Presc iption

Catharina Triwikatmani
 Mr Good Day, 25 y male, with productive
cough for a week
Rales in hemithorax dextra, x ray: infiltrates,
sputum: coccus gram +
Dx ? Tx ? Prescription ?
 Ms Communi Cation, 72 y female with long
standing hypertension
Treatment: nifedipin 3x10 mg
Px: BP 170/100 mmHg, pulse 88 x/mnt reg,
cardiomegali, no basal rales.
Px ? Tx ? Prescription ?
 Mr Best Zer, 45 y male, dysuria &
frequency for 5 days
Costovertebral angle flank pain dextra
Lab ? Dx ? Tx ? prescription
4A 3B
Influenza Acute Respiratory Distress
Asma bronkial Syndrome (ARDS)
Bronkitis akut SARS
Pneumonia, Flu burung
bronkopneumonia Status asmatikus (asma
Tuberkulosis paru tanpa akut berat)
komplikasi Pneumonia aspirasi
3A Efusi pleura masif
Bronkiektasis Penyakit Paru Obstruksi
Tuberkulosis dengan HIV Kronik (PPOK) eksaserbasi
Emfisema paru akut
Abses paru Edema paru
4A 3A
Hipertensi esensial Gagal jantung kronik

3B Fibrilasi atrial

Syok (septik, hipovolemik, Ekstrasistol

kardiogenik, neurogenik) supraventrikular, ventrikular
Angina pektoris Kor pulmonale kronik

Infark miokard Hipertensi sekunder

Gagal jantung akut Tromboflebitis

Takikardi: supraventrikular, Limfangitis

ventrikular Limfedema (primer,
Fibrilasi ventrikular sekunder)
Atrial flutter Insufisiensi vena kronik

Kor pulmonale akut

Ensefalopati hipertensi
4A
Kandidiasis mulut 3B
Ulkus mulut (aphtosa, Lesi korosif pada esofagus
herpes) Perdarahan gastrointestinal
Gastritis Botulisme
Gastroenteritis (termasuk 3A
kolera, giardiasis) Esofagitis refluks
Refluks gastroesofagus Ulkus (gaster, duodenum)
Demam tifoid Malabsorbsi
Keracunan makanan Hepatitis B
Penyakit cacing tambang Abses hepar amoeba
Strongiloidiasis Perlemakan hepar
Askariasis Divertikulosis/divertikulitis
Skistosomiasis Kolitis
Taeniasis Irritable Bowel Syndrome
Hepatitis A Proktitis
Disentri basiler, disentri
amuba
Hemorrhoid grade 1-2
4A 4A
Infeksi saluran kemih Infeksi saluran kemih

Pielonefritis tanpa bagian bawah

komplikasi Anemia defisiensi besi pada

3A kehamilan
Glomerulonefritis akut 3B
(Anak) Infeksi pada kehamilan:

Glomerulonefritis kronik TORCH, hepatitis B,

malaria
 3B
Ketoasidosis diabetikum
4A
Hiperglikemi hiperosmolar
Diabetes melitus tipe 1
Hipoglikemia berat
Diabetes melitus tipe 2
Tirotoksikosis
Hipoglikemia ringan
Cushings disease
Malnutrisi energi-protein
Krisis adrenal
Defisiensi vitamin
Sindrom metabolik (3B?)
Defisiensi mineral
3A
Dislipidemia
Diabetes melitus tipe lain
Hiperurisemia (intoleransi glukosa akibat
Obesitas penyakit lain atau obat-obatan)
Hipoparatiroid
Hipertiroid
Goiter
4A 3A
Anemia defisiensi besi Anemia hemolitik
Limfadenitis
Anemia makrositik
Demam dengue, DHF
Limfadenopati
Malaria
Toksoplasmosis
Leptospirosis
AIDS dengan komplikasi
Reaksi anafilaktik
Lupus eritematosus
Tetanus
HIV AIDS tanpa komplikasi
sistemik
Polimialgia reumatik
3B
Bakteremia Demam reumatik (Anak)

Dengue shock syndrome Artritis reumatoid

Sepsis Artritis, osteoartritis

Malaria serebral Osteoporosis
Rabies Tenosinovitis supuratif
Prescription sheet

Prescribing doctor: Physician's name, degree and

address (phone, license no.)
Date of prescription / treatment
R/
Prescription drug(s): name of drug, form, number,
dosage
Full name of patient (no nicknames) for whom
drug is prescribed, age, body weight
Rational approach to therapeutics
Define the patients problem
Specify the therapeutic objective
Selecting therapeutic strategies
Non-pharmacological treatment
Pharmacological treatment
Selecting the correct group of drugs
Selecting the drug from the chosen group
Verifying the suitability of the chosen pharmaceutical
treatment for each patient
Prescription writing
Giving information, instructions and warnings
Monitoring treatment
Variation in dose response

Drug formulation
Body weight and age
Physiological and pharmacokinetic variables
Drug distribution
Drug metabolism and excretion
Pharmacodynamic variables
Disease variables
Environmental variables
Geriatric Patients

They experience an increased incidence of

adverse drug effects
There is an increased likelihood that the patient
will respond atypically to a given drug
Enhanced effect
Diminished effect
Unexpected adverse effect
~ Age-related pharmacokinetic &
pharmacodynamic changes, be aware of
nonpharmacologic problems
 Geriatric Patients

Age-related :
physiologic changes in renal function

physiologic changes in liver function

changes in the CNS

changes in protein binding

changes in body composition

 Geriatric Patients

High incidence of adverse effects in the

elderly
Drug-drug interactions
Multiple chronic diseases require several
medications
ddi & becomes difficult to manage
Visit different providers for care & obtain meds at
different pharmacies
Medications considered inappropriate : risk >
benefit
Adverse Drug Reaction

An adverse drug reaction: a drug response that is

noxious or unintended and occurs at prophylactic,
diagnostic, or therapeutic doses
Adverse Drug Reaction
Major factors predisposing to adverse effects
Extremes of age
Can present atypically in the elderly
ex. symptoms from constipation confusion
Intercurrent illness
Drug interactions
Direct association: age ~ medication use
Strong relationship: number of medication ~ incidence of
adverse reactions
Incompatibilities between drugs and intravenous fluids
Adverse effects caused by traditional medicines
The effect of food on drug absorption
Polypharmacy

The use of multiple medications: 3-5, >9

medications/day
The administration of more medications than clinically
indicated
Risk factors: increased
increased age
increased number of physicians and pharmacies
increased number of office/hospital visits
decline in health status
the influence of pharmaceutical industry advertising
 Be aware that neither generic nor brand-name
prescribing is a superior method
 Polypharmacy

Contributing factor: tx of an adverse effect of one drug w.

another medication
Polypharmacy increases the risk of
ADR
drug interactions
medication noncompliance
decline in medical status
Increase in health care costs
Can be prevented: communication & education
Polypharmacy in geriatric patient

Obtain a geriatric drug history

If an adverse effect occurs, dont add a drug. Take
one away
Discontinue all drugs deemed unnecessary or of
questionable therapeutic efficacy
Identify the overtreated patient
Employ nonpharmacologic treatments whenever
feasible
Adherence (compliance) with drug treatment

Patient reasons
Disease reasons
Doctor reasons
The doctor-patient interaction
Prescription reasons
Pharmacist reasons
The health care system
Recommendations
Review the prescription to make sure it is correct.
Quiz the patient periodically to see if medication is being
taken correctly
Observe the patient
Reevaluate the regimen periodically
Spend time explaining the health problem and the
reason for the drug.
Establish good rapport with the patient.
Explore problems, for example difficulty with reading
the label or getting the prescription filled.
Utilize nonchildproof containers if necessary
Recommendations
Encourage patients to bring their medication to the
clinic, so that tablet counts can be done to monitor
compliance.
Inspect the contents of the patients medication bottles
Encourage patients to learn the names of their
medicines, and review their regimen with them.
Write notes for them.
Keep treatment regimens simple.
Consider combination agents when medically (and
financially) appropriate
Attempt to treat specific conditions with monotherapy or
groups of disease with the same medication
 Compliance

Dont assume that every patient can remember a

complicated medication regimen
Avoid qid and tid regimens if possible
Recommendations

Communicate with other health care proffessionals,

to develop a team approach and to collaborate on
helping and advising the patient.
Involve the partner or another family member.
Listen to the patient.
 Be aware that the prescribers job
does not end with the prescription
Thank you