37-49) has been indication a anemia, less a
Vitamin B and showed ulkus peptikum.
5.
DOSAGE AND WAY TO USING
Patient has been therapy with injection omeprazole dosage 2x1 ampl/day which
used to treat flank sore, cefotaxime has given with dosage 3x1 for 3 days is used to
infection breath duct, Lycoxy (multyvitamine) is used with dosage 1x1 tab/day is used to
keep stamina of body, Panadol (Paracetamol) has given with dosage 3x500 mg/day is used
to reduce fever (drunk in fever condition), OBH has given with dosage 3x1 tblspn/day is
used be a ekspektoran (thinner of mucus) in trouble cough, Hepamax (suplement) has given
with dosage 2x1 cps is used to keep healthy liver function, rifampisin has given with
dosage 1x300 mg/day 1 hours before eat or 2 hours after eat is used to pursue growing of
bacteria negative gram, INH has given with dosage 2x100 mg/day is used to pursue
dividing microba cell tuberculosis, Etambutol has given with dosage 3x250 mg/day is used
to pressure growing up tuberculosis bacteria, amikasin has given with dosage 2x500
mg/day is used be a anti-tuberculosis lini 2 and pyrazinamide has given wth dosage 3x250
mg/day is used to pursue growing up the tuberculosis bacteria.
6.
DRUG RELATED PROBLEMS
6.1
Needing medicine but it hasn’t given
this case the patient needs addition medicine is a vitamin B6 as antidotum for using
INH
6.2
Medicine Interaction
1474
Using rifampisin with pyrazinamide made of increasing others toksisitas with
farmacodynamic synergy, using isoniazed with pyrazinamide made of increasing
others toksisitas with farmacodynamic synergy, using isoniazed and rifampisin
made of increasing hepatotosic.
6.3
Adverse Drug Reaction
The patient be realized increasing SGOT and SGPT which both of have been
indication acute hepatitis,it made by tuberculosis medicines.
6.4
Drug Induce Hepatotocsic
From the result of inquiry clinic laboratorium chemistry showed SGOT and SGPT
are high. So that the patient needs addition therapy, it is a asetil sistein or curcuma
as a hepatoprotector.
7.
CONCLUSION
After done healing theory to patient issue, could be concluded that the patient got
DRP attempt the patient needed addition medicine as a antidotum from user INH is a
vitamin B6, the patient realized to increasing SGOT and SGPT it made by tuberculosis
medicines so that need addition therapy as hepatoprotector and had been medicine
interaction for using tuberculosis medicines it could be something wrong wasn’t be
happened.
REFERENCES
1. Harun S. Efusi Pleura Tuberculosis. http://www.kalbe.co.id. (diakses 19 april 2014)
2. Jati. Pleuritis Tuberculosis. http://agusjati.blogspot.com. (diakses 18 april 2014)
3. Alsagaff H, Mukhty A, Dasar-dasar Ilmu Penyakit paru. Surabaya : Airlangga
University press, 2002.
4. Baxter, K.(ed).2008. “Stockley’s Drug Interaction”. Eight Edition. Pharmaceutical
Press, London and Chicago.
5. Charles D.Hepler and Richard Segal. 2003. “Preventing Medication Errors and
Improving Drug Therapy Outcomes”.CRC Press LLC.Boca Raton. Florida.
1475
6. Depkes RI. 2008. “Informasi Obat Nasional ndonesia”. Dirjen Pengawasan Obat dan
Makanan. Jakarta.
1476
DRUG RELATED PROBLEMS (DRPs) ASSOCIATED WITH
TREATMENT FOR COLIC RENAL PATIENT IN PGI CIKINI
HOSPITAL
Husnul Chatimah1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
email : [email protected]
ABSTRACT
Renal colic in severe pain that characterize as intermittent (relapsing-remitting) is usually in
the area between the ribs and pelvis, which spread throughout the abdomen and can end up
in the genital area and inner thighs. Renal Colic usually starts at the back part of the upper
and mid-lateral anteroinferior spread towards the groin and genital area. Pain arising from
renal colic is mainly caused by dilation, stretching, and urinary tract spasms caused by
acute ureteral obstruction. When there is chronic obstruction, such as cancer, usually do not
feel pain. Patient. CJ, aged 38 years old, entered the hospital PGI Cikini on February 5,
2014 with was diagnosed of Renal colic (renal colic). Therapy for the treatment of
hospitalized namely: Ceftriaxon, Ketorolac, Lasix, Dumozol, Kalnex, Merofen,
Levofloxacin. Based on the practice court reporting in hospital wards K PGI Cikini, it can
be concluded that the presence of DRP (Drug Related Problem) dose regimen (dose
Dumozol low), the addition of unnecessary drug (Levofloxcin) and the presence of drug
interactions between Levofloxacin and Ketorolac, Ceftriaxon and Furesemid.
Keywords: renal colic and PGI Cikini Hospital
INTRODUCTION
One in 20 people suffer from kidney stones. Comparison between men and women is
3:1. The peak incidence at age 30-60 years or 20-49 years. The prevalence in the USA
about 12% for men and 7% for women. Struvite stones is more common in women than
men. (Sudoyo, 2006)
The most common etiology is the passage of kidney stones. Increased severity of pain
depends on the degree and site of obstruction; not on hard, size, or nature of kidney stone
abrasion. Blood clots or tissue fragments can also cause the same thing. Colic is often
1477
encountered due to a blood clot in a blood clotting disorder hereditary or acquired, trauma,
neoplasm of the kidney and urinary tract, bleeding after percutaneous renal biopsy, renal
cysts, renal vascular malformations, papillary necrosis, tuberculosis, and infarction of the
kidneys. Colic actually happened because vesicoureteral reflux. (Sudoyo, 2006)
Kidney stones move along the ureter and cause intermittent obstruction of the actual
cause of the pain is more severe than the rock that does not move. A constant obstruction
will lead to a range of autoregulation and reflex mechanisms that will help relieve the pain.
Twenty-four hours after total ureteral obstruction, the hydrostatic pressure will decrease
because of (1) a decrease in ureteral peristalsis, (2) a decrease in renal arterial blood flow,
which causes a decrease in urine production, and (3) interstitial edema which causes an
increase in lymphatic drainage. These factors lead to high-intensity renal colic lasted less
than 24 hours. If the obstruction is partial, the same changes occur, but the degree of the
lighter and longer. (Sudoyo, 2006)
Patient with renal colic should undergo urine filtration to find stones, blood clots, or
other tissues, as a determinant of diagnosis. If necessary, this is done for weeks due stone or
network can settle in the bladder without causing symptoms. Normally found in the urine
hematuria and crystalluria sometimes.
Successful medical management was determined by five factors: the accuracy of the
diagnosis, the location of the stone, the presence and severity of infection, the degree of
impaired renal function, and proper governance. Therapy is considered successful if:
complaints disappeared, stone recurrence can be prevented, has been able to eradicate the
infection and kidney function can be maintained. (Sudoyo, 2006)
CASE PRESENTATION
Patient. CJ, aged 38 years old, hospitalized PGI Cikini on February 05, 2014 at 20:15
pm. Patient present with left flank pain for a week, weak, limp, facial grimacing. The
patient ever went to Koja Hospital of date December 28, 2013 and January 30, 2014 with
the same complaint. The patient does not have allergies to medication or disease that used
previously because of heredity.
1478
Tests was done at PGI Cikini Hospital was checking blood pressure, clinical chemistry,
hematology, CT Scan, Ultrasound. Then given drug therapy Ceftriaxon, Ketorolac, Lasix,
Dumozol, Kalnex, Morphine, Levofloxacin.
CLINICAL EVALUATION
Laboratory results on the 5th of February 2014 showed abnormalities on examination Hb
(hemoglobin) is 12.8 g/dL (13-16 g/dL), converting the presence of anemia, leukocytes 11
ribu/mm3 (5-10 ribu/mm3) shows that patient experienced an infection. Hematocrit of 39%
(40-48%) indicates that the patient experienced a sudden blood loss, anemia, chronic renal
failure and peptic ulcer. Creatinine 1.4 mg/dL (0.6 to 1.1 mg/dL) indicates that the patient
has decreased renal function and contraction of sceletal muscle mass. Potassium (K) 3.3
mEq / L (3.5-5.0 mEq/L) indicates patient had hypokalemia due to potassium from foods
low input, expenditure through increased urine. Calcium (Ca) 7.9 mg/dl (9-11 mg/dl)
indicates that patient experienced gastrointestinal malabsorption, extensive infection and
chronic renal failure.
Test results urography Non-Contrast CT scan showed left hydronephrosis and
hydroureter, does not seem real level of the dam, the walls thickened ureter impression
(uretiritis).
Results examination renal and Buli ultrasound showed hydronephrosis and left
hydroureter with left renal cysts, debris intrabuli, does not seem right kidney abnormalities.
DOSAGE AND USED OF DRUGS
Dosage and how to using the drug in these patient was Ringer's lactate and 0.9% NaCl
was administered subcutaneously to prevent dehydration, a common dose Ringer's lactate
and sodium chloride 0.9% in accordance with the patient's condition. Ceftriaxone 1 g 1 x
daily administered intravenously over a day, the second day until the eighth days 2 times a
day, was used for the treatment of urinary tract infections with Ceftriaxon usual dose 1-2 g /
day intramuscular or intravenous in a single dose or divided into two doses , ketorolac 30
mg 3 times a day administered intravenously was used for the treatment of acute pain with
moderate to severe short-term (less than 5 days), which requires a level of opioid analgesic
1479
ketorolac ampoule with the usual dose 60-90 mg / day. Lasix 20 mg 2 times daily was
given on the second day of intra-venous, and the third day until the seventh day 3 times a
day, 1 day to eight times daily was used for edema, ascites in liver, mild to moderate
hypertension, the usual dose lasix ampoule 20-40 mg / day. Dumozol 1x daily 500 mg
given intravenously on day intravenous seventh, eighth day until the tenth day given 2
times daily, used for the treatment of anaerobic infections, trichomoniasis, amubiasis, pre &
post-surgical prophylaxis. Urethritis & vaginistis the usual dose infusion Dumozol 500 mg
every 8 hours. Kalnex 100 mg 2x a day was given on the seventh days intravenous, and the
ninth and tenth days 3 times daily, used for the treatment of abnormal postoperative
bleeding, bleeding after tooth extraction in patient with hemophilia with Kalnex usual dose
of 100 mg/ampoule 2,5 - 5 ml was injected intravenously or intra-muscular, divided into 12 doses. Merofen 1 x 1 g daily given in intravenous eighth day, the ninth and tenth days
given 2 times daily, used for the treatment of urinary tract infections, intra-abdominal
infections, gynecologic infections (including endometrisis), empirical therapy for infection
in adult patient with febrile neutropenic (as monotherapy or in combination with antiviral
or antifungal) with the usual dose of 1 g every 8 hours Merofen (Meropenem).
Levofloxacin 500 mg 1x per day given orally on the eighth days used for urinary infections,
the usual dose of Levofloxacin 250-500 mg 1 x day in a single dose (every 24 hours).
DRP 1: Conditions that need to be considered
By looking at the condition of the patient does not need the addition of the drug
Levofloxacin 500 mg on the eighth days. Giving merofen (meropenem) without doing a test
culture and sensitivity test of the bacteria can cause an increased risk of misuse and drug
resistance.
DRP 2: The dosage regimen, the drug dose is too low
Drug dose is too low, the recipe dumozol (metronidazole) 2 x 500 mg daily, according to
Dr.. Aine Burns (Renal Drug Handbook, 2009), it should be 3 x 500 mg daily. Suggested to
the doctor to re-evaluate the use of therapeutic doses dumozol. Do check the list
periodically nurses notes.
1480
DRP 3 : Drug Interaction
Use of Quinolones (Levofloxacin) with a NSAID (Ketorolac) may increase the risk of
central nervous system stimulants (CNS) and seizures, the drug should be administered so
that the distance in the offering (Anonymous, 2005). The use of cephalosporins
(Ceftriaxon) with furosemide can lead to increased nephrotoxicity. Avoid concurrent use
(BPOM, 2008)
DRP 4 : Human Error
In the book the list of drugs the nurses sometimes do not record the medication that was
given to the patient or the dose given. So it is advisable to nurses to always take note of
what has been given to the patient. Monitoring of nurses notes on the book list of drugs.
CONCLUSION
Based on the results of their clinical practice in internal medicine in Ward K PGI Cikini
Hospital it can be deduced that the presence of DRP (Drug Related Problem) in the form of
improper drug addition was the used of levofloxacin, which was not appropriate dosage
regimens in used dumozol (drug dose too low), drug interactions (levofloxacin and
ketorolac; ceftriaxon and furosemide).
REFERENCES
1. Anonim. 2005. Stocley’s Drug Interactions. The Pharmaceutical Press.
3. Bertram G.Katzung, 2012. Farmakologi Dasar dan Klinik, Edisi 10. Buku Kedokteran.
EGC.
4. BNF 61, 2011. British National Formulary 61 March 2011
5. Drs. Priyanto, Apt. M.Biomed, 2008. Farmakoterapi dan Terminologi medis. Lembaga
Studi dan Konsultasi farmakologis.
6. Sudoyo A, et al. 2006. Buku Ajar Ilmu Penyakit Dalam.Jakarta : FKUI.
7. Tjay, Tan Hoan dan Rahardja Kirana, 2007, Obat-obat Penting Edisi VI, Jakarta
1481
DRUG RELATED PROBLEM ASSOCIATED WITH THE
TREATMENT FOR HYPERCOAGULATE IN PGI CIKINI
HOSPITAL
Inggri Anjarsari1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
Hypercoagulation disorders (or hypercoagulable states or disorders) have the opposite
effect of the more common coagulation disorders. This disorder can cause clots throughout
the body's blood vessels, sometimes creating a condition known as thrombosis. Thrombosis
can lead to infarction, or death of tissue, as a result of blocked blood supply to the tissue.
However, hypercoagulability does not always lead to thrombosis. Patient Ms. TP, 25 years
old, present with pain and swelling in the left leg and right. Patients was diagnosed with
hypercoagulate. Diagnosis was based on the doctor's examination and laboratory values.
Patient has been treated with Neurobion 5000, Folic Acid, Lovenox (Enoxaparin), and
Simarc (Warfarin). Based on the result of the clinic secretariat at the ward K in PGI Cikini
Hospital, it could be concluded that there was DRPs (Drug Related Problems). However, it
can be concluded that the therapy and treatment of patients was right, but there are some
things that should be evaluated. The using of folic acid and simarc simultaneously give
antagonists effect toward anticoagulant effect of simarc.
Keyword: Hypercoagulate, Anticoagulants, RS PGI Cikini
1.INTRODUCTION
Hypercoagulation disorders (or hypercoagulable states or disorders) have the
opposite effect of the more common coagulation disorders. In hypercoagulation, there is an
increased tendency for clotting of the blood, which may put a patient at risk for obstruction
of veins and arteries (phlebitis or pulmonary embolism). (1)
This disorder can cause clots throughout the body's blood vessels, sometimes
creating a condition known as thrombosis. Thrombosis can lead to infarction, or death of
tissue, as a result of blocked blood supply to the tissue. However, hypercoagulability does
1482
not always lead to thrombosis. In pregnancy, and other hypercoagulable states, the
incidence of thrombosis is higher than the general population, but is still under 10%.
However, in association with certain genetic disorders, hypercoagulation disorders may be
more likely to lead to thrombosis. Hypercoagulation disorders may also be known as
hyperhomocystinemia (1).
The diagnosis of hypercoagulation disorders is completed with a combination of
physical examination, medical history, and blood tests. An accurate medical history is
important to determine possible symptoms and causes of hypercoagulation disorders. There
are a number of blood tests that can determine the presence or absence of proteins, clotting
factors, and platelet counts in the blood. Among the tests used to detect hypercoagulation is
the Antithrombin III assay. Protein C and Protein S concentrations can be diagnosed with
immunoassay or plasma antigen level tests.
Many factors can lead to excessive blood clotting, causing limited or blocked blood
flow and can be life-threatening. Signs and symptoms of excessive blood clotting depend
on where the clots form. A blood clot in the heart or lungs could include symptoms such as
chest pain, shortness of breath, and upper body discomfort in the arms, back, neck, or jaw,
suggesting a heart attack or pulmonary embolism (PE). A blood clot in the brain could
cause headaches, speech changes, paralysis (an inability to move), dizziness, and trouble
speaking or understanding speech, suggesting a possible stroke. A blood clot in the deep
veins of the leg may create symptoms such as pain, redness, warmth, and swelling in the
lower leg, and could suggest deep vein thrombosis (DVT) or peripheral artery disease
(PAD)(2).
2.METHODOLOGY
dosage and mode of administration and rationalization of using of the drug (the right dose,
the right indication, the right patient, the right of use) by seeing the Drug Related Problems
of drugs based on the literature.
1483
3.CASE PRESENTATION
Patient Ms. TP, 25 years old, was hospitalized in PGI Cikini Hospital on 5 month
ago, patient suffered pain and swelling in the left leg and had no history of previous illness.
Patients was diagnosed hypercoagulate.
Patient has been treated with folic acid to overcome the deficiency of folic acid
and Neurobion 5000 has an adjunctive therapy. Lovenox (Enoxaparin) was used as an
anticoagulant and prevention of thrombus on extracorporeal circulation and venous
thrombosis. Simarc (Warfarin) was used as prophylaxis and treatment of venous
thrombosis and pulmonary embolism, prophylaxis of embolization in rheumatic heart
disease and atrial fibrillation (3).
5.RESULTS AND DISCUSSION
Based on the results of hematology laboratory tests on the first day, the result was
abnormal. Erythrocyte sedimentation (ESR) value was increased ( 55 mm / h (0-20 mm /
h), leukocytes 11.6 3μL 10 ^ (10 ^ 5-10 3μL), APTT 38.4 seconds (26.4 - 37.5 seconds),
Fibrinogen 351 mg / dL (180-350 mg / dL), d-dimer 6200 μ / L (0-500 μ / L).
The aPTT is one of the coagulation parameter. Monitoring was done through
laboratory testing, the timing of the APTT was the most widely technique used(3).
The next day, the value of aPTT still high ( 41.6 seconds), and in the 2 days later,
the value of aPTT was decreased to 38.5 seconds, although it is still high. Examination the
following day showed the aPTT value is very high (108.9 seconds). Examinations
performed again 4 days later , aPTT values decreased to 38.9 seconds and then decreased
again reach to normal level (36.5 seconds) on the next day. Severe blood pressure of
patients on the first day, ie 125/70 mmHg. Two days later fell to 120/80 mmHg and be
110/90 mmHg a day later.
Patient has been treated with 4 types of drugs , that were Neurobion 5000, folic
acid, Lovenox (enoxaparin) and Simarc (Warfarin).
1484
Neurobion 5000 was given for 10 days with a dose of 1 x 1 tablet and folic acid
with a dose of 1 x 2 tablets. Folic acid was used to threat folic acid deficiency and delivery
Neurobion 5000 as an adjunctive therapy for vitamin deficiency (3).
Patient received Lovenox injection at the dose of 1 x 1 ampoule (0.6 ml) on the
fifth day for 2 consecutive days, due to a very high value of aPTT value. Lovenox was used
as an anticoagulant and prevention of thrombus on extracorporeal circulation and
thrombosis vena(3).
After the value
of APTT was decreased, patient
continued
with oral
anticoagulants (simarc /Warfarin), with a dose of 1 x 2 tablets (5mg) (3).
In these case was found 2 DRP (Drug Related Problem), those are :
Based on Ms. TP laboratory test on the first day, the value of leukocytes was high but
the patient did not get antibiotic. The patient should give antibiotic to decreased the
value of leukocytes.
2. Drug interaction
Using of folic acid and simarc
simultaneously give antagonists effect toward
anticoagulant effect of simarc.
6.CONCLUSION
Based on the results of the clinical examination of patients was found the presence
of DRPs. Those are untreated indication which required additional medication with
antibiotics and drug interactions that occur between simarc (Warfarin) and folic acid.
7.SUGGESTION
1. Should be given the addition of treatment with appropriate antibiotics.
2. Should be setting the time interval between the administration of simarc and folic acid.
1485
8.REFERENCES
1. Prasanto H. 2007. Hypercoagulation Chronic Kidney Disease in. Complete manuscript.
The 7th Jakarta Nephrology & Hypertension Course. PERNEFRI
2.Perdana, Rizky.2011. Fenomena Sindroma Kekentalan Darah (Sindroma Hughes).
Retrieved
April
20,
2014,
from
http://kesehatan.kompasiana.com/medis/2011/04/30/fenomena-sindroma-kekentalandarah-sindroma-hughes-359283.html
3. POM RI. 2008. Informatorium Obat Nasional Indonesia. Jakarta
4.Saragi, Sahat. 2012. Panduan Penggunaan Obat Dilengkapi
dengan Konsep
Pharmaceutical Care, Teori Konseling Obat, Teori Kepatuhan Minum Obat. Publisher
Rosemata Publisher. Jakarta
5. Stockley, I.H. (2008). Stockley's Drug Interaction. The eighth edition. Great Britain:
1486
FOR TUBERCULOSIS (TBC) PATIENT IN PERSAHABATAN
HOSPITAL
Irawati 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
Tuberculosis (TBC) is a spreading disease in many cases that can cause death that
influenced by Mycobacterium tuberculosis. Classic symptom of active Tuberculosis
infection that is chronic cough with red spotted sputum or phlegn, fever, sweat in night and
body weight are lessen (Ahmad, 2011).
Patient Tn. Ry, age 56 years old, had treatment in RSUP Persahabatan on June 28, 2014
with diagnose of acid resistant bacillus lung TB (negative), CAP and dyspepsia syndrome
.Medical therapy during treatment, they are oxygen, NaCl 0,9%, syrup inpepsa ,
omeprazole, ceftriaxone and OAT 4FDC. According to the practice result of the clinical
secretariat in lung disease emergency housing at RSUP Persahabatan so we can conclude
that with DRP (Drug Related Problem) such as the use of the omeprazole with the inpepsa
that can reduce the omeprazole effect.The omeprazole and rifampisin can reduce the
omeprazole effect. The use of antituberculosa medicine can cause hepatotoksik. The
medicine dosage is too low by using inpepsa and patients’ failure in accepting medicine.
Key words
: Lung TB, Soka room above I and RSUP Persahabatan
I.INTRODUCTION
Tuberculosis (TBC) is a spreading disease in many cases that can cause death that
influenced by Mycobacterium tuberculosis. Classic symptom of the active Tuberculosis
infection that is chronic coughing with red spotted sputum or phlegn, fever, sweating at
night and the body weight are lessen (Ahmad, 2011).
Most Mycobacterium tuberculosis will attack a lung organ. sufferers of the lung
tuberculosis, category I is lung TB which is classified as a new case sufferer with the
1487
examination result of the direct dying phlegm BTA positive or BTA negative (Muchid,
2005).
Reducing a risk infected by TB can be done by taking care the body health and their
environment, for instance putting in order a house so it gets enough sunbeam that can have
the bactery is fast to die by direct sunbeam. Consuming nutrient food, not spitting,
sneezeing and coughing anywhere, some things that need to be known by TB sufferers.
consits of :
1. Consuming the medicine in long enough time (6-9 months)
2. Obediency in consuming the medicine is very influenced to recovery process.
3. Therapy is influenced by a good nutrient, especially a ptotein.
4. Environment problem of the sufferers’ health dwelling and health life habit (Ahmad,
2011).
2.CASE PERCENTATION
Mr. Ry 56 years old took treatment in RSUP Persahabatan on 28 June 2014. The
patient had treatment there because of tight breath that be felt since one month ago, his
tight breath come and vanish but it was not influenced by weather and activity.
3.CLINIC EVALUATION
In this case, the patient is given therapy with oxygen, NaCL, ceftriaxone, inpepsa,
omeprazole and Rimstar 4FDC (Rifampisin 150 mg, INH 75 mg, Pirazinamid 400 mg,
Etambutol 275 mg). The result of laboratory examination for Tn. Ry on July 2, 2014 that
points an abnormality to the leukocyte value namely 13,49 thousand/mm3 (5-10
thousand/mm3), retrofit 83,1% (50-70%), limfosit 7,1% (25-40%), monosit 10,5% (2-8%),
eosinofil 1,8% (2-4%). The abnormality of the examination result refers to that patient has
had infection. The abnormality of the value PO2 133,6 mmHg (35-45 mmHg), saturasi O2
98,8% (96-97%) so the patient had tight breath.
The examination result of
sputum to Tn. Ry on 30 June 2014 result BTA I
(negative), on July 1, 2014 BTA II (negative), and BTA III (negative). To this examination
result points to that the patient had TB lung BTA negative.
1488
4.DOSAGE AND DIRECTIONS
Dosage and medicine direction to this patient, that is the oxygen to solve patient’s
tight breath, NaCl 0,9% 500cc that given through intravenously to subtitute the body
liquid, normal dosage NaCl 500cc until 1000cc. Ceftriaxon 1 times 2 g, that given through
intravenously to solve the bactery infection, with normal dosage 1 until 2 g/day. Syrup
Inpepsa 3 times 1 spoon that given orally to overcome the side irritation with normal
dosage 4 g/day in 2 until 4 divided dosage. Omeprazole 2 times 20 mg that given through
intravenously to the treatment of patient’s dyspepsia , with normal dosage 20 until 40 mg.
Rimstar 4FDC (Rifampisin 150 mg, INH 75 mg, Pirazinamid 400 mg, Etambutol 275 mg)
1 times 3 tablet that given orally to the treatment of Tuberculosis, with normal dosage
Rimstar 4FDC body weight 38 until 54 kg 3 tablet/day (IONI, 2008).
1.
Dose too low
Medicine dosage which is too low that is to the inpepsa rescipe 3 x C 1 / day.
According to Dr. Aine (Renal Drug Handbook, 2009), should be given 4 gr/ day in 2-4
divided. It is suggested for the doctor to reevaluate the therapy dosage by using the
inpepsa. Monitoring clinical symptom such as painful, queasy, and vomit.
2.
receiving medicine
The patient is failure accepting the medicine namely does not accept an omeprazole
injection. at 06.00 and 18.00 on June 30, 2014 and July 1, 2014, also at 06.00 on July
3, 2014. Asking the nurse and doing checklist of the nurse’s note periodically.
3.
Drugs interaction
a. Omeprazole and inpepsa can reduce omeprazole effect, so it is suggested to give
omeprazole for 30 minutes before inpepsa medicine (IONI, 2009).
b. Omeprazole and rifampisin can reduce omeprazole effect which can induct enzyme
to metabolisme stages so it is suggested to ask or observe the health improvement
that felt by the patient (queasy and vomit) and monitoring the therapy effectiveness
by observing patient’s condition (IONI, 2009).
1489
4.
Reaction of unexpected medicine
a. Using the INH medicine can cause neurotic periphery. So it is suggested to give
Vitamin B6
b. Using the antituberculosis medicine can cause hepatotoksik, so it is necessary to do
monitoring hepatotoksik for the sufferer by checking lab SGPT and SGOT
6.CONCLUSION
According to the practice result of the clinical secretariat to the lung disease house
at RSUP Persahabatan, so we can conclude that with DRP (Drug Related Problem) like the
use omeprazole with inpepsa can reduce the omeprazole effect. The omeprazole and
rifampisin can reduce the omeprazole effect. using the anti-tuberculosis medicine can cause
hepatotoksik. The medicine dosage that too low to the using of the inpepsa and patient’s
failure in accepting the medicine (BNF, 2011)
7. REFERENCES
2. Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford
3. Elin Yulinah, 2011, ISO Farmakoterapi 2, Penerbit: Ikatan Apoteker Indonesia, Jakarta
Gleadle, J. 2007. At A Glance Anamnesis. Jakarta : Erlangga.
5. Tjay, Tan Hoan dan Rahardja Kirana, 2007, Obat-obat Penting Edisi VI, Jakarta.
7. Ahmad, N. 2011, Tuberculosis Handbook For School Nurses. Global Tuberkulosis
Institute accessed on June 5, 2014. Page 7
1490
FOR CONGESTIVE HEART FAILURE PATIENT IN
MINTOHARDJO HOSPITAL
Monalisa Karinda 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Congestive heart failure is a disorder of the heart's function so it is not able to pump
blood in sufficient amounts to meet the perfusion network. The edema fluid and cause
increased body burden. Fluid accumulation in the lungs causing shortness of breath,
especially during exercise or training when fluid accumulation in the liver and intestine
causing nausea, stomach pain, and decreased appetite. Patient entered RSAL
Dr.Mintohardjo with congestive heart failure diagnosis. Based on the diagnosis, the patient
is treated with some medication Lasix (diuretic), ISDN, valsartan (ARB), nitrokaf (glyceryl
trinitrate), Aldactone (spironolactone), KSR, injection of Lantus (insulin glargine-long
acting), novorapid injection (insulin aspart-short-acting), simvastatin, glucodex
(sulfonylureas), eclid (acarbose), ranitidine and clopidogrel (antiplatelet). In these patients
found the presence of some of Drug Related Problems (DRPs) that is an indication that is
not handled, incorrect drug selection, failed to receive the drug, and drug interactions.
Keyword : Congestive heart failure, RSAL Dr.Mintohardjo
I. INTRODUCTION
Heart failure is the inability of the heart to pump blood strongly to maintain blood
circulation (Prince, 2006). Heart failure is a condition in the form of severe renal
patofisiologis heart so that the heart can not pump blood to meet the metabolic network and
or ability only if accompanied by an abnormal elevation of the diastolic volume (Robin &
Contran, 2009). Congestive heart failure is congestive circulation due to myocardial
dysfunction. Place a congestion depend on ventricular involved. Cause of left ventricular
dysfunction in pulmonary venous congestion, whereas right ventricular dysfunction
resulting in systemic venous congestion (Abdul, 2007).
1491
Symptoms felt by the patient varies from asymptomatic to cardiogenic shock. The
main symptom is shortness of breath which arise (especially when working) and fatigue
that can cause intolerance to physical activity. Other pulmonary symptoms including
orthopnea, parezysmal nocturnal dyspnea, tachypnea and cough. The high production of
fluid causing pulmonary congestion and peripheral edema (Mansjoer, 1999).
Causes of heart failure can be classified into six main categories:
a)
Failure associated with myocardial abnormalities, can be caused by loss of myocytes
(myocardial infarction), uncoordinated contractions (left bundle branch block) reduced
contractility (cardiomyopathy).
b) Failure associated with overload (hypertension)
c)
Failure of valve abnormalities associated with
d) Failure caused by abnormal heart rhythm (tachycardia)
e)
Failure caused pericardial abnormalities or pericardial effusion (tamponade).
f)
Congenital abnormalities of the heart (Sitompul, 2003).
80 year old female patient entered RSAL Dr.Mintohardjo diagnosed with
congestive heart failure shortness since 2 days before hospital admission. Patients initially
wanted the funeral to neighbors and then felt tightness accompanied pounding and pain
radiating from the chest to the left shoulder. Tightness is felt more pronounced when
exhaling and chest pain feels like crushed. Tightness often arise when patients do light
activity. Based on the classification of New York Heart Association (NYHA) heart failure
patients in NYHA classification 3 (symptomatic with little activity) and classification
according to the AHA / ACC guidelines, the patients included in stage C (is/are ongoing
with structural abnormalities LVD). Determination of classification are based on laboratory
results conducted on the 11th of February 2014. Patient radiological examination and
getting the heart of the left ventricular heart (LVH). In addition it can be seen also from the
symptoms experienced by the patient is already congested and pain radiating to the left
shoulder.
1492
Based on these results, the patient was given some medication. Treatment given to
patients is Lasix, isosorbit dinitrate, valsartan (angiotensin receptor blockers), nitrokaf
(glyceryl trinitrate), Aldactone, KSR, injection of Lantus (insulin glargine - long acting),
novorapid injection (insulin aspart - fast acting), simvastatin (statins), glucodex
(sulfonylureas), eclid (acarbose), ranitidine and clopidogrel (antiplatelet).
Lasix injection is indicated to resolve edema and stimulate the excretion of sodium
chloride, ranitidine injection to reduce gastric acid secretion. Valsartan is indicated as an
alternative to ACEI to prevent coughs and as an adjunct therapy to prevent
vasoconstriction. Nitrokaf and ISDN as a coronary vasodilator to widen the heart arteries,
improving blood and oxygen intake and thus ease the burden of heart. Aldactone is
indicated for reducing edema, regulate salt and water balance in the body and to prevent
hypokalemia. KSR is indicated to prevent hypokalemia. Lantus Injection as diabetes
mellitus requiring insulin therapy. Novorapid Injection is indicated for the treatment of DM
1 and DM 2. Clopidogrel to inhibit clot formation in the blood vessels so as to prevent a
heart attack. Simvastatin to lower total cholesterol and LDL. Glucodex indicated for the
treatment of diabetes mellitus in adults and in combination with a biguanide. Eclid
indicated for combination therapy with diet DM (Thay.T, 2003).
4. DOSAGE AND USAGE
Lasix injection dose IV 2x1, 2x1 IV ranitidine injection, 160 mg of valsartan tablets
1x1, 2x1 nitrokaf tablets 5 mg, 5 mg tablets ISDN 1x1, 1x1 Aldactone 25 mg tablets,
tablets KSR 1x1, 1x1 Lantus injection, injection novorapid 3x1, clopidogrel tablets 75 1x1
mg, simvastatin 20 mg 1x1, glucodex 1x1, 2x1 eclid 100 mg tablets, ranitidine tablets 2x1,
and 2x1 tablets lasix.
1493
5. LABORATORY RESULTS
Based on the laboratory results the first day, the patient developed hyperglycemia
with glucose levels when 472 mg / dl, hypokalemia with K + concentration of 2.6 mmol / l,
and increased levels of leukocytes 10,300. On the second day of the thorax examination,
patients had LVH (left ventricular heart) which indicated patients had congestive heart
failure and results of fasting glucose 395 mg / dl which indicates hyperglycemia. On the
third day the results of laboratory tests, patients experiencing hyperglycemia with fasting
glucose levels of 208 mg / dl, increased cholesterol is 237 mg / dl, and LDL is 156 mg / dl.
6. DISCUSSION
80 year old female patient entered RSAL Mintohardjo diagnosed with congestive
heart failure shortness since 2 days before admission. Patients present with shortness
accompanied pounding and pain radiating from the chest to the left shoulder. Tightness is
felt more pronounced when exhaling and chest pain feels like crushed. Patients often feel
tightness appears in light activity.
The patient has a past history of diabetes mellitus and hypertension are. On the first
day the patients were also examined glucose levels and outcome of patients experiencing
hyperglycemia. But on the first day there is no treatment for hyperglycemia patients cope.
Grant of diuretics in patients to drive NaCl excretion and water until the load is
reduced and symptoms of upper lung retention and reduced systemic retention. Diuretics
also decrease left ventricular volume and wall tension to decreased peripheral resistance.
Grant ranitidin in patients to prevent side effects from nitrokaf GI tract that is causing
interference. While providing ISDN and nitrokaf as a vasodilator to prevent fluid retention
in vasokinstriksi and suffered heart failure patients. Grant Aldactone and lasix in patients
should have been enough to prevent hiperkalemia, for it needs reviewing the use of KSR.
Grant injection lasix, lasix tablets and ISDN with nitrokaf simultaneously increase the side
effects of these medicines. For that needs reviewing the use of these medications is not to
be together.
1494
In general there is clinical improvement of patients with the provision of therapy as
already discussed above. Still there are some Drug Related Problems to be solved by
clinical pharmacists and other health workers.
Drug Related Problems are part of the pharmaceutical care process that describes a
situation, where a professional (pharmacist) assess treatment mismatch in achieving real
therapy (Hepler, 2003).
1) Indications untreated (Untreated Indication) : Found
Patients experiencing hyperglycemia on the first day of admission but not handled.
2) The choice of drug is less precise (Improper Drug Selection): Found.
Giving tablets KSR less precise because it has given Aldactone to prevent
hypokalemia.
There is duplication among injection drug lasix and lasix tablets, and ISDN with
nitrokaf. Administration of 2 drugs with the same group can increase the side effects
of the drug.
3) The use of the drug without indication (Drug Use Without Indication): Not found
4) Dose too small (Sub-Therapeutic Dosage): Not found
5) The dose is too large (Over Dosage): Not found
6) Failed to receive medication (Failure to Receive Medication): Patients not given
Lantus injection and injection novorapid on the first day, whereas patients
experiencing hyperglycemia.
7) Drug Interactions (Drug Interactions): The presence of multiple interactions.
Aldactone - Lasix: Lasix Aldactone boost potassium while lowering potassium.
Simvastatin - Valsartan: Simvastatin enhances the effect of valsartan.
Valsartan - Aldactone: Aldactone Valsartan and increase serum potassium
Valsartan - Lasix: Lasix Valsartan improves and lowers serum potassium
1495
8. CONCLUSIONS
There are 5 Drug Related Problems (DRP) that occurred in these patients. First
indications that are not addressed but that is experiencing hyperglycemia is not addressed.
Second, the less accurate drug administration namely KSR. Third, failure to receive
medication that is not given the injection and injection lantus novorapid on the first day.
Fourth, the case of drug interactions between Aldactone - lasix, simvastatin - valsartan,
valsartan - Aldactone, and valsartan - lasix. Fifth, there is some duplication of medication
that is lasix tablets lasix injection and ISDN with nitrokaf.
9.REFERENCES
1. Abdul Majid. , 2007. Coronary Heart Disease: pathophysiology, prevention and
treatment current. Jakarta.
2. Hepler CD, Segal R. 2003. Preventing Medication Errors and Improving Drug Therapy
Outcomes Through Systems Management. Boca Raton, FL: CRC Pres.
3. Mansjoer Arif, et al. , 1999. Capita Selecta Medicine. Jakarta. Media Aesculapius.
Faculty of medicine
4. Prince, Sylvia A. 2006. Pathophysiology Volume 2 Issue 6. Jakarta: EGC
5. Robin & Contran. , 2009. Basis for Disease Pathology. Issue 3. Jakarta. EGC
6. Sitompul, Banta., Sugeng, JI. , 2003. Failing Heart. In: Textbook of Cardiology. Editor:
Rilanto, LI et al. New York: FK UI.
7. Thay, T., and Rahardja, K. 2002. Important medications. The fifth edition. Second
printing. PT. Elex Media Komputindo.Jakarta
1496
FOR ATELECTATION AND PNEUMONIA PATIENT IN
PERSAHABATAN HOSPITAL
Maria Angelina Uto1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
Atelectation is a wrinkle a part or whole of lung caused bronchi blockage (bronkus or
bronkiolus) or caused inhalation too shallow. The main reason of electation is blockage a
bronchi. Bronchi is two main branches from trachea to lungs. If bronchi is blockage, the air
in alveoli will be reserved in blood current so alveoli will be narrow minded and solid.lungs
net which wrinkle usually filled by blood cell, serum, mucus and then will cause infection
(Arimbi, 2012). whereas Pneumonia is lung infection caused by microorganism (baktery,
virus, fungus, parasite). Infection risk in lung is very influenced to microorganism that can
deprave bronchi epitel surface (Misnadiarly, 2008). Patient Mr. HT, age 42 years old,
entered RSUP Persahabatan on 30 June 2014 with atelectation diagnose and pneumonia.
Treatment teraphy during nursed namely IVFD NaCl 0,9%, Neurobian inj, flukonazole tab,
N-Acetylsistein cap, ventolin nebulizer, meropenem inj, and levofloxacin. According to
practical result of clinical secretar at lung desease shed in RSUP Persahabatan so we can
conclude that there is DRP (Drug Related Problem) such as indication without medicine,
medicine dosage too high and medicine interaction.
Key Words
: Atelectation and Pneumonia, lung desease, Persahabatan Hospital
I.INTRODUCTION
Atelectation is a wrinkle a part or whole of lung caused bronchi blockage (bronchus
or bronchiolus) or caused inhalation too shallow. The main reason of electation is blockage
a bronchi. Bronchi is two main branches from trachea to lungs. If bronchi is blockage, the
air in alveoli will be reserved in blood current so alveoli will be narrow minded and
solid.lungs net which wrinkle usually filled by blood cell, serum, mucus and then will cause
infection. Atelectation consits of nature atelectation, obstruction, compression, syndrome
1497
atelectation lobus medialis, acceleration atelectation, microatelectation spread or localised
(Arimbi, 2012).
Atelectation can be happen gradually and only cause light breath tight. The
symptom can be respiration deragement, thorax pain, cough if along with infection can
happen fever and heart throb improvement sometimes until happen shock (low blood
pressure) . clinical symptom is very variety, depend on motive and atelectation scope in
general atelectation that happens to tuberculosis desease, limfoma, neoplasma, asthma, dan
desease that caused by infection for instance bronchitis seldom appears clearly clinical
symptom except there is obstruction on main bronchi (Arimbi, 2012).
Pneumonia is cold cough
along with breath tight or fast breath caused by
microornanism (bactery, virus, vungus and parasite). Infection risk in lung is very
influenced by microorganism ability to deprave bronchi epitel surface. Pneumonia is
inflamation desease to marked lung with consolidation because of excudate that enter in
alveoli area (Misnadiarly, 2008). Pneumonia is one of acute bronchi infection desease
(ISPA) that refer to lung part. Exchange oxygen and carbondioxide happen to blood
inconfection capilaries in alveoli. To pneumonia sufferer, suppuration (pus) and liquid will
fill the alveoli so happen difficulty oxygen pe. This case cause is difficult to breathe
(Departemen Kesehatan RI, 2009).
Then general symptom pneumonia deseases are cough, tachypnea, ekpektorasi
sputum, nostril breathing, shortness of breath, moaning and cyanosis. Marks of pneumonia
is retraction or drawing
deep beneath chest wall when breathing along with breath
frequency increasing, breath voice is low (Misnadiarly, 2008).
2.CASE PERSENTATION
Patient Mr. HT 42 years old entered RSUP Persahabatan on 30 June 2014. The
patient came with breath tight complaining during 2 weeks, weigh down by activating and
weak body before entering the hospital, cough and always sweat in night, feverish since 1
week, body weight is decreased 16 kg in lately 3 years. In 2011 untill 2012 patients come to
the clinic because of long cough and diagnose TB is cured with OAT for 9 months and
stated well.
1498
3.CLINIC EVALUATION
In this case the patient was treated with levofloxacin dan ventolin, neurobion, Nacetylsistein, meropenem and fluconazole. Result of laboratory examination Tn. HT on 30
June 2014 that refered to abnormality on leukosit value namely 30,84 thousand/mm3 (5-10
thousand/mm3), eritrosit; 3,94 million – 6,2 million/mm3.. Abnormality on result of this
examination, refered to that the patient have infenction. Abnormality on value PO2 81,8
mmHg (35-45 mmHg), saturation O2 96,3 (96-97%) so the patient is breath tight.
The examination result of sputum on 02 June 2014 the result of BTA I (negative),
on 03 june 2014 BTA II (negative), and BTA III (negative). The result examination,
refered to that the patient didn’t have new TB.
4.DOSAGE AND USING THE DRUG
Dosage and direction using medicine to the patient namely oxygen to solve the
patient’s breath tight, NaCl 0,9% infusion dan injection Neurobion given
intravenously to
subtitute body liquid, normal dosage NaCl dan Neurobion according to the patiens
condition, ventolin nebulizer is to solve the patien’s breath tight with normal dosage, per
day 2,5-5 mg maximum 6 hours per day, injection meropenam 3 times 1 gram given
intravenously to pneumonia therapy, with dosage meropenem 1000 mg each 8 hours/day.
N-acetylcystein 3 times 200 mg given orally as mukolitik and antioxidant, dengan normal
dosage N-acetylcystein 200 mg, 2 until 3 times per day per oral (IONI, 2008), flukonazole
given orally to therapy fungus to the patient with single dosage given per day one time
(ISO, 2013), injection Levofloxacin 1 x 1 per day to cure infection (IONI, 2008).
1. Failure receiving medicine
The patient is failure receive ventolin nebulizer at 06.00 and at 18.00 on 01 July 2014,
at 06.00 and at 12.00 on 02 July 2014, at 06.00 on
03 July 2014
not receive
fluconazole. Also medicine N-acetylcystein during treatment is not given. Pharmacist’s
suggestion is asking the nurse and doing checklist of the nurse’s note periodically.
1499
2. Drug interaction
a) Drug interaction between fluconazole and Ventolin nebulizer, where gift together
can cause
hypokalemia.therfore it is necessary done
potassium control by
laboratory examination periodically for the potassium (IONI, 2009).
b) Giving together fluconazole and levofloxasin can cause arrhythmias (DIF, 2006).
3. Improper Drug selection
The using of injection meropenem less accurate to the patient because there is no
treatment sensitive test for culture. Using Meropenam without be done culture can
cause medicine resistance.
3. Otther
On the book list of nursing sometimes the nurse doesn’t note the medicines that have
given to the patient. So suggested to the nurse to always note what have been given to
the patient. Monitoring the nurse’s note to book list of nursing.
6.CONCLUSION
According to practical result of secreteriat at lung desease shed at Persahabatan
hospital it can be conclude that there is DRP (Drug Related Problem). The DRPs are the
patient is failure receiving medicine drug interaction (DIF, 2006).
7. REFERENCES
2. Arimbi, 2012. Ilmu Penyakit Dalam, Jakarta : FK UWKS. Hal 2
3. Elin Yulinah, 2011, ISO Farmakoterapi 2, Penerbit: Ikatan Apoteker Indonesia,
Jakarta Gleadle, J. 2007. At A Glance Anamnesis. Jakarta : Erlangga. Hal 2
4. Tatro David, 2006. Drug Interaction FactTM, Amerika : Fact & Comparisons, hal
185.
5. Misnadiarly, 2008.
Penyakit Infeksi Saluran Napas Pneumonia. Pustaka Obor
Populer : Jakarta
6. Departemen Kesehatan RI, Dirjen P2PL, 2009, Pedoman Pengendalian Penyakit
Infeksi Saluran Persnapasan Akut, Jakarta.
1500
DISEASE TYPE II DIABETES MELLITUS (DM) AND
HYPERTENSION IN GENERAL HOSPITAL CENTER
PERSAHABATAN JAKARTA
Martina1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
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 decreased insulin sensitivity, or both and cause chronic
microvascular complications, macrovascular, and neuropathic (David, 2012 ). Hypertension
is an increase in blood pressure at a certain level, and gradually to three times during the
three weeks of intermittent measurements that can cause damage to the body. Increased
blood pressure, diastolic blood pressure which settled above 90 mmHg or systolic pressure
above 140 mmHg settled (Nugroho A, 2012). Ms. DY patient, aged 59 years old, entered
the department of Persahabatan on May 20, 2014 with the diagnosed: Type II diabetes,
hypertension, dyspepsia, hypoglycemia and hypokalemia. Therapy for the treatment of
hospitalized ie Ranitin, Domperidone, Sucralfate, Captopril, amlodipine, KSR, Simvastatin.
In this case found the existence of Drug Related Problems (DRP) is the interaction between
captopril and potassium chloride (KSR), which Captopril may increase levels of potassium
chloride to lower the elimination process, the risk of hyperkalemia. And the interaction
between Inpepsa (Sucralfate) and Ranitidine, which Inpepsa can reduce absorption or
bioavailability of Ranitidine so the drug should be administered within 2 hours before
giving Inpepsa (stoclie.com).
Keywords: Dm Type II, mild hypertension, Persahabatan Hospital
INTRODUCTION
Diabetes Mellitus (DM) is defined as an illness or a chronic metabolic disorder with
multiple etiologies was characterized by high blood sugar levels was accompanied by
impaired metabolism of carbohydrates, lipids, and proteins as a result of function
1501
insufficiency of insulin by the beta cells of Langerhans of the pancreas gland, or due to lack
of responsiveness of cells to insulin (Nugrohu A, 2012).
Diabetes mellitus or diabetes is a chronic metabolic disease characterized by
hyperglycemia resulting from absolute deficiency of insulin or the insulin resistance at the
receptor. The symptoms of diabetes mellitus are Glukosaria, 3P (Polyuria, polydipsia, and
polyphagia), weight loss, wounds difficult to heal, tingling / insensitive, lethargic, weak,
and ketoacidosis (Nugroho A, 2012).
High blood pressure or hypertension is a chronic condition in which the systemic
arterial blood pressure increases beyond the normal threshold. Blood pressure is considered
good blood pressure during diastole and diastole conditions. Normal blood pressure ranges
from 60-80 mmHg for diastolic dan for systolic 90-120 mmHg. Patient with hypertension if
their blood pressure said to be 90 mmHg for diastolic, and 140 for systolic. While the range
of 80-90 mmHg in diastole, and 120-140 on the said condition prehypertension systole. In
this prehypertension condition although it has not yet hypertensive patient should start
therapy especially therapeutic pharmacological therapy, and prevent activities that may
increase blood pressure (Nugroho A, 2012).
According to Nugroho A 2012 Hypertension is an increase in blood pressure, diastolic
blood pressure which settled above 90 mmHg or systolic pressure above 140 mmHg
settled. Where hypertension is composed of two types, namely:
1. Primary hypertension (essential): where more than 95% of patient with hypertension
is essential hypertension is influenced by genetic factors, hemostatic sodium (increased
salinity) and race (black and white).
2. Secondary hypertension: less than 10% of patient with hypertension is secondary to
comorbid disease or certain drugs that may increase blood pressure. In most cases of renal
dysfunction due to chronic kidney disease, endocrine system disorders: Cushing's
syndrome, Pheochromocytoma syndrome, vascular causes: koarktasi aorta and thyroid or
parathyroid disease.
1502
CASE PRESENTATION
Patient Ms. AT, aged 59 years old entered Persahabatan Hospital on May 20, 2014. Patient
present with loss of consciousness, nausea already 1 week, so that the patient no appetite
for eating and bowel movements are not smooth.
CLINICAL EVALUATION
In this case the patient receives treatment Ranitidine, treatment for gastric irritation
overcome, Domperidone for nausea vomiting, Sucralfate was used to coat the gastric
mucosa, Captopril for hypertension mild to moderate and severe hypertension that resistant
to other treatments: congestive heart failure, diabetic nephropathy in diabetes dependent
insulin, amlodipine to control high blood pressure, KSR to cope with hypokalemia,
Simvastatin for cholesterol overcome.
DOSAGE AND METHODE OF USAGE
On the first day the patient was treated with: 3 Lpm Oxygen Nk (K / P), IVFD RL 0.9 / 500
cc + KCl 25 mg / 8 h, soft diet DM 1700 kcal / day, 2x50 mg Ranitidine (IV),
Domperidone 3x10 mg (PO), Sucralfate syr 4x15 cc (PO), Captopril 2x25 mg (PO), 1x10
mg amlodipine (PO), KSR 2x600 mg (PO). The second day was: 3 Lpm O2 Nk (K / P),
IVFD NaCl 0.9 / 500 cc + kcl 25 mg / 8 h, soft diet DM 1700 kcal / day, 2x50 mg
Ranitidine (IV), Domperidone 3x10 mg (PO ), Inpepsa 3x10 cc (PO), Captopril 2x25 mg
(PO), 1x10 mg amlodipine (PO), KSR 2x600 mg (PO) Novorapid 3x 8 units. On the third
day: 3 Lpm O2 Nk (K / P), IVFD NaCl 0.9 / 500 cc + KCl 25 mg / 8 h, soft diet DM 1700
kcal / day, 2x50 mg Ranitidine (IV), Domperidone 3x10 mg (PO ), Inpepsa 3x10 cc (PO),
Captopril 2x25 mg (PO), 1x10 mg amlodipine (PO), KSR 2x600 mg (PO) Novorapid 3x 8
units (stop), 1x20 mg Simvastatin (PO). On day four, namely: 2x50 mg Ranitidine (IV),
Domperidone 3x10 mg (PO), Inpepsa 3x10 cc (PO), Captopril 2x25 mg (PO), 1x10 mg
(PO), KSR 2x600 mg (PO), 1x20 mg Simvastatin (PO).
1503
LABORATORY DATA
Date/timas
Assesment
Result
Normal
20/5/14/20.15
24.00
21/5/14/06.00
12.00
18.00
22/5/14/06.00
12.00
18.00
23/5/14/06.00
12.00
Glucotest (WBG)
Glucotest (WBG)
Glucotest (WBG)
Glucotest (WBG)
Glucotest (WBG)
Glucotest (WBG)
Glucotest(WBG)
Glucotest (WBG)
Glucotest (WBG)
Glucotest (WBG)
*30
231
133
557*
605*
104
136
142
136
133
Mg/dL 70-150
Mg/dL 70-150
Mg/dL 70-150
Mg/dL 70-150
Mg/dL 70-150
Mg/dL 70-150
Mg/dL 70-150
Mg/dL 70-150
Mg/dL 70-150
Mg/dL 70-150
DISCUSSION
In this case the patient has a history of diabetes mellitus. Patient treated with infusion
of Ringer's lactate as a liquid electrolyte and ranitidine injection, an H2 receptor blocker
antihistamine (AH2). H2 receptor stimulation will stimulate gastric acid secretion (FDA,
2008). In H2 receptor inhibits ranitidine work fast, specific and reversible through
reduction and hydrogen ion concentration of gastric fluid. Metformin is an oral
antidiabetika which lowers blood sugar in diabetics the pancreas is still able to produce
insulin. Amlodipine is a calcium antagonist of the dihydropyridine class that inhibits the
influx (influx) of calcium ions through the membrane into the vascular smooth muscle and
cardiac muscle contraction thereby affecting vascular smooth muscle and cardiac muscle is
used to treat hypertension. Infuks amlodipine inhibits calcium ion selectively, where most
of the have an effect on vascular smooth muscle cells compared to cardiac muscle cells
(ISFI, 2008). Captopril is a class of angiotensin-converting enzyme inhibitors (ACEI) 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 are used in the handling of hypertension, heart
failure, myocardial infarction, patient with diabetic nephropathy and progressive disorder.
This drug is not mempengruhi blood glucose levels so that appropriate when used in
diabetic patient with hypertension (Nugroho A, 2012). Simvastatin is a lipid-lowering drug
1504
class of HMG-CoA Reductase inhibitors. These drugs inhibit the enzyme action of HMGCoA Reductase, an enzyme that catalyzes the conversion of HMG-CoA into mevalonic
acid, determination stage in the synthesis of cholesterol (Nugroho A, 2012). Domperidone
is a dopamine antagonist that works as an antiemetic (Mycek, 2003). Sucralfate works by
protecting the mucosa from acid attack pepsin in gastric and duodenal ulcers after
Markowitz exudates that are complex with proteins such as albumin, and fibrinogen at the
ulcer site (Burns, 2009). KSR is the major cation of intracellular fluid and induce nerve
impulses in the heart, brain, skeletal muscle, and smooth muscle contraction, maintaining
normal kidney function, acid-base balance, carbohydrate metabolism and secretion of
gastrointestinal (GI) (Isniati, 2003). Novorapid (insulin aspart) is the main hormone
preparations quickly working that play a role in energy metabolism and the effect is a
decrease in blood glucose concentration, was administered subcutaneously. In the liver,
insulin inhibits glycogenolysis and glukogneogenesis role, and increase glycogen synthesis
and glucose utilization (glycolysis). Use of this Novorapid is indicated for pengobati DM
Type I and II (Nugroho A, 2012). The results of the examination of blood glucose
abnormalities in these patient is 557 mg / dl (normal 70-150 mg / dL), high LDLcholesterol levels of patient is 145.8 mg / dl (normal <130) which will lead to increase in
LDL levels the risk of ischemic heart disease . The increase in LDL caused due to plaque
vascular intimal thickening or atheroma (Nugroho A, 2012). DRP (Drug Related Problem)
and the interaction that occurs between the sucralfate and ranitidine can reduce the
absorption or bioavailability of ranitidine that these drugs must be given within 2 hours
prior to administration of sucralfate (stoclie).
1. Dose regimen
Drug dose was too low, the prescription ranitidine 2 x 50 mg a day, according to Dr. Aine
Burns (Renal Drug Handbook, 2009), should have 3 x 50 mg daily. Suggested to the doctor
to re-evaluate the use of therapeutic doses of ranitidine. Check list of nurses notes
periodically.
2. Drug interaction
1505
A. Captopril + potassium chloride
Captopril may increase levels of potassium chloride by lowering process of elimination,
with the risk of hyperkalemia
B. Inpepsa (sucralfate) + Ranitidine
Can reduce the absorption or bioavailability of Ranitidine so the drug should be
administered within 2 hours before giving Inpepsa (stoclie.com).
CONCLUSION
Based on the results of their clinical practice in internal medicine wards in Persahabatan
Hospital it can be deduced that the presence of DRPs (Drug Related Problems) improper
dosage regimen in the use of ranitidine (drug dose was too low) and drug interactions
where there is interaction between: Inpepsa (Sucralfate ) + Ranitidine: can reduce or
bioavailibilitas absorption of Ranitidine so the drug must be given within 2 hours before
administration Inpepsa, Captopril + potassium chloride: Captopril may increase levels of
potassium chloride by lowering process of elimination, with the risk of hyperkalemia.
REFERENCES
1.
Burns, Dr. Aine. 2009. Renal Drug Handbook third edition. New York : Oxford
2. Gunawan S. 2012. Farmakologi dan Terapi, Universitas Indonesia Fakultas
Kedokteran Jakarta
3.
Isniati, 2003, Hubungan Tingkat Pengetahuan Penderita Diabetes Militus Dengan
Keterkendalian Gula Darah Di Poliklinik Rs Perjan Dr. M. Djamil Padang Tahun.
Jurnal Kesehatan Masyarakat, September 2007, I (2).
4. Mycek, mary J. dkk. 2003. Farmakologi Ulasan Bergambar edisi 2, Jakarta: Widya
Medika
5. Lumman, H., Mohr, K., Ziegler,A. Bieger, D.,2000, Colour Atlas of Pharmacologi, 2nd
Edition, Thieme, New York.
6. Nugroho, Dr. Agung.2009.Farmakologi Obat-obat Penting dalam Pembelajaran Ilmu
Kefarmasian dan Dunia Kesehatan,Universitas Gadjah Mada Yogyakarta.
1506
DRUG RELATED PROBLEM (DRPs) ASSOSIATED WITH
TREATMENT OF DIABETES MELLITUS TYPE 2 DISEASE AT
Mildawati1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Diabetes mellitus (DM) is a metabolic disorder that is heterogeneous, both genetically and
clinically with symptoms such as lack of ability (tolerance) of carbohydrates (Price A,
2006). The common symptoms of diabetes mellitus are polyuria, polydipsia, polyphagia,
and weight loss is not always seen in patient with DM (Burduli, 2009). Patient Mrs. SR 38
years old, came to Persahabatan hospital on 20 May, 2014 with was diagnosed of diabetes
type 2 with history of hyperglycemia, blood sugar was not controlled, nosocomial
pneumonia, TB secondary infections, hypokalemia, hyponatremia, acute dyspepsia and
hypertension controlled. During the treatment the patient treated with oxygen, NaCl 0.9%,
restricted calorie intake, Ceftriazone, Azitromicin, Domperidone, Suckralfat, Paracetamol,
Ranitidine, KSR, Captopril and Insulin Lantus. Based on the results of clinical practice at
the in of internal medicine ward Persahabatan found any DRP (Drug Related Problems)
there is captopril drug interactions KSR where KSR can increase levels by lowering the
elimination process, causing the risk of hyperkalemia, drug dose is too low, the use of
lantus insulin prescribed 1 x 10 units a day, where the use of 1 x 10 units a day is not
enough to lower the patient's blood glucose levels. Dose is too low,a5 ranitidine 50 mg 2
times a daily, according to (Aine, 2009), should have been 50 mg 3 times a day.
Keywords: Diabetes mellitus type 2 and Persahabatan Hospital
INTRODUCTION
Diabetes mellitus is a disease caused by decreased insulin-a hormone produced by
the pancreas gland. Decrease of hormon to control sugar (glucose) can caused body's
glucose levels will increase. Sugars from polysaccharides, disaccharides, oligosakarida, and
monosakarisda are energy to support activities. All of this will be processed into energy by
the hormone insulin (Utami, 2003).
1507
Diabetes type II is mostly included in this category. Genetic factor is the cause seems
greater than virus or autoimmune antibodies. The observed metabolic changes is lighter
than that described for TYPE (e.g. patients with NIDDM is not of type ketotik), but the
consequences of long-term clinic can also destroy (Mycek, 2001).
The cause of type II Diabetes: The pancreas, NIDDM still had some β-cell function,
which causes insulin levels vary is not enough to maintain the homeostasis of glucose.
Patients with type II of diabetes are often obese. Type II of Diabetes is often associated
with target organ resistance which restrict endogenous and exogenous insulin response. In
some cases, insulin resistance is caused by a decrease in the number of insulin receptors or
mutations. However, defects that are not limited to events occurring after insulin was bound
to receptors, is believed to cause resistance in most sufferers (Mycek, 2001).
CASE PRESENTATION
Mrs. SR38 years old, came to Persahabatan hospital on 20 May 2014. Patient complaint
with a limp one day before came to hospital, almost fainting, nausea, vomiting, loss of
appetite, fever during the previous 3 days, slightly tightness, coughing, and so difficult to
defecation
CASE EVALUATION
In these cases the patient was treated with oxygen to tret breathing difficulties, NaCl given
intravenously to treat dehydration, NaCl usual dose adjusted to the patient's condition.
Azithromycin 1 times 500 mg administered orally to prevent pneumonia infections occur
commonly with a dose of 500 mg once daily for 3 days. 3 times 500 mg paracetamol
administered orally to cope with the usual dose of fever 250-500 mg every (4-6) if
necessary. Domperidone 3 times 10 mg administered orally to treat nausea with the usual
dose of 10-20 mg (4-8 hours). Sucralfat 4 x 15 cc administered orally to cope with
dyspepsia. KSR 1 times 600 mg administered orally to cope with hypokalemia usual dose
2-3 times a day 1-2 tablets. Captopril 2 times the 12.5 given orally to treat hypertension
with usual doses of 12.5 (2 times 1). Ranitidine 50 mg 2 times subcutan feed all the usual
1508
dose was 50 mg 6-8 hours. and Insulin Lantus 10 units 1 time given subcutan the usual
dose when blood sugar as 251-300 mg / dl (ioni, 2008).
RESULT OF THE LABORATORY
From laboratory test showed the value of Ms. SR May 19th, 2014 showed abnormalities in
13.75 million leukocytes M/ mm
3
(5-10 ribu/mm3), Neutrophils 81.9% (50-70%),
lymphocytes 11.2% (25-40%), Eosinophils 0.2 (2-4%). Abnormalities on test indicate of
infectious. Abnormalities in PCO 2 28.0 mmHg (35-45 mmHg), and O 2 of 80.9 mmHg
(85-95 mmHg) so that the patient had shortness. Abnormalities of the value of Sodium
123.0 mmol / L (135-145 mmol / L) and potassium abnormalities value of 3.40 mmol / L
(3.5 to 5.5 mmol / L). Because patient has hyponatremia and hypokalemia. Blood Sugar
Levels abnormalities is 474 mg / dl (<180 mg / dl). Patient's blood sugar levels every day ie
21 - 5-2014: 127 Morning, Noon 317. 22-5-2014: 131 morning, afternoon and evening 467
293. 23-5-2014: 360 morning, afternoon and evening 250 175. 24 -5-2014: day 307 and
290 pm. 25-5-2014: 236 Morning, afternoon and evening 116 371. 26-5-2014: Morning
168.
Based on the patient's medication therapy found Drug Related Problems (DRPS) :
1. Dose drug too low
On prescription ranitidine 50 mg 2 times a day, according to the supposed 50 mg 3 times a
day. Suggested to the doctor to re-evaluate the use of therapeutic doses of ranitidine or
ranitidine dose increase to 3 times a day 50 mg (Aine, 2009).
2. Low dose.
Used lantus insulin 1x10unit dayli is lower doses so not enough to control blood glucose
levels.
3. Interaction drug
Using of Captopril and KSR, can cause potassium retention and KSR can cause a risk of
hyperkalemia (Aine, 2009).
1509
CONCLUSION
Based on the results of clinical practice at the clinical in the of internal departemen
persahabatan medicine wards, it can be deduced the existence of DRP (Drug Related
Problem) Used of Captopril and KSR form, can cause potassium retention and KSR thus
cause a risk of hyperkalemia (Aine, 2009). Used of lantus insulin 1 x 10 units dayli, where
the use of 1 x 10 units a day is not enough to lower the patient's blood glucose levels. Drug
dose was too low, the prescription ranitidine 50 mg 2 times a day, according to (Aine,
2009), should have been 50 mg 3 times a day.
REFERENCES
1. American Diabetes Association. Diagnosis and classification of diabetes mellitus.
Diabetes Care. 2004: 27 (Suppl 1): S5-S10.
2. National authorities., 2006. Information Drug National Indonesia (ioni)
3. Bruns, Dr.Aine., 2009. Renal Drug Handbook Third Edition, New York: Oxford
4. Burduli M. The Adequate Control of Type 2 Diabetes Mellitus in an Elderly Age. ,
2009. Available from: http://www.gestosis.ge/ Diabetes Mellitus Type 2 Age Continue
Maj
Kedokt
Indon,
Volume:
60,
Number
12,
December
2010
583
eng/pdf_09/Mary_Burduli.pdf.
5. Sylvia A Price. Metabolism Glucose and Diabetes Mellitus, Pathophysiology Ed. 6
Jakarta, EGC, 2006; 2: 1260-65.
6. WHO Department of Noncommunicable Disease Surveillance Geneva.Definition,
Diagnosis and Classification of Diabetes Mellitus and its Complications. Report of a
WHO Consultation Part 1: Diagnosis and Classification of Diabetes Mellitus. 1999
1510
TREATMENT FOR HYPERTENSIVE DISEASE IN MINTOHARJO
HOSPITAL
Nadirah1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
Hypertension is the increased blood pressure, diastolic blood pressure remained
above 90 mmHg or systolic pressure above 140 mmHg settled. Hypertension can be caused
by: a drug (oral contraceptives, steroids), kidney disease (family history, proteinuria or
haematuria), renovaskular disease, phaeochromocytoma (a tumor on the adrenal Medulla,
an increase in the secretion of catecholamines, norefinefrin/efinefrin), Conn's syndrome
(hiperaldosteronisme, muscle overrun weakness, polyuria, hypokalemia), Coarcation
(narrowing of the aorta), Cushing's (overproduction cortisol hormone). Patient Mr. Ti, 55
years old, entered RSAL Mintohardjo on 23 February 2014 with anterior epistaxis. Patient
was diagnosed hypertension and was given Valsartan, Amlodipin, Vitamin K, Folic Acid,
bicarbonat Sodium, Allopurinol, and Atorwin (atorvastatin). Based on the result of the
clinic secretariat at the ward of Selayar in Mintoharjo Hospital, it could be concluded that
there was DRPs (Drug Related Problems). There was improper drug selection, its were
valsartan and amlodipin whereas patient suffered hypertension stage 2. The drugs that were
recomended for patient with hypertension stage 2 are diuretic and ACE inhibitor or ARB or
β-blockers or CCB. Other DRPs was pharmacokinetics interaction between sodium
bicarbonat with Allopurinol and Valsartan with atorvastatin which reduces the absorption
of allopurinolnol. atorvastatin will enhance the effect of Valsartan. (JNC VII, 2003)
Keywords: Drug Related Problems, hypertension, Mintohardjo Hospital.
1.INTRODUCTION
Hypertension is defined as a systolic blood pressure (SBP) of 140 mm Hg or more,
or a diastolic blood pressure (DBP) of 90 mm Hg or more, or taking antihypertensive
medication. Hypertension may be primary, which may develop as a result of environmental
or genetic causes, or secondary, which has multiple etiologies, including renal, vascular,
and endocrine causes. Primary or essential hypertension accounts for 90-95% of adult
cases, and secondary hypertension accounts for 2-10% of cases. The pathogenesis of
1511
essential hypertension is multifactorial and highly complex. Multiple factors modulate the
blood pressure (BP) for adequate tissue perfusion and include humoral mediators, vascular
reactivity, circulating blood volume, vascular caliber, blood viscosity, cardiac output, blood
vessel elasticity, and neural stimulation. A possible pathogenesis of essential hypertension
has been proposed in which multiple factors, including genetic predisposition, excess
dietary salt intake, and adrenergic tone, may interact to produce hypertension. Although
genetics appears to contribute to essential hypertension, the exact mechanism has not been
established. Secondary causes of hypertension related to single genes are very rare. They
include Liddle syndrome, glucocorticoid-remediable hyperaldosteronism, 11 betahydroxylase and 17 alpha-hydroxylase deficiencies, the syndrome of apparent
mineralocorticoid excess, and pseudohypoaldosteronism type II (Manuci G, 2007 and
Diskin, 2009)
According to the Health Research Foundation (RISKESDAS) 2013 the Ministry of
health of Indonesia, The prevalence of hypertension in the aged ≥ 18 years in Indonesia
were never diagnosed health workers amounted to 9.4 percent, while ever were diagnosed
health workers or were taking medication of hypertension alone amounted to 9.5 percent.
The prevalence of hypertension in Indonesia based on the results of measurements on age ≥
18 years of age amounted to 25,8 percent. The large majority of cases of hypertension in
the community not diagnosed are 63,2%.
Mr. Ti, 55 yearS old entered Mintohardjo Hospital on 23 February 2014. The
patient came with epixtasisis, patient had history of hypertension.
On the first day and second day patient was treated with valsartan, amlodipin, and
vitamin K. Laboratory Data demonstrated blood pressure 190/150 (130/80), Haemoglobin
13.6 (14-18 g/dl). Laboratory data on second day demonstrated BP was 180/140 (130/80),
LDL was 151 (< 130 mg/dL), uric acid was 11.3 (3.6-8,2 mg/dL), Creatinin was 1.8 (0.91.3 mg/dL), Clorida was 111 (96 – 108 mmol/L), triglycerides was 176 (< 170 mg/dL) and
1512
cholesterol was221 (< 200 mg/dL). On the third day patient was treated with Valsartan,
Amlodipin, Bicarbonat Sodium, Folic Acid, Allopurinol, Atorwin. Laboratory Data showed
that BP decrease ( 150/90 (130/80) and Ureum 63 (17-43 mg/dl) and others laboratory
parameter did not change
Administration valsartan and amlodipin for managing of hypertension, vitamin K
as a coagulant for treating epistaxis, sodium bicarbonat for resolve the acidosis because
from data laboratory showed level serum of chloride increased, folic acid, allopurinol and
atorwin (atorvastatin) for treated anemia, uric acid and hypercholesterolemia, respectivelly..
4. DOSAGE AND THE USING OF THE DRUG
Prescription
Dose
Name of The
Drug
Indication
How to Use
20 drop per
minute
Ringer
Lactate
Liquid
electhrolyte
sc
qd
Valsartan 160
mg
Anti
hypertensive
oral
qd
Amlodipin
tid
Vit K
Natrium
bicarbonat
Asam folat
bid
bid
bid
bid
Allopurinol
100 mg
Atorwin 10
mg
Anti
hypertensive
Coagulant
Therapy of
Acidosis
Folic Acid
Deficiency
Uric Acid
500 cc
oral
oral
oral
oral
oral
Anti
Cholesterol
Common
dose
oral
80-160
mg/day
2,5-10 mg/day
5 - 10 mg
1–4g
1 x a day 5-10
mg
2-3 x a day
50mg
maximum 800
mg a day
1 x a day 10
mg
5. DRUG RELATED PROBLEM
5.1. Improper Drug Selection
At the time of admission to hospital the patient's blood pressure was 190/150, is
classified as a level 2 hypertension. Patient was treated with valsartan and amlodipine,
while according to the JNC VIII patients with level 2 hypertension treated with
1513
combination of two drugs, there are diuretics and ACE inhibitors or ARBs or β-blocker or
CCB
5.2. Drug interaction
 Giving Sodium bicarbonate with
allopurinol would reduce the absorption of
allopurinol so advise the patient to take medicine at interval of 2 hours (Stokley,
2008).
 Giving Atorwin and valsartan simultaneously would increase the effect of valsartan
so we suggest the patient to take the medication at different times, valsartan taken in
the morning and atorwin at the night (Stokley, 2008).
6. CONCLUSION
Based on the result of the clinic secretariat at the ward of Selayar in Mintoharjo
Hospital, it could be concluded that there was DRPs (Drug Related Problems). There was
improper drug selection and pharmacokinetics interaction between sodium bicarbonat with
Allopurinol and Valsartan with atorvastatin.
7. REFERENCES
1. Manuci G, 2007. Management of Arterial Hypertension.
2. Joint National Commitee on prevention, 2003. evaluation and treatment of high blood
pressure.
5. Stockley, I.H, 2008,
Stockley’s Drug Interaction VIIIth ed, Great
Britain
6. Diskin, Arthur. 2009. Hipertension.www .medscape. com accesed 11/06/2011.
1514
CASE REPORT: DRUG RELATED PROBLEM ASSOCIATED WITH
TREATMENT FOR URETHRAL STRICTURE PATIENT IN
Aifa Neltji Batilmurik 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Urethral stricture is a constricting or blockage of the lumen urethra caused by growth
fibrotic tissue (scar tissue) in the urethra and / or the peripheral urethra. Urethral stricture
causing disturbances in micturition, from urinary flow ranging shrinking until up to
remove urine out of the body. Urine cannot get out of the body so can lead to many
complications, renal complications are the toughest2. Heart disease is a condition of the
heart does not function normally. include weakness of the heart muscle (congenital
abnormality) and the rise of a gap between the atrial. BPH (benign prostate hyperplasia) is a
non-cancerous growth magnification of the prostate gland. BPH can lead to compression
prostatic urethra and make difficult to voiding2. Mr. YP 69 years old came to Mintohartjo
AL hospital on 22nd April 2014 with Urethral Stricture diagnoses. Patient had prostate
surgery 2004, heart surgery in 2009. Patients was using the heart and hypertension drugs,
ie Bisoprolol 1 x 2.5 mg, 1 x 25 mg Aldactone, Cardace 2 x 2.5 mg. Patients getting
treatment Amoxillin 3 x 500 mg, Prednisone 3 x 5 mg, Mefenamic Acid 3 x 500 mg for
three days of hospitalization.
Keywords: heart, prostate, urethral stricture and Mintoharjo-Navy hospital.
I.INTRODUCTION
Urethra is the most important. For men and women, urethra has the main function to
remove urine out of the body. Urethra is also important in semen ejaculation process from
male reproductive tract, looks like a flower sprinklers. Urethral stricture is a constricting or
blockage of the lumen urethra caused by growth fibrotic tissue (scar tissue) in the urethra
and / or the peripheral urethra. Urethral stricture causing disturbances in micturition, from
1515
urinary flow ranging shrinking until up to remove urine out of the body. Urine cannot get
out of the body so can lead to many complications, renal complications are the toughest2
Urethra stricture is still a problem. Urethra stricture is more common in men than in
women, because of the shorter urethra in women and seldom infected. People can be born
with urethral strictures, although it rarely happens. Some surgery on the urinary tract can
cause urethral strictures, like prostate surgery, surgery with endoscopic tools2.
Mr. YP 69 years old came to Mintohartjo Navy hospital on 22nd April 2014, he
came up with a grievances: is difficult urinating, leakage of urine, hematuria, and pain in
the lower abdomen. Patient had prostate surgery 2004 and heart surgery in 2009
Patient was treated with Bisoprolol 1 x 2.5 mg. Bisoprolol is a Beta blockers
selective inhibitor of adrenal beta-1 receptors, blocking the sympathetic activity, reduced
cardiac output thus lowering blood pressure. Bisoprolol has a long acting so can be given
only once a day. Aldactone (spironolactone) 1 x 25 mg, a potassium-sparing diuretic, an
aldosterone antagonist, causing the kidneys to excrete sodium and water. Cardace
(Ramipril) 2 x 2.5 mg, is an ACE inhibitors, ACE inhibitors block the conversion of
angiotensin I to angiotensin II, affect the capacity and the resistance of blood vessels,
decrease arterial pressure, but did not affect the contraction of the heart 4. 23rd April 2014
urethral stricture dilation postoperatively the patient is given oral medication mefenamic
acid 3 x 500 mg, mefenamic acid is a nonsteroidal antiinflamation group. Mefenamic acid
binds the prostaglandin synthetase receptors COX-1 and COX-2, inhibiting the action of
prostaglandin synthetase 3 x 5 mg prednisone, Prednisone is a glucocorticoid receptor
agonist. Anti-inflammatory actions of corticosteroids are thought to involve phospholipase
A2 inhibitory proteins, lipocortins, which control the biosynthesis of potent mediators of
inflammation such as prostaglandins and leukotrienes. Amoxicillin 500 mg 3 times as betalactam class of antibiotics.
1516
4.DISCUSSION
Mr. YP 69 years old came to Mintohartjo Navy hospital on 22nd April 2014, he came up
with a grievances: is difficult urinating, leakage of urine, hematuria, and pain in the lower
abdomen with Urethral stricture diagnose. The first therapy is a laboratory test. Based on
laboratory tests (hematology test) and vital signs, Mr. YA is good conditions, the next
therapy to overcome patient grievances is carried urethra dilation surgery. Patients getting
treatment Amoxillin 3 x 500 mg, Prednisone 3 x 5 mg, Mefenamic Acid 3 x 500 mg. When
used mefenamic acid and prednisone can interfere with the patient's digestive tract.
Mechanism of action NSAIDs drugs (Non Steroid Anti Inflammatory) only inhibits the
enzyme COX 2 (inflammation), while COX 1 enzyme is not inhibited that Prostacyclin
(Pg12) with protective effect on the gastric mucosa remain to be established so an increase
in gastric acid6. Patient was treated with Bisoprolol 1 x 2.5 mg, Aldactone (Spironolactone)
1 x 25 mg and Cardace (Ramipril) 2 x 2.5 mg previous. When using ramipril and cardace
together can lead hypokalemia, Cardace (Ramipril) is an ACEI drug to inhibits angiotensin
I to angiotensin II changed and
the next effect of aldosterone excrete sodium and
potassium from the body, while aldactone aldosterone antagonists also working by
increasing the excretion of sodium and hold potassium acting on the distal tubule sodium
retention so this can cause hyperkalemia4.
5.CONCLUSION
There are DRP (Drug Related Problems) ie Adverse Drug Reaction (ADR) on the
case study Mintohardjo-AL hospital on the fourth floor Salawati Island Care. Aldactone
(Spironolactone) is a potassium-sparing diuretic, aldosterone antagonist that increases the
excretion of sodium and potassium resist acting on the distal tubule, causing sodium
retention, with Cardace (ramipril) is an ACEI drug to excrete sodium and potassium
retention in the body. This can led to hyperkalemia. Should be given furosemide to prevent
hyperkalemia 4. On the use of mefenamic acid and prednisone will cause an increased risk
of side effects on the gastrointestinal tract. When being used mefenamic acid and
prednisone can interfere with the patient's digestive tract. Mechanism of action NSAIDs
drugs (Non Steroid Anti Inflammatory) only inhibits the enzyme COX 2 (inflammation),
1517
while COX 1 enzyme is not inhibited that Prostacyclin (Pg12) with protective effect on the
gastric mucosa remain to be established so an increase in gastric acid6. Should be given
drugs known as H2 Blockers (e.g Ranitidine) to prevent an increase in stomach acid and
ulcers6
6.REFERENCES
2. Brunner & Suddarth. 1996.Critical Nursing: A Holistic Approach Volume II. EGC
Jakarta
3. Directorate of Pharmaceutical Services. 2005 Pharmaceutical Care For Urinary Tract
Infections Diseases. Ministry of Health, Jakarta.
4. Elin Yulinah 2011, ISO Pharmacotherapy 2, Publisher Pharmacist Association of
Indonesia, Jakarta
5. Mabsjoer, A, et al. (2011). Capita Selecta Medicine (Ed.III). Media Aezcolaius, Jakarta
6. Tan Hoan Tjay, 2007, important medications, Publisher Komputindo PT Elex Media
Group Kompas Gramedia, Jakarta.
1518
FOR ACUTE RESPIRATORY INFECTION PATIENT IN PGI CIKINI
HOSPITAL
Karmadina Oswanty1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
Acute respiratory infection is a serious infection that prevents normal breathing function.
Acute respiratory infection (ARIs) is a bacterial or viral infection of the respiratory tract
causing difficulty breathing, fever and other complications, including infections in the ear
and brain membrane1. Acute respiratory infections are infectious, which means they can
spread from one person to another5. Mrs. NS 55 years old was diagnosed ARIs. On
hematological examination showed an increased leukocytes, increased erythrocyte
sedimentation rate which indicates the presence of infection. Besides microbiological
examination is also conducted to see which antibiotic that is resistant. She has received 9
kinds of drugs, ie Rocer (Omeprazole), Panadol (Paracetamol), Pharodine (ceftazidime),
Cefila (Cefixim), Cetirizine, Futrolit, Codipront, OBH, Lesivit. Based on the result of the
clinic secretariat at the ward of K in PGI Cikini Hospital, it could be concluded that there
was DRPs (Drug Related Problems) such as Failure to receive medication ¸ Improper Drug
Selection, and Drug Interaction.
Keywords: Acute Respiratory Infection (ARIs, DRP (Drug Related Problems), PGI Cikini
hospital
I.INTRODUCTION
Acute respiratory infection is a serious infection that prevents normal breathing
function. Acute respiratory infection (ARIs) is a bacterial or viral infection of the
respiratory tract causing difficulty breathing, fever and other complications, including
infections in the ear and brain membrane1. Acute respiratory infections are infectious,
which means they can spread from one person to another5. Infectious agent is a virus or
1519
bacteria that cause respiratory tract infections. Some bacteria causing the infection ie type A
b-hemolityc
Streptococcus,
Staphylococcus,
Haemophylusinfluenzae,
clamydia
3
trachomatis, Mycoplasma and pneumococcus .
2.METHODOLOGY
dosage and mode of administration and rationalization of the use of the drug (the right dose,
the right indication, the right patient, the right of use) with see Drug Related Problems of
drug use based on the literature.
3.RESULT AND DISCUSSION
Mrs. NS 55 years old came to PGI Cikini hospital with fever for three days, nausea
and vomiting, and pain in the stomach, anxiety, often feeling shortness of breathing, and
rather turbid of urine. Patient had a history of ulcer disease and hypertension. Blood
pressure in beginning examination is normal 130/90 mmHg. During hospitalized, there was
no interference with the patient's blood pressure so patient does not require
antihypertensive therapy.
On hematological examination, it was found some abnormal test. Laboratory test on
the first day showed a high leukocyte value is 17,0.103 mL (5 - 10. 103μL). Erythrocyte
sedimentation rate values showed an increased from the normal value is 33mm/hour (0 20mm/hour), is associated with indication of infection. Eosinophil and neutrophil values
showed a decreases. To second day the examination still shown an increased of leukocytes
that 15,3.103 mL (5 - 10.103μL).
Also, increase of erythrocyte sedimentation rate is
29mm/hr (0 - 20mm/hr). Besides, the value of lymphocytes and monocytes still showed an
increase in the amount of 60% (20-40%) and 15% (2-8%). To seventh day, laboratory result
still shown an increased of leukocytes is 11,1.103μL (5 - 10.103μL), increased of monocytes
and lymphocytes, respectively at 56% (20-40%) and 9% (2-8%).
The higher value of leukocyte and erythrocyte sedimentation rate is an indication of
infection. Increased neutrophils associated with the body's defense against bacterial
1520
infections and other inflammatory process. The increased of eosinophil shown the presence
of parasites. Lymphocytes are also important in bacterial infections that is by making
antibodies, bind and then destroid the bacteria, and monocytes as phagocytosis or vacuum
cleaner to clean out bacteria, parasites or viruses that have been destroyed by neutrophils.
From the laboratory test showed that Mrs. NS had respiratory tract infections. That,
examination of Immunology Anti-S.typhi IgM showed a negative test means that the
patient does not Salmonella Typhy infection1.
Clinical chemistry examination and blood sugar test showed that Mrs. NS had
normal blood sugar 89mg/dL and 117mg/dL is on the sixth day of examination at 06.00am
and 10.00am. Value of sodium, potassium and calcium showed abnormal values on the first
day test. Natrium only 130mEq / L (135-147 mEq / L), calcium showed a decrease of
7.8mEq / L (8.8-10.3 mEq / L), potassium increased 5.2 mEq / L (3.5-5 , 0mEq / L).
Albumin of the patients Ny. NS also showed a decrease 2.9 g / dL of the normal value of
3.4-4.8 g / dL. Seeing abnormal condition of the liquid electrolyte treatment it is necessary
to normalize the patient's fluid balance electrolyte.
Besides the examination of hematology and clinical chemistry, microbiology
examination was also done to see which antibiotics are resistant and sensitive that they can
get proper treatment. From the test of using the sputum and Streptococcus cultures, found
four types of antibiotics that are resistant Ciprofloxacin, Erythromycin, Gentamycin, and
penicillin G.
The first day of treatment, patients received Rocer(omeprazole). This drug is used
for treatment of ulcers. Panadol is given to Mrs. NS to reduce fever and pain. Patients also
got Pharodin(ceftazidime) is a third of the cephalosporin class of antibiotics. Antibiotics are
given for treatment of respiratory tract infections in patients. For recovery therapy needs
carbohydrates, protein and electrolytes, patients was got Futrolit therapy. The second day of
treatment until the fourth day, patient received Codipront. Codipront is given to patients
who have a severe cough, with sputum. In the next treatment, patients received Lecivit as
vitamin tablets containing lecithin, vitamin B1, B2, B6, B12, nicotinamide, vitamin E and
β-carotene. On the seventh day until the tenth day, Mrs. NS had not received Panadol
therapy. There are used OBH and Cetirizine in the treatment of patients Mrs.NS on the
1521
eighth to tenth day. Cetirizine is given to treated allergies. OBH is used to help relieved
cough and expectoration.
Besides pharmacological treatment, patients also received non-pharmacological
therapy, such as soft foods. In treatment of Mrs. NS there found some problems of Drug
Related Problems (DRPs), including failed/did not receive the drug Lesivit on the first day
to fourth day. There was no drug use without indication, the dose is too small, too large
doses, improper drug selection, untreated indication. But there was an interaction between
Cetirizine with Codipront (containing Codeine). Using Cetirizine together with codeine
(Codipront) can increased side effects such as dizziness, drowsiness, and difficulty
concentrating and thinking2. Use of Cetirizine with drugs that act on the central nervous
system (CNS) can cause additive and loss of consciousness2. There was also has improper
drug selection is a combination of two types of antibiotics from the same class4. Pharodine
(ceftazidime) and Cefila (cefixime) is a third of the cephalosporin class of antibiotics.
4.CONCLUSION
Based on the result of the practice of clinic secretariat at the ward of K at PGI Hospital
Cikini, it can be conclude that there was DRPs (Drug Related Problems) such as Failure to
Received Medicine, Drug Interactions and Improper Drug Selection
5.REFERENCES
1. Catzel, Pincus& Ian robets. (1990). Capita Selecta Paediatric Edition II, EGC: Jakarta
2. Stockley, I.H, 2008, Stockley’s Drug Interaction, The eighth edition. Great Britain :
3. Whalley, Wong, 1991, Nursing Care of Infant and Children Volume II book 1, USA:
CV. Mosby-Year book. Inc
4. http://en.wikibooks.org/wiki/Pharmacology/Antibiotics, accessed on March 24, 2014
5. http://www.healthline.com/health/acute-respiratorydisease, accessed on March 24, 2014
1522
FOR LUNG TUBERCULOSIS PATIENT IN PERSAHABATAN
HOSPITAL
Perpetua Ananta Luturmas 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1Student of Pharmacist Program, Faculty of Pharmacy UTA'45Jakarta
2Lecturer of Faculty of Pharmacy UTA'45Jakarta
ABSTRACT
Tuberculosis (TB) is directly spread desease that caused by Mycobacterium tuberculosis,
most (80 %) attack lungs. Mycobacterium tuberculosis is bacillus positive gram formed
wall bar, the cell contains lipida-glikopida complex also candle (wax) that is difficul to
emerge by chemical. lung tuberculosis is tuberculosis that attacks lung parenkim net, not
include pleura (DepKes RI, 2005).
Patient Mr. HR, age 39 years old, entered RSUP Persahabatan on 29 June 2014 with
diagnose TB PARU LLKPO OAT. Therapy during nursed namely oxygen , NaCl 0,9%,
Ambroksol Syr, N.Acetylsistein, Vitamin B12, Ceftazidime, Inhalasi combiven and OAT
medicine category II (Rifampisin, INH, Pirazinamid, Etambutol dan Streptomisin).
According to practical result of clinical secretary on lung desease ward at RSUP
Persahabatan so can be concluded that there is DRP (Drug Related Problem) such there is
indication without medicine, medicine reaction unexpectancy, medicine interaction and
patient is failure receiving medicine.
Key Words : Lung Tuberculosis wide pale of break case medicine OAT, top soka and
RSUP Persahabatan.
1.INTRODUCTION
Tuberculosis (TB) is directly spread desease that caused by Mycobacterium
tuberculosis, most (80 %) attack lungs. Mycobacterium tuberculosis is bacillus positive
gram formed wall bar, the cell contains lipida-glikopida complex also candle (wax) that is
difficul to emerge by chemical. lung tuberculosis is tuberculosis that attacks
lung
parenkim net, not include pleura (DepKes RI, 2005).
Tuberculosis (TB) is society health problem is important in the world. In 1992
World health Organization (WHO) has proclaimed tuberculosis as Global Emergency. In
1523
Indonesia based on household health Survey in 2001 gained that desease on breathing
system is the second death motive after circulation system (DepKes RI, 2005).
According to suffere’s type , can be determined based on the treatment history
before can be classified on suffere’s type namely new case, relapse, transferring, negligent,
failure, chronic and used TB (Muchid, 2005).
According to the examination result of phlegm, TB lung consits of :
Lung Tuberculosis BTA Positive
At least 2 of 3 phlegm specimen result of BTA positive.
1 phlegm specimen the result BTA positive and chest x-ray photorefers to image of
tuberculosis aktive.
Lung Tuberculosis BTA Negative
The examination 3 phlegm specimen result of BTA negative and chest x-ray photo
refers to image of tuberkulosa aktive.lung TB negative x-ray BTA lung positive are
classified based on stage of seriously desease namely form of weight and light. Weight
form if chest x-ray photo shows image of wide lung damage, and general condition of
bad sufferer .
Lung extra Tuberculosis is tuberculosis that attack the other body organ beside
lungs, for instance, pleura, brain membran, heart membran (pericardium),
limfe
gland,pivot bone, skin, intestines, kidney,urine duct, sex organ etcetera (Muchid, 2005).
Normally, Mycobacterium tuberculosis attack lung and little part are the other
organsthe germ has specific traits namely endure from acid on dying , this case is used to
identify microscopic, so called as acid endured bacillus (BTA) (Muchid, 2005).
Spread source is sufferer of TB BTA positive when coughing or sneezing, the
sufferer spreads germ on air in dropel form (phlegm fragment). People can be infected if
the droplet is whiffed into breathing (Muchid, 2005).
Clinically, TB can happen through primer infection and pasca primer . primer
infection happens when people get germ TB for first time. After happening infection
through bronchi in the anveoli (lung vesicle) happens inflammation. This is caused by germ
TB that burgean with self fission in lung. The time happens infection until forming primer
complex is 4 -6 weeks (Muchid, 2005).
1524
TB Symptom for adult, normally the sufferer cought and phlegm continuously for 3
weeks or more, blood cough or ever blood cough, beside the other symptoms of TB for
adult is breathing tight and chest pain, weak body, desire and body weight are reduced the
body is not felt good, sweat in night and dizzy fever more than one month (Muchid, 2005).
While diagnose TB lung extra depend on infected organ for instance chest pain to
TB pleuritis, spleen gland swelling superfisialis pada limfadenitis TB and back bone
swelling on sponsdilitis TB (Muchid, 2005)
2.CASE PRESENTATION
Patient Mr. HR 39 years old entered Persahabatan hospital on 29 June 2014. The
Patient came with breathing tight complaint that is suffered since one week before entering
the hospital, excessively if activate and fever also queasy if consume medicine OAT
category II. The Patient had been ever cured since 13 March 2014 because of cough and
phlegm BTA positive, the patient was given medicine OAT category II. In 2001 the
patient was cured in RSUP Persahabatan because of old cough and diagnose TB, cured wit
OAT and stopped by self patient because her/his condition was felt well.
3.CLINIC EVALUATION
In this case the patient was cured with NaCl 0,9%, Ambroxol tablet, Rimstar 4FDC
tablet (Rifampisin, INH, Pirazinamid, Etambutol), Streptomisin injection , Inhalation
combivent, Ceftazidim injection and N-acetylcystein. The result of laboratory examination
Tn. HR on 29 June 2014 refered to abnormality on value HB 13,5 gm/dl (14-18 gm/dl),
netrofil 42 % (50-70%). Abnormality on the examination result refered to that the patient
got infectionabnormality on value PO2 11,6 mmHg (35-45 mmHg). Abnormality also to
the examination SGOT 21 ( > 25 ) whereas SGPT 23 ( > 30 ).
The examination result of sputum Tn. Rh onl 6 May 2014 the result of BTA I
(negative), on 7 May 2014 BTA II
(1 positive), and BTA III (1 positive). On the
examination result refers to that the patient got lung TB positive BTA.
4.DOSAGE AND USING THE DRUGS
1525
Dosage and direction using medicine to the patient namely oxygen to solve the
patient’s breathing tight, NaCl 0,9% infusion given intrravenously to subtitute body liquid,
normal dosage NaCl according to the patient’s condition. Ambroxol tablet 3 times 50 mg
given orally to solve productive cough with normal dosage diberikan ambroxol tablet 2
until 3times 45mg/15 ml. Rimstar 4FDC tablet (Rifampisin 150 mg, INH 75 mg,
Pirazinamid 400 mg, Etambutol 275 mg) 1 times 3 tablet given per orally to therapy
tuberculosis,with normal dosage weight body 30 until 37 kg 2 tablet/day. Streptomisin
injection 1 times 750 mg given intravenously to therapy the
patient’s tuberculosis
pasien,with normal dosage 750 mg per day 3 times/week. Inhalatioin combivent 4 until 6
timesi/day given inhalation to solve breathing tight with normal dosage per day 4 times 2
syringe, maximum 12 times per day. N-acetylcystein 3 times 200 mg given orally as
mucolitic and antioxide and with normal dosage 200 mg, 2 until 3 times one day per oral.
Vitamin B12 3 times 50 mcg given orally to help in forming red blood cell. Ceftazidime
injection 3 times 1 g/day gift intravenously to bacterial infection positive gram, and
negative gram bactery (IONI, 2008).
1. There is indication without medicine
The sufferers feel queasy each time they drink medicine OAT category II namely
medicine INH but not given medicine antqueasyl Vitamin B6 and to solve neurotri
perifer medicine INH.
2. The medicine reaction is unexpection
The sufferers feel queasy excessively after drinking medicine INH and using
Rifampisin and INH can increase hepatotocsity of INH so it is necessary done
monitoring hepatotoksik for the sufferers by checking SGPT and SGOT laboratory.
6.CONCLUSION
According to the practical result of clinical secretariat at lung desease ward in
RSUP Persahabatan so we can conclude that with DRP (Drug Related Problem) such there
is indication without medicine the sufferers complain queasy each time they drink medicine
1526
OAT category II namely medicine INH but not given medicine antiqueasy vitamin B6 and
to solve neurotri perifer medicine INH,medicine reaction is unexpectation, the sufferer feels
qyeasy excessively after drinking medicine INH and using Rifampisin and INH can
increase hepatotocsity of INH so it is necessary done monitoring for the sufferer by
checking monitoring hepatotocsit SGPT and SGOT laboratory.
7. REFERENCES
2. Departemen Kesehatan RI. 2005. Pharmaceutical Care Untuk Penyakit Tuberkulosis.
Jakarta. Hal 12-22
5. Tatro David, 2006. Drug Interaction FactTM, Amerika : Fact & Comparisons. Hal 841
1527
FOR HEMORRHAGIC STROKE PATIENT IN GATOT SOEBROTO
HOSPITAL
Petrus Kabul Togarma 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Stroke is a term used to describe an abrupt onset of focal neurologic deficit that lasts at
least 24 hours and is presumed to be of vascular origin (Dipiro, 2009). There are two main
types of stroke; ischemic stroke and hemorrhagic stroke. According to the Indoneisan
foundation of Indonesian stroke, hemorrhagic stroke is caused by the rupture of certain
blood vessel branches in the brain as a result of the fragility of the longstanding walls
(atherosclerosis / blood vessels) that are accelerated by a variety of factors. There are two
types of hemorrhagic stroke: Subarachnoid hemorrhage caused by trauma or rupture of an
intracranial aneurysm or arteriovenous malformation and Intracerebral hemorrhage which
is occurs when a ruptured blood vessel within the brain parenchyma causes formation of a
hematoma (Dipiro, 2009). In this case a patient Mr. Wj, 56 years old came with
complaints of right arm and leg weakness, vomiting, unconsciousness, no seizures, head or
neck pain, and based on the results of the CT scan of the patient, he experienced
Heamorrhage in the region paraventrikel lateral (a serebri cerebral) sinistra. The patient
had a history of hypertension and diabetes and had never had a stroke. The patient is treated
with Perdipine injection, Manitol, Ringer's lactate, transamin injection (tranexamic acid),
citicolin injection, amlodipine, noperten (lisinopril), codeine HCl, cardace (ramipril),
ceftriaxone injectio, paracetamol, pankreoflat, transamin tablets, citicoline tablets. From the
results of evaluation revealed that there was Drug Related Problem (DRP) which were
drug interaction and inappropriate drug selection.
Keywords: Drug Related Problem (DRP), Stoke Haemorrhagic, Indonesian Army Hospital
Gatot Soebroto
I.INTRODUCTION
Stroke is a term used to describe an abrupt onset of focal neurologic deficit that lasts
at least 24 hours and is presumed to be of vascular origin (Dipiro, 2009). There are two
main types of stroke; ischemic stroke and hemorrhagic stroke. According to the Indonesian
foundation of stroke, hemorrhagic stroke caused by the rupture of certain blood vessel
branches in the brain as a result of the fragility of the longstanding walls (atherosclerosis
1528
/blood vessels) that are accelerated by a variety of factors. There are two types of
hemorrhagic stroke: Subarachnoid hemorrhage caused by trauma or rupture of an
intracranial aneurysm or arteriovenous malformation and Intracerebral hemorrhage which
is occurs when a ruptured blood vessel within the brain parenchyma causes formation of a
hematoma (Dipiro, 2009).
Hemorrhagic stroke is the most deadly type of stroke. From 15% -20% of all strokes
haemoragic, 10-15% for intracerebral hemorrhage and about 5% for subarachnoid
hemorrhage (WHO, 2005).
2.CASE PRESENTATION
Patient Mr. Wj, 56 years old who had referral a stroke from Cengkareng District
Hospital with complaints of arm and right leg weakness, vomiting, unconsciousness, no
seizures, head or neck pain, and based on the results of the CT scan of the patient, showed
Heamorrhage in region paraventrikel lateral (a serebri media) sinistra.. The patient had a
history of hypertension and diabetes and had ever had a stroke. At the Emergency Room,
patients treated perdipine injection, mannitol and Ringer laktrat.
In this case, the patient was treated with perdipine injection indicated for the
treatment antihypertension. Mannitol indicated for the treatment diuretic. Infusions of
Ringer Lactate (RL) indicated for the treatment of electrolytes and minerals, transamin
(tranexamic acid) which is indicated as an anti-bleeding, citicolin as a neuroprotective,
amlodipine as an antihypertensive, noperten (Lisinopril) as an antihypertensive, codeine
HCl as an opioid analgesic and antitussive, cardace (ramipril) as an antihypertensive,
antibiotic ceftriaxone
as a treat infections that occur in patients, paracetamol as an
analgesic and antipyretic, pankreoflat for bloating in the digestive disorders.
In this case, the patient was treated with perdipine injection indicated for the treatment
antihypertensive, mannitol indicated for the treatment as a diuretic, Infusion of Ringer's
lactate (RL) 1000ml/ 24 hour IV from 19-29 May indicated for the treatment of electrolytes
and minerals. Transamin (tranexamic acid) injection 500 mg/ 8 hours IV from 19-29 May
1529
which is helping the blood clot normally to prevent and stop bleeding. It belongs to a class
of drugs known as anti-fibrinolytics.. Citicolin injection 500mg / 8 hours IV from 19-29
May as a neuroprotector. Amlodipine 10mg tablets/ 24hour orally , after waking up / early
day from 19 May-2 June to treat high blood pressure, lowering high blood pressure helps
prevent strokes, heart attacks, and kidney problems. Noperten (lisinopril) 5 mg/ 24 hour
orally from 19-21 May as an antihypertensive, but the patient complained of a dry cough
and then get codeine HCl 10 mg/ 8 hour orally from 22-24 May, as an analgesic opioid
and antitussive. Doctors replaced noperten with Cardace (ramipril) 5 mg/ 24 hour orally
before bedtime / night from 22 May-2 June, as an antihypertensive. Injection ceftriaxone
1g/ 24h IV from 19-26 May, is an antibiotic used to treat a wide variety of bacterial
infections, was used treat increased value lab of leukostit. Paracetamol 500mg was given
orally if necessary or when fever was indicated as an analgesic and antipyretic. Pankreoflat
tablet every 8 hours was given from 22-25 May for bloating in the digestive disorder. On
the 2nd of June the patient retured home, and got therapy transamin tablets 500mg/ 8 hour
orally, citicolin tablets 500mg/ 8 hour, amlodipine tablets 10mg / 24 hour after wake up/
morning, and cardace tablets 5mg / 24 hour before bedtime/ night.
4.LABORATORY VALUE
Results of laboratory test are generally normal and only showed an increase in the
value of the leukocytes on May 22, 22740 / µL (normal value 4800-10800/µL), although
the patient was suffering from diabetes, but the results of glucose (blood sugar) showed the
results of a controlled 115mg/ dL (normal value <140m/ dL). Based on the results of the
CT scan of the patient, showed Heamorrhage in region paraventrikel lateral (a serebri
media) sinistra. and the results of radiographs showed cardiomegaly.
5.DISCUSSION
1 Drug interactions
Drug interactions between codeine HCl and antihypertensive drugs showed a non
significant and moderate decrease in blood pressure. When patients were treated with both
codeine HCl and amlodipine, the patient's blood pressure decreased from 170 / 100mmHg
1530
to 140 / 90mmHg. Regularity uses the drug should be reviewed tightly because it can
caused
a
decrease
in
of opioid analgetik (codein HCl) with
blood
pressure, so
antihypertensive
it's recommended uses
(amlodipin) should
not
be
given concurrently or given the distance of time usage
2. Inappropriate drug selection.
Replacement noperten (ACE inhibitors) with cardace (ACE inhibitors) is less
precise because one of the side effects of ACE inhibitor cause a dry cough, on 20 May the
patient complained of a dry cough. For the replacement is advised to use the
antihypertensive drugs class ARB (candesartan, valsartan) which does not cause dry cough
as side effects (Dipiro, 2009).
6.CONCLUSION
The theraphy result of the patient Mr. Wj shows the presence of DRP which is the
interaction of drug between codein HCl (analgesic opioid) and antihypertensive amlodipin,
which caused a decrease in blood pressure. It is recommended to give spare time in the use
the drugs. The replacement of the same antihypertensive drugs between ACE Inhibitors
(lisinopril, ramipril) is less precise and causes side effects of dry cough. It is suggested to
use the antihypertensive drugs class of ARB (candesartan, valsartan).
7.REFERENCES
1. Anonymous, 2011. Dowloaded in July 17, 2014. Sekilas Tentang Stroke.
http://www.yastroki.or.id/file/strokesekilas.pdf.
2. Arofah, Annisa Nurul., 2011. Downloaded in July 17,2014. Penatalaksanaan Stroke
Trombotik:
Peluang
Peningkatan
Prognosis
Pasien.
http://ejournal.umm.ac.id/index.php/sainmed/article/view/1088
3. Dipiro, J.T., Wells, B.G., Schwinghammer, T.L., Dipiro, C.V., 2009, Pharmacotherapy
Handbook, Seventh Edition, McGraw-Hill Medical, New York.
4. ISFI, ISO Farmakoterapi, Penerbit PT. ISFI Penerbitan: Jakarta
5. Katzung, B., Masters, S., dan Trevor, A. (2006). Basic and Clinical Pharmacology (9th
ed). New York: Mc Graw Hill Medical
1531
6. Lacy CF. et al, 2005, Drug Information Handbook International. Lexicomp
7. Perhimpunan Dokter Spesialis Saraf Indonesia. 2007. Guideline Stroke 2007. Jakarta:
PERDOSSI.
8. Ropper, A.H., Brown, R.H., 2005. Adams and Victor's Principles of Neurology. 8th Ed.
New York: McGraw-Hill
9. Tjay, T.H, Rahardja, K., 2002, Obat-obat Penting, ed. 5, Penerbit PT Elex Media
Komputindo: Jakarta
1532
GENERAL STUDY CARE WARDS GERIATRIC
Rosita Walakula1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Chronic Kidney Disease or chronic renal failure is a process of pathological changes in
kidney structure and function, resulting in a progressive decline in renal function and
generally end up with kidney failure. Mr. FT aged 68 years old, come in Gatot Subroto
Army Hospital on May 17th 2014 was diagnosed of Chronic Kidney Disease on
Continuous Ambulatory Peritoneal Dialysis. Diagnosed during hospitalizad, he was
receved 0.9% NaCl, Lasix, folic acid, vitamin B 12, CaCO3, vib albumin and Combivent.
Based on the results of their clinical practice in a general medical ward at the Gatot Subroto
Army Hospital, it can be concluded that there is a DRP (Drug Related Problem) is a disease
that is untreated and drug selection is less effective for the treatment of hypertension.
Keyword : CKD On CAPD, Gatot Subroto Hospital.
INTRODUCTION
Chronic renal failure with hemodialysis therapy, always increase every year, it is
associated with an increase in the number of hemodialysis measures from year to year.
From Indonesia dialysis services found 125.441 cares per year by dialysis corresponding
form Health departement hospital1. In patient with chronic renal failure, almost always
accompanied by hypertension, because hypertension and chronic kidney disease are two
things that are always closely connected. besides, kidney disease has long been known as a
cause of secondary hypertension. Hypertension occurs in approximately 80% of patients
with terminal renal failure 2.
Blood pressure exceeds 140/90 mm Hg. classified as hypertensive. The National
Heart, Lung, and Blood Institute, high blood pressure classified into two levels, normal
blood pressure is less than 120/80 mmHg, prehypertension 120-139 mmHg systolic
1533
pressure, diastolic pressure of 80-89 mmHg. High blood pressure is first rate, systolic
pressure of 140-159 mmHg, 90-99 disatolik pressure, and high blood pressure both systolic
blood pressure level of 160 mmHg or more and diastolic pressure of 100 mmHg or more³.
Hypertension is a blood pressure exceeding 140/90 mmHg. Hypertension in patients
with chronic renal failure may occur as an effect of vascular disease who have been there
before or as a result of kidney disease itself. This condition can also caused to an increase
in fluid volume, increased secretion of renin, uremic toxins, sodium intake, secondary
hyperthyroidism, and others. Increase of blood pressure in the long term can lead to
thickening of the left ventricular wall. The presence of multiple comorbidities that occur in
patients with chronic renal failure such as diabetes and hypertension can accelerate to poor
kidney function of patients1.
CASE OF PERCENTATION
Patient Mr. FT 68 years old come to Gatot Subroto Army Hospital on may 17,
2014. Patient present with shortness of breath since last night, shortness reduced after using
the oxygen in the treatment room. Day morning the patient is discharged, but re-emerged
when in crowded airports. There cough white phlegm, drink about 500 cc, pips difficult.
The patient had disease kidney history, and also the lasts dialysis fours time . Day ago and
now he used CAPD.
Patient also a history cardio and hypertension, diabetes meletus, asthma and lung
disease since 2006. Patient had a allergy of penesilin too.
CLINICAL EVALUATION
At this time the patient treated with amlodipine 5 mg 1 x 1 a day, Lasix 20 mg 2 x 1
a day, which is given when patient was came 17 May 2014. CaCO3 500 mg 3 x 1 day, folic
acid 50 mg 3 x 1 day , B
12
3 x 1 day, VIB albumin 3 x 1 day. Combivent given 3 x 1 day
on the tenth day care on 26 May 2014.
1534
1. Inj furosemide 20 mg
As antihypertensive to reduce edema, furosemide dose given 2 x 20 mg IV dose of 20
mg is not unusual for 1, 5 g / day but for kidney failure patients with a GFR <10 ml /
min is the dose can be increased from the normal.
2. Amlodipine 5 mg
As an antihypertensive as for blood pressure patients. The dose given 1 x 5 mg dose for
patients with GFR prevalent <10 ml / min dose of amlodipine given is 5-10 mg / day
3. CaCO3 500 mg
As a phosphate binder, the dose given 3 x 500 mg
4. Folic acid 50 mg
For anemia treatment, the dose given 3 x 50 mg
5. Vitamin B 12
For anemia treatment, the dose given 3 x 50 mg
6. Vib albumin
As the albumin enhancer, the dose given 3x 1
7. Combivent
As an anticholinergic bronchodilator, dose of 3 x 20 micrograms. Usual dose is 20-80
micrograms 3 x 4 times daily
RESULTS OF LABORATORY
Abnormal laboratory test results
Laboratory examination showed on December 17th, hemoglobin decreased to 8.6 g /dl,
while the normal value of hemoglobin is 13-18 g/dL, hematocrit 23%, while the normal
hematocrit value is 40-52%, erythrocytes 2.7 million / mL, while normal values are 4.3 6.0 million / mL, Laboratory Examination on December 20 MCH values decreased to
normal values 27-32 pg 26 pg, MCHC 31g/dl normal values 32-36 g / dL. Laboratory
examination on December 19, the value of urea 162 mg / dL, while normal values of 20-50
mg / dL, albumin 3.1 g / dl, while normal values 3.5-5.0 g / dL, globulin value be increased
1535
by 3.8 g / dl normal values 2.5-3.5 g / dL, kolerterol 105/dl (<100 mg / dL), creatinine 9.5
mg / dl normal values 0.5-1.5 mg / d L.
1. Improper drugs effective
Improper drug selection is antihypertensive amlodipine, since amlodipine is not the first
line therapy for patient whith a history of hypertension and diabetes meletus, can lead to
hyperglycemia, it is recommended to choiec
athother antihypertensive therapy e.g
ACE-inhibitors is catopril.
Based on the results of laboratory tests showed that cholesterol (LDL) exceeds the
normal value, it is recommended that therapy with statins are simvastatin 10-20 mg /
day. for lowering LDL and total cholesterol in patients with kidney disease (with or
without nephrotic syndrome) and is generally regarded as the drug of choice. Statins can
lower LDL indicated in patients with CKD
CONCLUSION
Based on the results of their clinical practice in a general medical ward at the Gatot
Subroto Army Hospital, it can be concluded that the presence of DRP (Drug Related
Problems). In Mr. FT treatment propile there found DRP that is :
1. Improper drug selection is selection is selection of anthypertensive amlodipine as fist
line therpy.
2. Untreated indication, patient has abnormal value of LDL cholesterol. So it recomended
to give simvastatin 10-20 mg / day
1536
REFERENCES
1. William L, Henrich, MD. Principles and Practice of Dialysis. Lippincott. 1999; 14:209211.
2. Barry M, Brenner, The Kidney sevent edition, U.S., Saunders, 2004; 47:2109- 2112
3. Suzanne C Smeltzer, Brenda Bare, Textbook of Medical-Surgical of Nursing, Lippincott,
2004; 23: 855-858.
4. Dr. Burns Aine.2009 "The Renal Drug Handbook Third Edition" Edited by Caroline
Ashley and Aileen Currie UK Renal Pharmacy Group.
5. T. Joseph DiPiro, PharmD, FCCP. 2005, "A pathophysiologic Approach, Sixth Edition"
By Editors
Joseph T. DiPiro, PharmD, FCCP Professor and Executive Dean, South
Carolina College of Pharmacy, University of South Carolina, Columbia, and the Medical
University of South Carolina, Charleston
6. Kidney disease improving global outcomes. 2003 "Clinical Practice Guideline for Lipid
Management in Chronic Kidney Disease" Vol 3/Issue 3 / November 2013
1537
TREATMENT FOR CHRONIC KIDNEY DISEASE AT THE
INTERNAL DISEASE IN PGI CIKINI HOSPITAL
Roy Oktavianus Bunga1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
E-mail: [email protected]
ABSTRACT
Chronic kidney disease (CKD) is a life-threatening condition characterized by progressive
and irreversible loss of renal function. The increasing inability of the kidneys to properly
clear the blood of waste products eventually results in the implementation of dialysis (or
kidney transplant) in order to prevent azotemia, systemic organ damage and death. Due to
its high prevalence and associated mortality, CKD is an important human and social
burden. It is estimated that over 10% of adults in developed countries suffer some degree of
CKD. Patient Mr. BM, 56 year old, entered PGI Cikini hospital on February 4th 2014, was
diagnosed as having non-functioning right kidney. The patients got Ceftriaxon, Kalnex
(Tranexamic Acid), Vitamin K, Vitamin C, Vomizole (Pantoprazole), Torasic (Ketorolac)
and Calcium for eight days. Based on the result of the clinic secretariat at the ward of
internal disease in Cikini Hospital, it could be concluded that there was DRPs (Drug
Related Problems). There is the presence of the drug without indication, too high dose and
drug interactions.
Keywords : Chronic kidney disease (CKD), Internal Disease, PGI Cikini Hospital
1. INTRODUCTION
Chronic kidney disease (CKD) is a life-threatening condition characterized by
progressive and irreversible loss of renal function. The increasing inability of the kidneys to
properly clear the blood of waste products eventually results in the implementation of
dialysis (or kidney transplant) in order to prevent azotemia, systemic organ damage and
death. Due to its high prevalence and associated mortality, CKD is an important human and
social burden. It is estimated that over 10% of adults in developed countries suffer some
degree of CKD (1).
1538
Chronic kidney disease (also known as chronic renal disease) can arise from
progression of acute renal failure or congenital or familial diseases, or as the result of
acquired conditions affecting glomerulotubular function that have developed over a period
of months or years. The most common underlying histopathology associated with chronic
kidney disease in cats is tubulointerstitial nephritis. A primary cause is often not identified
in cases of CKD, however the associated lesions are irreversible and typically progressive.
Remaining intact nephrons undergo a compensatory hypertrophy in order to maintain
function. The maladaptive mechanisms that occur as a result of nephron damage further
contribute to the progressive decline in kidney function. Among the homoeostatic
derangements that may contribute to further progression are mineral imbalance, for
example phosphorus retention and secondary hyperparathyroidism, and renal hypertension.
Although no treatment can repair irreversible renal lesions, the clinical consequences of
reduced renal function can be minimised by appropriate medical management (1,2).
Biochemical changes associated with kidney disease included elevated serum
creatinine and blood urea nitrogen (BUN), or azotemia. Azotemia refers to the
accumulation of nitrogenous wastes in the blood as a result of decreased glomerular
filtration. Additional findings with diagnostic testing and examination may include:
Elevated phosphorus, Hypokalaemia, Anaemia, Hypertension, Abnormal acid-base status,
Abnormal size of kidneys on palpation or radiography(3).
According to the data from the United States Renal Data System (USRDS), in 2009,
end stage renal failure is commin and the prevalence is about 10-13%. In the United States,
the number reached 25 million people and in Indonesia is estimated about 12,5% or 18
million peoples4. According to data collected by the Indonesian Renal Registry (IRR),
patients with end stage renal failure who underwent the hemodialysis in Indonesia starting
from 2007 to 2009 is 1885,1936,4707,5184,6951, and 91615. Data from several research
centers that spread through Indonesia reported that the cause of the end stage renal failure
that underwent dialysis was glomerulonephritis (36,4%), kidney obstruction and infection
(24,4%), diabetic kidney disease (19,9%), hypertension (9,1%), and other reasons (5,2%)(4).
1539
2. CASE PERCENTATION
Mr. BM, 56 years old patient entered the PGI Cikini Hospital in February 4th 2014.
Patient was diagnosed of non-functioning right kidney. Patients came with a complaint of
pain on right waist and limp. Results of laboratory tests showed that increasing in serum
creatinine and glomerular filtration rate calculation results (GFR) using the Kockcroft Gault
formula was 50.09 ml / min which indicates renal disease stage 3rd.
In this case, the patient was treated with Ceftriaxon to treat urinary tract infections
which are characterized by an increase in the leukocytes value. Kalnex (Traneksamat Acid)
and coagulant vitamin K to prevented bleeding. Vitamin C to prevented vitamin C
deviciency and help maintain the immune system. Vomizole (Patoprazole) for gastric ulcer
or duodenum ulcer. Torasic (Ketorolac) to treat moderate to severe acute pain while Ca.
Gluconas to manage hipofosfatemia.
4. DOSAGE AND DIRECTIONS
During eight days of treatment, Mr. Bm got seven kind of treatment. The first day,
the patient got Ceftriaxon injection with a dose of one gram twice a day. Ceftriaxon was
given daily for eight days. Day two patients received Kalnex (Tranexamic Acid) 500 mg
orally 3 times a day and was given for seven days, vitamin K injection 2x1 ampules was
given for seven days, Vitamin C injection 1x400 mg a day was given for seven days,
Vomizole (Pantoprazole) injection of 2x1 vial a day was given for seven days, Torasic
(Ketolorac) injection of 30 mg 3 times was given for seven days. While the third day the
patient got Ca. Gluconas, one ampules injection a day given for three days
5.LABORATORY EXAMINATION RESULT
The results of the hematology examination on February 3rd, 2014 showed that the
value of the erythrocyte sedimentation rate (ESR) is high i.e. 23 mm/h (0-20 mm/hour)
indicates the presence of inflammation or infection, the increased value of the globulins of
3,9 g/dl (1,3-3,7 g/dl) indicates the presence of liver disorders infection, the increased value
1540
of total protein i.e. 8,1 g/dl (6,0-8,0 g/dl) indicates the presence of flammation, the
decreased value of neutrophil i.e. 1% (2-6%) indicates the presence of infection, the
increased numbers of lymphocyte i.e. 45% (20-40%) indicates the presence of infection, the
increased value of creatinine i.e. 1,7 mg/dl (0,6-1,1 mg/dl) indicates the presence of
decreased kidney function, the decreased value of potassium i.e. 3,3 mEq (3,5 to 5,0 mEq)
indicates the occurrence of hipofosfatemia. The results of urinalysis inspection on February
5th 2014 showed the increase in the value of Leukocyte i.e. 3/lpb (0-2/LPB) and the results
of Hematologic examinations on February 6th 2014 showed the decline of the Leukocyte
value i.e. 13,2 10^3µL which indicates the presence of infection.
6. DISCUSSION
The patient, Mr. BM, entered the PGI Cikini hospital on February 4th 2014 with a
diagnosis of non-functioning right kidney. Patients came with a complaint of right waist
pain and limp. The results of the laboratory tes showed an increase in patients creatinine
serum i.e. 1,7 mg/dL, and the value of glomerural filtration rate (GFR) obtained by
calculation with Kockcroft Gault is 50,09 ml/min which indicates the third degree renal
disease. Patient was treated with Ceftriaxon, Kalnex (Tranexamic Acid), Vitamin K,
Vitamin C, Vomizole (Pantoprazole), Torasic (Ketolorac), and Ca Gluconas. Ceftriaxon.
Result of laboratory test showed present an urinary tract infections which can be seen from
the increasing of Leukocytes value. According to BNF, 2009 gift of Ceftriaxone for renal
failure patients up to 2 g a day by monitoring plasma levels. The using of Kalnex
(Tranexamid acid) and vitamin K are to prevent or overcome bleeding, but there are no data
that indicates the existence of bleeding cases in patients. The using of Vitamin C to prevent
and treat vitamin c deviciency and helps nurture endurance. According to Burns, A (Renal
Drug Handbook, 2009) the granting of vitamin c to the kidney failure patient needs to use a
dose which is low to prevent the formation of oxalate. The using
of Vomizole
(Pantoprazole) to gastric ulcers or duodenal ulcers.The use of Torasic (Ketolorac) for a
short-term moderate to severe pain. According to Burns, A (Renal Drug Handbook, 2009)
ketolorac is nephrotoxic, may cause decreased kidney function and third degree kidney
1541
failure patients only allowed to take maximum 60 mg/hari while the use of Ca Gluconas for
handling hipofosfatemia.
1. Drug without Indication
Patient received Kalnex and Vitamin K, while according to BNF, 2009 Kalnex was
indicated for local fibrinolysis and vitamin K for blood clotting production factor. But
there is no data showing that patient experienced bleeding
2. Overdosage
Dose Torasic (ketorolac) 3 x 30 mg for seven days was too high. According Renal Drug
2009 if the value of LFG patients between 20-50 ml / min maximum, then the dose of
ketorolac was 60 mg / day for two days.
Drug Interactions that occurs i.e. the usage of Ceftriaxone with Torasic (Ketolorac) may
cause increasing effect of Ketolorac; The using of Ceftriaxone with Ca Glukonas can
increase particulate liquids in lungs and kidneys; the using of torasic with vitamin K can
decrease coagulan effect vitamin K and the using of vitamin C with Ceftriaxone and
torasic can increase the effect of Ceftriaxone and Torasic that can worsen the condition
of patient.
8.CONCLUSION
Based on the results of the Clinical practice in internal medicine wards in PGI Cikin
hospital can be concluded that the value of the Mr. BM LFG is 50,09 ml/mn which
indicates third degree kidney failure disease and the presence of DRP (Drug Related
Problem) which is Drugs without indications, Too High doze drugs and Drugs Interactions.
1542
9. REFERENCES
1. De Zeeuw, D., Hillege, H. L., & de Jong, P. E. (2005). The kidney, a cardiovascular
risk marker, and a new target for therapy. Kidney Int Suppl 68(Suppl. 98), S25−S29.
2. Novoa , L.M., Salgado, M.C., Pena R, Hemandez ,L.J., 2010.
Common
Pathophysiological mechanisms of chronic kidney disease. Pharmacology and
Therapeutics, 128, 61-81
3. Prodjosudjadi, dkk. 2009. End-Stage Renal Disease In Indonesia. Treatment
velopment. Hal 33-36
4. PERNEFRI. 2012. Report Of Indonesian Renal Registry5th. Perkumpulan Nefrologi
Indonesia. Hal 11
Hal 159, 381, 672, 681, 686, 871, 1076, 1098
6. Burns, A. 2009. Renal Drug Handbook third edition. New York : Oxford. Hal 65, 111,
132, 410, 558, 584, 745
7. BNF. 2009, British National Formulary. BMJ Group. UK. Hal 13, 17-21, 24, 50, 138,
297, 543
8. Baxter, K. 2008. Stockley’s Drug Interactions eight edition. Pharmaceutical Press.
London. Hal 158
1543
FOR PULMONARY TUBERCULOSIS PATIENT IN
Septiana Dwi Pramita 1, Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
[email protected]
ABSTRACT
Tuberculosis is an infectious disease caused by the Mycobacterium tuberculosis that is
capable of infecting a latent or progressive. Mycobacterium tuberculosis is transmitted from
person to person through coughing and sneezing. Hypertension can be defined with
increased arterial blood pressure that is persistent. The symptoms usually arise i.e. fever,
cough, chest pain, malaise. Suffering from hypertension stage II classed in more sistolic
pressure 160 mmHg and diastolic more than 100 mmHg hypertension whereas stage III
pressure sistolic when more than 180 mmHg and diastolic pressure is more than 116 mmHg
(Palmer, 2007). Patient Mrs R, 68 years old came to Persahabatan Hospital on July 2, 2014.
She has received 4FDC therapy treatment 1 times 3 tablet, 500 mg 1 time Streptomycin
given intramusculary, amlodipin 1 times 10 mg per oral captopril, given 3 times 12,5 mg
administered orally, per ceftriaxon given by injection. Based on result of clinical secretarit
at Persahabatan Hospital can be conclude that there was DRP (Drug Related Problem) such
as Adverse Drugs Reaction, Failure to Received Medicine, Untreated Indication
Keywords: Tuberculosis, Hypertension stage II, and Persahabatan Hospital
1544
I.
INTRODUCTION
Tuberculosis is a disease caused by infection with Mycobacterium tuberculosis that is
capable of infecting a latent or progressive. Mycobacterium tuberculosis is transmitted from
person to person through coughing and sneezing. The contact too close to people with TB
will increase the likelihood of transmission. (Elin Y. S, et al, 2008)
The cause of tuberculosis are mycobacterium tuberculosis germ, a Rod shaped with
length 1 – 4/um and thick 0.3 – 0.6/um. Most germs are composed of fatty acids of the
lipid. Lipids this is what makes germs more resistant to acids and is more resistant to
chemical and physical disorders. Germs can hold live on dry air or in a State of cold. This
occurs because germs are in the nature of dormant (sleeping). On the network, germs live
as parasites in the intracellular cytoplasmic macrophages. Other properties of this germ is
aerobic. This indicates that the nature of germs prefer high network their oxygen content. In
this case the oxygen pressure at the apical lung is higher than the other, so this is where the
apical part predilection disease tuberculosis. (Department of health RI, 2004)
Pulmonary tuberculosis is still a public health problem, especially in countries that
are developing. The death toll since the beginning of the 20th century began to decrease.
Since he set up the principle of treatment with improved nutrition and the life of the
sufferer. State of the patient is better since the discovery of the drug streptomycin.
(Doenges E M, 2002)
The most common symptoms in people with Pulmonary Tuberculosis are:
1. Fever
Usually resemble influenza fever subfebris and sometimes hot bodies can reach 40 –
41 0 c attack fever can be healed back so it went on missing arising
2. Cough
symptoms are found. Cough occurs due to irritation of the bronchial cough, it is
necessary to dispose of the products of inflammation of the bronchial involvement out
due to any disease are not the Sam
3.
Chest pain Symptoms is rather rarely found chest pain occurs when the inflammation
has been infiltration to the pleura causing pleuritis.
1545
4. Malaise
Tuberculosis disease is inflammation of the Malaise the chronical. Symptoms of malaise
is often found in the form of anorexia (no appetite). The Agency is getting skinny
(weight), hot and cold, headache, muscle pain, night sweats and others. The longer this
malaise symptoms are more severe and occur in irregular has occurred is los
Hypertension can be defined with increased arterial blood pressure that is persistent.
Patients with diastolic blood pressure of less than 90 mmHg and systolic blood pressure
bigger equals 140mmHg systolic hypertension have isolated. (Elin y. S et al, 2008)
According to the WHO limit normal blood pressure is 120 – 140 mmHg systolic
pressure and 80 – 90 mmHg diastolic pressure. Someone stated to have hypertension when
his blood pressure is 140/90 mmHg >. Whereas according to the JNC VII 2003 (The
seventh report of the joint National on Prevention, detection, evaluation, and treatment of
high blood pressure) blood pressure in adults above 18 years of age are classified as
suffering from hypertension stage I in pressure systolic 140 – 159 mmHg 90 – dyastolic
pressure and 99 mmHg. Suffering from hypertension stage II classed in more sistoliknya
pressure 160 mmHg and diastoliknya mmHg counts more than 100 hypertension stage III
pressure systolic when more than 180 mmHg and dyastolic pressure is more than 116
mmHg (Palmer, 2007).
High blood pressure causes are largely unknown, especially essential, however there
are a number of risk factors are high blood exposed, for example, overweight, lack of
exercise, consuming food containing high salt, less consuming fresh fruits and vegetables
and drinking too much alcohol.
2.
CASE PERSENTATION
Patient Mrs.R 68 years old came to Persahabatan Hospital on July 2, 2014. The main
complaint of patients coughing blood since 4 days before entering the hospital, coughing
blood approximately 1 small spoon, after which only patches. Cough is more or less 1
month before entering the hospital, positive yellow phlegm. A history of the patient's
disease type 2 DM, i.e. given the drug metformin and glibenclamid circa 1980 patient ever
in therapy with category I and OATS from June 2014 in therapy patients with OAT
1546
category II in lung with poly injection.
3.
CLINICAL EVALUATION
Patient was treated with 4FDC (Rifampin 150 mg, INH 75 mg, Pirazinamid 400 mg,
Ethambutol 275 mg), Streptomycin injection, amlodipin, captopril and ceftriaxon. The
results of laboratory examination on 3 July 2014 suggests abnormality in Leukocyte value,
lymphocytes, fasting blood glucose, sodium, triglycerides, total cholesterol and LDL
cholesterol.
4.
DOSE AND USING OF DRUGS
4FDC (Rifampin 150 mg, INH,75 mg, Pirazinamid 400 mg, Ethambutol 275 mg) 1
tablet 3 times per given in oral for the treatment of Tuberculosis, with a dose of common
4FDC weight 30 to 37 kg 2 tablets/day. Streptomycin was given 500 mg 1 time in i.m for
the treatment of tuberculosis patients, amlodipin 1 times 10 mg captopril and 3 times 12, 5
mg oral per given for the treatment of hypertension, ceftriaxon injection for managing
infection that was caused by gram positive or gram negative bacteri.
5.
1.
Untreated indication
Of the patient's blood sugar is high and has a history of DM type 2 so need checked
HbA1c and blood sugar levels in order to be given the Drug
2
Adverse drug reactions:
- Rifampin and INH increased the hepatotoksitas of INH anti- hepatotoxic monitoring
needs to be done so that for sufferers with checking lab SGPT and SGOT
- Giving Captopril on patient with TB can cause cough side effects and urinate
3
Patient failed to receive medication
Remedy hypertension has been given but forgot to drink, suggest on nurses to
control drugs are already given in patients
1547
6.
CONCLUSION
Based on result of clinical secretarit at Persahabatan Hospital can be conclude that
there was DRP (Drug Related Problem) such as Adverse Drugs Reaction, Failure to
Received Medicine, Untreated Indication
7. REFERENCES
1. RI Department of health. 2005. Pharmaceutical Care For Tuberculosis Disease.
Jakarta
2. Marilynn e. Doenges, et al, Nursing Care Plan, issue publishers EGC, Jakarta
3. Muchid A, 2005. Pharmaceutical Care For Tuberculosis Disease, Jakarta
4. Yulinah s., Elin et al, 2008, ISO Farmakoterapi, PT. ISFI publishing, Jakarta
1548
TREATMENT FOR BENIGN PROSTATE HYPERPLASIA IN
MINTOHARJO HOSPITAL
Windy Fitriany Sumarauw Aprilita Rina Yanti Eff2 and Diana Laila Ramatillah2
1
2
ABSTRACT
The prostate is a gland in men. It helps make semen, the fluid that contains sperm.
The prostate surrounds the tube that carries urine away from the bladder and out of the
body. A young man's prostate is about the size of a walnut. It slowly grows larger with age.
If it gets too large, it can cause problems. This is very common after age 50. The older men
get, the more likely they are to have prostate trouble (Galih, 2012). Patient Mr. Murni, age
59 years old, with weight 77 kg, has been diagnosed of prostate disease (after the surgery).
The patient had been treated with ceftriaxon, ketorolak, kalnex (traneksamat acid), vitamin
K, adona (karbazokrom natrium sulfonat), by intra vena and diazepam oral. Based on the
result of the clinic secretariat at the ward of Salawati in Mintoharjo Hospital, it could be
concluded that there was DRPs (Drug Related Problems). There was an interaction
between ketorolac dan vitamin K (Menadione). Ketolorac activity was increase by vitamin
K and could be toxcicity. The use of both these drugs must be separated and monitored
(Anderson, 2002).
Key Words: Drug Related Problem, Benign Prostate Hyperplasia, .Mintohardjo Hospital.
1.
Introduction
The prostate is a gland in men. It helps make semen, the fluid that contains sperm.
The prostate surrounds the tube that carries urine away from the bladder and out of the
body. A young man's prostate is about the size of a walnut. It slowly grows larger with age.
If it gets too large, it can cause problems. This is very common after age 50. The older men
get, the more likely they are to have prostate trouble. (Galih, 2012).
Prostate has size little bit bigger from the canary nuts; it is placed in front of anus,
right under the bladder where the urine is patched, and surround the urine duct (urethra)
which take out the urine from inside of the body (Anonym, 2008).
1549
The gland have role as the part of the man reproduction system with produce the
white liquid that contain sperm. Prostate also consist of the smooth muscle that help to take
out the sperm while ejaculating (Anonym, 2013).
The disruption could happen in the prostate gland that is inflammation or infection
(protatitis), the enlargement of benign prostate (Benign Prostatic Hyperplasia-BPH), and
cancer. Prostatitis is the clinical term to explain the wide of the spectrum disruption that
stretch from the infection of the bacteria to the painful chronic syndromes. This is not
spread (commonly do not spread through the sex contact). Kinds of prostatitis, those are
BPH (Benign Prostatic Hyperplasia) is the second common problem that can be happen in
the prostate. “Benign” means “not cancer” and “hyperplasia” means “the over growth or the
enlargement”. By the addition of the man age, the prostate gland slowly becomes larger.
The gland itself disposed to be wider on the area which is not get wider with it; it caused
the pressure on the tract that can cause the urine problem. The pressure to take out the
urine, the weak of the urine wiring, the break of urine wiring or slit, all of them are the
symptom of the elnlargement of prostate. The worse, BPH can cause weaken of the bladder
or the kidney infection, the complete stop of the urine wiring and the kidney failure.
(Crahmayadi, 2013).
The prostate cancer is one of cancer disease that commonly happen to US man.
There are no early signs for the prostate cancer symptom. The malignant tumor caused the
gland of the prostate swollen significantly or the cancer spread oversteps the prostate.
These signs might be appear such as : the needed to take out the urine, especially in the
night, the difficulty in starting or stopping the urine wiring, the spread of the urine is weak
or breaking, the painful sensation or burn when take out the urine or ejaculation, there is
blood in urine or sperm (Dani, 2012).
2.
Case Presentation
Patient Mr. Murni, age 59 years old, weight 77 kg, has been diagnosed of having the
enlargement of prostate ( after the surgery). The patient came to hospital with the gripe of
urinate that feel a prop, cannot sleep because he felt pain in the stomach. The result of the
laboratory checked showed the abnormality on eritrosit that is 3,76 ( normal score
1550
Million/mm3 P: 4.5-5.5),
hemoglobin that was 11.1 ( normal score P: 14-18 g/dL),
hematokrit that is 32 ( normal score % P: 43-51). The patient was treated with ceftriaxon
injection 2 times 1 g ampl for 4 days. Ketolorac injection 3 times 10 mg ampl for 4 days,
kalnex (treneksamat acid) injection 3 times 1 g ampl for 4 days, vitamin K injection 3 times
5 mg ampl for 4 days, adona (karbazokrom natrium sulfonat) injection 3 times 10 mg ampl
for 4 days, diazepam oral 1 time 5 mg for 4 days.
3.
Discussion
This patient has diagnosed that he having the enlargement of prostate (after the
surgery), the patient was treated with cefriaxon (sefalosporin type of antibiotic on 3rd
generation) that active on the negative gram bacteria and positive gram bacteria. Ceftriaxon
was used to prevent the infection on the patient because it was apprehensive about the
infection after the surgery. (Tan Hoan Tjay, 2007). The giving of ketolorak that was main
anti inflammation non steroid (AINS), has indicated to the management of critical short
painful, medium to serious (Tan Hoan Tjay, 2007). The patient had also been given kalnex
(traneksamat acid), vitamin K and adona (karbazokrom natrium sulfonat) to help stopped
the bleeding condition that happened after the surgery. The combination both of these drugs
vitamin K (menadione) and kalnex (traneksamat acid) sometimes used by the doctor in
blood clotting process. If there is lack of vitamin K it can caused the disruption of blood
clotting so it caused the blood is harder to clot. Adona (karbazokrom natrium sulfonat) had
given to the patient for abnormal bleeding treatment that happen to the patient after the
surgery because of the reduction of caviler resistance. The patient had the gripe of hard to
sleep because of the pain in the stomach so the patient had been given diazepam. From the
laboratory data the number of hematokrit had reduced, it was sign with there was a
disruption in blood clotting so it was given the therapy of drugs that have functions in
blood clotting process (Tan Hoan Tjay, 2007).
The result of the therapy on the patient showed that there was an interaction
between ketolorac and vitamin K, ketolorac give the anti inflammation effect by blocked
the granulocyte placement on the broken blood artery and blocked the migration of
macrophage to the infection place. So by the used of ketolorak and vitamin K together,
1551
cause the work of ketolorak gain until it caused toxic. So the use of the drugs on patient
must be separated and monitored (Anderson, 2002).
4.
Conclusion
Based on the result of the clinic secretariat at the ward of Salawati in Mintoharjo
Hospital, it could be concluded that there was DRPs (Drug Related Problems). There was
an interaction between ketorolac dan vitamin K (Menadione). Ketolorac activity was
increase by vitamin K and could be toxcicity. The use of both these drugs must be
separated and monitored (Anderson, 2002).
5. References
1. Hepler, C. D., Strand, L. M., 1990, Opportunities and responsibilities in
pharmaceutical care. Am J Hosp Pharm
2. Hepler, C. D., Segal, R., 2003, Preventing Medication Errors and Improving Drug
Therapy Outcomes, A Management Systems Approach, CRC Press LLC, Boca Raton,
Florida
3. Dipiro, J.T., Talbert, RI., Yee, G.C., Matzke GR., Wells BG., Posey LM.
2008,Pharmacotherapy:A Pathophysiologic Approach, 7th. ed.,Appleton & Lange,
Stamford.
4. Herfindal, E.T., and Gourley, D.R., 2000, Textbook ofTherapeutics, Drug and Disease
Management, 7th. ed.,Lippincot & Williams, Philadelphia
5. Schwinghammer, T.L., Koehler JM., 2009, Pharmacotherapy Casebook: APatient
Focused Approach, 7th. Ed., McGraw-Hill Companies,New York
6. Stockley, I.H, 2008, Stockley’s Drug Interaction VIIIth ed, Great Britain
1552

International Journal of Pharmacy Teaching

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